Every finding on record at William Penn Nursing and Rehab

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen with Employee 1, dietitian, on April 14, 2026, at 10:12 AM revealed the following: The wall mounted soap dispenser located adjacent to the handwashing sink was coming off the wall. The walk-in freezer contained a box of bagged broccoli cuts and lima beans that were open to the ambient air. The spice rack contained the following outdated containers of spices: ground all spice with a use by date of July 19, 2024; rosemary with a written use by date of September 19, 2024; thyme with a use by date of March 6, 2025. The dry goods storage area contained a container of whole bay leaves with a written use by date of December 20, 2024. There was a bent adaptive piece of silverware in a drawer on the table that held the coffee machine. The piece of silverware had a discolored piece of scotch tape on the handle. Employee 1 reported the adaptive silverware is not used anymore. The dishwasher room contained the following: The ceiling contained areas of black, gritty discoloration. There was a printed paper sign in a plastic protective covering on top of the dishwasher that noted, Dish room rules. The paper sign was wet and discolored and there was moisture build-up inside of the plastic protective covering. There were personal protective gowns for staff hanging on the wall that had a build-up of stains. There were three observed winged insects on the gowns. There were cobwebs under the stainless-steel table along the wall. There were cobwebs on a pipe going into the ceiling next to the ice machine. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 14, 2026, at 11:02 AM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate transmission-based precautions (TBP) for two of three residents reviewed on TBP (Residents 127 and 129).Findings include: The facility policy entitled Transmission-Based (Isolation) Precautions, last reviewed without changes on March 19, 2026, revealed it is the facility policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident, or the resident's environment. Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used. Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or resident's environment. Healthcare personnel caring for residents on contact precautions are to wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning and doffing PPE up on entry into the resident's environment and discarding before exiting the room is done to contain pathogens. Clinical record review revealed the facility admitted Resident 127 on April 5, 2025. A physician order dated April 5, 2026, revealed staff were to initiate contact precautions for Resident 127 for VRE (vancomycin resistant enterococci, a type of bacteria resistant to the antibiotic vancomycin) in her foot wound. Observation of Resident 127's room on April 14, 2026, at 10:29 AM revealed there was a three-drawer bin with gowns in it, outside of Resident 127's room. There were no gloves. Observation of a sign on Resident 127's door revealed she was on contact precautions, and everyone must put gloves and a gown on before entry, and discard gloves and gown before exiting Resident 127's room. Observation of Resident 127's room on April 14, 2026, at 1:58 PM revealed Employee 5 (licensed practical nurse) entered Resident 127's room. Employee 5 did not put a gown or gloves on at any point while in the room. Upon exiting the room, the surveyor questioned Employee 5 and he stated that he was getting vitals. Observation of Resident 127's room on April 15, 2026, from 9:22 AM to 9:38 AM revealed Employee 7 (nurse aide) provided morning care to Resident 127's roommate in the residents shared bathroom. Employee 7 did not put a gown or gloves on at any point while in Resident 127's room. Interview with Employee 7 confirmed that Resident 127 can utilize the bathroom. Observation of Resident 127's room on April 15, 2026, at 9:58 AM revealed Employee 8 (nurse aide) was at Resident 127's bedside, getting Resident 127's lunch order. Employee 8 did not put a gown or gloves on at any point while in Resident 127's room. The facility failed to implement appropriate contact precautions for Resident 127. The above findings for Resident 127 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on April 15, 2026, at 2:07 PM. Clinical record review for Resident 129 revealed a diagnosis of Enterocolitis due to Clostridium Difficile (inflammation of the intestines due to a bacterial infection, also referred to as C. difficile). Further review revealed the resident was on Transmission-Based Precautions (additional infection control measured used to prevent the spread of infectious diseases, also referred to as TBP). According to the Centers for Disease Control and Prevention (CDC), strict adherence to glove use is the most effective means of preventing hand contamination with C. difficile spores as these spores are not killed by ABHR (alcohol-based hand rubs) and may be difficult to remove even with thorough hand washing. Contamination of high touch environmental surfaces (e.g., bedside table, bed rails, toilets, sinks, and handrails), contributes to transmission of pathogens including C. difficile. C. difficile spores can live on inanimate surfaces for up to 5 months. Observation of Resident 129's room on April 15, 2026, at 10:05 AM revealed the appropriate TBP items, including gloves and cloth gowns, located outside of the resident's room. Upon exiting the resident's room and removing the TBP items, there were two bins located at the doorway, one for the contaminated soiled gowns/laundry, and one for contaminated disposable gloves/refuse. Both bins were noted to have a lid in place and required the user to use their hand to access the bins and dispose of any contaminated items and then replace the lids. Observation of Resident 127's room on April 14, 2026, at 10:29 AM, revealed there were two bins located between the window and door beds against the wall, one for contaminated soiled gowns/laundry, and one for contaminated soiled gloves/refuse. Both bins were noted to have a lid in place that required the user to use their clean hand to access the bins and dispose of any contaminated items and then replace the lids. The above concerns regarding Residents 129 and 127 were discussed with the Nursing Home Administrator and the Director of Nursing on April 16, 2026, at 2:30 PM. