Every finding on record at Wesley Enhanced Living Pennypack Park

Based on review of facility documentation and staff interviews it was determined that the facility failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for one of 22 residents reviewed (Resident R102). Findings include: Review of Resident R102's clinical records and admission documents revealed that upon admission to the facility on April 11, 2025, Resident R102 signed numerous admission, financial, consent, and resident right documents written in English. A review of facility documentation revealed numerous items with Resident R102's signature dated April 11, 2026, that included but were not limited to, the admission summary, insurance member responsibility forms, financial admission policy, physician authorization, advance directives power of attorney information, beneficiary notice of non-coverage, vaccine information, informed consent, informed consent for treatment, media release acknowledgement of private practices authorization for release of information, resident fund management services, laundry permission, privacy notice regarding the use and disclosure of medical information, grievance procedure, corporate compliance information, non-discrimination notice, abuse and zero tolerance information, visiting policy and resident rights and legal arbitration agreement .The majority of these documents were also signed by the facility admissions director, Employee E8, on April 11, 2025. Further review of Resident R102's clinical record revealed the resident's primary language is Spanish and that the resident does not speak, read or understand English. Continued review of facility documentation and Resident R102's clinical record revealed no documented evidence that the admission documents were translated into Spanish, and interpreted by a qualified medical interpreter, reviewed through a language assistance service, or otherwise communicated in a language and manner Resident R102 could understand prior to obtaining the resident signatures. There was no documentation identifying an interpreter, translator, bilingual staff member, or witness attesting to the contents of the document were accurately explained to the resident before signature. Review resident R102's comprehensive care plan revealed the resident has communication needs. The care plan documents that Resident R102 is Spanish speaking and, when spoken to in this native language answers appropriately follow commands and makes needs known. The care plan further indicated Resident R102 does not understand English and understands only a few basic English words and phrases. The care plan reveals staff should utilize nonverbal communication techniques, and that Resident R102 was provided a Spanish English communication board. Interventions directed staff to use verbal and visual cues, nonverbal techniques and gestures, and other communication strategies to facilitate understanding. Interview on July 23, 2026, with Admissions Director, Employee E8, revealed she does not speak Spanish and is unable to translate. When asked how Admissions Director, Employee E8, communicated the admissions agreement documents to Resident R102, Employee E8 reported using a tablet for translation. Admissions Director, Employee E8, acknowledged and confirmed that none of the admission documents contained any notation indicating that a translation method, including the tablet, or qualified translator was used. Admissions Director, Employee E8, further confirmed the paperwork was not provided in Spanish, and that there was no documentation to demonstrate that Resident R102 received translation assistance or understood the documents prior to signing them. Admissions Director, Employee E8, confirmed there was no independent witness present during the signing process and that she was the only individual present. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights.

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure assessments accurately reflected the resident status for one of 22 residents reviewed (Resident R13).Findings Include: Review of Resident R13's clinical record revealed the resident has documented psychotic symptoms, including hallucinations, and was prescribed psychotropic medications (drugs that affect mood, behavior, and cognition), including Risperdal, Trazodone, and Depakote. Review of Resident R13's comprehensive care plan dated June 16, 2025, revealed the resident has a history of expressing feeling down/depressed/hopeless and has a diagnosis of Major Depressive Disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident R13's Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 22, 2026, revealed depression was not checked as a diagnosis. Interview on July 22, 2026, at approximately 1:23 p.m., the Registered Nurse (RN) Assessment Coordinator (RNAC) acknowledged Resident R13 had a history of hallucinations and was receiving psychotropic medications. The RNAC confirmed the MDS did not accurately reflect Resident R13's diagnosis. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of 22 residents reviewed (Resident R13).Findings Include: The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability. A Level I PASRR must be completed for all persons considering admission to a Medicaid-certified nursing facility. A Level II PASRR evaluation must be completed if the Level I PASRR determines that the person is a targeted individual with mental illness or an intellectual disability. The Level II PASRR determines whether placement or continued stay in the requested or current nursing facility is appropriate. Review of Resident R13's Minimum Data Set (MDS - federally mandated resident assessment and care screening) revealed the resident was admitted to the facility on [DATE], and has a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Per the MDS, Resident R13 has a diagnosis of Cognitive Impairment (problems with memory and thinking). Review of Resident R13's clinical record revealed the resident has documented psychotic symptoms, including hallucinations, and was prescribed psychotropic medications (drugs that affect mood, behavior, and cognition), including Risperdal, Trazodone, and Depakote. Review of Resident R13's comprehensive care plan dated June 16, 2025, revealed the resident has a history of expressing feeling down/depressed/hopeless, has a diagnosis of Major Depressive Disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest), and was evaluated by psychiatry on 4/29/2026. Review of Resident R13's PASRR dated June 3, 2025, revealed the assessment did not include Resident R13's documented hallucinations or diagnosis of major depressive disorder. Interview on July 22, 2026, at 2:00 p.m. the social worker confirmed Resident R13's PASRR was not updated with Resident R13's hallucinations or diagnosis of depression. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of resident records and interview with staff it was determined that the facility failed to review and revise a care plan for two of 22 residents reviewed (Resident R66 and R117). Findings include:Review of clinical records revealed Resident R66 was admitted to the facility on [DATE], with diagnoses including, but not limited to, muscle weakness, abnormalities of gait and mobility, and dementia. Review of the resident's most recent MDS (minimum Data Set, a periodic assessment of resident care needs) completed on May 29, 2026, revealed in Section C: Cognitive Patterns, that the resident was unable to complete a BIMS assessment (Brief Interview for Mental Status, an assessment of cognitive abilities), The Staff Assessment of Mental Status revealed that the resident had both short term and long term memory problems, and that their decision making abilities were moderately impaired-decisions poor; cues/supervision required.A review of the resident's care plan revealed a history of falls with fractures, with risk factors for future falls including anti-hypertensive medication use, change in safety awareness, gait dysfunction and.[the resident] self-transfers without using assistive device. Continued review of Resident R66's care plan revealed that it included numerous repeated interventions and/or interventions inappropriate for a resident with the above cognitive deficits. These interventions included, but were not limited to, the following: [the resident] should be reminded frequently to call/wait for assistance to complete tasks/ADLs (Activities of Daily Living). There were 14 variations on educating or reminding the resident of safety measures or to call for assistance, which is ineffective given the resident's cognitive status. These interventions were initiated on dates ranging from June 26, 2021, to September 29, 2025. Aide or nurse monitoring resident for help to get out of bed or use call bell. There were 7 variations on monitoring the resident for safety initiated on dates ranging from March 14, 2024, to March 24, 2026. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. There were 5 variations on encouraging the resident to socialize and/or participate in activities. These interventions were initiated on dates ranging from October 1, 2022, to April 17, 2025. Offer assistance to transfer when [the resident is] seated in the common area, initiated February 14, 2026, and Frequently ask if resident needs assistance while in the common area, initiated July 13, 2026. Removed from situation and made comfortable in bed, initiated September 2022, and resident toilet, assessed for pain and neuro-checks, assist resident from floor, initiated December 21, 2025, are the immediate actions taken following actual falls, and are not appropriate as care planned interventions. Interview with Employee E2, Director of Nursing, on July 24, 2026 at 1:45 p.m. confirmed that reminders and education are not appropriate for a cognitively impaired resident, that immediate actions taken after a fall should not be entered into the care plan, and that numerous repetitions existed in interventions initiated over the course of several years. Director of Nursing, Employee E2, also confirmed that interventions should be appropriate and up to date. Review of Resident R117 clinical record revealed an admission Minimum Data Set (MDS- a federal mandated resident assessment tool) dated May 30, 2026, documented a brief interview for mental status (BIMS) score of three (severe impaired cognition), and a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and moderate impairment and decision making. Review of facility documentation submitted to the State Survey Agency revealed on June 9, 2026, the facility reported allegations of physical abuse against Resident R117's family member. Review of the facility documentation/investigation revealed that on June 9, 2026, Resident R117's family became verbally and physically aggressive towards staff. Resident R117's son became aggressive pushing two nursing assistants out of the way, and while attempting to demonstrate care for Resident R117, the resident fell and hit his/her head against the wall. The facility's investigation substantiated the above incident. Review of Resident R117's comprehensive care plan revealed no documented evidence the care plan was reviewed/revised to include individualized interventions addressing the residents newly identified safety needs, including interventions to protect the resident from further abuse, or staff instructions regarding supervision or monitoring of visits with family member. Findings were discussed via an interview with the Director of Nursing, Employee E2, on July 23, 2026. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to ensure one resident environment was free from accident/hazards for one of 22 residents reviewed (Resident R63). Findings include: Review of facility documentation submitted to the State Survey Agency revealed on November 28, 2025, Resident R63 was seated in his/her reclining wheelchair while a maintenance employee performed repairs to the chair. While performing repairs, the wheelchair unexpectedly reclined backwards causing Resident R63 to hit the side of his/her head against the wall. Resident R63 was subsequently transferred to the emergency room for evaluation. Review of Resident R63's Minimum Data Set (MDS- federally mandated resident assessment and care screening) dated July 28, 2026, revealed the resident was admitted to the facility on [DATE], with diagnosis including traumatic brain injury, deep being thrombosis (blood clot) diabetes, and cerebral vascular accident (stroke). The MDS documented a brief interview for mental status (BIMS) score of nine indicating moderate cognitive impairment. Review of resident R63's comprehensive care plan revealed the resident has multiple safety related risk factors including an above the knee amputation, cognitive impairment with short term memory deficits, dependence on staff for transfers using a Hoyer left, and a risk for falls. Resident R63's care plan directed staff to observe and monitor the resident's environment for fall and trip hazards, ensure the safe use of the resident's wheelchair and other assistive devices, consult physical and occupational therapy as indicated, and utilize adaptive equipment and positioning devices to promote the resident safety. Review of facility documentation revealed a work order dated November 26, 2025, for Resident R63's wheelchair that the anti-tippers (Anti tip device or safety devices attached to the back lower frame of a wheelchair their purpose is to prevent the wheelchair from tipping backwards) are not stable. The work order asked for new anti-tippers be placed or somehow be fixed so they don't move. Review of facility documentation and internal investigation revealed Resident R63 was in his/her wheelchair while Maintenance Director, Employee E9, performed repairs on the wheelchair. While repairs were being performed, the chair suddenly reclined backwards, causing Resident R63 to strike the right side of his/her head against the wall. Resident R63's spouse, who was present in the room at the time of the incident, notified nursing staff. Nursing assessment revealed a skin tear to the resident R63's right forearm with small amount of bleeding. Interview on July 23, 2026, with Maintenance Director, Employee E9, confirmed responding to a work order to fix Resident R63's wheelchair. Maintenance Director, Employee E9, stated the repair involved tightening the anti-tip mechanism located underneath the wheelchair and believed it was a minor adjustment that only required a tightening a nut. Maintenance Director, Employee E9, stated he did not believe it was necessary to remove the resident from the wheelchair while the repair was being performed. Maintenance Director, Employee E9, reported Resident R63 remained seated in the wheelchair, while the Maintenance Director, Employee E9, positioned himself under the chair to complete the repair. During the repair the reclining back of the wheelchair suddenly released, causing Resident R63 to recline backward and strike his/her head against the wall. Interview on July 23, 2026, Maintenance Director, Employee E9, acknowledged that the component of the wheelchair that released was the reclining mechanism, not the anti-tip mechanism that was intended to be repaired, and suspected the recliner had not fully secured or locked into place. Maintenance Director, Employee E9, reported that following this incident, residents will not be seated in equipment while repairs are being made. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident Rights

Based on observation staff interview the facility failed to ensure medications were stored in a secure manner for one of two medication rooms observed (First Floor). Findings include: Review the facility policy titled Medication Labeling and Storage revealed that all medications in biologicals are to be stored in a locked compartment under appropriate temperature humidity and light conditions. Access to medication storage areas is limited to authorized personnel. Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy further requires that medication drawers, cabinets, rooms, refrigerators, and carts containing medications or biologicals remain locked when not in use and that medication trays or carts are not left unattended when open or otherwise accessible to unauthorized individuals. Observation of nursing station on first floor on July 21, 2026, at 11:05 a.m. revealed the medication room door was open and unattended allowing unrestricted access to medications and medication supplies. Interview at the time of observation with licensed nurse, employee E5, confirmed medication room was open and accessible. Licensed nurse, employee E5, acknowledged the medication room should have remained secured when unattended. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, record review, review of facility policy, and staff interview it was determined the facility failed to implement enhanced barrier precautions for one of 22 residents reviewed (Resident R69). Finding include: Review of the facility policy titled Enhanced Barrier Precautions dated August 2022 revealed that enhanced barrier precautions (EBPs) are implemented to reduce the transmission of multidrug resistant organisms (MDROs). The policy requires staff to wear gown and gloves when performing high contact resident care activities, including urinary catheter care. Observation on the first-floor nursing unit on July 21, 2026, at approximately 10:45 am Resident R69 was observed seated in the hallway, in his/her wheelchair, appearing upset. Resident R69 reported waiting for staff assistance with his/her urinary catheter. Further observation on July 21, 2026, at approximately 10:45 am revealed licensed nurse, employee E4, responding to Resident R69's request and escorting the resident into his/her room and closed the door to provide catheter care. Continued observations on July 21, 2026, revealed Licensed nurse, Employee E4, exiting Resident R69's room and removing her gloves. Interview on July 21, 2026, with licensed nurse, Employee E4, confirmed the employee just got done assisting Resident R69 with his/her urinary catheter. When asked what personal protective equipment (PPE) was worn, Licensed Nurse, Employee E4, acknowledged required PPE (such as a gown) was not worn and should have been. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records and review of facility provided documentation, it was determined that facility did not ensure complete documentation related to pressure ulcers treatment for one of three residents reviewed (Resident R1) Findings include:Review of facility policy 'Wound Care,' revised in October 2010, indicates that the following information is to be documented in residents' medical record post wound treatments:1. The type of wound care given2. The date and time the wound care was given3. The position in which the resident was placed4. The name and title of the individual performing wound care5. Any change in the resident's condition6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound7. How the resident tolerated the procedure8. Any problems or complaints made by the resident related to the procedure9. If the resident refused the treatment and the reason(s) why.10. The signature and title of the person recording the data.And notify the supervisor if the resident refuses the wound care.Review of Resident R1's clinical record revealed medical diagnosis of hemiplegia and hemiparesis (paralysis/weakness) affecting left non-dominant side, pressure ulcer of sacral region - stage 4 (ulcer involving loss of skin), Review of Resident R1's clinical record revealed no documentation of wound treatments completed on October 17, 2025, and October 28, 2025, to right buttock and right heel.Further review of Resident R1's clinical record revealed no documentation to wound treatments on October 17, 2025, to sacrum and left ischial.Further review of Resident R1's clinical record revealed no documentation to wound treatments on November 23, 2025, to left ischial, sacrum and right heel.Further review of Resident R1's clinical record revealed no documentation of wound treatments on December 1, 2025 to left ischial, sacrum, right heel and lateral ankle.28 Pa Code 211.12(d)(1)(5) nursing services

