Every finding on record at Woodhaven Health & Rehab Center

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of fourteen residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).Findings include: Review of the facility policy Inventory Control of Controlled Substances last reviewed 3/31/26, indicated A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile current inventory to the controlled mediation declining inventory record and to the residents MAR (medication administration record). Review of Resident R1's MAR (medication administration record) for July and August 2026, revealed an order for Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) to be given every eight hours as needed for pain. Review of Resident R1's Individual Narcotic Log (7/15/26 - 8/5/26) indicated that ten additional doses of tramadol were signed out without corresponding documentation of administration to the resident on 7/17/26, 7/19/26, 7/27/26 x2, 7/28/26 x2, 7/29/26, 7/31/26, 8/4/26, and 8/5/26. Review of Resident R2's MAR for July and August 2026, revealed an order for oxycodone 5 mg (a narcotic pain medication used to treat moderate to severe pain) to be given every four hours as needed for pain. Review of Resident R2's Individual Narcotic Log (7/16/26 - 8/7/26) indicated that 28 doses of oxycodone were signed out without corresponding documentation of administration to the resident on 7/16/26 x2, 7/17/26, 7/18/26 x2, 7/19/26, 7/21/26, 7/22/26 x2, 7/23/26 x2, 7/24/26 x2, 7/26/26 x2, 7/27/26 x3, 7/29/26, 7/30/36 x2, 8/2/26, 8/5/26, 8/6/26 x2, and 8/7/26 x2. Review of Resident R3's MAR for July 2026, revealed an order for oxycodone 5mg to be given every four hours as needed for pain. Review of Resident R3's Individual Narcotic Log (7/15/26 - 7/28/26) indicated that 18 additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 7/16/26, 7/17/26 x2, 7/18/26 x2, 7/19/26 x2, 7/20/26, 7/21/26, 7/22/26, 7/23/26, 7/24/26, 7/26/26, 7/27/26 x4, and 7/28/26. Review of Resident R4's MAR for July 2026, revealed an order for oxycodone 10 mg to be given every six hours as needed for pain. Review of Resident R4's Individual Narcotic Log (7/6/26 - 7/24/26) indicated that five additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 7/10/26, 7/11/26 x2, 7/12/26, and 7/20/26. Review of Resident R5's MAR for July 2026, revealed an order for hydrocodone/ acetaminophen 10-325 (hydrocodone, an opiate narcotic pain medication and acetaminophen) to be given every six hours as needed for moderate pain. Review of Resident R5's Individual Narcotic Log (7/4/26 - 7/24/26) indicated that four additional doses of hydrocodone/ acetaminophen were signed out without corresponding documentation of administration to the resident on 7/4/26 x2, 7/17/26, and 7/18/26. Review of Resident R6's MAR for July 2026, revealed an order for hydrocodone/ acetaminophen 10-325 to be given every six hours as needed for moderate pain. Review of Resident R6's Individual Narcotic Log (7/1/26 - 7/31/26) indicated that 16 additional doses of hydrocodone/ acetaminophen were signed out without corresponding documentation of administration to the resident on 7/4/26 x2, 7/7/26, 7/9/26 x2, 7/11/26 x2, 7/13/26, 7/14/26, 7/20/26, 7/21/26, 7/22/26, 7/23/26, 7/24/26, 7/27/26, and 7/28/26. Review of Resident R7's MAR for July and August 2026, revealed an order for Tramadol 50mg to be given every six hours as needed for pain. Review of Resident R7's Individual Narcotic Log (7/1/26 - 8/6/26) indicated that five additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 7/13/26, 7/19/26, 7/28/26 x2, and 8/4/26. Review of Resident R8's MAR for August 2026, revealed an order for oxycodone 5 mg to be given every eight hours for as needed for pain. Review of Resident R8's Individual Narcotic Log (8/1/26 - 8/7/26) indicated that eight additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 8/1/26 x2, 8/2/26, 8/4/26, 8/5/26 x2, 8/6/26, and 8/7/26 x2. Review of Resident R9's MAR for August 2026, revealed an order for oxycodone 5 mg to be given every six hours for as needed for pain. Review of Resident R9's Individual Narcotic Log (8/1/26 - 8/7/26) indicated that two additional doses of oxycodone were signed out without corresponding documentation of administration to the resident on 8/2/26 and 8/5/26. During an interview on 8/8/26, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain controlled substances were accounted for accurately for nine of fourteen residents. 28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, observations and staff interview, it determined the facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness in one of one deep freezer and one of one milk coolers and failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line, which created the potential for food borne illness. Findings include: Review of the facility policy Storage of Frozen Foods, dated 3/31/26, with a previous date of 1/1/25, indicated that frozen foods will be stored at appropriate temperatures and methods which promote food quality and safety. Review of the facility policy Storage of Refrigerated Foods, dated 3/31/26, with a previous date of 1/1/25, indicated that refrigerators will be maintained at temperatures of 41 degrees or below. Refrigerators in the facility shall be equipped with an internal thermometer. Review of the facility policy Employee Sanitary Practices , dated 3/31/26, with a previous review date of 1/1/25, indicated all food and nutritional staff will practice good personal hygiene and safe food handling practices. Employees will wash hands and use gloves per policy. Review of the facility policy Dress and Personal Hygiene, last reviewed on 3/31/26, with a previous review date of 1/1/25, indicated that nutritional services staff are expected to wear a clean and appropriate hairnet/restraint and cover ALL hair. Beards and facial hair will be contained. During the initial Main Kitchen tour on 5/27/26, from 8:45 a.m., through 9:09 a.m., the following was identified: Milk cooler had no internal thermometer. Package of unsealed hash browns in freezer exposing the hash browns to potential ice. During an interview on 5/27/26, at 9:09 a.m., Certified Dietary Manager Employee E3 confirmed that the facility failed to properly store refrigerated and frozen foods which created the potential for foodborne illness in one of one deep freezer and one of one milk coolers. During the tray line food service on 5/28/26, from 11:35 a.m., through 11:48 a.m., the following was observed: [NAME] Employee E1 had long thick hair extending out of the hair net which had covered only the top of his hairline. Dietary Aide Employee E2 had the back of his hair uncovered. [NAME] Employee E1 was serving foods and left tray line to cover hair, the Certified Dietary Manager Employee E3 initially did not go to tray line to keep serving foods and when prompted to possibly do so, so that food would not be late, he did not wash hands nor apply gloves. Upon [NAME] Employee E1's return to tray line, he did not wash his hands and donned new gloves and began again plating foods. [NAME] Employee E1 left tray line again to obtain a new pan of lasagna and did not perform hand washing or glove change between tasks. During an interview on 5/28/26, at 12:48 p.m., the Certified Dietary Manager Employee E3 confirmed the observations and that the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. which created the potential for food borne illness.28 Pa Code: 211.6(c)(d)(f) Dietary services.

Based on a review of facility policy, resident interviews, resident council meeting minutes, resident choice menu selections and staff interview, was determined that the facility failed to provide resident selected menu items for 5 of 12 residents (Resident R707. R708, R709, R710 and R711). Findings include: Review of the facility policy Meal Identification and Preference Cards last reviewed on 3/31/26, with a previous review date of 1/1/25, indicated that a meal identification and food preference card will be used to properly identify each individual's needs including food and beverage preferences. Review of the facility policy Resident Rights and Facility Responsibilities, last reviewed on 3/31/26, with a previous review date of 1/1/25, indicated the facility will comply with all Resident rights. During the Resident Group Meeting on 5/26/26, at 2:00 p.m., the resident consensus indicated that the facility was not providing meals as indicated per menu, the menu had days of meals not identified and the facility failed to provide a special meal as indicated for Memorial Day. Review of the facility Spring Summer Menus dated 5/24/26 through 6/20/26 and indicated as the four-week rotation cycle identified two Thursday lunch meals as Resident's Choice and two Thursday breakfast choices as Regional breakfast favorite. During a phone interview on 5/27/26, at approximately 10:29 a.m., the Regional Dietician Employee E4 stated that menu choices are done at the corporate level for certain days called Port of Call days and are sent to each facility via email to each Dietary Manager to provide the specific meal chosen and emails are generated with ingredients required for each item on the menu, portion sizes and how to provide for each consistency. The Regional Dietician Employee E4 also stated that the lunch Resident choices are supposedly decided during resident council meetings. During an interview on 5/27/26, at approximately 12:30 p.m., Certified Dietary Manager Employee E3 stated that he could not get the food from the distributor for the Hawaii Port of call so could not provide the meal as planned for this Thursday. During an interview on 5/28/26, at approximately 9:45 a.m., the Corporate Dietician Employee E4 confirmed that the facility failed to provide residents with their selected menu items and preferences as indicated on the menus. Pa. Code: 211.6(a) Dietary services.

Based on observations and a staff interview, it was determined the facility failed to ensure the availability of the most recent survey results and any plan of correction were accessible to residents and visitors in two of two areas (Lobby and Activity Department). Findings Include: The residents have the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors. Reports of surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years and any plan of correction in effect with respect to the facility. During observations on 5/28/26, at 11:00 a.m. the Nursing Home Administrator and surveyor reviewed the facility posting, indicating the facility prior Department of Health's survey results are available for review in a binder located in the lobby and in the activity department. Upon inspection the binder located in the lobby did not contain the last full health survey results or plan of correction for 2025. There was no binder in the activity department to review. During an interview on 5/28/26, at 11:10 a.m. the Nursing Home Administrator confirmed the facility failed to make the Department of Health's most recent survey results readily accessible to residents and visitors. 28 Pa. Code 201.14(i) Responsibility of licensee.