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 63 and 79).Findings include:The facility's medication error rate was 12 percent based on 25 medication opportunities with three medication errors.Observation on April 17, 2026, of Resident 79's medication administration at 8:28 AM revealed that Employee 3, licensed practical nurse, administered one 20 mg (milligram) tablet of Lasix (a diuretic medication used to treat fluid retention). Clinical record review for Resident 79 revealed a physician order dated April 6, 2026, stating, Furosemide 20 MG Tablet TAKE THREE TABLETS (60MG) BY MOUTH ONCE DAILY RELATED TO EDEMA, UNSPECIFIED. Concurrent observation of Resident 79's medication administration revealed that Employee 3 administered two tablets of Potassium Chloride Crys ER (Extended Release) Oral 20 MEQ (milliequivalent), and broke both tablets in half prior to administration. The medication reference Drugs.com (a comprehensive and widely visited website that provides free, peer-reviewed, accurate, and independent drug information) instructions regarding the administration of Potassium Chloride noted, Do not crush, chew, break, or suck on an extended-release tablet or capsule. Interview with Employee 3 on April 17, 2026, at 8:50 AM confirmed that the medication card for Resident 79 contained Furosemide 20 MG Tablets, and the employee administered only a single pill. The above information regarding Resident 79 was reviewed with the Director of Nursing on April 17, 2026, at 11:00 AM Review of Resident 63's current physician orders revealed an order dated September 3, 2025, for Tamsulosin HCL (a medication that is used to improve urine flow); give 0.8 milligrams (mg) by mouth one time a day related to anuria (the body fails to produce urine or there is a blockage in the urinary tract preventing proper urine flow) and oliguria (reduction of urine production); give within 30 minutes of breakfast; do not crush, chew, or open. The order indicated that the pharmacy supply was dispensed and received on March 19, 2026, and the medication on hand was Tamsulosin HCl 0.4 mg capsules; take two capsules (0.8 mg) by mouth once daily related to anuria and oliguria. Observation of Resident 63's medication administration pass on April 17, 2026, at 8:27 AM revealed that Employee 6, licensed practical nurse (LPN), prepared the medications prior to administration. This preparation included one Tamsulosin 0.4 mg capsule. Employee 6 then proceeded to administer the medication to Resident 63. An interview with Employee 6 on April 17, 2026, at 9:47 AM revealed that the LPN administered only one capsule of the Tamsulosin and Resident 63 should have received two capsules for a total dose of 0.8 mg per the physician order. The above information for Resident 63 was reviewed with the Director of Nursing on April 17, 2026, at 9:55 AM. Review of Resident 63's medication supply card with the Director of Nursing at the medication cart on April 17, 2026, at 10:00 AM revealed the supply was Tamsulosin 0.4 mg capsules and the directions noted to administer two capsules for a total dose of 0.8 mg. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide recommended pneumococcal immunizations for one of five residents reviewed for immunizations (Resident 3).Findings include: The facility policy entitled Pneumococcal Vaccine, last reviewed without changes revealed March 19, 2026, revealed it is the facility policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. Each resident will be assessed for pneumococcal immunizations upon admission. Each resident will be offered a pneumococcal immunization unless it is contraindicated, or the resident has already been immunized, the type of pneumococcal vaccine (PCV15, PCV20, PCV21, or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations. Clinical record review revealed the facility admitted Resident 3 on December 27, 2021. Documentation in Resident 3's clinical record revealed he received two pneumococcal vaccines prior to his admission (Prevnar 13 and Pneumovax 23). Review of Resident 3s pneumococcal consent dated February 20, 2022, revealed Resident 3 refused noting already had it. According to the CDC guidance entitled Pneumococcal Vaccine Timing for Adults dated October 2024, Resident 3's pneumococcal vaccinations would not be completed until he received one dose of Prevnar 20 or Prevnar 21 at least five years after the last pneumococcal vaccine dose. There was no evidence to indicate that the facility offered Resident 3 an updated pneumococcal vaccination. Interview with Employee 2, infection control preventionist, on April 16, 2026, at 9:10 AM confirmed the above findings for Resident 3. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of select facility policies and procedures, clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies and provide care consistent with professional standards of practice for one of one resident reviewed receiving hemodialysis (Resident 10).Findings include: Clinical record review for Resident 10 revealed a diagnosis list that included the following related to hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities): end stage renal disease, chronic kidney disease, and an arteriovenous (AV) fistula (surgically created connection between an artery and a vein to provide an access for hemodialysis). Review of the current physician orders for Resident 10 revealed the following: An order dated August 24, 2025, noted, dialysis precautions: no blood draws, injections, or blood pressure from (specify) arm. Emergency kit at bedside containing appropriate equipment; tourniquet, sterile gauze, gloves, etc. Nursing documentation dated August 24, 2025, at 11:23 AM revealed the facility staff received report from the hospital that indicated that Resident 10 receives dialysis and has a catheter in the right chest and an AV fistula in the left arm. Review of Resident 10's care plan revealed that the resident has renal insufficiency related to chronic renal failure and the presence of a fistula/graft/catheter. An intervention dated September 11, 2025, noted Emergency equipment at bedside. Review of a recent dialysis communication worksheet dated April 3, 2026, revealed that the access site for dialysis was noted as the right chest port. Observation of Resident 10's room on April 16, 2026, at 11:18 AM with Employee 4, licensed practical nurse, revealed an emergency kit contained in a mesh bag that was hanging on the wall above the head of the bed. Review of the kit with Employee 4 revealed the