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include:Review of facility policy titled, General HACCP Guidelines for Food Safety undated, indicate that all food must be dated and put away promptly. Continued review revealed rapid cooling instructions included, place cooling items on top shelf or refrigerator in 2-inch shallow pans and stir every 15 to 60 minutes. A tour of the Food Service Department was conducted on September 8, 2025, at 10:12 a.m. with Employee E8, Food Service Director (FSD), revealed the following concerns: Five packages of ground beef (10-15 lbs.) were undated and unlabeled; two packages of beef hot dogs (10lbs) were undated and unlabeled; 3 trays of hashbrowns were uncovered and undated; a container of provolone cheese was expired, dated September 9/6; American cheese was expired, dated 9/6; cup up onions expired , dated 9/6; diced potatoes cooling in the fridge for a salad undated, in a 1/3 size and 4 inch depth steel steam table pan. Interview with the FSD throughout the kitchen tour confirmed the above-mentioned findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly. Findings include:On September 8, 2025, at approximately 10:30 a.m. during the receipt of a food delivery, a delivery truck was parked at the facility's receiving dock. Staff were observed walking boxes of food into the kitchen storage areas through the receiving zone. At the same time, the following unsanitary conditions were observed: Three large grey trashcans were uncovered. One trashcan contained trash with a foul odor, with refuse exposed to open air. A foul, white, milky liquid was observed pooling across the receiving area floor. The liquid appeared to be leaking from the trash compactor and had spread into multiple walking and delivery zones used by staff to transport food into the facility. A strong, pervasive odor was present throughout the receiving area, consistent with decomposing waste. Interview with Food Service Director, Employee E8 along duration of the tour confirmed observations of the receiving and dumpster area. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on observations, clinical record reviews and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for two of three residents reviewed (Resident R32 and R60).Findings include:Observation of Medication Administration by Employee E4, Licensed Nurse for Resident R32 on September 9, 2025, at 8:58 a.m. revealed that the nurse prepared and administered the medication in the dining room where 9 other residents and other staff were sitting. Continued observation revealed that the staff administrated the nasal spray after the pills were administered after telling the resident what she was going to administer which was audible across the room.Observation of the Medication Administration by Employee E4, Licensed Nurse for Resident R60 on September 9, 2025, at 9:03 a.m. revealed that the nurse left the medication cart to administer medication for Resident R60 and the computer screen was left open with Resident R60's information including medications visible to anyone passing through the hallway.Further observation of the Medication Administration by Employee E4, Licensed Nurse for Resident R60 on September 9, 2025, at 9:03 a.m. revealed that the nurse prepared and administered the medication in the dining room where 9 other residents and other staff were sitting. Continued observation revealed that the staff administrated the eye drop after the pills were administered which was visible for other staff and residentsInterview with the Director of Nursing on September 10, 2025, at 11:00 a.m. confirmed that the computer screen personal health information should have been covered when the nurse was not attending the medication cart and should provide privacy during medication administration,28 Pa. Code 211.5(b) Clinical Records.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in a language and manner they understand. Findings Include:Review of Resident R122's medical records revealed that on July 3, 2025, Resident R122 was transferred to the hospital for evaluation. Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. On June 20, 2025, Resident R122 was transferred to the hospital for an emergency evaluation. Continued review failed to reveal documentation of a written notification to the resident or resident's representative notifying them of the transfer and the reasons for the move in writing. On July 1, 2025, Resident R8 was transferred to the hospital due to a fall. Interview with the facility administrator conducted on September 11, 2025, at 11:25 a.m. confirmed that the facility failed to provide the resident and resident's representative with a written notification indicating the reason for the transfer in writing. Interview with the Administrator and Director of nursing concocted on September 11, 2025, at approximately 2:00 p.m. confirmed that it is not facility practice to provide the resident and the resident representative with a written notice which specifies the duration of the bed-hold policy; and the reasons for the transfer in writing and in a language and manner they understand. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on the observations, review of professional standards, clinical records and interview with staff, it was determined that the facility failed to administer medications according to professional standards of practice one of three residents reviewed (Resident R32)Findings Include:According National Library of Medicine (Operated by the United States federal government, a biomedical library and a national resource for health professionals, scientists, and the public) five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices.Review of FDA (Food and Drug Administration) guidelines for Tacrolimus (medication for the prophylaxis of organ rejection in de novo kidney transplant patients in combination with other immunosuppressants) extended release tablet revealed instructions to take tacrolimus extended-release tablets once daily with fluid (preferably water) on an empty stomach, at least 1 hour before or at least 2 hours after a meal, at the same time each day (preferably in the morning).Review of clinical record for Resident R32 dated July 5, 2023, revealed an order for Tacrolimus ER Oral Tablet Extended Release 24 Hour 1 MG (Tacrolimus), Give 3 tablet by mouth one time a day for anti-rejection.Observation of the Medication Administration by Employee E4, Licensed Practical Nurse for Resident R32 on September 9, 2025, at 8:58 a.m. revealed that the nurse prepared and administered the medication, Tacrolimus extended-release tablet for Resident R32. At the time of the observation, the resident was eating breakfast.Interview with the Unit Manager, Employee E3, on September 10, 2025, at 12:00 p.m. stated she spoke to the pharmacy, and it was recommended by the family the medication should be taken on an empty stomach. Employee stated the medication time would be changed to the appropriate time.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to maintain complete and accurate inventory record for two of two residents reviewed. (Resident R12, R36)Findings Include:Review of the facility policy titled Living Reporting Grievances, last revised March 27, 2017, revealed that it is designed to ensure that each resident, responsible person, or resident agent has an opportunity to express their concern or grievance and that a system is in place for them to be heard and their concern resolved.Review of the clinical record for Resident R36, who was admitted on [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. Resident R36's wife, Resident R12, who was admitted on [DATE], had a BIMS score of 99, which indicates that the resident was unable to participate in the assessment due to severe cognitive impairment.On September 8, 2025, at 11:34 a.m., an interview was conducted with Resident R36, which revealed that the resident was missing the following clothing items: 7 undershirts, 18 T-shirts, 6 shirt, and 4 dress blouses ($32 each) for my wife, Resident R12. This was in January, and I gave it to them in June to review, but they didn't take any action. Last week, they searched for the shirts but couldn't find them. The girl from the laundry came down to see me today, and they still did not locate any of these clothing items. They offered to reimburse me $300, but these clothes were special to me and cost more than $300.On September 9, 2025, at 1:45 p.m. an interview with the Social Worker, Employee E9 revealed that she first learned about grievance last Friday August 27, 2025, when laundry staff, employee E10 told her about missing clothing. Clothing is being personal laundry is being done in house.On September 10, 2025, at 10:31 a.m., during an interview with the social worker, Employee E9 revealed that the only inventory sheet, dated March 24, 2025, did not list any clothing. Administration needs to review and determine the system error that resulted in the lack of documentation. Employee E9 was asked to provide his wife's inventory sheet, as he claimed that four blouses were missing. No inventory sheet was provided during the survey.The process for a resident upon admission is as follows: per the admission package, there is a $25 labeling fee. Clothing is labeled using the machine in the laundry room, ironed with the labels, and then returned to the resident. Families are instructed to place clothing in a bag and give it to nursing staff, who take it to the laundry for labeling and complete an inventory sheet, which is then placed in the resident's clinical file.On September 10, 2025, at 11:45 a.m., Lead Housekeeping Aide, Employee E10, was interviewed and reported that she first learned about the missing clothing for Residents R36 and R12 last week and could not locate any of their clothing items. It was confirmed that nursing staff are responsible for completing inventory sheets.On September 11, 2025, at 2:34 p.m., an interview with the Administrator, Employee E2, and Director of Nursing, Employee E1, confirmed that inventory sheets had not been completed for any of Resident R36 and R12's clothing. It is the responsibility of nursing staff to complete the inventory sheet when family brings in personal belongings. The facility agreed to reimburse Residents R36 and R12 a total of $500 for all of their missing items.28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on a review of facility policies, clinical records, incident/accident documents, staff training records as well as staff and resident interviews, it was determined the facility failed to ensure Resident R1 was free of neglect by failing to have sufficient staff during a mechanical lift transfer. This failure resulted in actual harm for Resident R1 who fell, sustaining multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital for one of five residents reviewed. (Resident R1). Findings include: Review of undated facility document, Use of a mechanical lifting machine revealed All C.N.As (Certified Nurse Aides) must read residents Kardex and get report from charge nurse prior to giving care to the residents. The Kardex will show level of care for residents, any special equipment and behavior issues. General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning. Make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Inspect sling for any damage or deterioration. If sling is damage do NOT use. Discard any worn, frayed or ripped slings. Review of Resident R1's clinical record revealed diagnoses of Morbid (severe) Obesity, Dementia (progressive degenerative disease of the brain) and muscle weakness. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated January 28, 2025, revealed Resident R1 had a BIMS (Brief interview of Mental Status) of 9 which indicated the resident's cognitive status was moderately impaired. Continued review of the MDS assessment revealed the resident was dependent for bed mobility and was dependent on staff for transfers to and from bed to chair. MDS assessment also revealed, dependent status coding indicates Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's care plan dated June 11, 2024, revealed Resident R1 required extensive assistance of two staff with transfers via stand-up lift. Review of physician order for Resident R1 dated June 11, 2024, revealed an order for extensive assistance of two staff with transfers via stand-up lift. Review of facility investigation dated April 23, 2025, revealed Resident R1 had a fall while he/she was being transferred from the wheelchair to the bed, charge nurse found the resident lying on the floor in a supine position with hands on (his/her) sides and legs stretched out. Nurse Aide, Employee E3, reported the resident fell because the sling on the pad broke off. Additional review of facility investigation revealed the resident was found to have skin tear on the left elbow down toward the forearm measuring 14.5 x 4 (did not include a unit of measurement), and right foot 4th toe measuring 2 x 1 (did not include a unit of measurement) and there was fresh blood, steri strip applied on the left elbow, banded and wrapped with kerlix (type of gauze bandage). Continued review of the facility investigation revealed resident's event description as follows: I hold on to it, but I slide and fell. Review of Resident R1's progress note dated April 24, 2025, revealed that the Nurse Aide, Employee E3 reported the resident fell because the sling on the pad broke. Review of post fall investigation record for Resident R1 dated April 23, 2025, revealed the incident occurred during resident care and the resident fell while attempting to transfer from wheelchair to bed. Additional review of same document revealed action taken was staff would be able to complete all transfers with a stand-up lift and extensive assist of two staff member. Review of a employee corrective action form for Nurse Aide, Employee E3 dated April 23, 2025, revealed on April 23, 2025, employee used a stand-up lift with Resident R1 by himself. It was mandatory to have at least 2 people to use any lift. The sling broke during transfer. This resulted in a failed transfer and fall. The resident was hospitalized because of the fall. This is possible neglect and/or abuse of a resident. This is also a failure to follow resident's care plan, policy for mechanical lifts, and standard of nursing practice. Review of Resident R1's nursing note dated April 24, 2025, revealed on April 24, 2025, at approximately 1: 30 p.m. resident complained of headache, neuro check at (his/her) baseline however bruising under right eye and at the back of head present. Physician assessed the resident and gave an order to send resident to emergency room for fall evaluation. Review of facility investigation documentation failed to reveal evidence a second staff member present during the mechanical lift transfer of Resident R1 on April 23, 2025 as per the facility policy, resident care plan, and physician order. Continued review of the facility investigation documentation and clinical record failed to reveal evidence the sling used for the resident transfer was examined by the facility staff and verified the sling was defective or broken prior to or after the incident. Interview with Nurse Aide, Employee E4 on April 29, 2025, at 1:00 p.m. revealed she examined the sling that was used during the transfer of Resident R1 on April 23, 2025, which resulted in fall of the resident the next day. Nurse Aide, Employee E3 revealed the pad was not broke or defective. Observation of Resident R1 skin conducted on April 29, 2025, at 1:10 p.m. with Employee E5, Licensed Practical Nurse revealed Resident R1 had skin damage sustained during the fall, to the left upper extremity from left knuckles to left elbow. Resident had a skin tear wound measuring 6.5 centimeter (cm) x 5.5 cm x 0.1 cm to the left hand, with active bleeding from the wound and the dressing was sticking to the wound. Resident had a skin tear wound measuring 1.5 cm x 1cm to the left forearm hand. There was another skin tear wound right below the above-mentioned area to the left forearm measuring 2.4 c.m. x 1.5 c.m. Resident had a skin tear wound measured 2.4 cm x 1.5 c.m. to the wrist area. There was a scabbed area above the elbow measuring all together 6.5 c.m. x 5.5 c.m. Interview with Resident R1 on April 29, 2025, revealed Resident R1 experienced severe pain of the left arm which (he/she) revealed was a result of the fall a week prior. Resident R1 indicated (his/her) pain level at the time of the interview was 8 on a scale of 10. Resident R1 revealed the worst pain (he/she) experienced to the area was 10 on a scale of 10. Interview with the Employee E2, Director of Nursing, on April 24, 2025, at 1:30 p.m. revealed Nurse Aide, Employee E3, used the mechanical lift to transfer Resident R1 by himself without other staff assistance which resulted in an injury to Resident R1 when the resident fell out of the mechanical lift. Director of Nursing, Employee E2 indicated there was no issues with the mechanical lift sling after it was inspected by the staff. Director of Nursing, Employee E2 confirmed facility policy required two staff for all lift transfers. Employee E2 confirmed the injury was sustained when Employee E3 independently transferred Resident R1 using the mechanical lift. The facility failed to ensure Resident R1 was free of neglect by ensuring facility staff followed safety protocols of having two staff during a mechanical lift transfer. This failure resulted in actual harm to Resident R1 who sustained multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of facility policies, clinical records, incident/accident documents, staff training records as well as staff and resident interviews, it was determined the facility failed to ensure resident's environment remained free of accident hazards and failed to ensure safe transfer techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital for one of five residents reviewed. (Resident R1) Findings include: Review of undated facility document Use of a mechanical lifting machine, revealed All C.N.As (Certified Nurse Aides) must read residents Kardex and get report from charge nurse prior to giving care to the residents. The Kardex will show level of care for residents, any special equipment and behavior issues. General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning. Make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Inspect sling for any damage or deterioration. If sling is damage do NOT use. Discard any worn, frayed or ripped slings. Review of Resident R1's clinical record revealed diagnoses of Morbid (severe) Obesity, Dementia (progressive degenerative disease of the brain) and muscle weakness. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated January 28, 2025, revealed Resident R1 had a BIMS (Brief interview of Mental Status) of 9 which indicated the resident's cognitive status was moderately impaired. Continued review of the MDS assessment revealed the resident was dependent for bed mobility and was dependent on staff for transfers to and from bed to chair. MDS assessment also revealed, dependent status coding indicates Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R1's care plan dated June 11, 2024, revealed Resident R1 required extensive assistance of two staff with transfers via stand-up lift. Review of physician order for Resident R1 dated June 11, 2024, revealed an order for extensive assistance of two staff with transfers via stand-up lift. Review of facility investigation dated April 23, 2025, revealed Resident R1 had a fall while he/she was being transferred from the wheelchair to the bed, charge nurse found the resident lying on the floor in a supine position with hands on (his/her) sides and legs stretched out. Nurse Aide, Employee E3, reported the resident fell because the sling on the pad broke off. Additional review of facility investigation revealed the resident was found to have skin tear on the left elbow down toward the forearm measuring 14.5 x 4 (did not include a unit of measurement), and right foot 4th toe measuring 2 x 1 (did not include a unit of measurement) and there was fresh blood, steri strip applied on the left elbow, banded and wrapped with kerlix (type of gauze bandage). Continued review of the facility investigation revealed resident's event description as follows: I hold on to it, but I slide and fell. Review of Resident R1's progress note dated April 24, 2025, revealed that the Nurse Aide, Employee E3 reported that the resident fell because the sling on the pad broke off. Review of post fall investigation record for Resident R1 dated April 23, 2025, revealed the incident occurred during resident care and the resident fell while attempting to transfer from wheelchair to bed. Additional review of same document revealed action taken was staff would be able to complete all transfers with a stand-up lift and extensive assist of two staff member. Review of a employee corrective action form for Nurse Aide, Employee E3 dated April 23, 2025, revealed on April 23, 2025, employee used a stand-up lift with Resident R1 by himself. It was mandatory to have at least 2 people to use any lift. The sling broke during transfer. This resulted in a failed transfer and fall. The resident was hospitalized because of this fall. Review of nursing note dated April 24, 2025, revealed on April 24, 2025, at approximately 1: 30 p.m. resident complained of headache, neuro check as (his/her) baseline however bruising under right eye and at the back of head present. Physician assessed the resident and gave an order to send resident to emergency room for fall evaluation. Review of facility investigation documentation failed to reveal evidence a second staff member was present during the mechanical lift transfer of Resident R1 on April 23, 2025 as per the facility policy, resident care plan, and physician order. Continued review of the facility investigation documentation and clinical records failed to