Every finding on record at Wyndmoor Hills Rehabilitation and Nursing Center

Based on observation, resident and staff interviews, and review a facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment related to bed linens for two of two residents interviewed (Resident R2 and Resident R5) and for five of six resident council meeting minutes reviewed (March, April, May, June, and August 2026). Findings include: Review of facility policy Resident Supplies and Central Supply Par Level Policy revealed that the facility is responsible for maintaining appropriate inventory levels to ensure necessary resident care supplies were readily available to meet the resident needs. The policy identified linens as a resident care supply and required the facility to maintain sufficient quantities of the essential supplies to minimize shortages or interruptions in resident care. The policy further required inventory and established par levels to be routinely monitored and replenished as needed. Identified shortages or supply concerns that could affect resident care were to be addressed promptly, with alternative arrangements and implemented as necessary to ensure residents essential care needs continue to be met. Review of the facility assessment dated [DATE], revealed the facility was licensed for 77 beds, with an average daily census of 73 residents and an average of two to three admissions per week. The assessment identified bed and bath linens as a necessary non-medical supply under the responsibility of central supply team and required the facility to evaluate its physical resources and processes to ensure adequate supplies were available to meet the needs and promote the health and safety of the resident population. Review of resident council meeting minutes day the March 17, 2026, revealed eight residents were documented as being in attendance. Further review of the meeting minutes revealed residents requested that additional linens be made available and expressed concerns at laundry services were not being completed. Review of resident council meeting minutes dated April 22nd, 2026, revealed thirteen residents were documented as being in attendance. further review of the meeting minutes reveal residents continues to request that additional linens, washcloths, and towels be made available Review of resident council meeting minutes dated May 20th, 2026, revealed ten residents were documented as being in attendance. Further review of the meeting minutes revealed residents requested that additional linens be made available. Review of resident council meeting minutes dated June 16, 2026, revealed 12 residents were documented as being in attendance. Further review of the meeting minutes revealed residents voiced concerns regarding the availability of linens and requested that additional linens and wash clothes be made available. Review of resident council meeting minutes dated August 19th, 2026, revealed 15 residents were in attendance. Further review of the meeting minutes revealed residents expressed concerns regarding the availability and condition of facility linens. Residents requested that additional linens, washcloths and towels be made available and reported concerns that the available linens were dirty, spotted and or stained. Interview with Resident R2 on August 25th, 2026, revealed there are never enough sheets available for residents. Resident R2 state sheets were frequently unavailable, and the linen cart was routinely empty. Interview with Resident R5 on August 25th, 2026, at approximately 10:00 AM the resident stated that during the night he/she experienced an incontinent episode which resulted in the bed linens becoming wet with urine. Resident R5 stated a nurse aide responded and assisted with changing the incontinent brief; however, the urine soil bed linens were not changed. Resident R5 stated the nurse aide informed him/her that no clean sheets were available and that Resident R5 would have to remain on the wet sheets. Interview with nurse aide, Employee E5, on August 25th, 2026, confirmed there were not enough sheets available to meet the resident's needs. Employee E5 stated sheets were routinely unavailable on the nursing units, including on the linen carts and the linen storage area. Employee E5 further stated that laundry department closed at 3:00 PM, after which staff did not have access to additional linen supplies. When asked how staff obtain needed linens when a resident experienced an incontinent episode or otherwise required clean linens after 3:00 PM, employee E5 stated we have to improvise. Interview on August 25th, 2026, with housekeeping director, employee E6, confirmed the facility did not maintain an adequate supply of linens and stated the facility was continually running out of linens. Housekeeping Director, Employee E6, stated he believed one contributing factor was staff discarding facility linens in the trash. Employee E6 stated he had personally retrieved linens from the trash receptacles. Housekeeping Director, Employee E6, stated that although he continued to order additional linens, the facility continued to experience linen shortages. Observation with Housekeeping Director, Employee E6, on August 25, 2026, of the facility linen storage, revealed supply was limited with only one package of fitted streets observed to be available. 28 Pa Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 204.13 Linen. 28 Pa Code 211.12(d)(5) Nursing services.

Based on review of facility policy, review of facility grievances, review of call bell audits, observations, and resident and staff interviews, it was determined the facility failed to ensure residents receive timely assistance in response to activated call bells for three of seven residents reviewed (Resident R2, R4, and R5). Findings include: Review all the facilities policy titled Call Bell Policy for Long Term Care Facility undated, revealed the facility was responsible for ensuring residents had timely access to assistance through the call bell system and received prompt and appropriate responses from staff. the policy directed staff to aim to respond to call bells within five minutes and, when unable to respond immediately, to inform the resident and provide an estimated response time. during high demand periods, staff were to prioritize calls based upon the urgency of resident's needs. The policy further required the nursing supervisor to review call bell response times weekly and address identified delays or concerns, with quarterly audits conducted to evaluate the effectiveness and efficiency of the call bell system and response time. Resident and family feedback regarding the Call bell system was to be obtained during resident council meetings and used to improve services. Interview with Assistant Administrator, Employee E2, on August 25, 2026, the employee stated the facility's expected response time for an activated resident call bell was approximately five minutes. Interview with resident R2 on August 25th, 2026, is approximately 10:10a.m., revealed staff did not respond to call bells timely and that residents could wait hours for staff to respond, if they responded at all. At the surveyor's request, Resident R2 activated his/her call bell at 10:17a.m. Observations revealed Resident R2's call bell remained activated and unanswered. During this time two additional resident call bells were observed activated on the unit without staff response. The surveyor inquired with Licensed Nurse, Employee E8, regarding the location of the assigned nursing aide (identified as Employee E11) for Resident R2. Licensed Nurse, Employee E8, stated that the Resident R2's assigned nurse aide may have gone on break. Director of Nursing, Employee E3, was present at the nurse's station and subsequently responded to Resident R2's call bell at 10:38a.m., approximately 21 minutes after the call bell was light was activated. The surveyor informed the DON, Employee E3, that the call bell has remained activated for approximately 21 minutes before being answered. Review of a facility grievance dated August 3, 2026, revealed a resident reported activating his/her call bell and waiting more than one hour for staff to respond. Review of the facility investigation revealed nursing staff were interviewed regarding the resident's concern and response to her needs. The documented resolution indicated nursing staff were reminded of the importance of timely call bell response and communication with residents when delays occurred. Review of a call bell audit completed by the Assistant Administrator, Employee E2, on August 9, 2026, in response to the grievance revealed the following results regarding the resident call system: room [ROOM NUMBER]O7 had no call bell; room [ROOM NUMBER], 311, 332, and 214 have broken call bells; 310, 312, and 338 had call bells that would not turn off; and rooms [ROOM NUMBERS] corresponding call bell lights did not illuminate when activated. The audit documented that the identified call bell issues were subsequently resolved. Interview with Resident R4 revealed he/she thinks the call bell is a waste of time and he/she doesn't even use it because nobody ever comes. Interview with Resident R5 revealed the staff never come when you use a call bell. Resident R5 reported an incident where he/she required assistance getting into bed, kept pressing the call bell, and it went unanswered all night. Review of facility audits from multiple months revealed that audits were consistently conducted during the daytime early afternoon hours and did not include evening, overnight, or weekend shifts. Therefore, the audits did not evaluate call bell response across all shifts, days, and staffing periods. Based on observations, review of facility policies and procedures, facility grievances and call bell audits, and resident and staff interviews, it was determined the facility failed to ensure residents receive timely assistance in response to activated call bells. 