kit contained gauze, pressure dressing, and tape. The kit did not contain a tourniquet and gloves as specified in the physician order. Observation of Resident 10's room on April 16, 2026, at 12:08 PM, with the Director of Nursing confirmed that the kit contained gauze, pressure dressing, and tape. A concurrent interview with Resident 10 confirmed the resident received hemodialysis and has both an AV fistula in the left arm and a right chest port for dialysis access. The Director of Nursing further noted that the emergency kit should also contain tubing clamps which were not present. A review of the facility policy titled, Hemodialysis, last reviewed by the facility on March 19, 2026, revealed that the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, and psychosocial needs of residents receiving hemodialysis. The policy did not address an emergency kit and what supplies are to be kept in the kit. A meeting with the Nursing Home Administrator and Director of Nursing on April 16, 2026, at 2:08 PM revealed that the facility would have to contact the medical provider to clarify the order and see exactly what was needed in the emergency kit that is kept at the bedside. Further review of Resident 10's clinical record revealed a physician order dated August 25, 2025, that noted no treatment or blood pressure to the left arm due to AV fistula (arteriovenous fistula). Review of the care plan for Resident 10 revealed that the resident has renal insufficiency related to chronic renal failure and the presence of a fistula/graft/catheter. An intervention dated September 11, 2025, noted, Do NOT take blood pressure or blood specimens from LEFT/RIGHT arm. Review of the Kardex (documentation by nursing to note important information and care planning and facilitate resident care) for Resident 10 revealed a section titled, Safety. This section noted, Do NOT take blood pressure or blood specimens from LEFT/RIGHT arm. Resident 10's care plan and Kardex did not reflect the physician order. It was unclear if the resident had a limb restriction in only the left arm (as indicated by the physician order) or both arms (as indicated by the care plan and Kardex). The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 16, 2026, at 2:08 PM. The Director of Nursing reported the facility would have to clarify the limb restriction. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff, it was determined that the facility failed to ensure the highest practical care related to PICC lines (peripherally inserted central catheter, provides access to the large veins near the heart by inserting a thin flexible tube into a vein the upper arm) for two of 23 residents reviewed (Residents 127 and 128). Findings include: Clinical record review revealed the facility admitted Resident 128 on April 5, 2026. Nursing documentation dated April 6, 2026, at 4:48 PM, revealed Resident 128 stated, he wanted a pair knife to cut his line. Documentation revealed Resident 128 then tried to pull at his PICC line. Further review of Resident 128's clinical record revealed a physician order dated April 5, 2026, for staff to maintain an emergency kit for Resident 128's PICC line at his bedside. Observation of Resident 128's room on April 14, 2026, at 1:05 PM revealed there was no emergency kit visible in his room. Further observation on April 15, 2026, at 10:02 AM, revealed a small bag of gauze in his top dresser drawer under his personal items. Clinical record review revealed the facility admitted Resident 127 on April 5, 2026. Further review of Resident 127's clinical record revealed a physician order dated April 5, 2026, for staff to maintain an emergency kit for Resident 127's PICC line at her bedside. Observation of Resident 127's room on April 14, 2026, at 11:55 AM revealed there was no emergency kit visible in her room. Observation of Resident 127's room with the Director of Nursing on April 15, 2026, at 9:36 AM revealed that she was unsure if there was an emergency kit in Resident 127's room. After searching for the emergency kit she was able to find some gauze in Resident 127's dresser drawer mixed in with Resident 127's personal items. Interview and observation of Resident 127's room with Employee 5 (licensed practical nurse) on April 15, 2026, at 11:57 AM revealed the facility usually tapes emergency kits on the wall behind the residents' beds. Employee 5 searched Resident 127's room for three and a half minutes before finding the gauze in Resident 127's drawer with her personal items. The facility failed to ensure accessibility of necessary emergency supplies for Residents 127 and 128 PICC lines. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan for infection control concerns for two of 23 residents reviewed (Residents 127 and 128).Findings include: Clinical record review revealed the facility admitted Resident 127 on April 5, 2026. A physician order dated April 5, 2026, revealed staff were to initiate contact precautions (measures to prevent the spread of infections transmitted by direct/indirect contact with a resident or their environment) for Resident 127 for VRE (vancomycin resistant enterococci, a type of bacteria resistant to the antibiotic vancomycin) in her foot wound. Further review of Resident 127's clinical record revealed her care plan-initiated April 5, 2026, listed infection of and was blank after. The care plan noted staff were to maintain isolation precautions as indicated but did not specify what. Clinical record revealed the facility admitted Resident 128 on April 5, 2026. A physician order dated April 6, 2026, revealed staff were to initiate contact precautions. Nursing documentation dated April 5, 2026, at 9:49 AM, revealed Resident 128 has a PICC (peripherally inserted central catheter, provides access to the large veins near the heart by inserting a thin flexible tube into a vein the upper arm) in his left upper extremity and MRSA (Methicillin-resistant Staphylococcus aureus, a type of bacteria that causes skin infections and is resistant to many antibiotic) in his blood. Further review of Resident 128's clinical record revealed his care plan-initiated April 5, 2026, noted Resident 128 had infection of sepsis, bacteremia, and pneumonia. The interventions listed were to administer medications per physician orders, obtain labs as ordered and notify physician of results, and obtain vital signs as indicated. Resident 128's plan of care did not address Resident 128 being on contact precautions related to MRSA in his blood. The above findings for Residents 127 and 128 were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on April 16, 2026, at 2:11 PM. 28 Pa. Code 211.10. (a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 23 residents reviewed (99).Findings include: Clinical record review for Resident 99 revealed a MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 21, 2026, that facility staff assessed Resident 99 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 99 received an anticoagulant medication during the assessment period for the MDS noted above.Interview with the Director of Nursing on April 16, 2026, at 2:07 PM confirmed that Resident 99's February 21, 2026, MDS was coded in error regarding receiving an anticoagulant medication. 