Based on review of facility policy, resident observations, resident council interview, a confidential staff interview and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of fourteen of twenty-four residents (Residents R78, R83, R120, R700, R701, R702, R703, and R704, R705, R706, 707, 708, 709, and 710).Findings Include: Review of the facility policy Call Light Resident Communication System Policy, reviewed on 3/31/26 with a prior review date of 1/1/25, indicated, attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. Minimum staffing requirements imposed by the state are adhered to when determining staff rations but are not necessarily considered a determination of sufficient and competent staffing. Answer the resident's call light as soon as possible. Do what the resident requests, if capable/allowed. Otherwise seek assistance of charge nurse or someone who can assist. If you have promised the resident you will return with an item or information, do so promptly. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment During a resident group interview on 5/26/26 at 2:00 p.m., group consensus (Residents R700, R701, R702, R703, R704, R705, and R706) is there are not enough staff to provide care, causing residents to wait for care and at times some have soil themselves due to the wait time. The lack of staff does not allow call lights to be responded to timely, causing residents to have to wait for toileting. Showers are not always provided because there are not enough staff, you end up getting a bed bath. Staff are having conversations on their cell phones and using earbuds while proving resident care such as bathing and changing residents. When the staff come in, they turn the call light off and then leave without addressing what you need, they say they will be back. They do this to make the call light audit numbers look good. Review of Resident R78's clinical record indicated admission to the facility on 1/8/25. Review of Resident R78's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/4/26, indicated diagnoses of seizure disorder (sudden disruptions of the brain's normal electrical activity). hypertension (high blood pressure), and lupus (your immune system attacks your healthy tissues and organs) a BIMS of 15. Section GG 130: Functional Abilities toileting and shower/bathe self, resident is dependent (resident is unable to complete the activity two or more people are required to complete the activity). GG0170 mobility is dependent on staff for transfers and moving from one location to another. During an interview on 5/28/26, at approximately 10:00 a.m. Resident R78 was asked if she had any concerns or delays with receiving care including when using her call light and she said yes. There is not always enough staff, me and my roommate can tell you have to wait maybe a half hour or more until the staff can get to you, they work very hard, they need more help. On 2/12/26 facility records reveal the Director of Nursing (DON) interviewed the resident who reported she had been left in a wet brief from 11:00 p.m. until 6:00 a.m . Resident stated, sometimes they come in and turn the light off and don't come back for an hour or so, I think they get busy and forget. Review of Resident R83's clinical record indicated admission to the facility on 3/6/25. Review of Resident R83's MDS dated [DATE], indicated diagnoses of heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), depression (feelings of sadness and loss of interest in activities), and cerebrovascular accident (stroke blood blow to part of the brain is cut off causing cells to die) a BIMS of 14. Section GG 130: Functional Abilities toileting and shower/bathe self, resident is dependent (resident is unable to complete the activity two or more people are required to complete the activity). GG0170 mobility is dependent on staff for transfers and moving from one location to another. During an interview on 5/28/26, at approximately 1:30 p.m. Resident R83 was asked if he had any concerns or delays with receiving care including when using his call light. Resident stated he had reported his concerns related to treatment by a staff member when he needed to be changed and administration addressed it. You still wait at least 30 to 40 minutes when you use your call light. Just last week I laid in a soiled brief again, I waited over an hour to be changed after using my light. Review of Resident R120's clinical record indicated admission to the facility on 5/14/26. Review of Resident R120's MDS dated [DATE], indicated diagnoses of heart failure (heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), benign prostatic hyperplasia (BPH prostate gland grows larger symptoms include frequent urges to urinate), and hyperlipidemia high cholesterol) a BIMS of 13. Section GG 130: Functional Abilities toileting and shower/bathe self, resident requires partial/moderate assistance (caregiver provides less than half the effort lifting, holding, supporting trunk or limbs. GG0170 mobility resident requires partial/moderate assistance (caregiver provides less than half the effort lifting, holding, supporting trunk or limbs. During an interview on 5/27/26, at approximately 2:00 p.m. Resident R120 and his family were asked if he had any concerns or delays with receiving care including when using his call light. The resident stated yes, when you are older and need to go to the bathroom the urge comes quickly and you have to wait. I waited long enough that I just couldn't hold it and I soiled myself and the bed. The staff tell me to plan ahead when I have to go, at this age it doesn't work that way anymore. These concerns have been shared with administration. During observations on 4/14/26, at approximately 12:00 p.m. with the Nursing Home Administrator (NHA) confirmed with the surveyor and Resident R51, that his fingernails were long and soiled and arranged for grooming. During an observation on 4/15/26, at approximately 10:30 a.m. Resident 36 was observed with matted unkept hair. Residents clinical record shower documentation failed to reveal evidence that showers were provided twice a week, or as ordered. every Tuesday and Friday. The Director of Nursing (DON) confirmed the facility keeps paper shower logs, though they were unable to produce the documents. Review of grievances filed by residents, or on behalf of residents, revealed thirteen grievances between 12/1/25 through 5/22/26 were care and call light wait times. Review of the nine confidential complaints reported to the state agency between 4/13/26 through 5/27/26 and investigated during this survey, were by current residents (Resident R707, R708, R709, and R710), with thirteen allegations related to care and call light wait times. The complainants requested anonymity. Review of resident council meeting minutes from December 2025 through April 2026 revealed resident concerns regarding care, call lights and staffing for the months of December 2025, January, March and April 2026 (May 2026 resident council meeting was held after the survey start date). During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, it depends on the day, there are call offs and sometimes the shifts don't get filled, on these days it takes us longer to get to everyone and take care of what the need. During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, the staff member stated, I think we have been short staffed for a while now. We have agency staff, but it doesn't solve the problem we still work short staffed. I know the residents have to wait but really, we do our best. During an interview on 5/28/26, at approximately 5:22 p.m., the NHA and DON confirmed the facility failed to provide sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents in two of two locations where grievances boxes are located (first and second floors). Findings include: A review of the facility policy Resident Grievances and Concerns Policy reviewed on 3/31/26 with a prior review date of 1/1/25, indicated the facility will make available to all residents via a posting in a prominent location in the facility, information of the right to file grievances orally or in writing; the right to file grievances anonymously. The Centers for Medicare & Medicaid Services (CMS) mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During observations on 5/28/26, at 11:00 a.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes on the second and first floors, at a height was 50 inches at each location. Access to the box on the first floor was blocked by multiple tables that had items stored on them. During an interview on 5/28/26, at 11:10 a.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents. 28 Pa. Code 201.29(a)Resident rights.

Based on observation and staff interviews, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift for one of four observed days. Findings include: Observation conducted on 5/26/26, at approximately 9:30 a.m., revealed that nurse staffing information was posted in the main lobby on the reception desk. At that time, the nurse staffing information had the date of (4/3/26), resident census, and the staffing hours did not accurately reflect the current total number of hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift for the current date. During an interview with the Nursing Home Administrator (NHA) on 5/26/26, at approximately 10:00 a.m., the NHA confirmed the facility failed to post the required current facility information for staffing hours and the facility census. 201.18(b)(3) Management.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to report allegations of abuse for one of five residents (Resident R1). Findings include: Review of facility policy Abuse Prevention Policy dated 8/27/25, indicated all alleged violations involving abuse/neglect are promptly and thoroughly investigated. Documentation in the nurses' note should include the results of the resident's assessment, the notification of the physician and responsible party, and treatment provided. All allegations must be reported immediately to the Nursing Home Administrator (NHA) and Director of Nursing (DON). If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the DOH immediately, but not later than 2 hours after the allegation is made. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 2/18/26, indicated diagnoses of transient ischemic attack (temporary blockage of blood flow to the brain) and chronic pain. The resident is alert and oriented, is understood, and understands. Review of email correspondence from Registered Nurse (RN) Employee E1 dated 2/23/26 at 2:37 a.m., indicated that the allegation was put into an email and sent to the NHA and DON. Review of a written statement by Resident R1 dated 3/25/26, stated that I only reported the third incident that happened. I told [RN Employee E1] the supervisor and she was going to tell the [DON]. Review of a written Employee Disciplinary Action Form dated 3/30/26, indicated RN Employee E1 received a written warning for failure to follow procedure regarding reporting abuse and neglect. Signed by NHA and RN Employee E1. During an interview on 4/6/26, at approximately 1:00 p.m. the Regional Director of Clinical Services Employee E2, stated that IT completed an audit identifying no email regarding allegation was received by NHA. During an interview on 4/6/26, at approximately 1:35 p.m. the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to report allegations of abuse for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide activity of daily living (ADL) assistance for five of eleven residents (Residents R19, R20, R23, R25, and R26).Findings include: Review of the facility policy Resident Communication and Call Light Policy dated 6/27/24, indicated staff will respond to call lights promptly. During an observation on 1/12/26, at approximately 10:40 a.m. Resident R25 was seated in his wheelchair in front to the nurses' station wearing only a gown, tied at the neck, but pulled forward off of his shoulders. Resident R25's hair was unkempt and he had a crusted around his mouth. During an observation on 1/12/26, at 10:54 a.m. it was noted that a resident in Resident R19 and R20 was yelling for staff from behind a closed door. Observation at this nurse aides caring for residents and Licensed Practical Nurse Employee E3 standing at the medication cart. During an observation on 1/12/26, at 10:57 a.m., it was noted that the nurses' station call light monitor revealed that Resident R19 and R20's call light had been alarming for 17 minutes. During an observation on 1/12/26, at 11:01 a.m., it was noted that the nurses' station call light monitor revealed that Resident R19 and R20's call light had been alarming for 21 minutes when the surveyor was required to leave the floor. During an observation on 1/12/26, at 12:52 p.m. Nurse Aide Employee E1 was heard to be engaged in a personal conversation on her phone while feeding Resident R26. During an observation on 1/12/26, at approximately 12:55 p.m. Resident R23 yelled out the door to the surveyor for assistance. Resident R23 asked the surveyor to open the salt packet and sprinkle it on his french fries, open the ketchup packet and salad it onto his plate, and open the salad dressing packet and empty it onto his salad. During an interview on 1/12/26, at approximately 12:57 p.m. Nurse Aide Employee E2 confirmed that Resident R23 was unable to complete those tasks for himself, and confirmed that staff had not set up his lunch tray for him. During an interview on 1/12/26, at approximately 1:15 p.m. the Nursing Home Administrator confirmed the facility failed to provide activity of daily living assistance for failed to provide activity of daily living assistance for five of eleven residents. 28 PA. Code:201.18(b)(2) Management. 28 PA. Code:201.29(a) Resident's Rights.

