Every finding on record at Willow Grove Post Acute

Based on observations and interviews with residents and staff and facility documentation determined that the facility failed to ensure safe and operable equipment were available for use relating to blood pressure cuffs, and two mobility assistance devises, (Hoyer and Sit-to-Stand lifts) for two of 24 residents reviewed. Resident R68 and R20)Findings include: Review of the Resident R20's Minimum Data Set (MDS- a federal mandated assessment tool for all residents), dated July 14, 2025, revealed the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision or touching assistance with activities of daily living (ADLs) and had diagnoses including anxiety disorder (excessive worry and feelings of fear), bipolar II disorder (episodes of mood changes including depression and hypomania), and depression, unspecified (persistent feelings of sadness and loss of interest). On May 11, 2026 at 9:30 a.m., an interview with Resident R20 revealed concerns with use of a mechanical Hoyer lift. (A mechanical lifting device used to safely move a person who cannot stand or bear weight on their own, such as moving from a bed to a wheelchair.) Resident R 20 stated that during a transfer the prior week, the lift stopped working and staff required a key to remove her from the lift and return her to bed. Resident further stated that lift batteries are frequently not charged. Review of the Resident R51's Minimum Data Set (MDS- a federal mandated assessment tool for all residents), dated June 13, 2025, revealed the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired The resident required supervision or touching assistance with activities of daily living (ADLs) and had diagnoses including bipolar disorder, unspecified (a mental health condition characterized by mood swings including depression and elevated mood), neuromuscular dysfunction of bladder (impaired nerve control of bladder function), and morbid obesity (severe excess body weight that increases health risks On May 11 ,2026 at 9:41 am interview with Resident R51 revealed that on several occasions the sit-to-stand lift (a mechanical assist device used to help a resident who can bear some weight transfer safely from one surface to another, such as from a bed to a chair) was inoperable or staff stated the batteries were charging. Resident further stated that nursing aides typically informed him they would return once the equipment was charged to assist him out of bed. On May 11, 2026 at 9:50 am, observation revealed a Hoyer lift stored in the 2nd floor hallway against the wall. At 9:55 am, Unit manager, Employee E5 attempted to power on and operate the Hoyer lift. Initial attempt was unsuccessful. Unit manager, Employee E5 retrieved three separate batteries from the charging station behind the nursing station; each battery was attempted without success. The lift remained inoperable. Interview on May 11, 2026, at 10:11 am, Unit manager, Employee E5 confirmed the Hoyer lift was not functioning and stated it may be a connection issue and a work order would be placed. Unit manager further stated there was no designated staff responsible for ensuring equipment is charged or operational prior to use. Review of Resident R68's Quarterly MDS (an assessment of resident's needs) dated March 2026 revealed the resident was alert and oriented, admitted to the facility on [DATE], diagnosed with respiratory failure and fractures, status- post vehicle accident prior to admission. Further review of the MDS assessment revealed the resident was dependent on staff for transfers, and bathing. Interview with Resident R68 on May 13, 2026, at approximately 11:30 a.m. with the second-floor unit manager voiced concerns with the nursing staff using blood pressure cuffs that were too small for his bariatric sized arm. They use the blue cuff because the larger sized cuff is never available, they will instead put the blue cuff on my forearm and it is too tight and too small and gives an inaccurate reading. During the same interview Resident R68 stated that two aides attempted to transfer him using the sit to stand but instead of using the correct sized belt that is used with the sit to stand the aides wanted to use the body sling used with the Hoyer lift. They had the Hoyer sling around my waist trying to use it as the belt. I saw the Director of Therapy in the hallway and came to help me. Immediately after the interview, the Director of Therapy confirmed that he witnessed the staff attempting to incorrectly use the wrong sized sling for the resident when they were using the sit to stand. Review of the facility's investigation/documentation revealed on May 12, 2026, two aides attempted to utilize the incorrect sling/belt during the mechanical transfer with Resident R68. Review of the nurse aides' witness statements revealed one aide sat with the resident while the other aide went to the laundry room looking for the correct sized sling. The aide stated, I could not find the larger grey pad for the sit to stand. Instead, the aide took a larger hoyer pad even though the aide stated she knew it was the wrong and the resident was getting upset. The other aide went to the laundry room to look for the sling while the one stayed with the resident. Laundry told the aide it must be in the wash. The aide came back from the laundry room and said the resident was upset, looking for the therapist. Review of the facility's Competency Assessment Lifting Machine, Using a Mechanical, skill check list given to the nursing staff indicates, Make sure the battery is charged and Make sure that all necessary equipment (sling, hooks, chains, straps and supports) is on hand and in good condition. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(3)(5)(e)(1) Management

Based on observation, interviews with resident and staff and review of clinical records, it was determined that the facility failed to provide care and services to maintain adequate grooming for one of 24 resident records reviewed (Resident R68). Findings include: Review of Resident R68's Quarterly MDS (an assessment of resident's needs) dated March 2026 revealed the resident was alert and oriented, admitted to the facility on [DATE], diagnosed with respiratory failure and fractures, status post motor vehicle accident prior to admission. Further review of the MDS assessment revealed the resident was dependent on staff for bathing. During an interview with Resident R68 on May 13, 2026 at approximately 11:30 a.m. indicated he had not been given a shower in at least three weeks. The resident said he was not sure why. He said he had only refused a shower one-time because it was late and he was ready to go to bed. Observation of the resident's hair during the interview appeared oily with flakes of skin around the ears. The resident stated his wife has tried washing his hair with a wet towel, but it does not work well. Review of the resident's clinical record revealed the resident received two showers in the past 30 days. The above was confirmed with the Director of Nursing on May 14, 2026, at 11:00 a.m. 28 Pa. Code 201.29(j) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based upon observation, review of clinical records, interviews with facility residents and staff and review of facility policy, it was determined that the facility failed to ensure a resident received the necessary services and treatment to prevent pressure ulcers and to promote healing for one of 24 resident records reviewed (Resident R47)Findings include: Review of facility policy titled, Pressure Injury Risk Assessment revised on March 2020 states, Develop the resident-centered care plan and interventions based upon on the risk factors identified in the assessment, and the resident's overall clinical condition. Review of Resident R47's clinical record revealed the resident was admitted on [DATE], diagnosed with cardiac heart disease, and impaired mobility. Interview with Resident R47 on May 15, 2026, at 10:00 a.m. indicated at times the resident's feet hurt if (he/she) is in bed too long. Observation conducted at the time of the interview, revealed a pair of heel boots near the bedside. The resident was asked if he elevated (his/her) heels when in bed. The resident pointed to the boots that were not in use and said sometimes I use them when the staff put them on me, it helps with the pain. Review of Resident R47's current care