reveal evidence the sling used for the resident transfer was examined by the facility and verified that the sling was defective or broken prior or after the incident. Interview with Nurse Aide, Employee E4 on April 29, 2025, at 1:00 p.m. revealed she examined the sling that was used for the transfer of Resident R1 on April 23, 2025, and resulted in the resident fall the next day. Nurse Aide, Employee E3 revealed the pad was not broke or defective. Observation of Resident R1 skin was conducted on April 29, 2025, at 1:10 p.m. with Employee E5, Licensed Practical Nurse revealed the resident had skin damage sustained during the fall on April 23, 2025, to the left upper extremity from left knuckles to left elbow. Resident had a skin tear wound measured 6.5 centimeter (cm) x 5.5 cm x 0.1 cm to the left hand, there was active bleeding from the wound and the dressing was sticking to the wound. Resident had a skin tear wound measured 1.5 cm x 1cm to the left forearm hand. There was another skin tear wound right below the above-mentioned area to the left forearm measured 2.4 c.m. x 1.5 c.m. Resident had a skin tear wound measured 2.4 cm x 1.5 c.m. to the wrist area. There was a scabbed area above the elbow measured all together 6.5 c.m. x 5.5 c.m. Interview with Resident R1 on April 29, 2025, revealed Resident R1 experienced severe pain on the left arm which (he/she) revealed was a result of a fall at the facility a week prior. Resident R1 indicated (his/her) pain level at the time of the interview was 8 on a scale of 10. Resident R1 revealed the worst pain (he/she) experienced to the area was 10 on a scale of 10. Interview with the Employee E2, Director of Nursing, on April 24, 2025, at 1:30 p.m. revealed Nurse Aide, Employee E3, used the mechanical lift to transfer Resident R1 by himself without other staff assistance which resulted in injury to Resident R1 when the resident fell out of the mechanical lift. Director of Nursing, Employee E2 indicated there was no issues with the mechanical lift sling after it was inspected by the staff. Director of Nursing, Employee E2 confirmed facility policy required two staff for all Hoyer lift transfers. Employee E2 confirmed the injury was sustained when Employee E3 independently transferred Resident R1 using the mechanical lift. The facility failed to ensure resident's environment remained free of accident hazards and failed to ensure safe transfer techniques were used during a transfer via mechanical lift. This failure resulted in actual harm for Resident R1 who sustained multiple skin damage to the left forearm, experienced severe pain, and bruising to the head and face and required transfer to the hospital 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on the review of facility documentation, review of personnel files and interview with staff, it was determined that the facility failed to complete performance review of every nurse aide at least once every 12 months for one of one staff educational records reviewed. (Employee E3). Finding include: Review of facility investigation dated April 23, 2025, revealed Resident R1 had a fall while he/she was being transferred from the wheelchair to the bed, charge nurse found the resident lying on the floor in a supine position with hands on (his/her) sides and legs stretched out. Nurse Aide, Employee E3, reported the resident fell because the sling on the pad broke off. Interview with the Employee E2, Director of Nursing, on April 24, 2025, at 1:30 p.m. revealed Nurse Aide, Employee E3, used the mechanical lift to transfer Resident R1 by himself without other staff assistance which resulted in injury to Resident R1 when the resident fell out of the mechanical lift. Director of Nursing, Employee E2 indicated there was no issues with the mechanical lift sling after it was inspected by the staff. Director of Nursing, Employee E2 confirmed facility policy required two staff for all Hoyer lift transfers. Employee E2 confirmed the injury was sustained when Nurse Aide, Employee E3 independently transferring Resident R1 using the mechanical lift. A request was made to the facility Nursing Home Administrator for Employee E8's annual training records on April 16, 2023, at 12:00 p.m. Review of Nurse Aide, Employee E3's personnel files revealed no documented evidence that Nurse aide, Employee E3, had a performance evaluation completed for the year 2024 and 2025. Interview with the Director of Nursing on April 29, 2024, at 1:30 p.m. confirmed that the facility did not have process of completing performance evaluation of the employees and did not have performance evaluation of Nurse Aide, Employee E3. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. 211.12(c) Nursing services

Based on staff interviews, review of facility policy and review of clinical records, it was determined that the facility failed to re-admit a resident back into the facility after a change in condition for 1 out of 5 residents reviewed (Resident R1). Findings include: Review of the facility policy, Transfer or Discharge, Facility-Initiated, with a revision dated of October 2022, indicated that if the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include, but not limited to: the specific resident needs that cannot be met; the facility's attempt to meet those needs; the receiving facility's service(s) that are available to meet those needs, and that an appropriate notice was provided to the resident and/or legal representative from the facility. Review of the March 2024 physician orders for Resident R1 included the following diagnoses: morbid obesity; transient cerebral ischemic attack (a brief stroke-like attack); hypertension (high blood pressure); cognitive communication deficits; diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and a urinary tract infection. Resident was also being treated at the facility for anxiety (intense, excessive and persistent worry and fear about everyday situations); visual hallucinations (seeing people, places and things that do not exist), and disorientation. Review of multidisciplinary notes from January 14, 2024 through March 3, 2025 documented various behaviors that included, but were not limited to, kicking staff, scratching staff, yelling, screaming uncontrollably and unprovoked. Refusing meals and having a poor appetite, refusing medications, punching staff, hitting other residents; Resident noted with increased anxiety, trying to climb out of bed, taking his diaper and clothes off, and biting staff. Review of nursing note dated March 3, 2025 at 7:13 p.m. described the resident as being very aggressive, trying to hit other residents in the common area, trying to get out of wheelchair, and making loud noises. The note indicated that staff tried to redirect him, and offered snacks, but the resident did not calm down. The nursing note indicated that physician was contacted and advised the facility to send the resident out to the hospital. Review of a nursing note dated March 3, 2025 at 9:15 p.m. indicated that the resident when the transferred out to the hospital, was very combative and tried to bite the attendants who arrived to take him to the hospital. Review of a nursing note dated March 3, 2025 at 4:13 a.m. indicated that the nurse spoke to the nurse at the hospital and was informed that the resident was admitted with Acute kidney injury. Review of hospital records dated March 3, 2025 indicated that labs were performed on the resident and that he was being treated for a urinary track infection. Information provided by the hospital and reported to the State Survey Agency on March 14, 2025 indicated that the facility refused to accept the resident back after the facility reported to the hospital that the resident could not be admitted back to the facility if he was still required the use of Haldol (a medication that he was treated with during a a portion of his stay in the hospital) and if he still required the use of physical restraints. The hospital reported that upon the hospital's attempt to discharge the resident back to the facility on March 12, 2025, the resident no longer required the use of Haldol and had been off physical restraints for more that 60 hours prior to March 12, 2025. Review of hospital records written by the hospital social worker on March 12, 2025 at 11:07 a.m. documented that the patient had been off restraints for over 48 hours and that the hospital social worker arranged transportation for the resident to return to the facility at 1:00 pm. on March 12, 2025. The hospital social worker's note also indicated that she notified the facility regarding the resident's return. SW made pt team & facility aware. Review of a hospital note written by the hospital social worker on March 12, 2025 at 1:23 p.m., documented that she was notified by the facility's admission director (Employee E4) that the facility Nursing Home Administrator (NHA) was not happy that the resident was coming back to the facility on the above referenced date due to the resident being on restraints and being treated with the medication, Haldol. Continued review of the hospital social worker's documentation indicated that the social worker informed the facility admission director that the information was untrue and asked the facility's admission director to review the chart again and to inform the hospital social worker of where it stated that the resident is currently being administered Haldol, and on physical restraints. The hospital social worker reported that the facility admission's director informed her that if the resident is returned to the facility, the facility will send him back to the hospital. Continued review of hospital documentation on March 12, 2025, at 1:23 p.m. indicated that the facility admission's director contacted the hospital social worker and reported that the facility's Director of Nursing (DON) did not think the resident was stable because the hospital did not have 3 nursing notes a day stating the resident was stable. The hospital social worker documented in her progress note that that the facility's admission director stated, that's not good enough when the hospital social worker informed the facility admission director that the resident was medically stable. Review of a hospital's physician note dated March 13, 2025 at 8:31 a.m. documented, Pt was medically stable for discharge for several days prior to DC Was off restraints >60 hours at time of discharge. The physician's continued documentation stated, the director of nursing refused to re-admit the resident due to inadequate documentation of lack of restraints. Review of the clinical record did not show evidence of any documentation, as required from March 3, 2025 through March 12, 2025 indicating that the facility was not able to meet the resident's needs or and what the needs were, if they were unable to meet them. Continued review of the resident's clinical record at the facility did not show evidence of documentation from the facility indicating that the facility collaborated with the hospital related to the facility not be able to meet his needs. During an interview with the Director of Nursing (DON) on March 27, 2025 at 4:34 p.m. the DON confirmed that she notified nursing staff to send the resident back to the hospital when the hospital transported the resident back to the facility on March 12, 2025. The DON reported during the above-referenced interview that she had hospital records for the resident(e.g. physician notes, social worker notes, other multi-disciplinary notes, etc), but that she wanted to see the hospital nursing notes and reported that she did not have access to the nursing notes. During an interview with the NHA and the DON on April 7, 2025, at 2:15 p.m. it was discussed that the facility did not allow the resident to be re-admitted to the facility and had no documentation, as required to show that they collaborated with the hospital during the time that they resident was admitted prior to making the decision that he could not return to the facility. 