Based on review of facility policy and documents, observations and staff interviews, it was determined that the facility failed to ensure an environment free from the potential spread of infection for 21 of 28 residents. Findings include: Review of the facility, Transmission Based Precautions and Isolation Policy last reviewed 8/27/25, indicated, When Airborne Precautions cannot be implemented due to lack of AIIR (Airborne Infection Isolation Room): Resident should be placed in a private room with the door closed, and healthcare staff provided with N95 or higher respirators. Signage indicating the appropriate type[s] of precautions and indicating that visitors should stop at Nurses Station before entering, will be placed on the resident's door. Staff will educate visitors regarding donning appropriate Personal Protection Equipment while adhering to the resident's right for privacy protection. Review of the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit dated 11/24/25, indicated, The LTCF (long-term care facility) should encourage masking of HCP (health care personnel), residents, and visitors during any respiratory virus outbreak. Masks help to prevent the spread of illness. This provides protection for the wearer (if using a fitted N95 or KN95) and protection for others (some surgical and N95/KN95). When a resident is suspected or confirmed to have a respiratory viral infection, additional precautions are needed to protect HCP during resident care. These precautions should be used in addition to standard precautions, source control, and proper hand hygiene. Proper institution of TBP (transmission-based precautions) includes placement in a private room, if available. The toolkit further stated that for SARS-CoV-2 (Covid-19) airborne, contact, and eye protection should be used, per the United States Department of Health and Human Services, Centers for Disease Control and Prevention, guidelines: Airborne Precautions indicated everyone must:Clean their hands, including before entering and when leaving the room.Put on a fit-tested N-95 or higher-level respirator before room entry.Remove respirator after exiting the room and closing the door.Door to room must remain closed. Contact Precautions indicated everyone must:Clean their hands, including before entering and when leaving the room.Put on gloves before room entry. Discard gloves before room exit.Put on gown before room entry. Discard gown before room exit.Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Review of facility provided documentation on 01/12/26, revealed that 18 of the 28 current residents on the Two South Nursing Unit had tested positive for Covid-19. Review of the facility provided signage used to denote what precautions were required for entering rooms of residents with active Covid-19 stated:Everyone must: Clean their hands, including before entering and when leaving the room.Providers and staff must also: Gown, N-95 or PAPR (powered air purifying respirator), eye protection, and gloves for high-contact resident care.Room requirements: Keep door closed. Patient must wear surgical mask when leaving room. During an observation on 1/12/26, beginning at approximately 10:30 a.m. the following was observed on the Two South nursing unit: Room door for Resident R2 and R3 was open. PPE caddy hanging on door did not have N-95 masks available. No signage was hanging on or by the room door. Resident R2 had an active Covid-19 infection. Room door for Resident R4 and R5 had only signage for Enhanced Barrier Precautions. Both residents had active Covid-19 infections. Room door for Resident R6 and R7 had only signage for Enhanced Barrier Precautions. Resident R6 had an active Covid-19 infection. PPE caddy hanging on door for Resident R8 and R9's room did not have N-95 masks available. Resident R9 had an active Covid-19 infection. Room door for Resident R10 and R11 was open. Resident R10 had an active Covid-19 infection. Room door for Resident R12 and R13 was open. No PPE caddy hanging on door. Resident R12 had an active Covid-19 infection. Room door for Resident R14 and R15 had no signage was hanging on or by the room door. Both residents had active Covid-19 infections. Room door for Resident R16 had only signage for Enhanced Barrier Precautions. Resident R16 had an active Covid-19 infection. Resident R17's room door had signage for Covid-19 precautions. Neither Resident R17 nor former roommate Resident R18 were documented in the medical record for testing positive for Covid-19. Room door for Resident R19 and R20 had no signage hanging on or by the room door for transmission-based precautions. Both residents had active Covid-19 infections.Room door for Resident R21 and R22 was open. PPE caddy hanging on door did not have N-95 or surgical masks available. Both residents had active Covid-19 infections. During an interview on 1/12/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure an environment free from the potential spread of infection for 21 of 28 residents. 28 Pa. code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(a)(d) Resident Care Policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during bed mobility for one of six residents (Resident R1). This was identified as past-noncompliance.Findings include:Review of facility Resident Incident Accident Report Policy dated 8/27/25, indicated that an incident/accident is any occurrence which is not consistent with the routine care of a particular resident and all incident/accidents involving residents will be analyzed and reported.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the admission Observation form dated 12/13/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension with heart failure (a condition where the force of blood against your artery walls is too high and making your heart work harder), and chronic kidney disease (a long term condition where your kidneys are damaged and cannot filter your blood effectively).Review of Resident R1's New admission Nurse Hand to Hand Report dated 12/13/25, indicated Resident R1 had a transfer status of max assist x2 and a bed mobility of 2 to roll.Review of a progress note dated 12/14/25, at 9:00 p.m. indicated, This RNS notified that resident fell out of bed during personal care- rolled out of L sided of bed- hit face off chair armrest by head of bed- hit floor per CAN who was providing care. Resident observed lying supine with head/shoulders resting against chair- moderate bleeding from laceration on bridge of nose and laceration below R eye, subconjunctival bleeding in R eye. Resident able to state full name and date of birth , c/o double vision and pain at R eye.Review of an employee statement written by NA Employee E1 dated 12/14/25, indicated, I was giving care doing a full bed bath. I pulled him towards me then turned him on his side. [I] turned to get the sheet and brief to put on him. [That's] when he grab for the chair. Before I could even try to help, he hit the chair then on to the floor.On 10/9/25, the facility initiated a plan of correction that included:-Residents' representative aware.-Physician notified.-Whole house audit of residents to ensure accuracy of fall status.-Whole house education to obtain fall status in PCC by reviewing the Kardex and following each resident's plan of care.-All incidents are reviewed by the IDCP team and QAPI committee.During interviews completed on 12/30/25, three staff interviewed confirmed they had received education on the appropriate way checking a resident ' s transfer status and demonstrated how to navigate to the appropriate area in the electronic medical record system.Facility in compliance as of 12/30/25.During an interview on 12/30/25, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision during bed mobility for one of six residents. This was identified as past noncompliance.