483.20(g) Accuracy of AssessmentsPreviously cited 5/9/25 28 Pa. Code 211.5(f)(ix) Medical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interview, it was determined that the facility failed to maintain COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network for one of one staff reviewed (Employee 3). Findings include: The surveyor requested information regarding the COVID-19 vaccination status for the facility's current employees during an interview with Employee 4 (Registered Nurse, Infection Preventionist), on May 9, 2025, at 11:00 AM. Employee 4 indicated that she has not been tracking vaccination status for staff. She also indicated that she had no evidence of offering COVID-19 vaccinations to staff because they do not ask each staff member individually as they post a sign by the time clock and in the employee breakroom indicating that if staff were interested in receiving a vaccine that they need to visit their primary care physician or local pharmacy. The Nursing Home Administrator and Director of Nursing were made aware of concerns related to staff COVID-19 vaccinations on May 9, 2025, at 11:35 AM. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to assist residents to obtain routine dental care for six of eight residents reviewed (Residents 34, 50, 95, 4, 20, and 37). Findings include: Observation of Resident 34 on May 7, 2025, at 10:23 AM revealed that she had some natural teeth. Resident 34 was unable to be interviewed due to her current cognitive status. Clinical record review revealed the facility admitted Resident 34 on January 8, 2018, with payment sources that included the state Medicaid benefit. Further review of Resident 34's clinical record revealed that she last saw a dentist on February 13, 2020. An interview with Employee 1 (licensed practical nurse) on May 8, 2025, at 11:34 AM confirmed these findings for Resident 34. There was no other documentation that indicated Resident 34 was offered routine dental services every six months as the State plan allows. Observation and interview with Resident 50 on May 6, 2025, at 1:06 PM revealed she had her own teeth, and she stated that she couldn't remember the last time she saw a dentist. Clinical record review revealed the facility admitted Resident 50 on April 30, 2021, with payment sources that included the state Medicaid benefit. Further review of Resident 50's clinical record revealed that she last saw a dentist on March 13, 2023. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Resident 50. There was no other documentation that indicated Resident 50 was offered routine dental services every six months as the State plan allows. Observation of Resident 95 on May 7, 2025, at 11:27 AM revealed that she had some natural and broken teeth. Resident 95 was unable to be interviewed due to her current cognitive status. Clinical record review revealed the facility admitted Resident 95 on May 19, 2024, with payment sources that included the state Medicaid benefit. Further review of Resident 95's clinical record revealed no evidence that Resident 95 saw a dentist. Review of Resident 95's admission MDS assessment dated [DATE], revealed staff assessed Resident 95 as having obvious or likely cavity, or broken natural teeth. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Resident 95. There was no other documentation that indicated Resident 95 was offered routine dental services every six months as the State plan allows. The findings for Residents 34, 50, and 95 were reviewed with the Director of Nursing on May 9, 2025, at 9:55 AM and she confirmed the facility had no further evidence the above-mentioned residents received routine prophylactic dental cleanings as covered under the State plan. Clinical record review for Resident 4 revealed that the facility admitted her on September 6, 2024. Her admission MDS indicated that she is edentulous. Further clinical record review revealed that she has upper and lower dentures. There was no evidence in Resident 4's clinical record to indicate that she was offered or provided routine dental services. Clinical record review for Resident 20 revealed that the facility admitted her on May 16, 2016, with payment sources that included the state Medicaid benefit. Review of Resident 20's significant change MDS dated [DATE], revealed staff assessed her as having some or all her natural teeth. Further review of Resident 20's clinical record revealed no evidence that she was seen by a dentist or offered dental services. Clinical record review for Resident 37 revealed that the facility admitted her on May 16, 2019. Review of Resident 37's annual MDS dated [DATE], revealed that she has some or all her natural teeth. There was no evidence in Resident 37's clinical record to indicate that she was offered or provided with routine dental services. Interview with Employee 1 on May 8, 2025, at 11:34 AM confirmed these findings for Residents 4, 20, and 37. There was no other documentation that indicated Residents 4, 20, and 37 were offered routine dental services every six months as the State plan allows. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for six of 26 residents reviewed (Residents 4, 14, 20, 71, 75, and 81). Findings include: Clinical record review for Resident 75 revealed a Quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated February 2, 2025. The facility staff assessed the resident as taking an anticoagulant (a medication that prevents or reduces clotting time of the blood). Further clinical record review revealed no evidence that Resident 75 was on an anticoagulant. An interview with Employee 2, registered nurse assessment coordinator (RNAC), on May 7, 2025, at 10:50 AM confirmed that Resident 75 was not on an anticoagulant during the assessment period, and this was marked in error on the MDS. The Nursing Home Administrator and Director of Nursing were informed of the above findings during a meeting on May 7, 2025, at 2:00 PM. Clinical record review for Resident 4 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a limb restraint when in a chair less than daily. Interview with Employee 2, RNAC, on May 7, 2025, at 9:20 AM revealed that Resident 4 never utilized a limb restraint, and this was an MDS coding error. Clinical record review for Resident 20 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having an impairment of both of her lower extremities. Clinical record review for Resident 71 revealed an annual MDS dated [DATE]. The facility staff assessed her as having an impairment of her bilateral lower extremities. Interview with Employee 6, RNAC, on May 9, 2025, at 12:10 PM revealed that Residents 20 and 71 do not have an impairment of their bilateral lower extremities, and this was marked in error on the MDS. The Director of Nursing was made aware of the concerns with Resident 20 and 71's MDS coding concerns on May 9, 2025, at 12:15 PM. Clinical record review for Resident 14 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily. Clinical record review for Resident 81 revealed a quarterly MDS dated [DATE]. The facility staff assessed the resident as having used a trunk restraint in a chair or out of bed, less than daily. Interview with Employee 2 on May 7, 2025, at 9:06 AM revealed that Residents 14 and 81 never utilized a trunk restraint and that this was an MDS coding error. The Director of Nursing was made aware of the concerns with Residents 14 and 81 MDS coding concerns on May 9, 2025, at 12:16 PM. 483.20(g) Accuracy of Assessments Previously cited 6/25/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide dignity regarding covering urinary catheter bags for one of one resident reviewed for catheters (Resident 87). Findings include: Clinical record review for Resident 87 revealed a current physician's order for them to have a Foley urinary catheter to straight bag drainage for urinary retention. Observation of Resident 87 on May 6, 2025, at 12:58 PM, May 7, 2025, at 11:02 AM, May 8, 2025, at 12:42 PM and May 9, 2025, at 10:15 AM revealed that they were in bed with the urinary catheter bag hanging on the side of the bed uncovered. During the May 6, 2025, at 12:58 PM observation, the catheter bag was on the door side, in full view from the hallway, and visible to all passing. During the May 7, 2025, at 11:02 AM observation, the bag was on the window side of the bed, lying on the floor, in full view from the hallway, and visible to all passing. During the May 8, 2025, and May 9, 2025, observation, the catheter bag was on the window side and attached to the bed and remained uncovered. Concurrent interview on May 9, 2025, at 10:15 AM with the Director of Nursing confirmed the findings. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation and staff interview, it was determined that the facility failed to properly store resident medications on one of two nursing units reviewed (Station Two Nursing Unit; Honey Creek Hall). Findings include: Observation during the medication pass on the Station Two Nursing Unit (Honey Creek Hall) on May 9, 2025, at 9:35 AM revealed a medication cart being utilized by Employee 5, licensed practical nurse. Observation of the medication cart revealed the following: There was a significant accumulation of debris and dirt including hair in the bottom of the drawers. There were several unsecured and unidentified medication tablets found in the drawer that contained the medication punch cards that included several unidentified pills: two white colored round pills, two orange colored round pills, a multi-colored capsule, and a large brown colored pill. The above findings were reviewed in a meeting with the Director of Nursing on May 9, 2025, at 9:57 AM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1) Nursing services

Clinical record review and resident and staff interview, it was determined that the facility failed to have sufficient nursing staff to meet resident needs related to call bell response time for two of 26 residents reviewed (Residents 50 and 66). Findings include: In an interview with Resident 50 on May 6, 2025, at 12:56 PM she stated that she has waited an hour to go the bathroom. She stated that she is usually only incontinent when she rings her call bell and must wait a long time for staff to assist her. Resident 50 stated that the licensed practical nurse will come into her room and turn off her call bell stating they will let the nurse aide know but nobody comes back. Clinical record review for Resident 50 revealed her most recent annual MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) assessment dated [DATE], indicated Resident 50 was cognitively intact and occasionally incontinent of her bladder function. Resident 50 filed a grievance on January 1, 2025, stating her call bell was on for over an hour, noting she was incontinent and embarrassed. Review of Resident 50's grievance revealed no resolution to her concern. Interview with Employee 7 (social services) on May 9, 2025, at 10:43 AM confirmed these finding for Resident 50. There was no evidence of any call bell audits completed until January 14, 2025. The above call bell response times were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:00 PM. Interview with Resident 66 on May 6, 2025, at 12:15 PM revealed that he has concerns with the facility not having enough staff. He indicated that when he rings his bell to go to the bathroom or use the urinal there are not enough staff to answer it timely. He could not provide specific dates, but he indicated that it happens on all the shifts. He said that he is incontinent often because they don't answer the call bell timely. He said the that often he has to wait over 30 minutes. Review of Resident 66's MDS dated [DATE], revealed that he is always continent of bowel and frequently incontinent of bladder. The above noted concern related to Resident 66 was reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on May 8, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(3)(4)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to post the daily nurse staffing information at the beginning of each shift for two of two nursing units reviewed (Nursing Unit One and Nursing Unit Two). Findings include: Observation of the nurse staffing information posted on the wall adjacent to the main lobby of the facility on May 8, 2025, at 11:19 AM and 12:38 PM revealed a nurse staffing sheet dated May 7, 2025. Observation at the Nursing Unit Two nurse station and concurrent interview with Employee 5, licensed practical nurse, on May 8, 2025, at 11:30 AM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse's station. Observation of Nursing Unit One nurse station and concurrent interview with Employee 6, social worker, on May 8, 2025, at 12:43 PM revealed that there was no nurse staffing information posted in a prominent place at or near the nurse station. An interview with Employee 8, scheduler, on May 8, 2025, at 12:53 PM revealed that the posted nurse staffing information located near the main lobby was changed to reflect the correct date of May 8, 2025. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 8, 2025, at 2:15 PM. 28 Pa. Code 201.18(b)(3) Management

Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for 10 of 24 residents reviewed (Residents 9, 19, 32, 41, 55, 60, 63, 85, 97, and 109). Findings include: Interview with Resident 60 on June 23, 2024, at 10:38 AM revealed that she denied ever having a physical restraint. Resident 60 indicated that she is unable to transfer herself out of bed, and that a staff member utilizes a stand-up mechanical lift to transfer her out of bed to a chair. Clinical record review of an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment for Resident 60 dated May 4, 2024, revealed that staff assessed the daily use of a bed rail as a restraint. The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument, MDS) Manual for Item P (Physical Restraint) instructs that if the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. Clinical record review for Resident 60 revealed no evidence of the use of a physical restraint. Interview with the Director of Nursing and the Nursing Home Administrator on June 23, 2024, at 2:30 PM confirmed that the MDS coding for Resident 60's restraint was an error. They indicated that Resident 60 never had a restraint. Clinical record review for Resident 19 revealed the resident was admitted to the facility on [DATE]. A quarterly MDS for Resident 19 dated April 17, 2024, noted that the facility staff assessed the resident as being on an anticoagulant (blood thinner). Further clinical record review revealed no evidence that Resident 19 received an anticoagulant during the assessment period for the MDS. An interview with Employee 2, the Registered Nurse Assessment Coordinator, on June 25, 2024, at 11:50 AM confirmed that Resident 19 did not receive an anticoagulant and the data entered in the MDS was an error. Observation of Resident 109 on June 23, 2024, at 9:26 AM revealed the resident was in bed. There was an enabler bar attached to the resident's left side of the bed. There was no observed evidence of any restraints being utilized. Clinical record review of a quarterly MDS for Resident 109 dated May 14, 2024, revealed that staff assessed the daily use of a bed rail as a restraint. Further clinical record review for Resident 109 revealed no evidence of the use of a restraint. Interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at 2:00 PM confirmed that restraints were not used on Resident 109. An interview with Employee 2 on June 25, 2024, at 11:50 AM confirmed that the MDS coding that indicated a restraint for Resident 109 was an error, and the resident never had a restraint. Clinical record review for Resident 9 revealed an MDS dated [DATE], that indicated she was taking an anticoagulant (a medication that thins the blood to reduce or prevent blood clotting). Further clinical record review of Resident 9's medication administration for March and April 2024, revealed no indication that she was taking an anticoagulant medication at that time. Interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at 2:20 PM confirmed the above noted findings that Resident 9 was not on an anticoagulant medication and the MDS was coded in error. Interview with Resident 41 on June 23, 2024, at 12:00 PM revealed that she denied ever having a physical restraint. Resident 41 indicated that she is unable to transfer herself out of bed. Resident 41 indicated that a staff member utilizes a stand-up mechanical lift to transfer her out of bed to a chair. Clinical record review for Resident 41 revealed an MDS dated [DATE], that indicated staff assessed the daily use of a bed rail as a restraint. Clinical record review for Resident 41 revealed no evidence of the use of a physical restraint. Interview of Resident 97's wife on June 23, 2024, at 12:10 PM revealed that he never had a restraint. She also indicated that he is unable to transfer himself and that it takes two people to get him out of bed. Clinical record review for Resident 97 revealed an MDS dated [DATE], that indicated staff assessed the daily use of a bedrail as a restraint. Interview with the Director of Nursing and the Nursing Home Administrator on June 23, 2024, at 2:30 PM, confirmed that the MDS coding for Residents 41 and 97's restraints was an error, and that Residents 41 and 97 never had a restraint. Clinical record review for Resident 32 revealed that the facility completed a quarterly MDS on December 19, 2023, and March 15, 2024, and an annual MDS on June 4, 2024, which indicated that the resident was restrained by bed rails daily. Review of Resident 32's clinical record revealed a current physician's order and a care plan for two quarter side rales to assist with turning and repositioning due to weakness and deficits from a diagnosis of non-traumatic intracerebral hemorrhage (brain bleed). A facility assessment completed on April 29, 2024, revealed that Resident 32's bilateral siderails were for bed mobility and not a restraint. Clinical record review for Resident 55 revealed that the facility completed a quarterly MDS on May 31, 2024, that indicated the resident was restrained by bed rails daily. Review of Resident 55's clinical record revealed a current physician order and a care plan for two quarter side rails to assist with turning and repositioning due to weakness and hemiplegia (paralysis). A facility assessment completed on April 29, 2024, revealed that Resident 55's bilateral siderails were for bed mobility and not a restraint. Clinical record review for Resident 63 revealed that the facility completed a quarterly Minimum Data Set assessment