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18 (b) (2) Management 28 Pa. Code 201.24(b) Admission 28. Pa Code 201.29(a) Resident rights 28 Pa Code 201.29 (f) Resident rights 28 Pa Code 201.29 (g) Resident rights 28 Pa Code 201.29 (j) Resident rights 28 Pa Code 201.25 (a) Discharge policy

Based on staff interviews and the review of clinical records, it as determined that the facility failed develop a person-centered plan of care for behaviors and refusal of medications for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the March 2024 physician orders for Resident R1 included the diagnoses of morbid obesity; transient cerebral ischemic attack (a brief stroke-like attack); hypertension (high blood pressure); cognitive communication deficits; diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and a urinary tract infection. Resident was also being treated at the facility for anxiety (intense, excessive and persistent worry and fear about everyday situations); visual hallucinations (seeing people, places and things that do not exist), and disorientation. Review of multidisciplinary notes from January 14, 2025 through March 3, 2025 documented various behaviors that included, kicking staff, scratching staff, yelling, screaming uncontrollably and unprovoked. Refusing meals and having a poor appetite, refusing medications, punching staff, hitting other residents; Resident noted with increased anxiety, trying to climbing out of bed, taking his diaper and clothes off, and biting staff. Review of nursing notes date January 25, 2025 at 10:41 p.m. revealed that at 10:41 a.m the resident was anxious, making loud noises and shouted at staff. Nursing note dated January 27, 2025 at 10:15 p.m. revealed that the resident was confused and lethargic, and was sent out to the hospital at 10:15 p.m. Continued review of nursing notes dated January 28, 2025 p.m. at 4:44 a.m. revealed that the resident returned to the facility at 4:24 a.m. with no new orders. Nursing note dated 1/30/2025 at 12:18 a.m. the resident was in the hallway yelling that he wanted to go home. On the same date at 12:36 a.m. the resident was still yelling, was anxious, and refused to go to bed. At 4:51 a.m. the administration of the resident's prn (as needed) medication used to help manage his anxiety was ineffective and nursing staff contact the resident's wife to assist with calming him down. Nursing note dated 2/1/2025 at 2:33 p.m. the resident refused all oral medications. Nursing note dated 2/7/2025 at 2:47 a.m. the resident was anxious, unable to sit in the chair, would not to stay in bed and when he was in bed he was climbing out of bed and when nursing staff put him in his chair he want to go back to bed. Very difficult to redirect. At 6:42 a.m. Resident continues on 1 hour checks due to multiple behaviors. Resident was noted as yelling out and screaming. Nursing note dated 2/8/2025 at 12:45 a.m. - Resident noted with increased anxiety, Restlessness, climbing out of bed, staff talk and listen, toileting done. Staff members assisted him in to the w/c (wheelchair) and brought him out to the common area with staff supervision. Nursing note dated 2/13/2025 at 2:36 p.m. - Resident had random outbursts of yelling and was hard to redirect at this time. At 4:52 a.m. Resident noted with behavior and had to be redirected Resident constantly tries to get up and move. He could not settle in bed to sleep. Staff brought him to the common area sat with him offered snacks Staff. Resident continues to scream uncontrollably and unprovoked. Nursing note dated 3/3/2025 at 5:10 a.m. the resident was combative during care scratch staff. At 4:46 p.m. the resident was calling out and trying to get out of wheelchair. The resident wanted to go home and was making loud noises. At 7:13 p.m. the resident was described as being very aggressive, trying to hit other residents in the common area, trying to get out of wheelchair, and making loud noises. The note indicated that the staff tried to redirect him, and offered snacks, but the resident did not calm down. The physician was contacted and advised the facility to send the resident out to the hospital. Review of the resident's person-centered plan of did not include a plan of care for the management of the resident's behaviors to ensure appropriate care and interventions are utilized to prevent behaviors from occurring and/or the management behaviors. During an interview with the Unit Manager (Employee E3) on March 27, 2025 at 3:25 p.m. the Unit Manager confirmed that there was no person-centered plan of care to address and management the resident's behaviors. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews and the review of clinical records, it was determined that the facility failed to ensure that physician orders were followed and recommendations were addressed regarding obtaining labs to ensure appropriate care and services could be provided for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of a physician's note dated January 14, 2025 at 9:41 p.m. indicated that the resident was admitted to the facility on [DATE] from a local hospital after being brought to the hospital by his wife after exhibiting signs of increased confusion at home. The resident was subsequently diagnosed with acute encephalopathy (damage or disease that affects the brain that lead to an altered mental status) and a urinary tract infection. The resident was transferred to the facility for rehabilitation services once discharged from the hospital. Review of the March 2024 physician orders for Resident R1 included the following diagnoses: morbid obesity; transient cerebral ischemic attack (a brief stroke-like attack); hypertension (high blood pressure); cognitive communication deficits; diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and a urinary tract infection. Resident was also being treated at the facility for anxiety (intense, excessive and persistent worry and fear about everyday situations); visual hallucinations (seeing people, places and things that do not exist), and disorientation. Review of multidisciplinary notes from January 14, 2025 through March 3, 2025 documented various behaviors that included, kicking staff, scratching staff, yelling, screaming uncontrollably and unprovoked. Refusing meals and having a poor appetite, refusing medications, punching staff, hitting other residents; Resident noted with increased anxiety, trying to climbing out of bed, taking his diaper and clothes off, and biting staff. During an visit with the psychiatric nurse practioner on January 24, 2025 at 4:06 p.m. the nurse practitioner reported that she was seeing the resident due to facility concerns with his behavior. The nurse practitioner indicated in her assessment that the resident had a history of UTI with delirium and presented to her with reports of visual hallucinations, agitation, anxiety, and restlessness. Recommendations made by the nurse practitioner included the facility obtaining labs on the resident for further assessment of the resident. Collect U/A, CBC. CMP, to rule out infectious or metabolic cause of patient's mental status. Review of nursing notes from January 24, 2025, through January 31, 2025 indicated that resident's behavior continued and included but was not limited to the following: 1/25/2025 at 10:41 p.m. nursing note indicated that at 10:41 a.m indicated that the resident was anxious, making loud noises and shouted at staff 1/27/2025 at 10: 15 p.m. the resident was noted with confused and was lethargic, and was sent out to the hospital at 10:15 p.m. and per a nursing note dated returned on 1/28/2025 p.m. at 4:44 a.m. the resident returned to the facility at 4:24 a.m. with no new orders. 1/30/2025 at 12:18 a.m. the resident was in the hallway yelling that he wanted to go home. 1/30/2025 at 12:36 a.m. the resident was still yelling, was anxious, and refused to go to bed. 1/30at 4:51 a.m. - the administration of the resident's prn (as needed) medication used to help manage his anxiety was ineffective and nursing staff contact the resident's wife to assist with calming him down. Review of the nurse practitioner's note on January 31, 2025 at 1:30 p.m. after her visit with the resident, the nurse practitioner documented documented that the urine analysis lab work that she recommended during her January 24, 2025 visit had not been done. U/A not collected per previous recommendation- can reconsider to rule out that this is not a delirium related to an unresolved UTI. The nurse practitioner's recommendation for the January 31, 2025 visit included completing a urine analysis on the resident. Reconsider collecting U/A. Review of a note dated February 14, 2025 at 9:43 p.m. by the psychiatric nurse practitioner who visited with the resident indicated that the ressidents assessment remains unchanged from her last visit (January 31, 2025) The nurse practitioner also asked the facility to reconsider obtain a urine analysis on the resident. Reconsider collecting U/A to rule out all possible causes of patient's current mental status. Review of nursing notes from February 14, 2025, through March 3, 2025 when resident was discharged to the hospital, indicated that the resident's behaviors continued as follows: 3/3/2025 at 5:10 a.m. the resident was combative during care scratch staff. 