28 Pa. Code 201.14 (a) Responsibility of Licensee 28 Pa. Code 201.18 (a)(1) Management 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store food in accordance with standards for food service safety (main kitchen). Findings include: Review of facility policy Guidelines for Storage undated, revealed Date your products with Use By Dates. A tour of the main kitchen conducted on July 13, 2026, at 9:50 a.m. with Employee E9, Dietary Director, revealed the following: Observation in the dry storage room revealed a wall behind a food rack was soiled with a brown substance; the same wall had openings and holes along the baseboard, which would allow for pests to enter. The floor had a heavy buildup of grime. Observation in the kitchen by the steamer revealed a drain in the floor that was open and uncovered. Observation of refrigerator box 1 revealed an open bag of chicken nuggets that was left open to air, an opened bag of egg salad that was undated and a pan of oatmeal that was unlabeled and undated. Observation of refrigerator box 2 revealed multiple tubs of expired cottage cheese, with expiration dates including: 5/18/26, 7/6/26, 6/22/26, 4/6/26 and 12/6/25. Nine tubs of margarine were observed with no received or expiration dates. Observation of refrigerator box 4 revealed a pitcher of juice consisting of a mix of water and fruit that was unlabeled and undated; a personal food storage dish that was unlabeled and undated; and an open case of packages of sliced turkey breast with no use by or expiration dates. Observation of the main kitchen revealed a storage area that contained a broken steam table. The storage area was full of trash and debris on the equipment. There was a build up of grime, trash, debris and a large amount of mice droppings on the floor. The door that leads to the corridor had a large gap in the door sweep, which would allow pests to enter. Observation of the kitchen cooking area revealed the handwashing sink and the area under the sink were covered with dirt and debris. The paper towel holder was falling off the wall. The floor throughout the cooking area was soiled with a build up of dirt and debris. The cooking ovens had a heavy build up of baked on food spillage on the bottom and door of the ovens. The drawers in the preparation counter were unable to be opened and soiled with grease and food debris. There was a box of powdered pureed rice mix that was open with the contents left open to air and an expiration date of 7/7/26. Observation of the emergency food closet revealed a large bag of powdered milk that expired 5/17/26; a case of saltines that expired May 2025; a case of raisin bran cereal that expired 2/4/26; and a case of canned fruit salad that expired 6/19/26. Continued observation revealed a box of chemical sanitizer on the floor, mixed in with cases of food items. A case of canned pasta was on the floor. The floor was soiled with trash and debris, there was a pool of water on the floor; and there were mice droppings on the floor. Observation of another closet, labeled as emergency food supply, revealed a case of cake mix that expired February 2024; a case of rice crispies that expired January 2024; a case of salsa cups that expired in 2024; and a case of crispy rice that expired October 2024. Continued observation revealed mice droppings on the floor of the room. Observation of the kitchen bread storage area revealed two cases of bread with no received, use by or expiration dates. There was also a box of powdered pureed honey wheat bread mix that expired in April 2026. Observation on July 13, 2026, at 12:40 p.m. of the second floor steam table revealed that the side and bottom of the table were heavily soiled with grease and food debris. Continued observation of the kitchen area on July 13, 2026, at 1:52 p.m. revealed that the door that leads to dumpster area was propped open, which would allow pests to enter. Observations of the dishwashing area with Employee E11, dietary, revealed that the floor was heavily soiled with grime and debris; there were also several broken floor tiles. During the wash cycle, the dish machine leaked water onto the floor. The above findings were reviewed and confirmed with Employee E9, Dietary Director, at the time of the observations. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations and staff interviews, it was determined that the facility failed to ensure equipment was maintained in safe and operating conditions related to the main kitchen. Findings Include: An initial tour of the food services department conducted on July 13, 2026, at 9:50 a.m. with Employee E9, Dietary Director, revealed the following: Observations revealed that the main kitchen was equipped with four walk-in refrigerators, a steamer, two soup kettles, a tilt skillet, four ovens, a gas stove with two additional ovens and a fryer. Interview, at the time of the observations, Employee E9, Dietary Director, revealed that refrigerator box 3, the steamer, soup kettles, tilt skillet and two of the ovens were broken and unable to be used. Continued observation revealed that half of the gas stove and the fryer were unlit (no pilot lights) and unable to be used. Employee E9 stated that they were still waiting for the vendor to come out to relight the pilot lights for the stove and fryer. Further observations of the main kitchen area revealed several portable air conditioning units on the counter tops. Interview with Employee E11, dietary, revealed that the HVAC (Heating Ventilation Air Conditioner) vents did not work in the kitchen and that the staff rely on the portable air conditioning units because the kitchen gets hot during the day. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations and interviews with staff, it was determined that the facility failed to ensure that trash was properly disposed of in the dumpster area. Findings include: An initial tour of the food services department conducted on July 13, 2026, at 9:50 a.m. with Employee E9, Dietary Director, revealed the following: Observation revealed the lid to the dumpster was left open and the ground around the dumpster was covered with debris such as cups, gloves and plastic eating utensils. There were several wooden pallets piled against the side of the building and a broken wooden fence. There was a blue bin full of stagnant water and trash. Employee E9 proceeded to close the lid to the dumpster and stated that the bin belonged to housekeeping and did not know what was in the bin. Continued observations revealed that the door leading to the kitchen from the dumpster area had a drain in the ground. Interviews with Employees E9, Dietary Director, and Employee E11, dietary, revealed that staff dump kitchen water, such as dirty mop water, into the drain; the water is then pumped through a pipe which drains nearby to the street. Continued observation on July 13, 2026, at 1:52 p.m. revealed that the lid on the other side of the dumpster was propped open. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations, review of facility policies and interviews with residents and staff, it was determined that the facility failed to serve foods at appetizing and palatable temperatures on one of two nursing units (second floor nursing unit). Findings include: Review of facility policy Food Serving Temperatures undated, revealed Food is at an acceptable temperature at preparation at point of service of the resident. The point of service temperature to residents will be within the range of 120-140 degrees. Observation on July 13, 2026, at 10:30 a.m. of the kitchen revealed that there was no tray line station in the kitchen. Interview, at the time of the observation, Employee E9, Dietary Director, revealed that no trays are plated in the kitchen; all trays are plated and served from the steam table in the second floor dining room. Observation on July 14, 2026, at 8:21 a.m. of the tray line service in the second floor dinning room revealed Employee E12, Cook, plating meals from the steam table. Plates were then trayed by additional dietary personnel, loaded into food trucks and distributed to nursing units and residents. Continued observation at 8:31 a.m. Employee E12, Cook, finished plating all residents' meals and then plated a test tray, consisting of scrambled eggs, toast, oatmeal and sausage. Employee E12 was not able to find a thermometer at the tray line station and called the kitchen to bring up a thermometer. Employee E9, Dietary Director, arrived with a thermometer and obtained temperatures of the test tray, including: the eggs were 101 degrees Fahrenheit, the sausage was 94 degrees Fahrenheit and the toast was 89 degrees Fahrenheit. Employee E9 confirmed that the foods were not served at appetizing and palatable temperatures. Interview on July 14, 2026, at 11:53 a.m. Resident R42 stated that he/she did not eat breakfast this morning because the food was cold. Observation, at the time of the interview, Resident R42's breakfast was still at the bedside and was uneaten. 28 Pa Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of facility policies and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not accurately completed according to the resident assessment for two of six residents reviewed (Residents R4 and R34). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual disability. The Level II PASRR would determine if placement or continued stay in the requested or current nursing facility is appropriate. Review of Resident R34's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated May 8, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including Bipolar disorder (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior). Review of Resident R34's PASRR, dated July 24, 2024, revealed that the resident had a diagnosis of depression. Continued review revealed that the resident's diagnosis of bipolar disorder was not included on the evaluation. Review of Resident R4's Significant Change MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), bipolar disorder and schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations). Review of Resident R4's PASRR, dated September 3, 2019, revealed that the resident had a diagnoses of depression and bipolar disorder. Continued review revealed that the resident's diagnosis of schizophrenia was not included on the evaluation. Interview on July 15, 2026, at 1:48 p.m. Employee E 8, social worker, confirmed that the PASRR evaluations for Residents R34 and R4 did not accurately reflect those residents' mental health conditions. 28 Pa Code 211.5(iv)(v) Medical records

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain a safe environment for residents and staff related to a corridor and a kitchen door area. Findings include: Observations on July 13, 2026, at 9:50 a.m. revealed that the door leading to the kitchen from the dumpster area had a drain in the ground. Interview with Employee E9, Dietary Director, revealed that staff dump kitchen water, such as dirty mop water, into the drain. The ground around the drain area was wet. Electrical power cords were observed on the wet ground; one cord was connected to a pump inside the drain, another cord was connected to a cooler truck. Staff were observed walking around the wires to enter and exit the kitchen. The electrical cords extended across an entry point into the main kitchen, creating a tripping hazard, and plugged into an outlet above a kitchen counter. Interview on July 13, 2026, at 11:16 a.m. Employee E9, Dietary Director, revealed that all food prepared in the kitchen gets transported along a corridor to get to the nursing units. Employee E9 stated that they do not like to walk through the corridor because of rodents and safety hazards. Observations of the corridor revealed numerous broken tiles and several open holes on the floor, including one very large hole that was covered with a mound of broken bricks and debris. The floor was wet from water that was dripping from bricks in the walls and ceiling. Along the corridor was a door that leads to outside; the door was unable to be completely shut, allowing for pests to enter. Interview on July 13, 2026, at 11:27 a.m. Employee E11, dietary, stated that they feel unsafe traveling along the corridor because of the rodents, bugs, debris, holes and other hazards. Interview on July 14, 2026, at 10:05 a.m. with seven alert and oriented residents revealed that they would like to do their own personal laundry and that there were no laundry machines on the nursing units. Interview on July 14, 2026, at 1:16 p.m. the Nursing Home Administrator revealed that residents are able to do their own personal laundry and that the machines are located past the kitchen. The Administrator stated that residents are escorted by activities staff and that residents could either go through the corridor or go outside around the building to get to the machines. Interview on July 15, 2026, at 9:52 a.m. Employee E13, Activities Director, confirmed that activities staff escort residents to the personal laundry area. Employee E13 escorted the survey team through the same corridor that was previously observed with dietary staff, to the laundry room. Employee E13 then escorted the survey team along the alternate route that could be used to access the laundry area. Observations of the hallway from the laundry room to the exit door revealed broken furniture, trash and debris along the floor, and loose and missing floor tiles. The lighting along the hallway was dim, making the hazards more difficult to see and maneuver. Upon exiting the building, Employee E13 led the survey team along a sloped parking lot to the main entrance of the skilled nursing building. Employee E13 confirmed that both routes to get to the personal laundry area were hazardous for residents and staff. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of facility documentation, observations, and interviews, it was determined that the facility failed to maintain an effective pest control program. Findings include: A review of the facility policy Pest Control revised January 2026, revealed the purpose of this policy is to prevent and control the entrance of pests and eradicate infestations. Windows, doors and exterior walls are sealed to prevent easy entrance of pests. Observation in room [ROOM NUMBER] on June 9, 2026, at 12:05 p.m. revealed multiple live roaches crawling inside the trash can between Resident R4's bed and toilet. Interview with Resident R4 on June 9, 2026, at 12:05 p.m. revealed the resident sees roaches all the time including in the dresser drawers. Resident R1 was not surprised about the live roaches in the trash can. Resident R1 reported that the Nursing Home Administrator, Employee E1, comes in his/her room [room [ROOM NUMBER]] and kills the roaches all the time. Interview with the Director of Nursing, Employee E2, in room [ROOM NUMBER] at 12:20 p.m. confirmed the live roaches crawling on the floor. Interview on June 9, 2026, at 12:02 p.m. with Resident R3 in room [ROOM NUMBER] revealed that roaches and mice are a problem. Resident R3 was observed to be cleaning up the room which was piled with stacks of used paper products. Resident R3 claims to keep these stacks of used paper products to recycles these products and makes items such as a fan made from used plastic food wrappers. Interview on June 9, 2026, at 12:09 p.m. with Resident R5 revealed that he/she sees roaches all the time and pointed at the sticky glue traps located between the bed and nightstand, and one in the corner of the room. Observation of both white glue boards revealed that they were covered with ten to twenty roaches each. Observation in room [ROOM NUMBER] on June 9, 2026, at 12:15 p.m. revealed that the window was open. Window observed to be pushed open with no screen. Observation in room [ROOM NUMBER] on June 9, 2026, at 12:25 p.m. revealed that Resident R9 window was open. Window observed to be pushed open with no screen. Observation in room [ROOM NUMBER] on June 9, 2026, at 12:15 p.m. revealed that the window was open. Window observed to be pushed open with no screen. A review of the pest control company's reports revealed the following concerns: March 9, 2026, Invoice 572775 - inspect & treat room [ROOM NUMBER], 331 for roach activity.March 16, 2026, Invoice 572776 - inspect & treat first floor breakroom for roach activity.March 23, 2026, Invoice 572777 - inspect & treat 2nd floor pantry for roach activity.April 13, 2026, Invoice 577537 - inspect & treat room [ROOM NUMBER], 225 (verbal report), lobby for roach activity.April 20, 2026, Invoice 577538 - inspect & treat 2nd fl nurse station for roach activity.April 27, 2026, Invoice 577539 - could not treat room [ROOM NUMBER] for roach activity resident changing.May 11, 2026, Invoice 582857 - inspect & treat room [ROOM NUMBER], 2nd fl nurse station for roach activity.May 18, 2026, Invoice 582858 - inspect & treat room [ROOM NUMBER] for roach activity, could not treat room [ROOM NUMBER] for roach activity due to sign on door contact precautions.May 26, 2026, Invoice 582859 - observed a few baby roaches in the pantry cabinets on the 2nd floor at the time of service. Observed a few baby roaches in the pantry cabinets on the 2nd floor at the time of service. Recommend improving sanitation habits throughout the nurse station and pantry area.May 26, 2026, Invoice 587200 - inspected and treated room [ROOM NUMBER] for roaches. Baited voids throughout. Baited cabinets, nightstand and placed insect monitors throughout. Excessive roach activity observed in the nightstand and dresser at the time of service. An interview on June 9, 2026, at 2:30 p.m. with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed the above observations and stated that the pest control company comes once a week. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on observation, resident and staff interview, and a review of clinical records, it was determined that the facility failed to ensure full visual privacy for one of 15 residents reviewed (Resident R9).Findings include:Clinical record review revealed Resident R9 was admitted to the facility on [DATE], with diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side), affecting the right dominant side.Observation of Resident R9 in his/her room (room [ROOM NUMBER]) on June 9, 2026, at 11:35 a.m. revealed there was no privacy curtain extending around the toilet and sink (which was not in a separate room). Further observation revealed a metal track on the ceiling extending around the toilet area with empty metal clips hanging down, but no privacy curtain. Anyone entering room [ROOM NUMBER] has full view of the toilet, preventing full visual privacy.Interview with Resident R9 on June 9, 2026, at 12:25 p.m. revealed the resident was embarrassed about using the toilet for fear that someone would come in while using the toilet. Resident R9 stated that there has been no privacy curtain since his/her admission on [DATE]. Interviewon June 9, 2026, at 12:28 p.m. with Nurse Aide, Employee E5, confirmed that there was no privacy curtain around Resident R9's toilet area.Interview on June 9, 2026, at 12:30p.m. with Assistant Administrator, Employee E4, confirmed that Resident R9's privacy curtain was missing and that there should be a privacy curtain around the toilet area for privacy.The above findings were discussed with the Nursing Home Administrator, Employee E1, on June 9, 2026, at 12:35 p.m. regarding the missing privacy curtain preventing full visual privacy for Resident R9.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(j) Resident rights

Based on a review of facility policies, facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents remained free from significant medication errors for one of 15 residents reviewed (Resident R2).Findings include: Review of the undated facility policy titled, Administering Medications states, Medications shall be administered in a safe and timely manner, and as prescribed. Interview on June 9, 2026, at 1:05 p.m. with Resident R2 revealed that she was admitted to the facility on Friday, May 29, 2026, by ambulance from the hospital. She said that the ambulance driver gave her a big envelope packet of papers which she did not read but gave it to the nurse. The resident stated that she was concerned about staff asking her to check her blood glucose level several times. The resident also stated that she told them staff that she was not diabetic, but that they insisted. Continue interview with Resident R2 revealed that staff gave her shots in her stomach and lift a little blue mark. When asked the surveyor asked if this was from the insulin she said, I guess so. When asked what the shots were she said she remembered that one was heparin, which she did not remember getting in the hospital. She said that they finally listened to her the next day when she refused to allow the finger stick to check her blood glucose. Resident R2 stated that they came back and told her about the medication error that had occurred with the paperwork from the hospital being for someone else. Review of resident R2's medical record revealed a Medication Administration Report for May 2026, which revealed that Resident R2 received the following medications: May 29, 2026 at 1600 (4:00 p.m.) insulin lispro inject subcutaneous (under the skin) for type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication) 6 units with a corresponding blood sugar of 104.May 29, 2026 at 2100 (9:00 p.m.) insulin glargine inject 26 units subcutaneously at bedtime for type 2 diabetes.May 29, 2026 at 2200 (10:00 p.m.) inject Heparin Sodium (Porcine) Solution 5000 UNIT/ML subcutaneously every 8 hours for DVT (deep venous thrombosis is a blood clot (thrombus) that forms inside deep veins in your legs or pelvis). A corresponding warning note was automatically transcribed in the progress notes for Resident R2 as follows: Note Text : The order you have entered Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML (Heparin Sodium Porcine) Inject 1 ml subcutaneously every 8 hours for dvt until 06/15/2026 23:59, Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction, The system has identified a possible drug interaction with the following orders: Aspirin Oral Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for stroke prevention. Severity: Severe Interaction: Aspirin may enhance the anticoagulant effect of heparin. Clopidogrel Bisulfate Oral Tablet 75 MG Give 1 tablet by mouth one time a day for stroke until 05/31/2026 15:00, Severity: Severe Interaction: Clopidogrel Bisulfate Oral Tablet 75 MG may enhance the anticoagulant effect of heparin. Further review of Resident R2's clinical record revealed that the resident did not have diabetes, not type 1 or type 2 diabetes. A review of the physician orders revealed that on May 29, 2026, the following orders were entered for Resident R2: Aspirin 81 mg oral tablet once a day for stroke prevention. Clopidogrel bisulfate 75 mg oral tablet give one time a day for stroke prevention. Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML, Inject 1 ml subcutaneously every 8 hours for DVT. The administration of these medications to Resident R2, together with the administration of insulin causing possible low blood sugar reaction and the heparin having a synergistic reaction with the aspirin and Clopidogrel increase the risk of hemorrhage. Interview with the Director of Nursing on June 9, 2026, at 1:25 p.m. confirmed that some of Resident R2's medications were entered in error due to paperwork from the hospital with another resident's name and medication list. The facility did not notice the name was different on the medication list until May 30, 2026, when the nurse on duty, Employee E8, went to the supervisor, Employee E7, stating that Resident R2 was refusing a blood sugar test insisting that she was not diabetic. The supervisor investigated and found that the insulin and heparin were on a sheet from the hospital with another resident's name on the paperwork. Interview with the Nursing Supervisor, Employee E7, confirmed that he had found the mistake noticing the wrong name on the one hospital sheet, and that the resident was assessed and the physician and resident were notified of the mistake. Review of the paperwork from the hospital that was entered into Resident R2's orders confirmed that it was for another resident who was also discharged from the hospital on the same day. Review of statements taken during the investigation into Resident R2's significant medication error revealed a statement from the Registered nurse on duty, Employee E9, on May 29, 2026, who stated that she helped the unit manager to enter the medications into the system. A statement from the Unit manager, Employee E10, confirmed that Employee E9 helped her enter the medications from the hospital recommendations. A statement from Licensed nurse, Employee E8, confirmed that he was attempting to take a blood sugar test from Resident R2 when she refused and that he went to the charge nurse and supervisor, Employee E7 who then found the significant medication error. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility documentation, facility policy, clinical records and staff interviews, it was determined that the facility failed to ensure an appropriate, safe, and properly documented discharge process for 1 of 15 residents reviewed (Resident R1).Findings include:Review of undated facility policy titled Intravenous Therapy Policy, revealed the policy is intended to ensure the safe administration, monitoring, and management of intravenous (IV) therapy for residents requiring hydration, medication administration, blood products, or other physician-ordered IV treatments.Review of Resident R1's medical record revealed the resident was admitted to the facility on [DATE], with admitting diagnosis of sepsis (body's extreme response to an infection) due to methicillin susceptible staphylococcus aureus (type of bacteria).Review of Resident R1's medical record revealed a physician order dated May 11, 2026, for Cefazolin Sodium Injection Solution Reconstituted (intravenous antibiotic) administer 2 grams every 8 hours for 37 days for post operative hip surgery.Further review of Resident R1's medical record revealed a physician order written on May 11, 2026, at 21:43 (9:43 p.m.) to transport patient back to hospital for IV antibiotic therapy.Interview on June 9, 2026, at 1:30 p.m. with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, revealed Resident R1 was discharged because after Resident R1 was admitted , it was discovered that the resident was a Level 3 sex offender under Megan's Law. Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, reported that the facility could not have Resident R1 living at the facility for fear that he/she may display inappropriate behaviors. Electronic communication with the Director of Nursing (DON), Employee E2, on June 10, 2026, at 11:52 a.m. confirmed that the facility does accept residents for IV antibiotic treatment.Review of Resident R1's nursing progress notes revealed no documentation on behaviors.During a telephone interview on June 12, 2026, at 3:09 p.m. the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, were made aware that Resident R2's discharge was not appropriate as the facility accepts residents with IV therapy orders and Resident R2 had no documented behaviors that would be deemed inappropriate for this population.28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18 (1)(e) Management

Based on review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to provide pain management for residents in severe pain for one of two residents reviewed (Resident R1).Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. The pain assessment consists of gathering both subjective and objective data. Under Equipment and Supplies the following equipment and supplies will be necessary when performing this procedure: #1. Standardized pain assessment tools as indicated per facility protocol for example a 5-point or 10-point pain intensity scale with word modifiers under section step in the procedure.Further review of the 'Administering Pain Medication policy revealed that the numeric pain assessment scale did not specify the scale numbers for mild, moderate or severe pain. Interview with a Director of Nursing, Employee E2 conducted on February 3, 2026, at 10:32AM revealed that the facility's pain scale was as follows 1-3 mild pain, 4-6 moderate pain, 7 -10 severe pain.Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Back Pain.Further review of resident R1's clinical record revealed physicians order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Further review of Resident R1's clinical record revealed an order for Pain Assessment/Pain Monitor (Able to communicate - Do you have pain? If Denies -Stop here. If Yes - Indicate Pain score 0-10, Offer a nonpharmacological intervention: 1. Repositioning/Turning, 2. Distraction, 3. Massage, 4. Hot/Cold Compress, 5. Emotional Support, 6. Quiet Environment, 7. Other, 8. Not Applicable every shift for Pain Monitoring ordered on December 22, 2025.Review of Resident R1's medication administration record for January 2026 revealed that on January 5, 2026, during the 3-11 shift, Resident R1 had a pain scale of 7. Further review of Resident R1's Medication administration record revealed that Resident R1 did not receive Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Further review of Resident R1 clinical record revealed no documented evidence that Resident R1 received any pain management technique to alleviate his pain.Interview with Employee E2 conducted on February 4, 2026, at 11:23 AM confirmed that Morphine was not administered to Resident R1 on January 5, 2026, during the 3-11 shift when he had a pain scale of 7. 28 Pa. Code 211.10(a) Resident care

Based on clinical record review, review of facility policy and interview with staff it was determined that the facility failed to ensure that pain medications were administered according to physician's order for one of two residents reviewed (Resident R1)Review of facility policy on Administering Pain Medications revealed that under section Purpose the purpose of this procedure is to provide guidance for assessing the residence level of pain prior to administering analgesic pain medication under section General Guidelines #1. The pain management program is based on a facility-wide commitment to resident comfort #2. Pain management is defined as the process of alleviating the residence pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals #7. The pain assessment consists of gathering both subjective and objective data. Under Equipment and Supplies the following equipment and supplies will be necessary when performing this procedure: #1. Standardized pain assessment tools as indicated per facility protocol for example a 5-point or 10-point pain intensity scale with word modifiers under section step in the procedure Further review of the 'Administering Pain Medication policy revealed that the numeric pain assessment scale did not specify the scale numbers for mild, moderate or severe pain. Interview with a Director of Nursing, Employee E2 conducted on February 3, 2026, at 10:32AM revealed that the facility's pain scale was as follows 1-3 mild pain, 4-6 moderate pain, 7 -10 severe pain.Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of but not limited to Back Pain.Further review of resident R1's clinical record revealed physicians order for Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain and Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Mild Pain Not to exceed 3000mg/24hrFurther review of Resident R1's clinical record revealed that there was no physician's order for pain medication for moderate pain. Review of Resident R1's medication administration record for January 2026 revealed that following:On January 2, 2026, at 10:46PM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 3, 2026, at 05:04 PM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 8, 2026, at 10:29AM, Resident R1 was given Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Mild Pain Not to exceed 3000mg/24hr. Pain scale for the day shift of January 8, 2026, was coded 0 for pain.On January 9, 2026, at 01:09 PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 14, 2026, at 04:58 AM, Resident R1 had a pain scale of 0 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 16, 2026, at 01:31PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 17, 2026, at 08:11AM, Resident R1 had a pain scale of 0 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 18, 2026, at 11:00AM, Resident R1 had a pain scale of 5 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 20, 2026, at 02:11PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe painOn January 21, 2026, at 04:17PM, Resident R1 had a pain scale of 4 and was given Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 6 hours as needed for Severe pain.Interview with Employee E2 conducted on February 4, 2026, at 11:23 AM confirmed that Morphine was administered to Resident R1 for pain scale of less than the indicated severe pain.Further, interview with facility administrator Employee E1 and Director of Nursing Employee E2 confirmed that there was no pain management for moderate pain. 28 Pa. Code 211.10(c) Resident care28 Pa. Code 211.12(d)(1) Nursing services

Findings include:Review of facility policy 'Comprehensive person-centered care plans ' revised December 2016, indicates that Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R1's admission interim care plan, completed on August 18, 2025, at 3:06 pm, indicated the resident was incontinent of bowel and bladder. The resident required total dependance for personal hygiene, toilet use and bathing.Review of R1's care plan revealed no evidence of goals or interventions related to incontinence care. Review of Resident R6's clinical record revealed that at times, the resident required substantial/maximal assistance with toileting hygiene and was dependent: helper does all of the effort. Resident does none of the effort to complete activity. Or, the assistance of two or more helpers is required for the resident to complete the activity.Further review of Resident R6 's clinical record revealed that at times, she was incontinent of bowel and bladder.Review of Resident R6's care plan indicates no evidence of goals or interventions related to incontinence care.Review of Resident R7 's ' functional abilities and goals - admission, ' completed on October 13, 2025 at 6:29 pm, indicated the resident she required substantial/maximal assistance with toileting hygiene; further review of clinical record revealed the resident was incontinent of bladder function.Review of Resident R7 's care plan revealed no evidence of goals or interventions related to incontinence care. Review of Resident R8 's 'interim care plan' completed on October 22, 2025 at 9:27 pm, revealed the resident required total dependance for personal hygiene, toilet use, and was incontinent of bladder and bowel function.Review of Resident R8 's care plan revealed no evidence of goals or interventions related to incontinence care.Review of Resident R9's ' functional abilities and goals - admission, 'completed on October 25, 2025, at 12:35 pm, revealed the resident was dependent for toileting hygiene; further review of clinical record revealed Resident R9 was incontinent of bladder function.Review of Resident R9 's care plan revealed no evidence of goals or interventions related to incontinence care.Interview with Nursing Home Administrator and Director of Nursing on October 29, 2025 at 2:30 pm confirmed the above findings.28 Pa Code 211.10(d) Resident Care Policies