on November 21, 2023, an annual MDS on February 21, 2024, and another quarterly MDS on May 21, 2024, that indicated the resident was restrained by bed rails daily. Review of Resident 63's clinical record revealed a current physician's order and a care plan for two quarter siderails to assist with turning and repositioning due to a diagnosis of morbid obesity. A facility assessment completed on April 29, 2024, revealed that Resident 63's bilateral siderails were for bed mobility and not a restraint. Clinical record review for Resident 85 revealed that the facility completed a quarterly MDS on March 19, 2024, that indicated the resident was restrained by bed rails daily. Review of Resident 85's clinical record revealed a current physician's order and a care plan for two quarter side rails to assist with turning and repositioning due to vertebral fracture, spinal stenosis (narrowing), and quadriplegia (paralyzed). A facility assessment completed on April 29, 2024, revealed that Resident 85's bilateral siderails were for bed mobility and not a restraint. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and Director of Nursing on June 23, 2024, at 2:15 PM. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to maintain the highest practicable care for two of 26 residents reviewed (Residents 41 and 81). Findings Include: Interview with Resident 41 on June 22, 2024, at 2:00 PM revealed that she is legally blind from macular degeneration (an eye disease that causes a gradual breakdown of the cells in the part of the eye that is responsible for central vision). Clinical record review for Resident 41's plan of care revealed that there was no care plan related to her vision loss. This information was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during an interview on June 23, 2024, at 2:07 PM. A care plan for Resident 41 related to her impaired vision was provided to the surveyor on June 24, 2024, at 8:55 AM. The care plan indicated that it was initiated on September 14, 2020. Review of the care plan history in the facility's computerized documentation system, revealed that the care plan provided to the surveyor was resolved on September 16, 2020, and was originally created as impaired vision related to impaired peripheral vison (difficulty seeing things up or down or side to side without moving the head), and then revised on June 24, 2024, after the surveyor inquired about a care plan for impaired vision. Interview with Resident 81 on June 23, 2024, at 11:27 AM revealed that she had been going to a dentist outside of the facility because she needs a lot of dental work done and it could not be done by the dentist in the facility. She said she has receding gums and has several teeth that need pulled. Review of Resident 81's care plan revealed that there was no care plan related to her dental issues. These issues were discussed with the NHA and DON during an interview on June 23, 2024, at 2:13 PM. A care plan for Resident 81 related to her dental concerns was provided to the surveyor on June 24, 2024, at 8:55 AM. The care plan indicated that it was initiated on June 24, 2024, after the surveyor brought it to their attention on June 23, 2024. The facility failed to develop a comprehensive person-centered care plan to maintain the highest practicable care for Residents 41 and 81. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of select facility policies and procedures, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to intravenous access for one of one resident reviewed for intravenous access concerns (Resident 80). Findings include: The facility policy entitled, Midline Dressing Changes, last reviewed without changes on March 21, 2024, revealed that general guidelines include to change the midline catheter dressing every five to seven days or if wet, dirty, not intact, or compromised in any way. Label the dressing with initials, date, and time. The policy did not include interventions implemented into a resident's plan of care to prevent infection or other complications from the use of a midline. The policy did not include routine assessments needed to monitor the resident during the presence of a midline catheter. Clinical record review for Resident 80 revealed nursing documentation dated June 3, 2024, at 2:33 PM that Resident 80 presented on admission with a, PICC (Peripherally inserted central catheter, long, thin, tube that is inserted through a vein in the arm and passed through to a larger vein near the heart. The line requires careful care and monitoring for complications including bleeding, infection, and blood clots) lune (sic, line) present in RUA (right upper arm). Resident 80 had a foot ulcer and physician orders for wound care. Admission physician orders dated June 3, 2024, for Resident 80 included Meropenem (an antibiotic that is used to treat severe infections of the skin or stomach) one gram intravenously every eight hours until July 2, 2024, related to acute osteomyelitis (infection identified in the bone) of the right ankle and foot. Resident 80's physician orders dated June 3, 2024, that remained active until Resident 80's readmission from the hospital on June 11, 2024, pertaining to a midline (thin, soft tubing placed into a vein in the arm for intravenous access) venous access site, included the following: Midline, maintain emergency kit at bedside Change midline dressing and caps every seven days, day shift, every Monday, and as needed Monitor midline site every shift Resident 80's physician orders dated June 4, 2024, that remained active until Resident 80's readmission from the hospital on June 11, 2024, pertaining to a midline venous access site, included the following: Midline/PICC IV (intravenous) dressing, extension set, and cap change every week and as needed one time a day every seven day(s) for IV therapy dressing change and as needed for leakage, blockage, soilage Midline, measure circumference in CM (centimeters) of upper arm insertion site every shift for midline every shift and as needed. Midline, measure length in CM of the external midline line access every day shift from insertion site to port, daily and as needed. A plan of care initiated by the facility on June 4, 2024, to address Resident 80's potential for complications at her intravenous insertion site (midline to RUA) included only one intervention, which was to change the intravenous tubing per the physician order or per protocol. There were no interventions regarding