plan revealed intervention for the resident's impaired mobility that included keeping the residents' heels elevated in bed with the use of heel boots. Interview with the Unit Manager May 15, 2025, at 10:20 a.m. confirmed the heel boots should be in use at all times while in bed. 28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to ensure that as needed antianxiety medication was discontinued in accordance with the physician for one of 24 records reviewed. Findings include: Review of facility policy titled Medication Regimen Review dated May 20, 2025, revealed the facility policy outlines that medication regimen reviews must be completed for all residents within 14 days of admission and at least every six months thereafter. Residents who are prescribed nine or more medications are subject to mandatory comprehensive review at least every six months. The purpose of the medication regimen review is to evaluate each resident's current medication profile, including prescription and over-the-counter medications. The review is intended to identify potential issues such as medications acting as chemical restraints, adverse drug reactions, medication interactions, and any medication errors occurring since admission. The pharmacist is responsible for conducting on-site reviews of healthcare practitioner prescriptions and resident records for applicable residents. The review must assess whether medications are being used without a valid current indication, whether there are undesired side effects or adverse reactions, and whether any medications are contributing to overuse or inappropriate dosing. Following the review, the pharmacist is required to make recommendations and forward them to the appropriate authorized prescriber for consideration and follow-up. Review of Resident R4's physician order dated October 2, 2025, for Lorazepam (Ativan) 0.5 milligrams, one tablet by mouth as needed (PRN) for anxiety and restlessness, twice daily as needed. The order was written with an indefinite end date. Review of pharmacy documentation dated April 14, 2026, indicated the PRN Lorazepam order remained active despite no documented administration in over 60 days. The consultant pharmacist recommended discontinuation of Lorazepam due to lack of recent use and regulatory concerns related to indefinite PRN psychotropic orders. The resident's physician subsequently agreed and discontinued the medication; however, the original order remained active since October 2, 2025, without a defined stop date or documented ongoing clinical justification.Interview with the Director of Nursing (Employee E2) on May 15, 2026, at 10:35 a.m. confirmed that the medication reviews were not completed correctly and acknowledged the discrepancies identified. 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policies, clinical records, hospital records, care plans, fall investigations, observations, and interviews with staff and residents, it was determined that the facility failed to ensure residents received adequate assistants and interventions to prevent injury for three of 24 resident records reviewed. (Resident R2, Resident R47, Resident 101) Findings include:Review of the facility policy titled Falls Program, dated February 2017, revealed the facility utilizes assessments to identify residents at high risk for falls and implements interventions through the Falling Star Program. The policy further states that high-risk residents are to receive ongoing supervision, staff awareness, environmental safety interventions, and interdisciplinary review of fall risks. Review of the facility policy titled Assessing Falls and Their Causes, dated March 2018, revealed residents are to be routinely assessed for fall risk, with identified risk factors addressed promptly through implementation of safety interventions and monitoring. Review of Resident R47 clinical record revealed the resident was admitted on [DATE], diagnosed with cardiac heart disease, and impaired mobility. During an interview with Resident R47 on May 15, 2026, at 10:00 a.m. three medications revealed in a small cup sitting on the resident's overbed table. The resident was not aware what the medication was for. Observed Resident R47's nurse administering medication to other residents was asked about this medication left on the resident's table. Nurse unaware indicating the resident's medication for this morning was not dispensed and had never had this resident before today, stating, I don't know what kind of medication they are. Regional Registered Nurse Employee E12 observed medication and the RN and the Unit Manager Employee E13 confirmed medication should not be left at bedside. Continuing interview with resident revealed wounds on the resident's lower right leg, open to air with scabbing. The resident was asked about wound and stated, I have very thin skin, it's very fragile. If I bump it, it will bleed easily. I have told the nursing staff to please be careful when they move me. Last week an aide was putting the leg rests on my wheelchair while I was sitting in it. She was not careful and hit my leg. I was upset because it was one more thing I didn't need. Review of Resident R47's physician progress note date May 8, 2026, stated, Patient upset about right shin wound due to transfer to wheelchair - being dressed by nursing. Facility documentation related to the above incident indicated the nurse aide (NA) Employee E10 was not aware of the wound until Resident R47's nurse, Registered Nurse Employee E11 notified the nurse aide. The NA witness statement indicated awareness of the resident's frail skin and how it Cut's easily. Facility documentation indicated the NA was educated to be more mindful when placing equipment on and off wheelchair and of Resident R47's skin integrity. Resident R101 was admitted to the facility on [DATE], following hospitalization for a hip fracture requiring surgical repair after a fall. Review of the admission Minimum Data Set (MDS resident assessment of care needs) dated May 12, 2026, revealed diagnoses including dementia (a progressive neurocognitive disorder characterized by decline in memory, reasoning, judgment, communication, and the ability to safely perform activities of daily living); anxiety disorder, (a mental health condition involving excessive fear, nervousness, worry, or agitation that may interfere with daily functioning and safety awareness); and recent hip fracture status post-surgical repair. Continued review of the MDS revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, and was assessed as rarely or never understanding others or able to express needs. Review of the admission fall assessment dated [DATE], revealed the resident scored 14, indicating moderate fall risk, the assessment identified the resident at moderate risk for falls. Review of the resident's care plan initiated May 9, 2026, identified the resident as being at risk for falls and included interventions such as maintaining the bed in the lowest position, ensuring the call light was within reach, maintaining a clutter-free environment, providing adequate lighting.Review of the physical therapy evaluation dated May 10, 2026, revealed the resident was totally dependent for transfers and mobility, unable to tolerate standing, unable to ambulate, and demonstrated poor balance, weakness, impaired safety awareness, impulsive behaviors, and high fall risk. Review of the fall incident report dated May 10, 2026, revealed the resident experienced an unwitnessed fall in the resident room and was found on the floor by staff. The walker was not within reach. Documentation further indicated the bed was placed in the lowest position only after the fall occurred. Observation conducted on May 11, 2026, at 10:00 am. revealed the resident's bed remained in a high position.Interview with Licensed Nurse, Employee E6 at the time of the above observation revealed she had just received report and was unaware of the resident's specific safety precautions. Employee E6 stated she was unsure what fall prevention or safety interventions should have been implemented for the resident at that time. Interview conducted with the Director of Nursing, Employee E2 on May 15, 2026 at 10:10 am revealed the resident was subsequently placed on low bed positioning and fall-risk precautions. Review of Resident R2's annual MDS dated [DATE], revealed diagnoses including dementia; Huntington's disease, (a