Based on clinical records review, facility investigations and staff interview, it was determined that the facility failed to maintain accurate records regarding wound care and nutritional intake for three of 24 residents reviewed. (Resident R1, R2 and R3) Findings include:Review of facility policy, titled Advance Directives dated March 17, 2025 states, Policy Statement- Advance directives will be respected in accordance with state law and facility policy. Further review of the facility policy reads, 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directiveReview of Resident R3's clinical record revealed the resident was re-admitted to the facility on [DATE] with the diagnsoses of Heart Failure (a condition where the heart muscle cannot pump blood effectively), Muscle Weakness, and Dysphagia (difficulty or discomfort swallowing).Review of Resident R3's electronic medical record revealed a physician order dated September 16, 2025 listed as Full Code, that indicated the resident's code status was a CPR/Attempt Resuscitation (Cardiopulmonary Resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest).Further review of Resident R3's electronic medical record revealed a form, Physician Orders for Life Sustaining Treatment (POLST), dated and signed by the facility social worker Employee E7 on September 25, 2025, that specified the resident's code status was Do Not Resuscitate (DNR - allow natural death if resident found with no pulse and is not breathing).Interview with the social worker Employee E7 on October 16, 2025 at 11:33 a.m. revealed Resident R3 did have a care plan meeting held and that was when the discussion came up and the resident ' s POLST form was changed.Interview with the Director of Nursing Employee E2 on October 16, 2025 at 2:37 p.m. revealed the responsibility would fall on the director of nursing Employee E2 to complete the POLST review and update the order in the electronic system. Employee E2 confirmed the POLST form did not accurately reflect the physician order for code status on Resident R3's electronic medical record. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses of Dementia. Review of Resident R1's clinical record revealed a physician order dated September 1, 2025 to Cleanse B/L (Bilateral) Hallux (big toe) ingrown toenails, then apply topical antibiotic ointment to affected area, cover with band-aid every day shift. Review of Resident R1's September 2025 Treament Adminsitration Record revealed that the above stated treatment was documented as completed on September 8, 2025 Review of documentation of an investigation conducted by the facility as result of a concern presented by Resident R1's family member revealed that licensed nurse, Employee E12, failed to complete wound treatment to the resident left foot on September 8, 2025 as ordered by physician. Interview with Employee E2, Director of Nursing on October 16, 2025 at 1:30pm, revealed that dressing on resident's left foot, upon dressing change on September 8, 2025, was dated September 5, 2025. Employee E2, Director of Nursing confirmed that dressing changes were marked as completed in Resident R1's medical record daily between September 5, 2025 through September 8, 2025 but per the date on the dressing the last treatment was September 5, 2025. Review of Resident R2's clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnosis of, Chronic Kidney Disease, Dementia. Review of Resident R1's clinical record revealed significant weight loss. September 25, 2025- 109lbsOctober 6, 2025- 106 lbs October 14, 2025- 100.5 lbs Review of Employee E13, Registered Dietician's note dated October 14, 2025 revealed BMI 18.6, very underweight. Patient showing 6.9% weight loss from 9/25/25- 10/7/2025. Intake per nursing variable but average between 50-60%. Observation of dining room on October 14, 2025 at 12:30pm revealed Resident R2 encouraged by Employee E14, Nursing Assistant to eat multiple items on plate and offering alternatives. Resident refused to eat and spit out food. Interview with Employee E14, Nursing assistant on October 14, 2025 at 12:30 pm revealed Resident R2 refuses to eat anything, even with encouragement it is very difficult to get resident to eat. Review of Resident R1's clinical record revealed that Resident R2 ' s intake on October 14, 2025 at 2:45pm was recorded as having eaten 75-100% of his/her meal. Interview with Employee E15, Nurse Assistant on October 16, 2025 at 11:00 am revealed that Resident R1 had only consumed approximately 30% of her breakfast on October 16, 2025. Review of Resident R1's clinical record revealed that Resident R2 ' s intake on October 16, 2025 at 9:56am was recorded as having eaten 75-100% of his/her meal. 28 Pa. Code 201.18(b)(2) Management28 Pa. Code 211.12(d)(1) Nursing services

Findings Include:Review of requested staff training files revealed three of the employees reviewed should have a yearly evaluation. A request was made for Employee E9, E10, and E11's yearly reviews.Interview with the Human Resources Director Employee E6 on October 16, 2025 at 10:30 a.m. revealed she was still looking for the yearly reviews.Review of facility documentation revealed Employee E9 was hired on June 22, 2021 as a full-time employee. Employee E10 was hired as a part-time employee on October 12, 2023, and Employee E11 was hired as per necessary on March 2, 2023.After giving further time to locate the yearly reviews, on October 17, 2025 2:13 p.m. Employee E2 the Director of Nursing revealed they were not able to find the annual reviews for the three nurse aides requested.28 Pa. Code 201.18(b)(1)(3) Management28 Pa. 211.12(c) Nursing services

Based on a review of clinical records, facility policy, observations, and staff interview, it was determined the facility failed to ensure resident environment was free from potential accident hazards for one of two nursing units observed (third floor). Findings include:Facility policy titled Storage of Medication revised 2023, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments or room. The nursing staff is responsible for maintaining medication storage and unlocked medication carts are not to be left unattended. During an observation on October 14, 2025 at 11:17 a.m. on the third floor revealed 12 blister packs of medication left unattended on the medication cart outside of the nurse's station. Several residents were observed sitting near the unattended medication cart. Further observation on October 14, 2025 at 11:20 a.m. revealed the third floor medication storage room was propped open with an ointment bottle. Inside the medication room the medication was observed to have injectable medications and vials of insulin. Interview on October 14, 2025 at 11:25 a.m. with Employee E4, Licensed Practical Nurse, confirmed the 12 blister packs of medication on the medication cart should be locked and stored away from resident access and the medication storage room should be locked to restrict resident access. 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observations and clinical record review, it was determined that the facility did not ensure the comprehensive care plan was implemented related to wound care for three of twenty residents reviewed (Resident R1, R4, R5). Finding Include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE] with diagnoses of Dementia (irreversible, progressive degenrative disease of the brain). Further Review of Resident R1's clinical record revealed resident was seen by podiatry for follow-up on September 10, 2025 and findings included dry gangrenous changes on right toe related to peripheral vascular disease. Podiatry recommendations included Apply betadine and gauze to right hallux (great toe) daily. Monitor toe for worsening gangrene, redness, swelling and color. Take measurements of gangrene daily and record. Review of Resident R1's clinical record revealed resident was seen by podiatry on September 26, 2025 for the removal of ingrown toenails on left and right foot. Further review revealed that podiatry ordered Continue antibiotics. Leave dressing on for 24 hours. After removal bathe like normal, dry area, apply topical antibiotic ointment and band aid until next follow up. Review of Resident R1's care plan on October 15, 2025 revealed no care plan in place for wound care. Interview with Employee E2, Director of Nursing on October 16, 2025 at 12:00pm confirmed no care plan in place for resident's foot care or wound care. Review of Resident R4's clinical record revealed the resident was admitted to the facility on [DATE]. The resident had the following diagnoses: Unspecified Dementia with behavioral disturbances with a date of June 27, 2025. Review of Resident R4's current care plan revealed the resident did not have a care plan in place for Dementia.Review of Resident R5's clinical record revealed the resident was admitted to the facility on [DATE]. The resident had the following diagnosis: bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania and depression).Review of resident R5 's care plan revealed the resident did not have a care plan in place for bipolar disorder.