maintenance (e.g., changing the dressing and caps every seven days), assessment (e.g., measuring the circumference of the arm or length of the external tubing), prevention of complications (e.g., keeping site dry and restricting the use of the limb for blood pressures), or response for potential complications like bleeding (e.g., emergency kit at bedside). Resident 80's physician orders dated June 11, 2024, (upon her readmission from the hospital) included the following: Midline, measure length in CM of the external midline line access every day shift from insertion site to port, daily and as needed Midline, measure circumference in CM of upper arm insertion site every shift and as needed Midline/PICC IV dressing, extension set, and cap change every week and as needed one time a day every Wednesday for IV therapy dressing change and as needed for leakage, blockage, soilage Review of Resident 80's medication administration record (MAR, electronic system of documentation of medication administration) and treatment administration record (TAR, electronic system of documentation of treatment completions) dated June 2024 revealed that staff did not obtain a measurement of Resident 80's upper arm until June 11, 2024, night shift. Staff failed to obtain a measurement of the circumference of Resident 80's arm on night shift on June 17, 2024, and on day shift on June 19, 2024. Staff also failed to document any assessments of the external midline tubing length until June 22, 2024. Observation and interview with Resident 80 on June 22, 2024, at 12:46 PM confirmed that she had an open sore on her right foot and was receiving intravenous antibiotics through an intravenous site located in her right bicep area. Resident 80 stated that, .it is a midline. Observation of the clear dressing over the tubing in Resident 80's right arm revealed dated initials that indicated the dressing was applied on June 6, 2024. There was no emergency kit, or signs pertaining to restrictions for Resident 80's right arm visible in Resident 80's room. Observation of Resident 80 with Employee 1 (registered nurse) on June 23, 2024, at 9:23 AM confirmed that the midline dressing to Resident 80's right arm was dated June 6, 2024, indicating that the same dressing had remained in place for 17 days although physician orders instructed that staff change it every seven days. Review of Resident 80's TAR dated June 2024, revealed that staff initialed completion of a midline dressing change on June 12, 2024, at 8:00 AM; however, observation and staff interview confirmed that the dressing applied on June 6, 2024, was unchanged. Following the surveyor's questioning, staff discontinued the physician order related to changing the midline catheter dressing and restarted it on June 23, 2024, at 10:15 AM. The surveyor reviewed the above concerns regarding Resident 80's midline catheter care with the Director of Nursing and the Nursing Home Administrator on June 23, 2024, at 2:00 PM and June 24, 2024, at 2:00 PM. The facility did not provide a policy, procedure, or staff competency outline, that evidenced what the administration's expectations were of staff planning care for a resident with a midline catheter. 28 Pa. Code 211.5(f)(viii) Medical records 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a significant change MDS assessment was completed timely after election of hospice care for one of two residents reviewed (Resident 103). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (RAI, reference used to complete an MDS) revealed that the facility must complete a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine care needs) no later than 14 days after the effective dated of the election of hospice. Clinical record review for Resident 103 revealed that on June 6, 2024, their physician ordered hospice care. There was no documentation indicating that the facility completed a significant change MDS as indicated by the RAI Manual until after identified by the surveyor. The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at 2:00 PM. 28 Pa. Code 211.5 (f) Clinical records

Based on observation and interview, it was determined that the facility failed to provide a clean, comfortable environment in two shower rooms located on one of two nursing units (Nursing Unit 1, Windmill Hill). Findings include: Interview with Employee 3, nurse aide, on June 23, 2024, at 11:55 AM revealed that the staff utilize both shower rooms on Nursing Unit 1. The larger of the shower rooms is mainly utilized; however, the smaller shower room across the hall is used if the other shower is occupied. Observation of the larger shower room on June 23, 2024, at 11:56 AM revealed the following: A dislodged piece of tile on the floor that appeared to be from around the drain area in the floor. Two ceiling lights had debris that included dead insects in the protective coverings. The tiled floor in the shower had a build-up of grime and stains. The paint on the ceiling above the shower area was peeling in multiple areas. A ceiling light above the commode had debris and a dead insect in the protective covering. A metal hand hygiene product dispenser base was attached to the wall near the sink. There were six metal tabs sticking out from the base that were sharp and posed a potential hazard. A heater vent in the wall had an extensive build-up of dust on the vents. Observation of the second shower room across the hall on June 23, 2024, at 12:08 PM revealed the following: A ceiling light above the commode had debris in the protective covering. There was a baseball sized damaged and marred section of the wall behind the commode. A shower curtain was stained with dried, darker colored stains especially near the bottom of the curtain. There were multiple spiders observed: one spider near the floor outside of a shower stall, three spiders inside of the shower stall in webs, and one spider near the base of a wall on the far side of a large tub. There was a build-up of debris on the base of the wheelchair scale located in the shower room. Observation on June 23, 2024, at 12:13 PM revealed a maroon chair located at Nurse Station 1 that had extensive wear to the cushions of the chair. The cushions were extensively peeling and cracked on both the back rest cushion and seat of the chair. The above information for Nursing Unit 1 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on June 24, 2024, at 2:15 PM. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management