hereditary progressive neurological disorder causing involuntary movements, impaired coordination, cognitive decline, behavioral disturbances, and poor safety awareness); psychotic disorder, (a mental health condition involving impaired thinking, altered perception, hallucinations, delusions, or disorganized behavior); malnutrition, (a condition resulting from inadequate nutritional intake or absorption leading to weight loss); and recurrent falls. The resident had a BIMS score of 1, indicating severe cognitive impairment.Review of the resident's current fall's care plan revealed interventions including floor mats on both sides of the bed, pillows for positioning support, maintaining the bed in the lowest position at all times except during care, medication reviews, and ongoing safety monitoring due to psychotropic medication use and Huntington's disease-related involuntary movements. Review of the resident's clinical record revealed repeated falls throughout January 2026, including falls on January 4, January 5 (three falls), January 10, January 11, January 20, and January 21, 2026. Review of the fall risk evaluation dated January 11, 2026, revealed the resident scored 22, identifying the resident as high risk for falls. Additional contributing factors included use of antipsychotic, antidepressant, anxiolytic, and antihypertensive medications, all of which may increase fall risk. Review of the hospital record dated January 21, 2026, revealed the resident was transferred to the hospital following an unwitnessed fall with head strike and head laceration while receiving anticoagulant therapy.Facility investigation findings revealed the resident was found on the floor beside the bed while the bed remained in an elevated position.Interview with the resident's son on May 12, 2026, at approximately 10:30 a.m. revealed he recalled the incident involving the resident's fall and confirmed he was present in the resident's room earlier that morning. The son stated he remembered lowering the resident's bed before leaving the facility and denied ever stating or suggesting that he may have left the bed in an elevated position. The son reported he left briefly to go to the store and returned to the facility after the fall had occurred. Upon his return, the roommate's visitor informed him that nursing staff had entered the room, obtained the resident's vital signs, and left the bed in an elevated position without lowering it afterward.Interview with the Director of Nursing, Employee E2 on May 15, 2026 at 10:10 am regarding falls revealed that families are expected to notify nursing staff when leaving the facility. The DON stated the family was frequently present in the facility and always lets someone know, but ultimately acknowledged facility staff remained responsible for resident supervision and safety monitoring. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews with resident and staff, it was determined that the facility did not ensure that physician orders for daily weights were followed for one of 24 residents reviewed (Resident R47).Findings include: Review of Resident R47 clinical record revealed an admission date of April 23, 2026, diagnosed with cardiac heart failure (the heart does not pump efficiently) with orders for daily weights (weight gain is a marker for heart failure) dated April 25, 2026. The order instructed to contact the physician if a weight gain is more than two pounds in one day or five pounds in one week. On April 29, 2026, Resident R47 was seen by the cardiologist on April 29, 2026 that noted to Monitor daily weights closely.Interview with Resident R47 on May 13, 2026, at 10:00 a.m. stated the staff started to weigh (him/her) daily but stopped. Review of Resident R47's clinical record revealed daily weights were not being obtained as ordered. No evidence of the resident's weights for April 25, 27 and 30, and May 1,2,5,6,7,8,10, and 11, 2026. The above was confirmed with the Director of Nursing on May 13, 2026, at 1:00 p.m.28 Pa. Code:201.18(a)(b)(1)(3) Management28 Pa. Code:211.12(d)(1)(5) Nursing services

Based on record review and staff interview, the facility failed to accurately complete the PASARR (Preadmission Screening and Resident Review) documentation for 4 of 6 residents reviewed for PASARR compliance. (Resident R20, Resident 51, Resident 4 and Resident R2) Findings include: Findings Include:PASRR (Preadmission Screening and Resident Review) is a federally mandated process in the United States designed to ensure that individuals being admitted to Medicaid-certified nursing facilities are appropriately placed and receive the services they need. It requires screening before admission to identify whether a person has a serious mental illness, intellectual disability, or developmental disability, and if so, whether they require specialized services or a different level of care. If the initial screening (Level I) indicates a possible condition, a more detailed evaluation (Level II) is completed to determine appropriate placement and services. PASRR also includes ongoing resident review after admission if a person's condition changes or if additional concerns arise. The purpose of the process is to prevent inappropriate institutionalization and ensure individuals receive care in the most suitable setting. Review of the facility's Mission Criteria policy (dated February 2026, last revised) indicates that all admissions are screened in accordance with the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility completes a Level I PASARR screening for all potential admissions, regardless of payer source, to determine whether an individual may have a mental disorder, intellectual disability, or related condition. If the Level I screening suggests a possible diagnosis, the individual is referred to the state PASARR representative for a Level II evaluation to determine eligibility and any need for specialized or rehabilitative services, as well as appropriate placement. The admitting nurse is responsible for notifying the Social Services Department when a resident may meet criteria, and the social worker completes the required referral to the state authority. The policy applies to all individuals without discrimination based on race, color, religion, national origin, age, sex, gender identity, sexual orientation, marital or veteran status, or payment source. The Administrator and Admissions Department are responsible for ensuring compliance with these procedures. A review of the Pennsylvania PASRR (Preadmission Screening and Resident Review) Level I identification form shows that the process applies to all nursing facility applicants regardless of payer source, and that required PASRR documentation must be completed prior to admission in accordance with federal regulation 42 CFR 483.106. This includes the Level I screening form and, if indicated, a Level II evaluation. Review of Resident R20's Minimum Data Set (MDS), a federally mandated assessment tool, dated July 14, 2025, revealed the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required supervision or touching assistance with activities of daily living (ADLs) and had diagnoses including anxiety disorder (excessive worry or nervousness impacting daily functioning), depression (persistent low mood and loss of interest), and bipolar disorder (a mood disorder characterized by alternating episodes of depression and elevated or irritable mood). Review of the PASARR documentation for Resident R20 revealed discrepancies between the PASARR documentation and the resident's medical record. Specifically, Section III of the PASARR documentation identified only a diagnosis of depression. Further review of the clinical record revealed diagnoses of anxiety disorder, bipolar disorder, and depression. The PASARR documentation did not include the resident's complete psychiatric history and reflected incomplete mental health diagnostic information. Review of Resident R51's Minimum Data Set (MDS), dated [DATE], revealed the resident was admitted on [DATE], with a BIMS score of 12, indicating moderately impaired cognition. The resident required supervision or touching assistance with activities of daily living (ADLs) and had diagnoses including bipolar disorder, unspecified (mood changes occur) anxiety disorder, unspecified (excessive worry occurs) and morbid (severe) obesity due to excess calories (severe excess weight). Further