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on the facility documentation, clinical record review, observations and staff interviews, the facility failed to ensure that a mechanical lift was used in a safely manner to prevent accidents for one of six records reviewed. (Resident CL1)Findings include: Review of facility provided documentation titled, Invacare User Manual dated 2013, indicated that when lifting a resident or moving a resident while they are in the sling, the legs of the lift must be in the fully open position for maximum stability and safety. Review of clinical records for Resident CL1 revealed that the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness, and difficulty walking. Continued review revealed that the resident required two people to assist with transfers via Hoyer lift (mechanical lift utilize to transfer a resident from one surface to another). Review of nursing notes for Resident CL1, dated October 31, 2025, revealed that a nurse aide reported that during the Hoyer lift transfer from chair to bed, Resident CL1 was lowered to the floor due to the Hoyer tilted over to the side over one of the nurse aids. Review of facility investigation dated October 31, 2025, revealed that Resident CL1 was found laying on the floor on his back with the Hoyer pad under him, on the right side of the bed with two NA in the room. Continued review revealed that during the transfer from chair to bed, the Hoyer tilted over to the side over one of the Nurse aids and the patient had to be lowered to the floor. Interview conducted on December 3, 2025, at 12:15 p.m. with Nurse Aide, Employee E3, revealed that when transferring the resident from chair into bed via the Hoyer lift, the device tilted on to Employee E3, which resulted in the Resident CL1 being lowered to the ground. Continued interview revealed that the Hoyer lift legs were not widened at the time of transfer. Follow-up interview and observations conducted on December 3, 2025, at 12:30 p.m. with Employee E3, the Nurse aide demonstrated the Hoyer lift transfer and confirmed that the Hoyer lift was operated without properly widening the legs, which resulted in the lift tipping. Interview conducted on December 3, 2025, at 1:00 p.m. with facility Administrator and Director of Nursing, confirmed that the Hoyer lift legs must be widened upon transfer.28 Pa. Code 211.10 (d) Resident Care Policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observation, interview with residents and staff, review of facility policy, and facility documentation, it was determined the facility failed to ensure comfortable air temperature levels were provided on two of two nursing units (Second and Third Floor), placing 16 residents at risk for developing hypothermia (condition of having a lower body temperature than normal body temperature). This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 59 degrees Fahrenheit and 70 degrees Fahrenheit in two of two nursing units. (Second and Third Floor). Findings include: Review of the undated facility policy titled Facility Temperature Policy and Procedures revealed The facility will maintain indoor air temperatures within the required range to promote the health, safety, and comfort of residents and staff. The facility will monitor, document, and respond to temperature deviations in a timely manner to prevent adverse effects on resident well-being. It further under procedures outlines, Resident care areas (e.g., rooms, hallways, common areas) must be maintained between 71 F and 81 F (Fahrenheit) per federal regulations. Observations conducted on February 7, 2025, at 10:09 a.m. with the Maintenance Assistant, Employee E3 revealed the following air temperatures: 2nd floor nursing unit East hallway- 65.3 of degrees Fahrenheit -room [ROOM NUMBER]-64.9 of degrees Fahrenheit -room [ROOM NUMBER]-62.2 of degrees Fahrenheit -room [ROOM NUMBER]- 59.0 of degrees Fahrenheit 2nd floor nursing unit [NAME] hallway- 63.8 of degrees Fahrenheit -room [ROOM NUMBER]-64.0 of degrees Fahrenheit -room [ROOM NUMBER]-61.8 of degrees Fahrenheit -room [ROOM NUMBER]-59.0 of degrees Fahrenheit 2nd Floor nursing unit North hallway- 65.8 of degrees Fahrenheit -room [ROOM NUMBER]-63.8 of degrees Fahrenheit -room [ROOM NUMBER]-65.4 of degrees Fahrenheit -room [ROOM NUMBER]-66.9 of degrees Fahrenheit 3rd floor nursing station- 69.8 of degrees Fahrenheit -3rd Floor dining area 59.3 of degrees Fahrenheit -3rd East hallway 66.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.7 of degrees Fahrenheit -room [ROOM NUMBER]-59.3 of degrees Fahrenheit 3rd floor nursing unit [NAME] hallway- 66.2 of degrees Fahrenheit -room [ROOM NUMBER]-65.4 of degrees Fahrenheit -room [ROOM NUMBER]-60.2 of degrees Fahrenheit 3rd nursing unit North hallway -69 of degrees Fahrenheit -room [ROOM NUMBER]-62.9 of degrees Fahrenheit -room [ROOM NUMBER]-61.5 of degrees Fahrenheit On February 7, 2025, at approximately 10:25 a.m. an interview with Resident R3 who was observed wearing sweatshirt, and coat, reported yesterday I got up and it was so cold, facility has no heat no hot water. On February 7, 2025, at 10:28 a.m., an interview was conducted with Nurse Aide, Employee E9, who reported, It's cold today. Nurse Aide, Employee E9 noted that it had not been this cold the previous week. On February 7, 2025, at approximately 10:31 a.m. an interview was conducted with Resident R4 who was observed wearing a hat and reported, it's cold in this room referring to room [ROOM NUMBER]. On February 7, 2025, at approximately 10:33 a.m. an interview with Resident R5 reported it's cold. On February 7, 2025, at 10:45 a.m. an interview with License Nurse, Employee E8 revealed today was the first day that it has been this cold in the building. On February 7, 2025, at 10:54 a.m. an interview was conducted with the Maintenance Director, Employee E6. During the interview, Employee E6 reported the facility experienced issues last week due to water pipes breaking outside. As a result, sand and debris entered the toilets and pipes, affecting their functionality. The heat is working but it goes in and out. The last measurement of the heat temperatures was yesterday. On February 7, 2025, at 11:02 a.m., an interview was held with Resident R7 reported it's cold Resident R7 was covered with a blanket, dressed in a winter jacket, sweatshirt and hat. On February 7, 2025, at 11:05 a.m., an interview was conducted with the Nursing Home Administrator, Employee E1, on the second nursing unit. Employee E1 reported the thermometer gun used by the Maintenance Assistant was broken and their own thermometer gun was displaying fluctuating temperatures around 70 F. On February 7, 2025, at 11:12 a.m. Nursing Home Administrator recaptured air temperature levels using a different thermometer. Air temperature recordings were as follows: -room [ROOM NUMBER]- registered 68 of degrees Fahrenheit -2nd floor dining room - registered 65 of degrees Fahrenheit -2nd floor east hallway - 69.2 of degrees Fahrenheit -room [ROOM NUMBER]- registered 65 of degrees Fahrenheit -room [ROOM NUMBER]-69 of degrees Fahrenheit -room [ROOM NUMBER]- 68 of degrees Fahrenheit -2nd floor North hallway - 68 of degrees Fahrenheit -1st floor hallway by the elevators- 69 of degrees Fahrenheit On February 7, 2025 at approximately 11:20 a.m. observation of the second-floor supply room failed to reveal additional warm blankets. On February 7, 2025 at approximately 11:28 a.m. observations conducted of the the third-floor supply room failed to reveal additional warm blankets. On February 7, 2025, at 11:35 a.m., an observation was conducted with the Housekeeping Director, Employee E7, which revealed that only one warm blanket remained on the rack in the laundry room. During interview with the Housekeeping Director, Employee E7 at the time of the observation Employee E7 was asked if facility has any additional blankets? Employee E7 stated that he just returned from placing additional blankets to the 2nd and 3rd nursing units' supply room. Observation conducted of the 2nd and 3rd nursing units' supply room on February 7, 2025 at 11:40 p.m. in the company of the Nursing Home Administrator, Employee E1 revealed that the second-floor supply room had no warm blankets while the third-floor supply room contained one additional warm blanket along with a few additional regular thin blankets. Interview on February 7, 2025, at 11:59 a.m., an interview with Commercial Contractor, Employee E10, revealed there was an issue with the air handler; the supply fan had moved off the shaft and was rubbing against the housing. Due to this malfunction, they recommended shutting it off the system on Wednesday, February 5, 2025, to prevent further damage, and the facility was aware of this action. Continued interview with Commercial Contractor, Employee E10 stated that he/she returned today to assess the issue further and provide an exact repair quote. Commercial Contractor, Employee E10 was in the process of preparing a quote, after which the necessary parts will need to be ordered and repairs scheduled, pending approval. The facility instructed the contractor to turn the air handler back on. On February 7, 2025, at 12:28 p.m., an interview was conducted with Nursing Aide, Employee E4, who reported feeling cold. The facility has been providing blankets to residents who are experiencing cold temperatures. On February 7, 2025, at 12:32 p.m., an interview was conducted with Resident R8 who reported it's freezing here. Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on February 7, 2025, at 12:45 p.m. for failure to maintain comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit on two of two nursing floors which posed a health and/or safety risk to 16 residents on the Second and Third Floor nursing units through the loss of body heat. The Nursing Home Administrator was provided with the Immediate Jeopardy template on February 7, 2025, at 12:45 p.m. and an immediate action plan was requested. The following action plan was received and accepted on February 7, 2024, at 5:30 p.m. -On February 7, 2025, the facility initiated a comprehensive Quality Assurance/Performance Improvement Plan to ensure that facility air temperatures were maintained between 71- and 81- degrees Fahrenheit. -Residents that resided in affected rooms were offered a room move and declined. They were informed that if they were unconformable and would like to move rooms at any time to inform facility staff. -[Plumbing Company] on site on February 7, 2025, to address concerns related to the heating unit. Additional blankets were purchased and provided to residents. -Warming liquid hydration stations were placed in resident common areas by culinary staff on February 7, 2025. -All 16 residents identified were assessed by nursing staff to ensure that there have been no undesired outcomes related to hypothermia and that no signs and symptoms of hypothermia were present to the central heating system being temporarily inoperable to include vital signs, skin assessment and any other pertinent assessments. -All other rooms in the facility will have temperatures taken and residents affected will be continuously assessed every shift to ensure that no signs and symptoms of hypothermia are present to include vital signs, skin assessments along with any other relevant assessment related to hypothermia. -Facility staff will be educated on ensuring residents remain warm and to ensure that residents are assessed frequently to ensure that no signs of symptoms of hypothermia are present. -Facility temperature will be checked every shift by the manager on duty and facility administration to ensure that they are within appropriate range along with resident interview to ensure that they are comfortable with the current temperatures. -If the facility rooms affected does not meet and maintain the appropriate temperatures facility will initiate the emergency plan to include closure of the effected rooms and mandate movement of resident to functioning rooms. An Ad Hoc QAPI Meeting was held on February 7, 2025 to discuss the events surrounding the facility's failure to ensure temperatures in the facility were maintained between 71- and 81- degrees Fahrenheit, to identify the root cause, and to initiate improvement to the facility's processes and procedures regarding ensuring temperature levels are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central heating system has routine maintenance. -The PA Healthcare Coalition was notified via phone with a voice message left on February 7, 2025. On February 7, 2025, at 3:47 p.m., an interview was conducted with Heating and Air Contractor, Employee E11, reported that the heating issue had been resolved. Temperatures in the hallways and rooms were increasing. Observations on February 8, 2025, at 12:45 p.m. revealed the Second-floor nursing unit-maintained temperatures between 71- and 81- degrees Fahrenheit. The third nursing unit continued to have rooms with 7 rooms were below 71 degrees Fahrenheit. Facility brought portable space heater (safe) to maintain air temperature levels between 71- and 81- degrees Fahrenheit. The facility provided education to all staff on assessing residents for signs and symptoms of hypothermia. Staff were instructed to ensure residents remained warm by providing blankets, conducting vital sign checks every shift, and offering warm beverages as needed. The vital signs auditing was reviewed and residents were not exhibiting signs and symptoms of hypothermia. On February 8, 2025, at 5:30 p.m., the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1)(2.1) Management 28 Pa. Code 204.19 Plumbing, heating ventilation and air conditioning and electric