3/3/2025 at 4:46 p.m. the resident was calling out and trying to get out of wheelchair. The resident wanted to go home and was making loud noises. 3/3/2025 at 7:13 p.m. the resident was described as being very aggressive, trying to hit other residents in the common area, trying to get out of wheelchair, and making loud noises. The note indicated that the staff tried to redirect him, and offered snacks, but the resident did not calm down. The physician was contacted and advised the facility to send the resident out to the hospital. 3/3/2026 at 9: 15 p.m. the resident was transferred out to the hospital, was very combative and tried to bite the attendants who arrived to take him to the hospital. 3/4/2025 at 4:13 a.m. a follow up call to the spoke ER nurse indicated that the resident was admitted with Acute kidney injury. Review of hospital records dated 3/3/4 indicated that labs were performed on the resident and that he was being treated for a urinary [NAME] infection. Review of the January 2025 physician's order dated January 21, 2025 included a physician's order for the resident to have urine analysis/culture and sensitivity related to symptoms of a urinary [NAME] infections. u/a C&S dx uti symptoms. 1/21/25. Continued review of the clinical record did not show evidence that this was completed, as ordered. Review of the resident's clinical record did not show evidence that the facility addressed the nurse practitioner's recommendations of obtaining the above referenced labs on the resident when she visited on January24, 2025, January 31, 2025 and February 14, 2025. During an interview on March 27, 2025 at 2:53 p.m. with the Unit Manager it was confirmed that the urine analysis that was ordered on January 21, 2025 by the physician was not completed. It was also confirmed that the urine analysis that was recommended by the nurse practitioner on January 24, 2025, January 31, 2025 and February 14, 2025 were not addressed by the facility. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on interviews, review of clinical records and facility documentation and review of facility's policy, it was determined that the facility failed to assess and monitor Resident R85 for skin integrity related to the use of a security device which resulted in actual harm to Resident R85, who developed a deep tissue injury on the left lateral ankle for one of 19 residents reviewed (Resident R85) Findings include: Review of facility policy titled Pressure Ulcer Prevention dated January 1, 2009, revealed that the purpose was to heal or prevent further pressure ulcers. General Guidelines for Assessment may include but are not limited to: skin at risk and general condition of skin. Review of Resident R85's clinical record revealed the diagnoses of epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS- assessment of resident's care) dated February 10, 2022, indicated that the resident had short and long term memory impairments. Further review of the MDS revealed that the resident required extensive assistance of two people for bed mobility and dressing and total dependence of two people for transfer and bathing. The resident was assessed with no upper and lower extremities limitation of range of motion and at risk for the development of pressure ulcers. Review of Resident R85's care plan initiated October 7, 2021 revealed that the resident was at risk for skin breakdown due to bowel and bladder incontinence, and impaired physical mobility. Interventions included not to massage over bony prominence's and use mild cleansers for peri care/washing. Educate resident, family and care givers as to causes of skin breakdown, observed resident's skin areas when activities of daily living care were given. Report any redness or skin breakdown to nurse. Perform weekly skin checks noting any areas of redness or breaks in skin integrity. Follow skin protocol and follow up with physician as needed. Review of Resident R85's May 2022 physician orders revealed an order with a start date of October 12, 2021, and monthly thereafter, for the resident to have a Wanderguard placed on her left ankle, and for staff to check placement of the Wanderguard (a device placed on a resident's wrist or ankle that help protect residents against elopement) on all three nursing shifts. Continued review of physician's orders revealed an order for skin assessments weekly and document findings under skin note. Review of a nursing notes dated May 30, 2022, at 11:35 p.m. stated that the resident was noted with a deep tissue injury (DTI) on her left outer ankle. The nursing note stated that the DTI was found on the ankle that the resident's Wanderguard was placed on. The resident's Wanderguard was then removed. Review of the wound care physician progress note dated June 3, 2022, stated that Resident R85 was seen on the above referenced date for the evaluation of the resident's left ankle described as an acute partial thickness trauma wound. The initial measurements were 1.3 centimeter length 0.9 centimeter width with no measurable depth, with an area of 1.7 square centimeter. A treatment order was to cleanse the wound with Normal Saline, apply Skin Prep and leave open to air twice a day and as needed. Review of Resident R85's nursing documentation from October 12, 2021, through May 30, 2022, revealed no documented evidence that Resident 85's left ankle where the Wanderguard device was placed was assessed for skin integrity, skin tone and temperature, in order to ensure that the skin area underneath the device did not become compromised. During an interview with Licensed nurse, Employee E14 on March 3, 2023, at 10:56 a.m. regarding documentation related to the monitoring of the skin integrity under Resident R85's Wanderguard, Employee E14 reported that skin checks for residents with Wanderguard should be every shift and that this information would be in an order from the physician. On March 3, 2023, at 11:21 a.m. it was confirmed with Licensed nurse, Employee E14 that documentation related to the monitoring of the resident's left ankle for skin integrity could not be produced. During interview with Director of Nursing on March 43, 2023, at 11:45 a.m. it was reported that the resident was putting pressure on the leg were the Wanderguard was on while the resident was lying in bed. The facility failed to assessed and monitor Resident R85's skin integrity after placing a security device on the resident's ankle which resulted in actual harm to Resident R85 developing a deep tissue injury on the left lateral ankle. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 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 policies, review of facility documentation, and interviews with staff, it was determined that the facility failed to create a safe environment with proper supervision and failed to ensure that food was served at a safe temperature to prevent resident injury (Resident R1). This failure resulted in actual harm to Resident R1 who spilled cream of wheat on her right thigh which resulted in skin [CONDITION(S)] to include blistering. Findings include: Review of the July 2022 physician orders for Resident R1 revealed diagnoses that included: hypertension (high blood pressure), depression (persistent feelings of sadness), [CONDITION(S)] (a condition in which your [CONDITION(S)] doesn't produce enough of certain hormones), and muscle weakness. Review of the resident's interdisciplinary notes indicated that the resident was admitted to the facility on [DATE], and was discharged to another facility on July 22, 2022. Review of Resident R1's clinical record revealed a care plan note dated May 3, 2022, which revealed: Resident is receiving extensive assistance in bed mobility and transfers. Ambulates with RW (rolling walker) with extensive assistance. Feeds self with supervision. OOB (out of bed) to w/c (wheelchair) and wheel self. Extensive assistance in dressing, toilet use and personal hygiene. Review of a facility incident that occurred on July 16, 2022, revealed that Resident R1 was served cream of wheat for breakfast by a dietary staff member, Employee E3, in a dining room on the second floor. At the time the resident had a coloring book on the dining room table and went to move the book and spilled the bowl of cream of wheat on her right thigh and the palm of her right-hand palm area. Review of a nursing note dated July 16, 2022, with a time stamp of 8:00 a.m. indicated that both referenced areas were observed with slight redness with the redness to the right upper thigh measuring 12x3 centimeters in size, and the redness to the right palm measuring 4x3 centimeters in size. Review of an interdisciplinary note documented by Employee E4, Licensed Nurse, on July 16, 2022, with a time stamp of 8:00 a.m. revealed the physician was notified with no new orders, and for nursing to continue to monitor. Review of a nursing note written by Employee E4, Licensed Nurse, on July 16, 2022, with a timestamp of 4:25 p.m. Employee E4 documented that a skin blister was found on Resident R1's right upper thigh. The physician was notified, and a physician's order for normal saline solution (a medical used for wound cleansing) and triple antibiotic ointment (a medication used to treat minor skin infections) to be applied every evening: Right thigh (hot cereal spilled area) cleanse with NSS (normal saline solution), pat dry apply TAO (Triple-antibiotic ointment) and dry dressing until resolved every evening shift. Review of facility policy Food Safety: Preventing [CONDITION(S)], the policy stated that hot food and beverages will be served at a safe temperature that prevents [CONDITION(S)]. The policy also stated that hot beverages will be served at 160 degrees to 185 degrees, the optimum temperature for patient satisfaction. During an interview with the General Manager of Dining Services, Employee E5, on August 5, 2022, at approximately 12:53 p.m. it was explained that hot beverages also included soups and hot cereal. Continued review of the policy indicated that hot foods at the facility will be 165 degrees to 180 degrees when removed from the cooking heat source, and to assure a high enough holding temperature to maintain a temperature at or above 135 degrees during holding, distribution and service. Continued review of the investigation regarding the second degree burn that Resident R1 sustained indicated that the cream of wheat was served to the resident at 166-degrees Fahrenheit. The facility failed to create a safe environment and failed to serve foods and liquids at safe temperatures where hot cream of wheat cereal was served at a temperature of 166-degrees Fahrenheit and the resident had access to coloring books, where the resident moved the coloring books and spilled the hot cream of wheat cereal on herself which harmed the resident by causing redness to the right upper thigh measuring 12x3 centimeters in size, and the redness to the right palm measuring 4x3 centimeters in size, which eventually caused a skin blister on Resident R1's right upper thigh. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa.Code 211.12(d)(5) Nursing services