Based on a review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate care and services to two of five residents (Resident R10 and R11).Findings include: Review of facility policy Activities of Daily Living (ADLs), Supporting dated 6/1/25, indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, Section G: Functional Abilities defined dependent as Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDSn - periodic assessment of resident care needs) dated 11/4/25, included diagnoses of hemiplegia, arthritis, and presence of a pressure ulcer. Review of Section GG: Functional Abilities indicated Resident R10 was totally dependent on staff for bed mobility (rolling left and right in bed) and transfers. Review of Resident R10's plan of care for Risk of Falls initiated 10/30/25, included the interventions of side rails for positioning.Review of Resident R10's plan of care for Self-Care and Mobility Deficits initiated 10/30/25, included the interventions assistance with Mobility: bed mobility (rolling left to right, sitting to lying and lying to sitting), transfers (sit-to-stand, bed-to-chair, toilet transfer), ambulation distances and use of stairs.Review of a progress note dated 11/28/25, at 4:44 p.m. indicated, Called into resident's room. Resident sitting on the floor beside her bed. LPN (licensed practical nurse) had been doing dressing change to her buttocks area and she was lying on her left side. LPN stated she was near the edge and slid off. Resident stated she did not hit her head (witnessed by LPN), landed on her knees then she sat down. Resident was not on her knees when this Supervisor entered the room. Assessed her for injury. No open areas, no bruising, no swelling noted. Moving her upper and lower extremities at baseline. No hip deformity. Neuro at baseline. She denies pain or discomfort. VSS. Resident was lifted back to bed with assist of 3. Call to son. Note to MD. Will continue to monitor for changes.Review of a witness statement dated 11/28/25, written by LPN Employee E1 stated, I was packing and redressing [Resident R10's] sacrum pressure sore. She was leaning on her left side near the edge of the bed and slipped off onto the floor. She did not hit her head but landed on her knees. After being helped back onto her bed she claims to be ok and has no pain. Vitals were taken and were normal.Review of a facility provided Post Fall Huddle Form dated 11/28/25, completed by Registered Nurse (RN) Employee E2 revealed the section of Current interventions was blank and did not document if Resident R10's side rails were in place. The section for the root cause was answered, Resident too close to edge of bed.During an interview on 12/12/25, at approximately3:15 p.m., the Nursing Home Administrator confirmed that the resident's ability to maintain her own position during care is part of bed mobility, and if one staff member cannot do all of the effort (proving wound care while maintaining the resident's position on her side in bed) as Resident R10 is dependent on staff, then two staff members must provide care.Review of the clinical record revealed Resident R11 was initially admitted on [DATE], and readmitted to the facility on [DATE], and 10/7/25.Review of the MDS dated [DATE], included diagnoses of subdural hemorrhage and dementia without behavioral disturbances. Review of Section E: Behaviors failed to reveal documentation of hallucinations, delusions, physical or verbal behaviors to others, behavioral symptoms not toward others, rejection of care, or wandering behaviors.Review of Resident R11's facility diagnosis list failed to include diagnoses of agitation, anxiety, or behavioral disturbances.Review of Resident R11's plan of care for Altered Neurological Status initiated 7/13/25, included the interventions monitor for behavioral changes.Review of all progress notes from 10/1/25, through 12/6/25, failed to reveal documentation of incidences of behavioral disturbances, aggression, being physically inappropriate, or agitation.Review of a progress note dated 12/5/25, at 5:43 p.m. indicated, Resident confused and agitated since night shift. Reported to night RNS (RN Supervisor) to pass to dayshift to see if the doctor could order something to help resident rest. Throughout day shift resident yelling out, putting on the call bell. This nurse had entered room to attempt to comfort and help resident. Upon entering resident grabbed this nurse's wrist. Quickly redirected and asked resident what was wrong. removing bedding and throwing it on the floor. Asked this nurse to put in the laundry which this nurse did. Fluids given, poor appetite with meals. Continued to attempt to get OOB (out of bed). This nurse again redirected/educated that resident was in a nursing home, after resident stated. I'm walking over to the police station. Spoke with ADON (Assistant Director of Nursing) supervisor after was 3pm, she stated she was going to see if the doctor left any new orders for resident. At 1700 (5:00 p.m.) CNA (nurse aide) alerted this nurse that resident fell OOB. Resident hit head above right eyebrow, right shoulder, right elbow, and left wrist skin tears observed. First aid performed by ADON. Sent to [hospital] for evaluation, left with 2 EMT's via stretcher @ 1720 (5:20 p.m.).Review of the clinical record failed to reveal documentation that the doctor was contacted, or if unable to be contacted, and alternate provider was notified of behavioral disturbances (agitation, yelling out, grabbing staff, throwing linen on floor, and statements to leave) that were not normal behaviors for Resident R11.Review of a facility submitted report dated 12/6/25, included the above progress note and an update on 12/8/25, of Follow up: [Resident R11] has been increasingly confused since second admission on [DATE]. A subdural hematoma, that was inoperable.Review of the point of care record for behaviors from 10/7/25, through 12/5/25, failed to reveal documentation of new behavioral disturbances, aggression, being physically inappropriate, or agitation since readmission on [DATE]. During an interview on 12/12/25, at approximately 3:15 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide treatment and services related to activities of daily living for two of five residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide treatment and services related to heart failure (a progressive heart disease that affects pumping action of the heart muscles) for one of three residents (Resident R1).Findings Include:Review of the Unites States National Library of Medicine information Heart Failure dated 3/11/25, indicated symptoms of heart failure can include: Shortness of breath. Fatigue or weakness. Coughing. Swelling and weight gain from fluid in the ankles, lower legs, or abdomen. Difficulty sleeping when lying flat. Nausea and loss of appetite. Swelling in the veins of your neck. Needing to urinate often. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/18/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R1's plan of care initiated 6/12/25, did not include documentation of goals and interventions related to heart failure upon its facility diagnosis on 7/21/25. Review of Resident R1's facility diagnosis list failed to include heart failure. Review of a provider order dated 6/13/25, indicated Weights: Obtain weight upon admission, then weekly x 4. Review of a provider order dated 7/22/25, indicated Please obtain weight on 7/25/25. Review of a provider order dated 7/23/25, indicated Resident R1 was to receive daily weights related to edema. Review of a provider's order dated 6/12/25, indicated Resident R1 was to be given furosemide (Lasix) 20 mg (milligrams) once daily as needed. Review of a provider's order dated 7/22/25, through 7/25/25, indicated Resident R1 was to be given Lasix 40 mg once daily. Review of a provider's order dated 7/26/25, indicated Resident R1 was to be given Lasix 20 mg once daily. Review of Resident R1's weight record revealed the following: 6/12/25: 220.7 lbs. (pounds)6/17/25: 218.0 lbs. 7/01/25: 217.0 lbs.7/04/25: 234.2 lbs. (Gain of 14 pounds in three days)7/15/25: 235.0 lbs. 7/22/25: 240.0 lbs. (Gain of five pounds in seven days) 7/23/25: 241.4 lbs. 7/25/25: 242.6 lbs. 7/26/25: 246.8 lbs. (Gain of four pounds in one day)8/01/25: 241.8 lbs.8/03/25: 238.2 lbs.8/04/25: 234.6 lbs.8/05/25: 232.5 lbs.8/07/25: 235.2 lbs.8/09/25: 213.0 lbs. Review of Resident R1's progress notes (6/12/25-8/9/25) failed to reveal documentation referencing the 17-pound weight gain that occurred between 7/1/25, and 7/4/25. Review of a nurse practitioner note dated 7/8/25, at 12:08 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a physician note dated 7/10/25, at 11:27 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a physician note dated 7/15/25, at 9:46 a.m. does not include documentation that the weight gain was reviewed or addressed. Review of a progress note dated 7/19/25, at 11:07 p.m. indicated, [Resident R1] has a PRN order for (Lasix, a medication to remove excess fluid in the tissue). I advised she would need to ask for it when she needs it and her legs are swollen. Otherwise, suggest switching to daily dose. Review of a progress note dated 7/21/25, at 9:04 a.m. indicated, Resident has increase resp (respirations) with use of accessory muscles. Lungs have wheezes bil (bilaterally, both sides) with scattered crackles bil. Pulse ox is 90% with oxygen at 3 liters via nasal cannula. Resident has increased confusion during verbal interaction. Resident is easy to arouse with verbal stimuli. Heart rate strong and strong and reg. Cap refill (capillary refill) is less than 3 sec. VSS (vital signs stable) resident is afebrile. RNS (Registered Nurse Supervisor) aware and will make MD (Doctor of Medicine) aware during AM (morning) rounds. Review of a physician's note dated 7/21/25, at 11:03 a.m. indicated, Patient seen for increased LE (lower extremity) edema. Daughter had called in expressing concern in swelling in her legs. Patient is seen in her room this morning. The note further stated suspect CHF congestive heart failure. Review of a progress note dated 7/22/25, at 1:02 p.m. indicated that the physician was advised of a 13-pound weight gain. Review of the weight records indicated that Resident R1 had a 23-pound weight gain, not 13-pound. Review of a physician's note dated 7/23/25, at 9:46 a.m. indicated, Patient seen for follow-up of recent visits for leg swelling and weight gain. This morning, nursing noted her HR (heart rate) to be elevated to 120s. Patient was started on increased dose of Lasix yesterday for finding of LLL (left lower lobe of the lung) fluid on CXR (chest x-ray). During an interview on 8/27/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide treatment and services related to heart failure for one of three residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of the clinical record, physician documents, and staff interviews, it was determined that the facility failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents (Resident R2).Based on review of clinical records, and staff interview it was determined that the facility failed to make certain residents receive appropriate treatment and services for highest practicable mental and psychosocial services for one of three residents (Resident R28). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R2 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R2 dated 3/30/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), cancer of the breast and lung, and intellectual disabilities. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 03. Review of a provider note dated 3/14/24, indicated, Left voicemail for Director of Nursing at [facility]. Advised patient was dropped off at the front door again without any caregiver/attendant. Patient needs to have a caregiver with her when she comes for her appointments. Review of a provider note dated 4/1/24, indicated, Spoke with nursing supervisor at [facility], advised patient needs to arrive with caregiver as she has been dropped off at front door of the cancer center in the past and this is inappropriate for this patient and her needs. Nursing supervisor stated they would send a caregiver with patient to her upcoming appointment. Review of a provider note dated 4/9/24, indicated, Called and spoke with nursing supervisor, reviewed appointment on 4/11 for Faslodex and to ensure someone would be coming with the patient. Nursing supervisor stated they were told patient did not need an attendant with her because it was an injection. Advised at patient's last visit, the patient was very fearful coming to the infusion area alone and it created a negative experience for her. Nursing supervisor stated they would ensure that someone came with her. Review of a provider note dated 11/15/24, indicated, Pt with Faslodex appt on 11/12: Unable to receive treatment as a member from the patient's facility was unable to stay with her. AVS (After Visit Summary) with next appts printed and mailed to patient's facility. A note stating that a member from her facility must accompany her and stay for the duration of her treatment, as this has been previously discussed and agreed upon. Review of a provider note dated 1/7/25, indicated, Called [facility] to discuss the need to send a caregiver to [Resident R2's] appts. Spoke to Nursing Supervisor, and let her know that moving forward we will need to have a caregiver with [NAME] during her visits. We reviewed [Resident R2's] appts. Nursing Supervisor apologized and said she will communicate this with the administrator and this will be the case moving forward. Review of a provider note dated 6/5/25, indicated, Pt did not show for her Faslodex injection today. She resides at [facility] and requires a caregiver to accompany her. This is an ongoing issue. Pt did receive her last injection in May. Review of a provider note dated 6/5/25, indicated, Received call from Director of Nursing (DON) at [facility]. Reviewed ongoing issue of patient coming for Faslodex injections without an escort as well as during her office visits with [Doctor]. Reviewed patient has missed multiple appointments. DON stated he would help facilitate these appointments. Able to reschedule patients' Faslodex to 6/1/25, at 3:30 p.m. Advised subsequent appointments in July would be changed. Review of provider office visit notes dated 8/19/25, indicated, [Urology provider] stated there have been 4 appointments scheduled for this patient and [facility] had cancelled 3 of these appointments and had reported to [Urology provider] the did not have a escort for the appointment. The last appointment (4th appointment) was a no show. During an interview on 9/3/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to schedule ordered appointments and failed to make certain residents with intellectual disabilities receive appropriate services for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the clinical record, physician records, documents, and staff interviews, it was determined that the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents (Resident R2). Findings include: Review of the United States Food and Drug Administration product information dated January 2021, indicated that Faslodex (fulvestrant) is an injectable medication for the treatment of advanced breast cancer. Not taking Faslodex for hormone receptor-positive (HR+), HER2-negative advanced or metastatic breast cancer can lead to the cancer progressing more quickly or returning sooner, potentially lowering the chances of extending life and improving symptoms. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R2 was initially admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R2 dated 3/30/24, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), cancer of the breast and lung, and intellectual disabilities. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 03. Review of a provider note dated 3/7/24, indicated, Called [facility] and spoke to supervisor. Advised supervisor last dose of Faslodex here at the cancer center given in November 2023. Patient has not showed to appointment for follow up visit in January or CT scan. Advised that patient is to have monthly Faslodex injections to treat breast cancer. Supervisor confirmed patient is not receiving Faslodex at [facility]. Review of a provider note dated 10/31/24, indicated, [Facility] called about missed Faslodex appointment today. Rescheduled to next available opening on November 12th at 3:30 p.m. Adjusted future appointments to reflect every 28-day schedule. Review of a provider note dated 4/1/25, indicated, Spoke with staff at [facility] to alert them that [Resident R2] missed her 11:30 a.m. appt today for Faslodex. They will call back to reschedule. Review of a provider note dated 5/8/25, indicated, This writer called and spoke with nursing supervisor at [facility] where patient resides. Nursing supervisor aware patient needs to follow up/make appt with urology related to patient c/o (complaints of) right flank pain and hematuria. Review of a provider note dated 6/5/25, indicated, Pt did not show for her Faslodex injection today. She resides at [facility] and requires a caregiver to accompany her. This is an ongoing issue. Pt did receive her last injection in May. Review of a provider note dated 6/5/25, indicated, Received call from Director of Nursing (DON) at [facility]. Reviewed ongoing issue of patient coming for Faslodex injections without an escort as well as during her office visits with [Doctor]. Reviewed patient has missed multiple appointments. DON stated he would help facilitate these appointments. Able to reschedule patients' Faslodex to 6/1/25, at 3:30 p.m. Advised subsequent appointments in July would be changed. Review of a provider note dated 8/7/25, stated, Placed on hold by [facility], unable to leave message. Call was made to let caretakers know that [Resident R2] missed her appointment today. Waited on hold for 8 minutes but had to hang up. Review of office visit notes dated 8/19/25, indicated, [Urology provider] stated there have been 4 appointments scheduled for this patient and [facility] had cancelled 3 of these appointments and had reported to [Urology provider] they did not have an escort for the appointment. The last appointment (4th appointment) was a no show. Review of an appointment history from 4/1/25, through 8/27/25, provided by outside medical provider indicated the following cancelled or missed appointments: 4/01/25, Faslodex/labs: Cancelled.4/22/25, Faslodex injection: Cancelled.4/29/25, Faslodex injection: Cancelled.4/30/25, Abdominal CT: Cancelled.5/01/25, Faslodex/labs: Cancelled.5/13/25, Three-month follow-up: Cancelled.5/21/25, Abdominal CT: Cancelled.5/27/25, Faslodex injection: Cancelled.5/29/25, Faslodex injection: Cancelled.6/02/25, DXA (type of bone density x-ray): Cancelled.6/05/25, Faslodex/labs: No show.6/26/25, Faslodex injection: Cancelled.7/03/25, Faslodex injection: Cancelled.7/10/25, Faslodex injection: No show.7/31/25, Faslodex injection: Cancelled.8/07/25, Faslodex injection: No show. During an interview on 9/3/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to schedule ordered appointments and failed to provide transportation for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1))(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.2 (a) Physician services. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents (R2, R11, R58, R73, R86, and R94). Findings Include: Review of facility policy Diabetic Protocol dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The staff will identify and report complications such as hypoglycemia. Review of the facility Hypoglycemia Policy dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. When acute hypoglycemia is suspected, assess mental status (alert, drowsy, uncooperative, or unconscious) and use glucometer to determine the resident's blood sugar level. A blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment do the following: -If the resident is conscious and treatment is indicated, give 1 tube of dextrose gel (15 grams). -After 15 minutes, repeat blood sugar and if still under 70 mg/dL, repeat glucose gel. -After 15 minutes repeat blood sugar. If above 70 mg/dL, give a snack of protein and a carbohydrate (ex. ½ sandwich with bread and a protein or crackers and a protein.) Monitor until stable. -If the resident is drowsy or unconscious or is unable or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously. Monitor the resident for 15 minutes after treatment. -If, after 15 minutes, the resident is conscious and able to consume orally, give a snack of a protein and a carbohydrate (ex. ½ a sandwich with bread and a protein or crackers and a protein). Monitor until stable; -If, after 15 minutes the resident still cannot consume anything orally, repeat glucagon 1 mg subcutaneously and call 911. Further review of the policy failed to reveal procedures in the event of a resident experiencing hyperglycemia. Review of the Facility assessment dated [DATE], indicated the facility will provide care for residents diagnosed with diabetes. Review of the United States Food and Drug Administration prescribing information for basaglar insulin (insulin glargine, a long-acting injectable medication to diabetes) dated 12/2015, indicated basaglar insulin begins to work several hours after administration, the maximum effect of basaglar insulin is approximately 12 hours after administration, and works over 24 hours to lower blood sugar levels. Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. Review of the clinical record indicated that Resident R73 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/30/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician order for Blood glucose parameters dated 4/17/25, indicated If resident blood glucose 70< initiate Hypoglycemic protocol and Notify MD (Doctor of Medicine). If resident blood glucose 400> Notify MD. Review of Resident R73's plan of care for diabetes dated 4/14/25, indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R73's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up.: 5/29: 539 5/28: 409 5/24: 411 5/21: 453 5/14: 462, notified 8 hours later 5/13: 540 5/11: 565 5/11: 445 5/08: 489 4/30: 412 4/29: 425 4/03: 517 Review of the physician's order dated 6/6/24, indicated to provide insulin lispro on a sliding scale before meals and at bedtime. Review of Resident R73's meal consumption record on 8/25/24, indicated Resident R73 had consumed 50-75% of her lunch. Consumption was documented at 11:01 a.m. Review of Resident R73's blood sugar record indicated a blood sugar assessment on 8/25/24, at 11:55 a.m. of 371. Review of Resident R73's medication administration record for August 2024, indicated Resident R73 received 10 units of insulin lispro, the appropriate amount for a blood sugar of 371, if the blood sugar was assessed prior to eating. Review of a progress note dated 8/25/24, at 3:22 p.m. indicated Resident R73 was not responding to voice, was cold and clammy, and had a decreased level of consciousness. Resident R73's blood sugar was assessed at this time, noted to be 31. Resident R73 was transferred to the hospital by emergency services. Review of a progress note dated 8/25/24, at 10:14 p.m. indicated Resident R73 was admitted to the hospital for hypoglycemia. Review of hospital discharge paperwork dated 8/31/24, indicated, [Resident R73] was found by staff at [facility] with a sugar of 20. Review of a progress note dated 10/6/24, at 4:10 p.m. indicated that Resident R73 had fallen in her room. A blood sugar value was not documented in the note. Review of a progress note dated 10/6/24, at 5:38 p.m. indicated that Resident R73 had fallen in the hall. Resident was walking on the unit and fell. No injuries noted. While taking her vitals, staff noted that her CBG was 523. Resident has a fx (fracture) to R (right) shoulder from a fall about a month ago which is not completely healed. Son requested that she be sent to [hospital] to have her R shoulder evaluated and elevated blood sugar. MD notified. 911 called for transport. Review of hospital discharge paperwork dated 10/6/24, indicated Resident R73's reason for the emergency room visit was a fall, with the diagnosis of hyperglycemia. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease (gradual loss of kidney function). Review of physician orders dated 5/25/24, indicated Resident R11 received rapid acting insulin: with breakfast (7:00 a.m. - 10:00 a.m.), with lunch (11:00 a.m. - 12:00 p.m.), and with afternoon med pass (4:00 p.m. - 6:00 p.m.), If CBG <60 give 0 units. 60-100 give 8 units. If CBG >100, give 16 units. Review of Resident R11's plan of care for diabetes initiated 7/26/23, indicated for staff to Monitor for signs of hyperglycemia (blood glucose > 140mg/dl) and administer medications per physician's orders. Review of Resident R11's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/27: 480 6/24: 403 6/17: 533 6/17: 421 6/07: 421 6/07: 508 5/27: 490 5/24: 501 5/24: 430 5/22: 356 5/12: 360 5/11: 400 5/06: 388 5/05: 360 5/04: 369 5/08: 489 4/27: 357 4/18: High 4/15: 424 Review of Resident R11's blood sugar level on 5/29/25 indicated that at 8:26 p.m. Resident R11's blood sugar level was 515, and at 11:19 p.m. was 444. Review of a progress note written by Registered Nurse Supervisor Employee E9 dated 5/29/25, at 11:47 p.m. indicated, Call placed to on call provider for [doctor] in reference to resident blood glucose reading of 515, received 33u (units) of basaglar insulin, recheck performed and blood glucose 444. Spoke with on call physician, given order to transfer resident to ER for evaluation due to elevated blood glucose levels. Review of hospital discharge paperwork dated 5/30/25, indicated Resident R11 was seen in the emergency room for hyperglycemia and a urinary tract infection. Review of the physician notification sheet dated 5/29/25, indicated for Resident R11, Returning, had elevated (upward pointed arrow) BGM. During an interview on 7/2/25, at approximately 2:00 p.m. the Director of Nursing confirmed that basaglar insulin would not have an appreciable effect on Resident R11's elevated blood sugar level. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of a physician order dated 4/2/25, indicated for Resident R2 to sliding scale insulin coverage with meals, and to notify the MD if Resident R2's CBG is less than 60 or greater than 340. Review of Resident R2's plan of care dated 6/13/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R2's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/24: 460 6/24: 387 6/24: 389 6/21: 451 6/20: 394 6/18: 346 6/13: 414 6/03: 401 6/03: 435 5/28: 413 5/28: 477 4/23: 395 4/08: 402 4/08: 516 Review of the clinical record indicated that Resident R58 was admitted to the facility on [DATE]. Review of the MDS for Resident R58 dated 6/4/25, included diagnoses of diabetes, acquired absence of right leg below knee (amputation below right knee), unspecified intracranial injury without loss of consciousness (injury to the brain without loss of consciousness, might experience confusion, headache or amnesia). Review of a physician order dated 6/18/25, indicated for Resident R58 a sliding scale insulin coverage with meals, and to notify the MD if Resident R58's CBG is less than 60 or greater than 341. Review of Resident R58's plan of care dated 5/6/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R58's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/29: 371 6/27: 368 6/10: 394 6/04: 434 5/29: 406 5/27: 390 5/24: 395 5/23: 381 5/19: 359 4/29: 401 4/23: 355 4/22: 358 4/20: 373 4/09: 378 4/07: 386 4/01: 350 Review of the clinical record indicated that Resident R86 was admitted to the facility on [DATE]. Review of the MDS for Resident R86 dated 6/3/25, included diagnoses of diabetes, high blood pressure, osteomyelitis of vertebrae, thoracic region (bone infection in the middle back). Review of a physician order dated 4/17/25, indicated for Resident R86 a sliding scale insulin coverage with meals, and to notify the MD if Resident R86's CBG is less than 60 or greater than 340. Review of Resident R86's plan of care dated 5/8/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R86's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/10: 350 6/04: 351 5/04: 350 5/03: 396 4/19: 403 4/19: 366 4/19: 371 4/17: 388 4/11: 345 4/05: 371 Review of the clinical record indicated that Resident R94 was admitted to the facility on [DATE]. Review of the MDS for Resident R94 dated 6/3/25, included diagnoses of diabetes, history of falling, fracture of left femur (a break in the long bone in upper leg). Review of a physician order dated 4/17/25, indicated for Resident R94 a sliding scale insulin coverage with meals, and to notify the MD if Resident R94's CBG is less than 70 or greater than 350. Review of Resident R94's plan of care dated 5/15/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R94's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/20: 360 6/10: LOW (no repeat conducted) 6/07: 419 5/10: LOW (no repeat conducted) 4/18: 417 4/18: 403 The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 7/1/25, at 12:50 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 7/1/25, at 2:30 p.m. an acceptable Corrective Action Plan was received which included the following interventions: After record review, it was determined that [the facility] failed to notify the physician of blood sugars out of range timely for six residents and care plans were absent or did not include approaches for diabetic emergency management. Immediate Actions: -Resident R73, R11, R2, R94, R86, R58 was assessed by the Director of Nursing on 07/01/2025 at 1325. Residents R73, R11, R2, R94, R86, and R58 had no s/s hyperglycemia at that time. -Education was initiated on 07/01/2025 with facility RN's and LPN's on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range. The facility is currently not using any agency staff. Moving forward, if any agency RN or LPN need to be utilized, they will be educated on the diabetic protocol before their first day of work. -On 07/01/2025, Residents R73, R11, R2, R86, R58's blood sugars were reviewed from the past 24 hours to ensure none were out of range without physician notification. -On 07/01/2025, an ad hoc QAPI committee meeting was held, and the medical director was made aware of the findings. Like Residents: -Current residents with diabetes have the potential to be affected. Current residents with diabetes were reviewed on 07/01/2025 by the DON to determine if blood sugars were out of range and none were noted out of range. Correction of System: -Root cause analysis completed by the center QAPI committee on 07/01/2025 and determined failure to follow the Resident Change in Condition policy led to the allegation. -To prevent recurrence, the Director of Nursing initiated education with facility RN's and LPN's on 07/01/2025 on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RN's and LPN's that were not on duty received education via phone and will receive in person education on their next scheduled shift. -Moving forward any new RN's and LPN's hired will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee. Monitoring: -To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars daily x 2 weeks, 3x a week x 2 week and then weekly x 2 weeks to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified and new orders implemented as needed. -To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management 5 x a week for 2 weeks, then weekly x 3 weeks. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. On 7/2/25, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 7/2/25, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 8:30 a.m. on 7/2/25, four of four LPNs on duty were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. During interviews beginning at approximately 1:30 p.m. on 7/2/25, one of one RN on duty was able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. The Immediate Jeopardy was removed on 7/2/25, at 11:08 p.m. when the action plan implementation was verified. During an interview on 7/3/25, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were accurate and fully completed for five of twenty-six residents (Resident R14, R22, R25, R36, and R80). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2024, indicated in: Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days. Section K: Swallowing/Nutritional Status, to base weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the assessment reference date of this assessment or the previous weight is not available, weigh the resident again. Section O: Special Treatments, Procedures, and Programs, indicated to document what services and treatments were performed while a resident of the facility and within the last 14 days. Resident R42 had an MDS completed on 4/29/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R42 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R42 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R42 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R57 had an MDS completed on 4/4/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R57 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R57 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R57 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R80 had an MDS completed on 4/3/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R80 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R80 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R80 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R93 had an MDS completed on 5/28/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated Resident R93 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R93 is rarely understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R93 is rarely understood and the Resident Mood Interview assessment was not completed. Review of Resident R22's psychiatric evaluations dated 6/17/25, included diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R22's facility diagnosis list included bipolar disorder and post-traumatic stress disorder, both with a diagnosis date of 12/30/24. Resident R22 had an MDS completed on 4/15/25. Review of Section I: Diagnoses failed to include active diagnoses of bipolar disorder or post traumatic stress disorder. Resident R14 had an MDS completed 4/8/25, Review of Section I: Diagnoses failed to include active diagnosis of dementia with a diagnosis date of 9/29/23. Review of a physician's order dated 11/15/24, indicated Resident R25 was admitted to hospice services. Review of the clinical record confirmed that Resident R25 remained on hospice services at the time of the survey, without breaks in services. Resident R25 had an MDS completed on 5/7/25. Review of Section O: Special Treatments, Procedures, and Programs failed to indicate that Resident R25 received hospice services. Resident R203 had a MDS completed on 6/18/25. Review of Section O: Special Treatments, Procedures and Programs failed to indicate that Resident R203 received continuous oxygen therapy via a nasal cannula. Review of Resident R36's weight record revealed the following: -4/01/25 - 155.5 pounds -4/08/25 - 156 pounds -6/02/25 - 175 pounds -6/19/25 - 141.2 pounds -6/26/25 - 125.8 pounds Resident R36 had an MDS completed on 5/31/25. Review of Section K: Swallowing/Nutritional Status utilized the weight of 156 pounds, captured on 4/8/25, 53 days prior. During an interview on 7/3/25, at approximately 11:30 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed During an interview on 7/3/25, at approximately 3:50 p.m. the Nursing Home Administrator Director of Nursing confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for six of twenty-six residents (Resident R14, R22, R25, R36, R80 and R203). 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents (Resident R14, R22, R43, R73 and R85). Findings include: Review of the facility policy Comprehensive Care Plan dated 1/1/25, indicated an interdisciplinary plan of care will be established for every resident and updated in accordance with State, and Federal requirements and on an as needed basis. Review of the clinical record indicated Resident R14 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 4/8/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery (a stroke caused by a blockage or narrowing of a blood vessel in the brain, where the specific cause of the blockage is unknown), hemiplegia (inability to move one side of the body), unspecified dementia,severe with anxiety (a condition where cognitive decline is evident, but the specific type of dementia cannot be identified). Review of Resident R14's facility diagnosis list included diabetes, cerebral infarction, hemiplegia. unspecified dementia with severe anxiety. Review of the clinical record revealed that Resident R14's comprehensive care plan initiated on 4/8/25, failed to include plans of care with goals and interventions for dementia care. Review of active diagnoses list revelaed dementia diagnosis was made on 9/29/23. Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), anxiety, and depression. Further review confirmed that bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and post-traumatic stress disorder (PTSD, mental health condition triggered by experiencing or witnessing a terrifying event) were not included as diagnoses. Review of Resident R22's facility diagnosis list included bipolar disorder and post-traumatic stress disorder, both with a diagnosis date of 12/30/24. Review of Resident R22's psychiatric evaluations dated 6/17/25, included the diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R22's comprehensive care plan initiated on 7/10/24, failed to include plans of care with goals and interventions developed for bipolar disorder post-traumatic stress disorder. Review of the clinical record indicated Resident R73 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), diabetes, and depression. Review of Section F: Preferences for Customary Routines and Activities indicated that it is very important to Resident R73 to do things with groups of people. During on observation on 7/1/25, at 3:17 p.m. Resident R73 was noted to be in her room alone, seated next to her bed, without the television on or music playing. During on observation on 7/2/25, at 1:23 p.m. Resident R73 was noted to be in her room alone, seated next to her bed, without the television on or music playing. Review of a psychiatric evaluations dated 6/17/25, included the diagnoses of bipolar disorder post-traumatic stress disorder. Review of previous psychiatric evaluations included the diagnoses of bipolar disorder post-traumatic stress disorder on 12/30/24. Review of Resident R73's comprehensive care plan initiated on 1/28/25, for Activities included a plan of care for, [Resident R73] is dependent on staff for activities, cognitive stimulation, and social interaction due to -------------------. Review of the clinical record indicated Resident R43's was originally admitted on [DATE]. Review of Resident R43's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 5/12/25, indicated diagnoses included atrial fibrillation (irregular heart rhythm), morbid (severe) obesity (obesity associated with a higher risk of serious health issues), and diabetes. Further review confirmed that depression (mood disorder, affects how you feel, think, and behave) was not included as a diagnosis. Review of Section D: Mood D0150 indicated Resident R43 reported feeling down, depressed, or hopeless two to six days over the last two weeks. Review of Section E: Behavior E0200 indicated the following behaviors have not been exhibited: A. physical behaviors directed toward others (hitting, kicking, pushing, grabbing, abusing others sexually). B. verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others). C. other behavioral symptoms not directed toward others (self-harm behavior verbal/vocal symptoms like screaming). Review of Resident 43's progress notes from 1/1/25 thru 6/30/25 revealed Resident 43's summary of documented behavior events on the following dates. 