Based on the staff interviews, reviews of facility documents and observation, it was determined that the facility failed to ensure that the central air condition system was maintained in a safe operating condition for two of two chillers. This failure resulted in one non-operational chiller and a second chiller requiring extensive repairs and cleaning. This failure was identified as an Immediate Jeopardy with air temperatures rising above 81 degrees in two of two nursing units (2nd and 3rd floor). Findings include: Review of The Department of Energy's recommendation titled Maintaining Your Air Conditioner revealed that an air conditioner's filters, coils, and fins require regular maintenance for the unit to function effectively and efficiently throughout its years of service. Neglecting necessary maintenance ensures a steady decline in air conditioning performance while energy use steadily increases. Review of the manufacture's manual for model 23XRV Start-Up, Operation, and Maintenance Instruction revealed that the company recommendation for continual service is to establish a regular maintenance schedule based on your actual chiller requirements such as chiller load, run hours, and water quality. Some specifications are as follows; Check Safety and Operating Controls Monthly - To ensure chiller protection, the automated Control Test should be performed at least once per month. See Table 6 for safety control settings. See Table 15 for Control Test functions. Change the oil filter on a yearly basis or when the chiller is opened for repairs. A refrigerant filter/drier, located on the refrigerant cooling line to the motor, should be changed once a year or more often if filter condition indicates a need for more frequent replacement. The oil reclaim system has a strainer on the educator suction line, a strainer on the discharge pressure line, and a filter on the cooler scavenging line. Replace the filter once per year or more often if needed. Carrier recommends changing the oil after the first year of operation and every five years thereafter as a minimum in addition to a yearly oil analysis. At least once a year, disconnect the vent piping at the valve outlet and carefully inspect the valve body and mechanism for any evidence of internal corrosion or rust, dirt, scale, leakage, etc. Included in the manual is the refrigerator log which provides a convenient checklist for routine inspection and maintenance and provide a continuous record of chiller performance. It is an aid in scheduling routine maintenance and in diagnosing chiller problems. Review of portable air conditioner unit manufacturer's directions offer an extremely efficient and effective way to control the climate in any sized room. Because water cooled air conditioners do not discharge large amounts of heat, they do not require exhaust ducting and are used to great effect in enclosed areas. Portable air conditioner units that are water cooled simply require access to an appropriate power source, a source of water, and a drain. Our units ship with hoses as an accessory. They will connect to any standard sink but can also be used in janitor and utility sinks or used with any other type of wastewater outlet. Observation of the First floor on July 9, 2024, at 9:07 a.m. revealed water covering the floor. The Assistant Director of Maintenance, Employee E3 was mopping up First floor corridor. Interview with the Assistant Director of Maintenance, Employee E3 at time of observation revealed that the facility central air condition was not functioning and the administrator had temporary portable water-cooled spot cooling air conditioners installed on all the nursing units. The air-conditioned that was placed on the Second-floor- room [ROOM NUMBER] malfunctioned causing a leak onto the first floor. Tour of the facility nursing units, floors two and three, accompanied with Director of Nursing, Employee 4 on July 9, 2024, at 9:25 a.m. revealed the Second-floor portable malfunctioned air conditioner. The inspection of room [ROOM NUMBER] revealed that the portable water-cooled spot cooling air conditioner became dislodged forcing water to drain on the floor. Further observation revealed that there was one portable air-conditioning unit on each unit for a total of 3 protable air conditionings for the entire facility. Continued tour of the facility on July 9, 2024, between 9:25 a.m. and 10:20 a.m. revealed that the following air temperatures above 81 degrees: 2nd Floor nursing unit: room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit room [ROOM NUMBER] temped at 82.4 degrees Fahrenheit room [ROOM NUMBER] temped at 83.1 degrees Fahrenheit room [ROOM NUMBER] temped at 83.4 degrees Fahrenheit 3rd Floor Nursing unit: room [ROOM NUMBER] temped at 82.5 degrees Fahrenheit room [ROOM NUMBER] temped at 83.4 degrees Fahrenheit room [ROOM NUMBER] temped at 86.1 degrees Fahrenheit room [ROOM NUMBER] temped at 85.5 degrees Fahrenheit room [ROOM NUMBER] temped at 84.9 degrees Fahrenheit room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit room [ROOM NUMBER] temped at 83.6 degrees Fahrenheit room [ROOM NUMBER] temped at 90.6 degrees Fahrenheit room [ROOM NUMBER] temped at 87.9 degrees Fahrenheit room [ROOM NUMBER] temped at 88.3 degrees Fahrenheit room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit During interview with Nursing Home Administrator, Employee 2, on July 9, 2024, at 11:17 a.m. Employee E1 stated that the air conditioner system at the facility was working. That on July 7, 2024, Nursing Home Administrator, Employee E1 noticed the temperatures were approaching a dangerous zone and that he contacted an air condition rental company. Three portable air conditioning units (three of each nursing floor) were rented and HVAC (heating, ventilation and air conditioning) service company came to the facility earlier this day to clean the air condition tower and tubing. Nursing Home Administrator, Employee E2 stated that the air condition is fully working. Interview with Regional Owner, Employee E1 on July 9, 2024, at 11:45 a.m. revealed he has no contract with an HVAC company for routine maintenance. Regional Owner, Employee E1 confirmed the company was out to clean the tower July 9, 2024 and the system will take some time, the pumps are working, and the water temperature has become cooler, the air pushing from the chiller is forty-seven degrees Fahrenheit, indicating the air condition is working to its fullest capacity. Review of service report revealed that a call was requested from Employee E2 which stated, Looking to get a tech out there ASAP (as soon as possible) because the air handler belt is broken, and resident room is not reading. Further review of this service report revealed the chiller running a 12.5-degree condenser approach will look at the tower. The technician also cleaned the nozzle on cooling tower. Found large metal deposits blocking nozzles. The technician suspected the strainer on the chiller is blocked. The chiller condenser tubes also need cleaning. Telephone interview with HVAC company's Supervisor on July 9, 2024, at 3:35 p.m. confirmed that the HVAC technician was at the facility at 7:00 a.m. and determined that the chiller was not functioning at all and also was in needed of an oil pump. The second chiller was cleaned but was not running to its fullest capacity. The air condition system has not been serviced and maintained at the recommended quarterly operation inspection and yearly annual inspection. Review of HVAC Service Agreement revealed the HVAC maintenance plan consists of an operation inspection shall include specific tasks and recommended frequencies for each equipment type. Each inspection will be used to ensure and consistent and thorough review of the covered equipment such as parts, oil, lubricants, and materials to be completed quarterly. An annual inspection will be a pre- scheduled recurring preventive maintenance action, which is to be performed once a year or as recommended by the equipment manufacture. The facility's lack of having an AC contract to perform regular maintenance and preventative maintenance caused the facility's AC equipment to malfunction during an excessive heat wave which caused serious adverse outcome likely to occur related to increased hot air temperature in the facility (the air temperature could not be maintained between 71 and 81 degrees F) Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on July 10, 2024, at 1:04 p.m. for failure to ensure that the air conditioning system which included two chillers were in optimal operational condition to maintain air temperatures on the Second and Third Floor nursing units. The Nursing Home Administrator was provided with the Immediate Jeopardy template on July 10, 2024, at 1:04 p.m. and an immediate action plan was requested. The following action plan was received and accepted on July 10, 2024, at 7:37 p.m. -On July 10, 2024, the facility initiated a comprehensive Quality assurance, performance Improvement Plan to ensure that the facility's central air conditioning systems is maintained in operational conditions. -Residents that resided in affected rooms were offered a room move and declined. The were informed that if they were uncomfortable and would like to move rooms at any time to inform facility staff. -Plumbing company on sight July 10, 2024, at approximately 9:00 a.m. to address concerns relating to the cooling unit. -Portable cooling units provided by industrial rental company were placed in the affected areas to assist with maintaining temperatures. -Hydration Stations were placed in the resident's common areas by the culinary staff on July 9, 2024. -Additional portable cooling systems were installed appropriately in the affected resident rooms on July 10, 2024. -The maintenance director re-tested affected rooms after proper installation of portable cooling systems and rooms were confirmed to be within appropriate range. -Facility temperatures will be checked every shift to ensure that they are within