review of the clinical record on May 15, 2026, at 11:03am revealed only the diagnoses of anxiety disorder, and bipolar disorder. The PASARR documentation did not include the resident's complete psychiatric history and reflected incomplete mental health diagnostic information. Record review of May 15, 2026, at 10:54 am revealed Section IX of the form was signed and certified by a facility employee on June 25, 2025, for Resident R 20 and May 23, 2025, for Resident R51 confirming the accuracy of the information provided. An interview was conducted with the Social Worker (E9) on May 15, 2026, at 11:00 AM. The social worker stated that PASARR forms are normally completed upon admission by the admissions department. The social worker further stated she was new to completing PASARR documentation and is working closely with the PASARR nurse. further interview revealed, social worker E9 acknowledged that not all diagnoses had been transcribed onto the PASARR documentation for Residents R20 and R51 and Social Worker E9 confirmed that the forms were incomplete. Review of Resident R2's Minimum Data Set (MDS), dated [DATE], revealed the resident was admitted to the facility on [DATE]. The resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Diagnoses included anxiety, defined as a mental health disorder characterized by excessive worry, nervousness, or fear, and dementia, defined as a progressive decline in cognitive functioning affecting memory, thinking, reasoning, and the ability to perform daily activities. Further review of Resident R2's physician orders revealed an antipsychotic medication Risperidone prescribed for abnormal perception visual (Hallucinations). The review of the resident's PASRR form dated 6/19/2025 revealed that the resident was assessed as not having any mental disability. The PASRR form was signed and dated by staff on 6/19/2025. The resident's PASRR Level I form was completed on June 19, 2025, and is present in the record. Section III, which screens for serious mental illness or related conditions, was left blank, indicating no mental health conditions or diagnoses were identified or reported. The section regarding mental health conditions was not completed with any diagnoses, suggesting no evidence of mental illness was noted at the time of screening. Section IX of the form was signed and certified by a facility employee June 19, 2025, confirming the accuracy of the information provided. Review of the Resident R4's annual Minimum Data Set (MDS) dated [DATE], revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia, a progressive decline in memory, cognition, and the ability to perform daily activities; Huntington's disease, a hereditary neurodegenerative disorder causing movement abnormalities, cognitive decline, and psychiatric symptoms; malnutrition, a condition resulting from inadequate nutritional intake or absorption; psychotic disorder, a mental health condition characterized by impaired thinking and perception that may include hallucinations or delusions; and recurrent falls, indicating repeated episodes of falling associated with impaired mobility, weakness, or cognitive deficits. The resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment with significant deficits in memory, orientation, and recall abilities, with no behavioral symptoms noted. The resident received medications including antipsychotics, used to manage psychosis or severe behavioral symptoms; anxiolytics, prescribed to reduce anxiety; antidepressants, used to treat depressive symptoms; and antiplatelet. The resident's PASRR Level I form was completed on April 15, 2025, and is present in the record. Section III, which screens for serious mental illness or related conditions, was left blank, indicating no mental health conditions or diagnoses were identified or reported. The section regarding mental health conditions was not completed with any diagnoses, suggesting no evidence of mental illness was noted at the time of screening. Section IX of the form was signed and certified by a facility employee on April 15, 2025, confirming the accuracy of the information provided. Interview with [NAME] on May 15, 2026 revealed that she is new to the task of completing PASRRs and confirmed that the forms are incomplete. 28 Pa. Code 201.18 (a)(1)(2) Management 28 Pa. Code 201.24(f) admission 28 Pa. Code 211.15 (f)(v) Medical Records

Based on clinical record review, interviews with staff, review of hospital records and review of policy and procedure, it was determined that the facility failed to ensure that each resident maintained acceptable parameters of nutritional status for usual body weight or desirable body weight for one of twelve residents reviewed. (Resident R1)Findings include: A review of the facility policy and procedures titled nutritional assessment dated 2001 revealed that the physician, dietitian and nursing staff were responsible for the nutritional assessment and care of each resident. The policy indicated that a nutritional assessment was required when a resident experienced a change in condition. The policy indicated that the interdisciplinary team would use data gathered throughout the resident's stay to provide important interventions to meet the nutritional needs of each resident. The nutritional assessment was to identify a description of the resident's usual intake and appetite, advanced directives, usual meal and snack patterns, preferred portion size of food and current clinical conditions and events that affect each resident's nutritional status. The policy indicated that the dietitian was to assess and monitor each resident's nutritional intake and determine if it was adequate to meet his or her nutritional needs. The Dietitian was responsible for identifying increased need for calories and or protein due to onset or exacerbation of disease or conditions that result in a hypermetabolic state and increased demand for calories and protein. Clinical record review for Resident R1 revealed a quarterly MDS (Minimum Data Set- assessment of resident needs) dated October 11, 2025, that indicated Resident R1 had diagnoses of urinary tract infection and malnutrition (deficiencies or imbalances in a person's intake of energy or nutrients). The MDS assessment also indicated that Resident R1 was 66 inches in height and weighed 130 pounds. This assessment said that Resident R1 was on a physician prescribed weight gain regimen. Continued review of Resident R1's quarterly assessment dated [DATE], indicated Resident R1 had a pressure ulcer on the skin, a diagnosis of malnutrition and was 66 inches in height and weighed 122 pounds. The assessment indicated that Resident R1 was eating 25% or less of total calories provided. Review of a wound care assessment dated [DATE], revealed that Resident R1 developed a right lateral ankle-deep tissue injury measuring 4.8 centimeters (cm) by 4.1 cm by .1 cm depth. The physician ordered a treatment of cleansing the wound with a cleanser and applying betadine daily, leave open to air. The physician also ordered a nutritional supplement of active liquid protein for 30 grams protein and 140 calories on January 27, 2026. Review of nursing note dated February 11, 2026, indicated that the resident was identified with a right lateral leg wound. The nursing documentation also indicated that the physician had ordered that a treatment be applied to Resident R1's right lateral leg. The treatment documented by the nurse was cleansing the right lateral leg with wound cleanser and applying xeroform and dry dressing daily. Review of the wound consultant assessment dated [DATE], revealed that the resident was assessed with a Stage IV (ulcer involving loss of skin layers, exposing muscle) on the right lateral calf, measuring 12.7 cm by 3.9 cm by .1cm with tendon exposed. The treatment was a wound cleanser, apply Medi honey, ABD pad and Kling daily. The wound report also indicated that the right later ankle was continuing as an unstageable wound measuring 2.3 cm by 2.1 cm with no depth. The treatment ordered for the right lateral ankle pressure injury was wound cleanser and apply betadine daily. Interview with the director of nursing, Employee E2 at 10:30 a.m., on March 17, 2026, confirmed the wound care assessment dated [DATE], whereby Resident R1 had a stage IV pressure injury of the right lateral calf and an unstageable wound located on the right lateral ankle. Review of the