1/7/25 resident yelling at staff regarding staffing. 2/15/25 resident yelling to get him out of bed, requesting specific staff. 3/1/25 resident yelling and called 911 for his electric wheelchair (facility removed for safety and maintenance) a manual chair provided and explained to resident prior to the 911 call. 3/12/25 resident yelling and verbally aggressive to staff for taking too long to respond. 4/9/25 resident verbally aggressive to Resident R61 and Resident R43 placed hand on Resident R61's wheelchair and moved the resident causing Resident R61 to express frustration and anxiety. 4/27/25 resident yelling and verbally abusive to staff for someone to do his laundry, resident begins making barking noises at the nurse supervisor. 4/27/25 resident agitated, Resident R43 was chasing a female Resident R61 down the hall. 5/2/25 resident yelling at the nursing assistant and attempting to hit the nursing assistant with his wheelchair. 6/7/25 resident yelling obscenities toward staff and stated he was going to throw self out of bed if they don't get him up now, resident reportedly slid out of bed to the floor. Resident R43 informed staff he will do this again. 6/21/25 resident yelling and verbally abusive to staff for how they provide his care. Resident went to the nursing supervisor's office and Resident R43 began punching at the door and screaming obscenities at the nursing supervisor. Review of Resident R43's History and Physical (medical examination, assesses overall condition and medical history) dated 7/4/23, reveals a diagnosis of depression. Review of Resident R43's physician progress note dated 9/7/23 the resident is on cymbalta for depression and suicidal thoughts from November of 2022. Review of Resident R43's comprehensive care plan initiated on 10/28/23, failed to include plans of care with goals and interventions developed for depression. Resident R43's psychosocial well-being care plan goal edited on 4/24/25 will not harm self or others secondary to socially inappropriate disruptive behavior as described. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R85's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 4/1/25, included diagnoses of cancer of the colon, chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), depression. Review of Resident R85's facility diagnosis list included cancer of the colon, COPD, and depression. Review of the clinical record revealed that Resident R85's comprehensive care plan initiated on 4/22/25, failed to include plans of care with goals and interventions for hospice care and oxygen therapy. Review of the clinical record revealed orders were placed on 8/15/24, 12/10/24, and 6/17/24, for the resident to receive hospice evaluation and treatment. Further review of the clinical record revealed an order on 8/24/24, for resident to start oxygen therapy 2-4liters per minute via nasal cannula when necessary for shortness of breathe. During an interview on 7/3/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to develop and implement comprehensive care plans for resident and care needs for five of twelve residents. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on a review of facility documents, clinical records, and staff interview, it was determined that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment for 28 of 28 residents (Residents R8, R13, R14, R15, R16, R24, R29, R42, R45, R54, R59, R62, R65, R66, R72, R73, R81, R82, R88, R90, R91, R93, R96, R206, R210, R211, R310, and R311). The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the Life Enrichment Director job description indicated the Director will, Perform administrative requirements, such as completing necessary forms, reports, attending meetings, trainings, consulting, etc., and submitting information to the Administrator or others, as required. Review of the RAI Manual, Section F: Preferences for Customary Routine and Activity, indicated, The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. Review of the questions in Section F of the comprehensive assessment include: -How important is it to you to choose what clothes to wear? -How important is it to you to take care of your personal belongings or things -How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? -How important is it to you to have snacks available between meals? -How important is it to you to choose your own bedtime? -How important is it to you to have your family or a close friend involved in discussions about your care? -How important is it to you to be able to use the phone in private? -How important is it to you to have a place to lock your things to keep them safe? -How important is it to you to have books, newspapers, and magazines to read? -How important is it to you to listen to music you like? -How important is it to you to be around animals such as pets? -How important is it to you to keep up with the news? -How important is it to you to do things with groups of people? -How important is it to you to do your favorite activities? -How important is it to you to go outside to get fresh air when the weather is good? -How important is it to you to participate in religious services or practices? Each of the above questions provided the following options for answers: Very important Somewhat important Not very important Not important at all Important, but can't do or no choice No response or non-responsive During an interview on 7/3/25, at 12:20 p.m. Activities Director Employee E1 confirmed that she is responsible for completing the Activities component of the MDS comprehensive assessment. At this time, it was discussed with Activities Director Employee E1 that eight residents had been reviewed, and all eight residents had answers of Very Important documented for each of the above 16 questions. When asked if it was normal for each of the residents reviewed to have answered all the questions the same, the Activities Director confirmed that those were the answers told to her in the interviews and stated that possibly the eight chosen for review happened to be the same. Review of facility census information revealed that when the survey began, there were 106 residents present in the facility. Review of the clinical records revealed that 100 residents had been admitted to the facility long enough to have a comprehensive assessment completed. Review of the comprehensive assessments revealed the following: Activities Director Employee E1 completed 66 of the 100 assessments for Section F. -(3) assessments have differing answers for the above 16 questions. These assessments were completed in July and August 2024. -(1) assessment was documented as Not Assessed -(1) assessment had all answers documented as Somewhat Important -(61) assessments, 92.4%, had all answers documented as Very Important Registered Nurse Employee E2 completed 17 of the 100 assessments for Section F. -(7) assessments have differing answers for the above 16 questions. -(10) assessments, 58.8%, had all answers documented as Very Important Registered Nurse Assessment Coordinator Employee E3 completed 15 of the 100 assessments for Section F. -(3) assessments have differing answers for the above 16 questions. -(1) assessment was not completed -(11) assessments, 73.3%, had all answers documented as Very Important Employee E4 completed one of the 100 assessments for Section F, with all answers documented as Very Important. Employee E5 completed one of the 100 assessments for Section F, with all answers documented as Very Important. Review of the clinical record indicated Resident R8 had an Annual MDS completed on 12/11/24, with a BIMS score of 06. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R13 had an admission MDS completed on 1/22/25, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R14 had a Significant Change MDS completed on 11/19/24, with a BIMS score of 05. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R15 had an Annual MDS completed on 3/5/25, with a BIMS score of 02. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R16 had a Significant Change MDS completed on 2/18/25, with a BIMS score of 03. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R24 had an admission MDS completed on 3/19/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R29 had a Significant Change MDS completed on 9/24/24, with a BIMS score of 04. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R42 had an Annual MDS completed on 4/29/25, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R45 had an Annual MDS completed on 4/8/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R54 had a Significant Change MDS completed on 1/15/25, with a BIMS score of 05. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R59 had an Annual MDS completed on 7/30/24, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R62 had an Annual MDS completed on 2/26/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R65 had an admission MDS completed on 8/12/24, with a BIMS score of 05. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R66 had an admission MDS completed on 5/30/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R72 had an admission MDS completed on 4/3/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R73 had an Annual MDS completed on 4/30/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R81 had a Significant Change MDS completed on 9/3/24, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R82 had an admission MDS completed on 1/23/25, with a BIMS score of 00.Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R88 had an Annual MDS completed on 6/10/25, with a BIMS score of 05. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R90 had an admission MDS completed on 1/11/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Employee E2, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R91 had an admission MDS completed on 5/24/25, with a BIMS score of 04. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R93 had a Significant Change MDS completed on 2/28/25, with a BIMS assessment unable to be completed due to the resident being rarely understood. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R96 had an admission MDS completed on 4/25/25, with a BIMS score of 00. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R206 had an admission MDS completed on 4/25/25, with a BIMS score of 00. Review of Section F, documented as completed by the Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R210 had an admission MDS completed on 6/22/25, with a BIMS score of 07. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R211 had an admission MDS completed on 6/20/25, with a BIMS score of 06. Review of Section F, documented as completed by the Registered Nurse Assessment Coordinator Employee E3, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R310 had an admission MDS completed on 6/14/25, with a BIMS score of 00. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. Review of the clinical record indicated Resident R311 had an admission MDS completed on 6/12/25, with a BIMS score of 04. Review of Section F, documented as completed by Activities Director Employee E1, revealed all questions to be answered as Very Important and that this information was garnered from the resident. During an interview on 7/3/25, at approximately 4:00 p.m. the Nursing Home Administrator was informed that the facility failed to ensure that the Activities Director accurately completed, and/or directed or delegated the accurate completion of the activities component of the comprehensive assessment and failed to attempt to obtain information on resident preferences from family, significant others, or staff interviews for residents with severe cognitive impairment.