Based on review of clinical record, facility documentation, and staff interview, it was determined the facility failed to timely identify and increase interventions to prevent the development of a pressure ulcer for Resident R68 who was identified as a low risk for skin breakdown and with an increase in incontinence, resulting in actual harm to Resident R68 developing a sacral Stage III pressure ulcer for one of 47 clinical records reviewed. (Resident R68) Findings include: Review of Resident R68's February 2020 physician's orders [REDACTED]. Review of facility documentation, titled, Braden Scale for Predicting Pressure Sore Risk, dated April 29, 2019, indicated, Resident R68, was identified as a low risk for developing a pressure ulcer. Review of Resident R68's Bowel and Bladder Assessment, dated April 29, 2019, revealed that the resident was frequently incontinent of bowel and bladder and required the use of an incontent brief. Continued review of this assessment indicated, that Resident R68, required Extensive assist, requires frequent supervision/assistance. Section 4 of the Bowel and Bladder Assessment form, related to appropriate program based on the resident's functional abilities related to incontinence care, noted that Resident R68 should be kept clean and dry, use incontinence product and barrier cream as needed. It was also indicated that Resident R68 walked occasionally during the day, but for very short distances, with or without assistance. The resident spent the majority of each shift in bed or chair. Review of an Annual MDS, (Minimum Data Set - periodic assessment of needs), dated April 29, 2019, indicated under section G, Functional Status, that Resident R68 requires extensive assistance with one person for physical assistance for activities of daily living, such as dressing, bed mobility, transfering, walking, toilet use and personal hygiene. Review of Resident R68's care plan related to frequently incontinent, revised, Janaury 1, 2020, indicated, on June 1, 2015, the following measure was added To offer routine toileting, (every two hours), and provide incontinence care as needed. Continued review of Resident R68's care plan revealed an intervention to Observe skin areas when ADL care given. Report any redness or skin breakdown to nurse. Follow up with treatment protocol as needed. An interview with Employee E3, Licensed Nurse on February 21, 2020, at 11:20 a.m. confirmed Resident R68 was care planed to prevent skin breakdown, related to incontinent of bladder and bowel and impaired physical mobility. Review of facility documenation, related to Resident R68's bladder/bowel episodes, since last skin assessment completed on June 18, 2019, indicated that Resident R68 was not provided routine toileting, every two hours, from the last skin assessment, as indicated as a preventive approach in the resident's care plan. Further review of the bladder/bowel documenation indicated that Resident R68 experienced between six to seven episodes of urinary incontinence a day. Review of facility documenation, titled, Weekly Skin Review, from May 14, 2019 through June 18, 2019 indicated that Resident R68's skin was examined and found to be intact. Review of nursing progress note dated June 21, 2019, at 10:00 a.m. indicated that the resident was seen on wound rounds today for sacrum, 1.3 centimeters (cm), x 1.5 centimeters, x 0.1, centimeters, with 50% granulation, (new connective tissue and small microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size), and 50% slough, (non - viable yellow, tan, gray, green or brown tissues, usually moist, can be soft, string, and mucinous in texture), with serious/[DIAGNOSES REDACTED] to periwound, new treatment- santyl and CDD (cover with dry dressing) daily. An interview with Employee E3, Licensed Nurse, on February 24, 2020, at 10:30 a.m. confirmed that Resident R68 was identified to have a facility acquired stage III pressure ulcer to sacrum. An interview with Director of Nursing and Employee E3, Licensed Nurse, on February 24, 2020, at 12:00 p.m., revealed at the time Resident R68 was found to have the stage III pressure ulcer to sacrum (ulcer involving full thickness of skin loss, exposing tissue), the resident was noted to have an increase in incontinent episodes and health concerns related to a family members personal health concerns. Further during an interview with Director of Nursing and Employee E3, it was indicated that Resident R68's Stage III pressure ulcer required debridement (the removal of damaged tissue from a wound) by the wound consultant. Continued review of Resident R68's clinical record revealed a wound consultant report, dated June 21, 2019, which confirmed sacral wound of less than 3 days. The report further indicated wound #1 sacral is an acute Stage 3 pressure injury pressure ulcer initial wound encounter measurements are 1.3 cm ( length x 1.5 c.m. width x 0.1 depth, with an area of 1.95 sq (square) cm and a volume of 0.195 cubic cm. no tunneling has been noted . There is a scant amount of serous drainage (watery, clear fluid) noted which has no odor. The patient reports a wound pain of level 1/10. wound bed has with 50% slough and 50% granulation. Review of the most recent wound consultant report dated February 14, 2020, noted that the resident's stage III sacral pressure ulcer measuring 0.2cm x 0.2 with no measurable depth with an area of 0.4sq cm. no tunneling has been noted . There was no drainage noted. The patient reports a wound pain of level 0/10. The wound is improving. The facility failed to timely identify and increase interventions to prevent the development of a pressure ulcer for Resident R68 who was identified as a low risk for skin breakdown and with an increase in incontinence, resulting in actual harm to Resident R68 developing a sacral Stage III pressure ulcer. Treatment/Services to Prevent/Heal Pressure Ulcer CFR 483.25(b)(1)(i)(ii) 28 Pa Code 201.14(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3)(e)(1) Management 28 Pa Code 211.11(d) Resident care plan 28 Pa Code 211.10(c) Resident care policies 29 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(c)(d)(3) Nursing services 28 Pa Code 211.12(d)(3) Nursing services

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to assess and monitor one resident exhibiting a physical and mental decline resulting in a fall from a wheelchair and sustaining a fracture to her neck. (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed current physician's orders [REDACTED]. Review of a MDS (periodic assessment of needs) dated [DATE] that the facility assessed the resident as independent in cognition, was able to transfer from bed to chair and vice versa with one person assist, was able to ambulate in her room with one person assist, and was only occasionally incontinent of urine. The MDS dated [DATE] noted that the resident was now moderately impaired in cognition, did not ambulate, needed a mechanical lift for all transfers, and was always incontinent of urine. A review of a physical therapy evaluation dated [DATE] revealed that the Resident CL1 exhibited a new onset of reduced ability to safely ambulate and reduced functional activity and balance. An occupational therapy evaluation dated [DATE] revealed that the resident had muscle weakness and a new onset of decrease in strength and in functional mobility contributing for the need of increased assistance with transfers. Occupational therapy notes dated [DATE] revealed that the resident was discharged from therapy within only two weeks because the resident could not improve and a mechanical lift was recommended for all transfers. Clinical record review in the nursing progress notes indicated numerous incidents involving falls for this resident. On [DATE] and [DATE] the resident was found on the floor. On [DATE] the resident fell from her wheelchair and sustained injuries to her face and forehead, with a hematoma measuring 5 centimeters (cm.) long and 5.5 cm. wide. Falls were also indicated on [DATE], [DATE], [DATE], and [DATE]. Review of facility documentation related to the fall dated [DATE] revealed that predisposing factors to the fall were confusion and impaired memory. Review of nursing progress notes dated [DATE], [DATE], [DATE], [DATE] and [DATE], 2014 revealed that this resident had pain, [MEDICAL CONDITION] (swelling) and redness of both her legs and was diagnosed with [REDACTED]. Review of a reportable event and facility documentation dated [DATE] revealed that Resident CL1 was being pushed in a wheelchair when the resident put her feet down, fell forward, hit her head and face, causing a large hematoma, bruising, and blood in her mouth from biting her tongue. The resident was admitted to a hospital, the resident was admitted with a fracture to the upper mid vertebrae (cervical-neck) and was listed as a serious injury. A review of facility documentation of this incident revealed that the leg rests/foot pedals were not on the wheelchair. Predisposing factors to this fall were gait imbalance, impaired memory, and confusion. Review of Resident CL1's plan of care dated February 2013 was not updated to address the physical and mental decline, was not updated related to all the frequent falls, and did not include the recurrent episodes of [MEDICAL CONDITION] to the bilateral lower extremities (legs). In a telephone interview with the forensic investigator of the coroner's office on [DATE], it was learned that Resident CL1 died on [DATE]; the manner of death was an accident and the cause/sequellae was [MEDICATION NAME] neck trauma. The facility failed to assess and monitor the physical and mental decline of this resident and failed to implement assistive devices to increase resident safety during transport which resulted in actual harm. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing service. Previously cited [DATE].