Registered Dietitian evaluation dated October 8, 2025, indicated that Resident R1 had a height of 66 inches and an ideal body weight of 142 pounds. The resident's actual weight was 129.6 pounds on October 8, 2025. The nutrition care planned was for Resident R1 to gain weight to ideal body weight of 142 pounds. Review of the Registered Dietitian's progress note dated November 6, 2025, indicated that Resident R1 experienced a significant weight loss that was recorded at 122 pounds. On December 31, 2025, the Dietitian indicated that Resident R1 was 122 pounds, not 215.8 pounds as documented by the nursing staff on December 31, 2025. Interview with the director of nursing, Employee E2 at 10:35 a.m., on March 17, 2026, confirmed the weight recorded for Resident R1 on December 31, 2025, was 122 pounds. The director of nursing, Employee E2 also confirmed a weight of 122 pounds recorded by the nursing staff on February 26, 2026. Clinical record review for Resident R1 revealed poor evening meal consumption of food and fluids for 12 of 28 days reviewed for the month of February 2026. Further review revealed poor evening snack consumption for 21 of 28 days for the month of February 2026. Interview with the director of nursing, Employee E2 at 10:45 a.m., on March 17, 2026, confirmed the poor food and fluid intake during evening meals for twelve of twenty-eight days reviewed for the month of February 2026 as documented by the nursing staff. Further interview with the director of nursing, Employee E2 confirmed poor evening snack consumption for twenty-one of twenty-eight days during the month of February 2026, as recorded by the nursing staff. Clinical record review for Resident R1 revealed poor intake of foods and fluids at meals for March 1 through March 4, 2026. Further review revealed poor intake of the evening snack of foods and fluids for March 1 through March 4, 2026. Interview with the director of nursing, Employee E2, at 10:50 a.m., on March 17, 2026, confirmed the poor food and fluid intake at breakfast and dinner on March 2, 2026, for Resident R1, no documented food consumption of food or fluid intake during the noon meal on March 3, 2026, and the poor amount eaten at the dinner meal on March 4, 2026. There was no documentation to indicate that a nutritional assessment, was completed by the Registered Dietitian for the months of February or March 2026 for Resident R1. The Dietitian failed to evaluate Resident R1 despite a diagnosis of malnutrition, having no evidence of weight gain, or poor consumption of foods and fluids during the months of February and March 2026. There were no nutritional care planning changes or updates to Resident R1's diet for February or March 2026. The resident remained on a regular pureed diet with house shake 4 ounces twice a day and protein liquid twice a day. Interview with the Administrator, Employee E1 at 1:00 p.m., on March 17, 2026, confirmed the lack of documented assessment, monitoring and nutrition care plan revision and implementation of nutritional approaches and measures to ensure Resident R1 maintained acceptable parameters of nutritional status. Hospital record review for Resident R1 revealed that this resident was admitted to the hospital on [DATE]. The physician indicated that Resident R1 assessed with osteomyelitis (severe infection of the bone) of the right leg to include the tibia (shin bone), fibula (leg bone) and ankle. 28 PA. Code 211.10 (c) Resident care policies28 PA. Code 211.12(d)(3)(5) Nursing services

Based on interviews with staff, and clinical record reviews, it was determined that the facility failed to ensure that clinical records were accurately documented for one of twelve residents reviewed. (Resident R1)Findings include: A review of the facility policy and procedures titled nutritional assessment dated 2001 revealed that the physician, dietitian and nursing staff were responsible for the nutritional assessment and care of each resident. The policy indicated that a nutritional assessment was required when a resident experienced a change in condition. The interdisciplinary team would use data gathered throughout the resident's stay to provide important interventions to meet the nutritional needs of each resident. The nutritional assessment was to identify a description of the resident's usual intake and appetite, advanced directives, usual meal and snack patterns, preferred portion size of food and current clinical conditions and events that affect each resident's nutritional status. The policy indicated that the dietitian was to assess and monitor each resident's nutritional intake and determine if it was adequate to meet his or her nutritional needs. The Dietitian was responsible for identifying increased need for calories and or protein due to onset or exacerbation of disease or conditions that result in a hypermetabolic state and increased demand for calories and protein. Clinical record review for Resident R1 revealed a quarterly Minimum Data Set (MDS- assessment of resident care needs) assessment dated [DATE], that indicated Resident R1 was 66 inches in height and weighed 215 pounds. Clinical record review revealed a Dietitian's progress note dated December 31, 2025, noted that Resident R1 was 122 pounds, not 215.8 pounds as documented by the nursing staff on December 31, 2025. Interview with the director of nursing, Employee E2 at 10:35 a.m., on March 17, 2026, confirmed the weight recorded by the nursing staff for Resident R1 on December 31, 2025, was 122 pounds. The director of nursing, Employee E2 also confirmed a weight of 122 pounds that was recorded by the nursing staff on February 26, 2026, for Resident R1. 28 PA. Code 211.10 (d) Resident care policies

Based on observations, interviews with staff, and review of facility policies it was determined that the facility failed to ensure prevention of accidents and hazards related to unattended medication carts and medications for two of two nursing units reviewed. (First floor and Second floor)Findings Include: Review of facility policy titled, Administering Medications dated April 2019. Review of policy states, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Further review of facility policy revealed Policy Interpretation and Implementation- .20. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on the second floor on December 31, 2025 revealed a licensed nurse Employee E4 not observed around the medication cart assigned to them at 9:41 a.m. The medication cart had the narcotic book out and open, the medication cart was unlocked, resident information was up on the computer screen including the photograph. A second cart was observed at 9:44 a.m. to the right of the first nursing cart also unlocked with just a cellphone on top of the cart. At 9:46 a.m. the medication cart that was unlocked was identified a licensed nurse Employee E4 stated, the resident a few rooms down was having pain so I went to them to administer the pain medication. When asked the licensed nurse Employee E4 stated, they don't move the carts here from room to room, but I can if you want me to I can. The licensed nurse stated that she got moved units so there was confusion on what residents she had. When asked how many residents the licensed nurse was assigned to they stated 29 after counting the census sheet. At 10:25 a.m. licensed nurse Employee E4 asked the surveyor if a cellphone left on the second medication was hers and she stated no. The licensed nurse Employee E4 confirmed that the other cart was also left unlocked and that it was her cart as well. Further observation on the second hall on the second-floor nursing unit revealed licensed nurse Employee E3 was seen observed at 10:21 a.m. at the medication cart. Once the surveyor passed Resident R5's room, Employee E3 was observed leaving the medication cart and going into Resident R5's room empty handed and walking out with a medication cup in hand containing several pills. When asked the licensed nurse Employee E3 stated that she went to crush R5's roommate Resident 4's medication while she was waiting for Resident R5 to take her medication. The medication cart was located two rooms down from Resident R5's room on the opposite side of the hallway. When asked if this was standard practice the nurse stated that it was not. When asked how many residents the licensed nurse had today Employee E3 counted the census sheet and was assigned 31 residents for day shift and at the time was still completing morning medication pass. Observation of the first-floor nursing unit at 11:01 a.m. revealed a medication cart which was left unlocked with the resident information up on the computer. At 11:03 a.m. licensed nurse R5 came to the medication cart to lock it and close the screen on the computer. When asked if it was normal practice to leave the cart unlocked and screen visible the licensed nurse Employee E5 stated it is not. 28 Pa. Code 201.14(a) Responsibility of licensee28 PA. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and review of clinical record, it was determined that the facility failed to ensure timely and accurate medication administration for two of five residents reviewed (Resident R1, and Resident R6)Review of facility policy 'Administering medications,' revised April 2019, indicates that medications are to be administered in a safe and timely manner as prescribed. Further review of policy indicates that medications are administered in accordance with prescriber orders, including any required time frames. Review of Resident R1's electronic medication administration report (e-MAR), dated September 21, 2025, revealed an order for Carbidopa Levodopa, extended release 70-280 milligrams (mg), scheduled to be administered at 9:00 am for Parkinson's disease (progressive disease of the central nervous system). Further review of the e-MAR revealed that the medication was not administered until 3:49 pm. Continued review of the e-MAR revealed the medication Keppra, 500 mg, was scheduled to be administered at 9:00 am for seizure disorder, but was not administered until 6:59 pm. Further review of audit e-MAR indicated that Escitalopram, 20 mg, was scheduled to be given at 9:00 am. Further review of the e-MAR revealed that the medication was not administered until 3:48 pm. Continued review of the e-MAR, indicated Medline active liquid protein, 30 mls, was scheduled to be given at 8:00 am. Further review of the e-MAR revealed that the medication was not administered until 3:46 pm. Review of Resident R6's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Congestive Heart Failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, causing fluid to back up (congest) in the lungs, legs, and other areas, leading to symptoms like shortness of breath, fatigue, and swelling), Hypertension (high blood pressure), Depression (sadness and loss on interest), Atrial Fibrillation (type of irregular heartbeat (arrhythmia), where the heart's upper chambers quiver chaotically) Observation and interview held with Resident R6 on December 31, 2025 at 10:13 a.m. Resident R6 had not received their medications at the time of interview on December 31, 2025. Review of facility medication administration times revealed medication are administered at 8AM or 9AM with an hour window given before or after. Observation on December 30. 2025 of the second-floor nursing unit revealed licensed nurse Employee E3 was observed at 10:21 a.m. at the medication cart crushing medications. Once the surveyor passed Resident R5's room, Employee E3 was observed leaving the medication cart and going into Resident R5's room empty handed and walking out with a medication cup in hand containing several pills. When asked the licensed nurse Employee E3 stated that she went to crush Resident R5's roommate (Resident 4's) medication while she was waiting for Resident R5 to take her medication. The medication cart was located two rooms down from Resident R5's room on the opposite side of the hallway. When asked if this was standard practice to leave medications beside with a resident, the nurse stated that it was not. When asked how many residents the licensed nurse had today Employee E3 counted the census sheet and was assigned 31 residents for day shift and stated at the time she was still completing morning medication pass. Review of the facility grievance log revealed a grievance for Resident R9 dated November 10, 2025 stated, Grievance Details- Patient's sister complained he did not receive his meds on time. Further review of the grievance form revealed that, Summary of findings- There was a delay in medication administration. Resolved Note- Education will be provided to the nurse regarding the importance of administering medications in a timely and consistent manner. Per patient's sister request, this nurse will no longer be assigned to the patient's room. No further concerns at this time. Review of facility grievance log revealed a grievance for Resident R10 dated September 21, 2025 stated, Grievance Details-Patient complained her medication was late. Further review of the grievance form revealed that, Summary of findings- The Nurse was covering another nurse that day. She indicated that medications were late, but she then got to administer the medications as soon as she could. Resolved Note- Nurse will be verbally educated on giving residents medications in a timely manner. 28 Pa Code 211.12(d)(1) Nursing services

Based on review of facility provided documentation, it was determined that the facility failed to address residents' concerns related to late call bell response time three of six residents reviewed. (Resident R3, R4, R5) Findings include:During interview with Resident R3, on Monday, December 1, 2025 at 11:10 am, room [ROOM NUMBER]-A, he reported waiting excessively long time for response from nursing staff during overnight shifts, 11 pm to 7 am.Review of facility provided grievance reports for month of November 2025 revealed care concern was submitted on November 2, 2025 regarding Resident R4, and untimely hygiene care; unidentified shift.Further review of grievance reports revealed care concern was submitted on November 2, 2025, regarding Resident R5 and call bell response time; unidentified shift.Further review of facility report submitted to the State Survey Agency, dated November 18, 2025, revealed Resident R5's concern related to waiting long periods for care, and not cleaned properly after being soiled; unidentified shift.Review of facility provided call bell audits for month of November 2025 revealed that audits were mainly completed during day and evening shifts, unidentified times, and excluding room #'s from which concerns were reported.Further review of call bell audits, dated November 22, 2025, revealed unidentified shift and time, noting one hour wait time for call bell response from 2:30 pm to 3:30 pm. 28 PA Code 201.18(b)(3) Management

Based on review of facility provided documentation, interview with residents and observations, it was determined that facility did not ensure that call bells were properly functioning for one of six residents reviewed. (Resident R2) Findings include: Review of facility current policy 'Answering the Call Light,' indicates that purpose of this procedure is to ensure timely responses to the resident's requests and needs.Further review of policy indicates that staff are to ensure that the call light is plugged in and functioning at all times, and report all defective call lights promptly.During interview with Resident R2 on Monday, December 1, 2025 at 11:30 am, room [ROOM NUMBER]-B, the resident reported that his call bell had not function for a while and did not bother reporting it since (his/her) other concerns were unaddressed as well.Further observation of Resident R2's environment revealed non-functioning call bell system. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of employee files, and staff interviews, it was determined that the facility failed to provide training upon hire on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse for thirteen of forty employees reviewed (E11, E12, E15, E16, E17, E18, E19, E20, E21, E31, E32, E33, E34) Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 states, Policy Interpretation and Implementation- The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. Review of the Staff Development employee's job description revealed under Administrative Functions, Ensure that all personnel attend and participate in annual Center in-service training programs (e.g . Abuse Prevention .). Employee training records were requested for Employee E11, E12, E22, E23 on May 15, 2025 at 1:00 p.m. from the Nursing Home Administrator Employee E1 and Regional Director of Nursing Employee E3. A second request was made for Employees E11, E12, E22, and E23 on May 16, 2025. Employees E11, E12, E22, and E23 records were reviewed and none of them had abuse trainings records. Interview held with Scheduling/ Payroll staff, Employee E7 was asked to provided abuse training records and she stated, that would be the training department Staff Development, Employee E6. Interview with Staff Development Employee E6 on May 16, 2025 at 11:26 a.m. I would be responsible for making sure staff complete the trainings. Employee E6 was asked to pull up proof of Abuse training for Employees E22, E11, E12, and E23. Employee E6 pulled up each employee's online professional trainings individually and stated that there was nothing when each employee was pulled up individually and spelling of names were checked. When asked who was responsible for ensuring staff are training on abuse, neglect, and exploitation she said, I am but a lot of these people I don't see or I haven't seen. An additional request for abuse training records for all Employees hired since January 1, 2025 revealed serval staff not having documented evidence that the facility provided training for nine employees (E11, E12, E15, E16, E17, E18, E19, E20) on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse evidence that the facility provided training on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse. Review of facility training records revealed Central Supply, Employee E11 was hired March 4, 2025 and had no evidence of abuse training. Review of facility training records revealed Maintenance Employee E12 was hired on February 3, 2025 and had no evidence of abuse training. Review of facility training records revealed Licensed Nurse Employee E15 was hired on April 22, 2025 and had no evidence of abuse training. Review of facility training records revealed Licensed Nurse Employee E16 was hired on April 16, 2025 and had no evidence of abuse training. Review of facility training records revealed Licensed Nurse Employee E17 was hired on April 14, 2025 and had no evidence of abuse training. Review of facility training records revealed Nurse Aide Employee E18 was hired on March 11, 2025 and had no evidence of abuse training. Review of facility training records revealed Nurse Aide Employee E19 was hired on March 11, 2025 and had no evidence of abuse training. Review of facility training records revealed Nurse Aide Employee E20 was hired on March 4, 2025 and had no evidence of abuse training. Review of facility training records revealed Licensed Nurse E21 was hired on February 25, 2025 and had no evidence of abuse training. Further review of the new hire list since January 2025 revealed the following staff hired and not trained upon hire on a policy that includes abuse, neglect, exploitation, and misappropriation: Licensed Nurse Employee E31 was hired on April 8, 2025 and did not receive training until April 25, 2025. Nurse Aide Employee E32 was hired on March 18, 2025 and did not receive training until April 30, 2025. Nurse Aide Employee E33 was hired on March 4, 2025 and did not receive training until April 14, 2025. Maintenance Employee E12 was hired on February 2, 2025 and did not receive training until April 8, 2025. Licensed Nurse Employee E34 was hired on January 28, 2025 and did not receive training until April 2, 2025. Facility was provided additional time to submit documentation related to abuse training for the above employees, however no documentation was provided. 28 Pa Code 201.18(e)(1) Management.

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to hopsice services, enternal feeding, and intravenous device for three of nineteen records reviewed (Resident R18, R36, and R80). Findings include: Review of facility policy titled, Care Plans, Comprehensive Person-Centered revised March 2022 states, Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS statement. Review of Resident R18's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Hyptertensive Heart Disease with Heart Failure, Aphasia (difficulty speaking), and Adult Failure to Thrive. Review of Resident R18's hospice records revealed the resident entered into hospice services on April 16, 2025. Review of Resident R18's care plan revealed the resident did not have a had a care plan in place to address the goals and/or interventions for hospice services. Review of Resident R36's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Dysphagia (inability to swallow), Dementia (progressive degenerative disease of the brain), Type 2 Diabetes (failure of the body to produce insulin) and gastrostomy (a surgical placed device used to give direct access to the stomach for supplemental feeding, hydration or medication). A tour was taken of the first floor nursing unit on May 13, 2025 at 10:30 a.m. After entering Resident R36's room it was noted that the Resident R36 had an enternal tube feed placed next to her bed that was engaged. Review of Resident R36's physician orders revealed a physician order from February 11, 2025 of Start Tube Feed at 2PM via PEG tube. Review of Resident R36's current care plan dated September 10, 2024 states, Resident has an enternal feeding tube to meet nutritional needs, Date Initiated: 08/20/2024 Cancelled Date: 09/10/2024 Review of Resident R36's current plan revealed there is no current goal or interventions for the residents enternal feeding. Review of Resident R80's clinical record revealedthat the resident was oriented to person, with medical history of severe intellectual disability, borderline personality disorder, anxiety disorder, cognitive communication deficit. Review of facility provided incident list for months of April 2025 and May 2025, revealed that Resident R80 had a 'medical device/tube dislodgment' three times for the month of April 2025; on April 23, 2025 at 9:42 p.m., April 23, 2025 at 6:30 a.m., and April 18, 2025 at 4:00 p.m Review of nursing notes, dated April 23, 2025 at 8:15 a.m., revealed that the resident had right hand peripheral intravenous line placed for IV (intravenous) fluids and received 600 ml out of 100 ml of normal saline solution before pulling out IV. Further review of nursing progress notes, dated April 24, 2025 at 1:49 a.m., revealed that at approximately 9:30 p.m., resident was found with disconnected IV tubing again. It was also noted that this resident flooded her bathroom into the hallway Further review of R80's nursing progress notes, dated April 18, 2025 at 1747, revealed that On 4/18/25, resident's IV dislodged, MD into visit received order to start hypodermoclysis (method of infusing fluids into the subcutaneous tissue to rehydrate a patient). Review of incident report completed on Friday, April 18, 2025 at 4:00 p.m., revealed that staff were warned prior to administration by case manager that resident may pull IV out as she has done so in the hosptal. Root cause for dislodgement was due to resident diagnosis of intellectual disabiity (IDD) and nonverbal and does not understand necessity of the ivf's. Review of incident report completed on April 23, 2025 at 0942, indicates peripheral IV line was dislodged again due to resident's behavior and related to IDD diagnosis and inability to understand need. Review of R80's care plan revealed no evidence of goals and interventions related to resident's mental status and non-compliance with intravenous line device. 28 Pa Code 211.10(d) resident care policies 28 Pa Code 211.12©(d)(1) nursing services

Based on review of facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluations were completed for four of four nurse aides reviewed (Employees E24, E25 E26, and E27) Findings include: On May 14, 2025, annual performance reviews were requested from Staff Development, Employee E6 for Employees E24, E25, E26, E27. The facility did not provide the annual performance reviews requested for Employees E24, E25, E26, and E27 on May 16, 2025. Interview on May 16, 2025 at 11:26 a.m. with Staff Development, Employee E6 revealed that the facility had not completed any performance reviews for any staff for the current year (2025). Employee E6 stated that there were no record from the past year (2024), including Employees E24, E25, E26 and E27. Employee E6 stated that the old company took all of those records. When asked if the Staff Development, Employee E6 had completed any performance evaluations for the year of 2025, Employee E6 stated, No, they are not due till June so they told me to hold off on completing them. Nurse Aide Employee E24 was hired on May 12, 2024 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025. Nurse Aide Employee E25 was hired on September 1, 2004 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025. Licensed Nurse Employee E26 was hired on September 8, 2016 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025. Licensed Nurse Employee E27 was hired on October 8, 2015 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025. 28 Pa Code 201.19(2) Personnel Policies and Procedures