Based on review of clinical records and staff interview, it was determined that the facility failed to provide documentation of medication regimen reviews (MRR) completed at least monthly for two of five residents (Resident R22 and R34). This was identified as past non-compliance. Finding include: On 7/2/25, the MRRs for Residents R22 and R34 were requested, for the months of January through June 2025. On 7/3/25, the facility provided information that the Quality Assurance and Performance Improvement (QAPI) program members had identified that pharmacy recommendations were not being completed timely. Review of the performance improvement plan developed on 4/24/25, included: -The Director of Nursing (DON) will begin to receive all pharmacy reports and recommendations. -Medical Records staff will ensure any recommendations that re received are handed directly to the ADON (Assistant Director of Nursing) or the DON. -Once the recommendation is received, it will be reviewed by a physician and returned. The ADON/DON will review and complete adjustments as necessary. -Audits will be completed monthly for three months with results reviewed by the QAPI committee. During an interview on 7/3/25, at 12:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide documentation of medication regimen reviews completed at least monthly. This was identified as past non-compliance. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, job descriptions, and records, and staff interviews, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm of a worsened pressure injury for one of six residents (Resident R1). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.12. Freedom from Abuse, Neglect, and Exploitation defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility document entitled, Abuse, dated 11/2021, indicated that each resident has the right to be free from neglect. Review of the current Licensed Practical Nurse (LPN) job description indicated that the LPN will: -Safely administer quality skilled care in compliance with nursing policies and procedures, physician orders, and to provide external regulatory requirements for established plan of care, and -Administer medication and treatments accurately, observing resident response, as evidenced by documentation in the medical record and lack of negative outcomes. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 3/30/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M - Skin Conditions indicated that Resident R1 did not have any pressure injuries (breakdown of skin integrity due to pressure). Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record indicated that Graduate Practical Nurse Employee E1 documented that the dressing changes were completed for Resident R1 on 5/18/22, 5/19/22, 5/21/22, and 5/22/22. Review of a facility report form for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property dated 5/26/22, indicated on On 5/23/2022 during weekly assessment the facility wound nurse observed that resident's foot dressing was dated 5/20/2022. Resident's wound assessed, noted to have worsened from last assessment on 5/16/2022. Review of a witness statement written by Registered Nurse Employee E2 dated 5/23/22, indicated Upon wound care rounds with Certified Registered Nurse Practitioner Employee E3, left heel dressing found on Resident R1 was dated 5/20/22. Large amount of drainage and necrotic tissue was observed, wound is worse. Charge nurse on 1N (nursing unit) was GPN Employee E1, on the 21st and 22nd. Review of a witness statement written by GPN Employee E1 dated 5/23/22, indicted On the day in question I looked at my TAR, did my treatments that I was familiar with. I never received in report that the resident had a wound on her feat [sic]. I need a little more training on reading my TAR and understanding what is needed so this will not happen again. During an interview on 6/1/22, at 11:30 a.m. the Director of Nursing confirmed while the size of the wound had decreased, the presence of slough not there previously, and the lack of granulation indicated wound deterioration. The DON further confirmed that a facility investigation revealed that Graduate Practical Nurse Employee E1 stated that she just clicked off the dressing changes and that she confirmed that she did not provide dressing changes to Resident R1 on 5/18/22, 5/19/22, 5/21/22, and 5/22/22. During an interview on 6/13/22, at approximately 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to protect a resident from neglect that resulted in actual harm of a worsened pressure injury for one of six residents. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 2/26/21, 8/25/21, 11/15/21. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 201.20(b)(1) Staff Development.

Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to provide prescribed treatment and services, consistent with professional standards of practice, to prevent the development and worsening of pressure injuries as required, resulting in the actual harm of a worsened pressure injury, for one of six residents (Resident R1). Findings include: Review of facility document entitled, Pressure Injury Guidelines, dated 11/2021, indicated It is the policy of this facility to provide early identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 3/30/22, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M - Skin Conditions indicated that Resident R1 did not have any pressure injuries (breakdown of skin integrity due to pressure). Review of a progress note dated 4/20/22, at 11:32 a.m. indicated a new, unopened blister was observed on Resident R1's left heel. Review of a progress note dated 4/20/22, at 12:28 p.m. indicated Wound Care: Large blister left heel, 5cm (centimeters) x 5cm. apply [MEDICATION(S)] (transparent dressing) every seven days as needed for lifting. Review of a progress note dated 5/12/22, at 2:21 p.m. indicated that Resident R1 had intact skin. Review of a Certified Registered Nurse Practitioner (CRNP) note dated 5/16/22, at 11:24 a.m. indicated We have been consulted to follow along on a MASD (moisture associated skin damage) wound on her (Resident R1) lower back. During the initial exam, we found an unstageable pressure ulcer to her left foot. The progress note further stated the initial wound measurements are 3.5 cm length x 2.4 cm width x 0.2 cm depth. The wound bed was 26-50 % eschar (dry, dark scab or falling away of dead skin), 76-100 % granulation (new tissue development). Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a CRNP note dated 5/23/22, at 9:04 a.m. indicated subsequent wound encounter measurements are 1.3 cm length x 2 cm width x 0.2 cm depth. Wound bed has 76-100% slough (dead tissue that needs to be removed for wound to heal), no granulation, no eschar present. The wound is deteriorating. Review of the Treatment Administration Record indicated that Graduate Practical Nurse Employee E1 documented that the dressing changes were completed for Resident R1 on 5/18/22, 5/19/22, 5/21/22, and 5/22/22. During an interview on 6/1/22, at 11:30 a.m. the Director of Nursing confirmed while the size of the wound had decreased, the presence of slough not there previously, and the lack of granulation indicated wound deterioration. The DON further confirmed that a facility investigation revealed that Graduate Practical Nurse Employee E1 stated that she just clicked off the dressing changes and that she confirmed that she did not provide dressing changes to Resident R1 on 5/18/22, 5/19/22, 5/21/22, and 5/22/22. During an interview on 6/13/22, at approximately 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide prescribed treatment and services, consistent with professional standards of practice, to prevent the development and worsening of pressure injuries as required, resulting in the actual harm of a worsened pressure injury, for one of six residents. Refer to F600 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 2/26/21, 8/25/21, 11/15/21. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 201.29(a) Resident rights. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 211.10 (c) Resident care policies. Previously cited: 8/25/21, 11/15/21. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited: 2/26/21, 8/25/21, 11/15/21. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited: 2/26/21, 11/15/21. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited: 2/26/21, 8/25/21, 11/15/21.