Based on reviews of the facility assessment, staff training and competency skill sets to provide care and services to assure residents' safety and ensure that each resident attained or maintained their highest practicable well-being, it was determined that for two of two licensed nursing staff reviewed, the facility failed to have records of training and competencies available for review. (Employees E5 and E27) Findings include: A review of the facility assessment indicated that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care. Employee E26, a registered nurse was hired on September 8, 2016. There was no annual training and competencies available for review for the resident care areas of medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment and safe transfers during care. Employee E27, a registered nurse was hired on October 8, 2015. There was no annual training and competencies available for review for the resident care areas of medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment and safe transfers during care. Interview with the designated nurse trainer/instructor/facilitator Employee E6, at 9:00 a.m., on May 16, 2025 confirmed that these necessary trainings and competency sets were not documented or available for review for nursing staff (Employees E5 and E27) selected for review. 28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures

Based on clinical record reviews, interviews with residents and staff and reviews of policies and procedures and hospital records, it was determined that the facility failed to ensure that residents with bowel and bladder incontinence received care to maintain, restore or improve bowel and bladder function for two of five residents reviewed. (Residents R8 and R41) Findings include: Review of the facility policy titled urinary continence and incontinence assessment and management dated August 2022 revealed that it was the responsibility of the staff to screen for management of individuals with urinay incontinence. The policy indicated that staff will provide appropriate services and treatment to ensure residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Hosptal record review indicated that Resident R41 was admitted to the hospital on [DATE] and was treated for nephrolitiasis (kidney stones). Clinical record review for Resident R41 revealed an admission comprehensive MDS (Minimun data Set- assessment of resident's needs) assessment dated [DATE] that indicated this resident was cognitively intact. The assessment also indicated that the resident was dependent for toileting (ability to maintain perineal hygiene after use of the bedpan, toilet, commode or toilet). The assessment also indicated that this resident was frequently incontinent of bladder and had no functional impairments of the upper and lower extremities. Interview with Resident R41 at 11:30 a.m., on May 13, 2025 revealed that the resident was tired of wearing the brief and wanted to try a toileting program. Clinical record review revealed that there was no documentation to indicated that a voiding study to determine voiding patterns or types of incontinence had been developed and implemented for Resident R41. Clinical record review revealed that there was no documentation to indicate that a toileting trial and its' results had been implemented for Resident R41's care needs for urinary incontinence Interview with registered nurse, Employee E31 at 10:30 a.m., on May 14, 2025 confirmed that Resident R41 was able to let staff know when he had to have assistance with toileting and toileting transfers. The registered nurse, Employee E31, also confirmed that Resident R41 was wearing a brief and was not trialed for a toileting program based on a documented voiding trial. Clinical record review for Resident R8 revealed an admission comprehensive assessment (MDS-an assessment of care needs) dated April 26, 2025 that indicated this resident was frequently incontinent of urine and at risk for pressure ulcer development, having a stage II (ulcer involving loss of the top layers of the skin) pressure ulcer. The assessment also indicated that Resident R8 was alert and oriented and had no upper or lower extremity impairments. The assessment also said that Resident R8 was toilet, chair/bed transfer dependent, non-ambulatory and dependent on staff to assist with a roll left to right while in bed. Interview with Resident R8 at 11:00 a.m., on May 16, 2025 revealed that the resident was able to left staff know when she needed toileting. The resident said that it comes quick and hard to hold her bladder. Resident R8 explained that she would be willing to try a bedpan for her toileting needs; instead of a brief. Clinical record review revealed that there was no documentation to indicated that a voiding study to determine voiding patterns or types of incontinence had been developed and implemented for Resident R8. Clinical record review revealed that there was no documentation to indicate that a toileting trial and its' results had been implemented for Resident R41's care needs for urinary incontinence. Interview with Resident R8's nursing assistant, Employee E25, at 11:10 a.m., on May 16, 2025 revealed that Resident R8 could hold the enabler side rail for turning in bed with staff assistance. The nursing assistant confirmed that Resident R8 was alert and oriented and able to let staff know about her toileting needs. 28 PA. Code 211.12(d)(1)(3)(5) Nursing services 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies

Based on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides record reviewed. (Employees E24 and E25). Findings include: A review of the facility assessment revealed that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care. Employee E24, nursing assistant was hired on March 12, 2024. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Employee E25, nursing assistant was hired on September 1, 2004. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant. Interview with the designated nurse trainer/instructor/facilitator, Employee E6, at 9:00 a.m., on May 16, 2025 confirmed that the necessary trainings and competency sets for (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented or available for review for nursing staff (Employees E5 and E27) that were selected for review. 28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures

Based on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency and the State Long-Term Care Ombudsman program phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units) Findings include: During an observation of First Floor nursing units on May 13, 2025 at 11:44 a.m. revealed there was no posting for the required Department of Health contact information or required postings for the State Long-Term Care Ombudsman. A tour of the lobby area revealed there was a standard size page for the contact information for the State Long-Term Ombudsman in the entry way between the two glass entry doorways. Resident Council meeting was held on May 14, 2025, at 10:15 a.m. held on the second floor with four alert and oriented residents reported that they were not aware how to contact the State Department of Health or Ombudsman Office and have not seen any postings in the building. (R17, R58, R61, R77) Observations during a tour with the Director of Social Services, Employee E8 of the Second Floor Nursing unit on May 14, 2025 at 11:05 a.m. revealed there were no postings for the required Department of Health or the State Long-Term Care Ombudsman. The Nursing Home Administrator Employee E1 on May 14, 2025, at 3:06 p.m. confirmed the posting of the Ombudsman contact information was only posted in the entry way between the two glass entry doorways. There was no posting of the State Department of Health and Ombudsman contact information readily available on the Second floor. There was no Department of Health information posted in the facility. 28 Pa. Code: 201.18(a)(e)(1) Management 28 Pa. Code: 201.18(b)(1) Management