appropriate range along with resident interviews to ensure that they are comfortable with the current temperatures. -If the facility room affected does not meet and maintain the appropriate temperatures the facility will initiate the emergency plan to include closure of the affected rooms and mandated movement of residents to functioning rooms. A contract was entered into with HVAC company to ensure continuous operation of the central cooling system on July 10, 2024. A review of air temperature audits was completed on July 11, 2024, revealed that air temperatures on the Second and Third floor were maintained below 81 degrees. Observation on July 11, 2024, between 2:30-3:30 p.m. revealed that portable air conditioners units were placed at each resident room. It was confirmed that a signed contract was secured by the facility with an HVAC company for the extended of 3 years. Following verification of the implementation of the immediate action plan, review the Immediate Jeopardy was lifted on July 11, 2024, at 3:37 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on observation, interview with resident and staff, review of facility documentation and review of CDC recommendations, it was determined that the facility failed to ensure comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees. This failure resulted in an Immediate Jeopardy situation with air temperatures ranging between 82.4 degrees Fahrenheit and 90.6 degrees Fahrenheit in two of two nursing units (Second and Third Floor). Findings include: Review of The Center for Disease Control and Prevention recommendation titled Extreme Heat date June 21, 2024, revealed Heat-related illnesses, like heat exhaustion or heat stroke, happen when the body is not able to properly cool itself. While the body normally cools itself by sweating, during extreme heat, this might not be enough. In these cases, a person's body temperature rises faster than it can cool itself down. This can cause damage to the brain and other vital organs. Review of The Center for Disease Control and Prevention (CDC) recommendation titled Extreme Heat dated February 13, 2024, revealed that people aged [AGE] years or older are more prone to heat-related health problems. Older adults do not adjust as well as young people to sudden changes in temperature. They are more likely to have a chronic medical condition that changes normal body responses to heat. They are more likely to take prescription medicines that affect the body's ability to control its temperature or sweat. Observation of the First floor on July 9, 2024, at 9:07 a.m. revealed water covering the floor. The Assistant Director of Maintenance, Employee E3 was mopping up the First floor corridor. Interview with the Assistant Director of Maintenance, Employee E3 at time of observation revealed that the facility central air conditioning was not functioning and the administrator had temporary portable water-cooled spot cooling air conditioners installed on all the nursing units. The air-conditioner that was placed on the Second-floor- room [ROOM NUMBER] malfunctioned causing a leak onto the first floor. Tour of the facility nursing units, floors two and three, accompanied with Director of Nursing, Employee 4 on July 9, 2024 at 9:25 a.m. revealed the Second-floor portable malfunctioned air conditioner. The inspection of room [ROOM NUMBER] revealed that the portable water-cooled spot cooling air conditioner became dislodged forcing water to drain on the floor. 2nd Floor nursing unit: room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit room [ROOM NUMBER] temped at 82.4 degrees Fahrenheit room [ROOM NUMBER] temped at 83.1 degrees Fahrenheit room [ROOM NUMBER] temped at 83.4 degrees Fahrenheit 3rd Floor Nursing unit: room [ROOM NUMBER] temped at 82.5 degrees Fahrenheit room [ROOM NUMBER] temped at 83.4 degrees Fahrenheit room [ROOM NUMBER] temped at 86.1 degrees Fahrenheit room [ROOM NUMBER] temped at 85.5 degrees Fahrenheit room [ROOM NUMBER] temped at 85.5 degrees Fahrenheit room [ROOM NUMBER] temped at 84.9 degrees Fahrenheit room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit room [ROOM NUMBER] temped at 83.6 degrees Fahrenheit room [ROOM NUMBER] temped at 90.6 degrees Fahrenheit room [ROOM NUMBER] temped at 87.9 degrees Fahrenheit room [ROOM NUMBER] temped at 88.3 degrees Fahrenheit room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit Interview with Nursing Home Administrator, Employee 2, on July 9, 2024, at 11:17 a.m. revealed Employee E2 believed that there was a functioning air conditioning at the facility. Employee E2 stated that it was noticed that the temperatures were approaching a dangerous zone and an air condition rental company was contacted and water-cooled portable air conditioners for each unit (three on each floor) were rented. Employee E2 had a HVAC (heating, ventilation and air conditioning) service company come to the facility earlier during the day on July 9, 2024, to clean the air condition tower and tubing. Employee E2 stated that the air condition is fully working. Review of portable air conditioners manufacturer's documentation revealed that the protable air conditioners offer an extremely efficient and effective way to control the climate in any sized room. Because water cooled air conditioners do not discharge large amounts of heat, they do not require exhaust ducting and are used to great effect in enclosed areas. Portable air conditioner units that are water cooled simply require access to an appropriate power source, a source of water, and a drain. Our units ship with hoses as an accessory. They will connect to any standard sink but can also be used in janitor and utility sinks or used with any other type of wastewater outlet. Review of the facility tempeture logs for July 8, 2024, revealed temperatures above 81 degrees Fahrenheit and as high 87.6 degrees Fahrenheit. Further review of temperature logs revealed that there were missing temps on June 29, 2024, and June 30, 2024, July 4, 2024 and July 5, 2024. -Interview with Resident R1 on July 9, 2024, at 9:40 a.m. revealed that the room has had no air condition for five days, and it has been really very hot, and difficult to breath. -Interview with Resident R2 on July 9, 2024, at 9:51a.m. revealed that the temperature has been too hot, with no relief. -Interview with Resident R3 on July 9, 2024, 9:59 a.m. revealed that the temperature has been so hot, Resident R3 has not been able to sleep. -Interview with Resident R4 on July 9, 2024, 10:05 a.m. revealed that it has been really very hot the last few days. Resident R4 was observed with no fan in the room and requested a fan at the time of the interview. -Interview with Resident R5 on July 9, 2024, 10:11 a.m. revealed that his room tempeture is too hot, has been for a week. -Interview with Resident R6 on July 9, 2024, 10:18 a.m. revealed that it has been a little hot. Resident R6 observed with no fan in the room and the resident stated that he would like a fan. -Interview with Resident R7 on July 9, 2024, 10:34 a.m. revealed the he would like it to be cooler. -Interview with Resident R8 on July 9, 2024, 10:41 a.m. revealed this resident cannot get out of bed and stated it has been hot and that it is hard to breath. -Interview with Resident R9 on July 9, 2024, 10:45 am stated it has been very uncomfortable. -Interview with Resident 10, on July 9, 2024, 10:15 a.m. observed in the Third-floor hall sitting in front of the portable air conditioner, states that it's so hot and this is the only way she can get relief. -Interview with Facility County Ombudsman on July 9, 2024, at 11:05 a.m. revealed he was at the facility to investigate twenty-three complaints of resident with no air condition. Interview with Nursing Home Administrator, Employee E2 on July 9, 2024, at 2:20 p.m. revealed that the facility's plan to alleviate the heat was to make sure every resident has a working fan and try tabletop portable air cooler that works with ice cubes, and possible cooling blankets. Employee E2 believed that the central air would begin to cool the building. Tour of the facility nursing units Second and Third floors with Nursing Home Administrator, Employee E2 and Maintenance Assistant Director, Employee E3 on July 10, 2024, at 9:05 a.m. of the Third-floor nursing unit revealed two portable air conditioners on each wing (three total). One portable air conditioner was not functioning properly. Observation and test of air temperatures with the facility's thermometer revealed the following air temperatures: room [ROOM NUMBER] temped at 84.2 degrees Fahrenheit room [ROOM NUMBER] temped at 86.3 degrees Fahrenheit room [ROOM NUMBER] temped at 86.1 degrees Fahrenheit room [ROOM NUMBER] temped at 85.6 degrees Fahrenheit room [ROOM NUMBER] temped at 87.9 degrees Fahrenheit room [ROOM NUMBER] temped at 86.9 degrees Fahrenheit room [ROOM NUMBER] temped at 84.7 degrees Fahrenheit room [ROOM NUMBER] temped at 86.9 degrees Fahrenheit Interview with Regional owner, Employee E1 and Nursing Home Administrator, Employee E2 on July 10, 2024, at 2:00 p.m. confirmed the above air temperatures in resident rooms and that the portable air conditioners in the halls, fans, air chillers, and the facility central air condition has not improved the air temperatures. Interviews conducted with 10 residents revealed that it was difficult to breath, the room temperature was too hot, they were unable to sleep due to the hot temperatures in their room and they felt uncomfortable. The facility received 23 complaints from residents with no air conditioning in their rooms. In accordance with https://www.timeanddate.com/weather/usa/philadelphia the temperatures in the Philadelphia region from July 6-11, 2024 range from 91 degrees Fahrenheit to 97 degrees Fahrenheit. The increased age and comorbidities of the residents in the facility make them more susceptible to serious adverse outcomes related to reduced cardiovascular physiological reserves, an impaired sense of thirst, and compromised regulatory systems due to senile degeneration. In addition to medications that the residents' are receiving. Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on July 10, 2024, at 1:04 p.m. for failure to maintain comfortable air temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in two of two nursing floors. The Nursing Home Administrator was provided with the Immediate Jeopardy template on July 10, 2024, at 1:04 p.m. and an immediate action plan was requested. The following action plan was received and accepted on July 10, 2024, at 7:37 p.m. -On July 10, 2024, the facility initiated a comprehensive Quality assurance, performance Improvement Plan to ensure that the facility's central air conditioning systems is maintained in operational conditions. -Residents that resided in affected rooms were offered a room move and declined. The were informed that if they were uncomfortable and would like to move rooms at any time to inform facility staff. -Plumbing company on sight July 10, 2024, at approximately 09:00 a.m. to address concerns relating to the cooling unit. -Portable cooling units provided by industrial rental company were placed in the affected areas to assist with maintaining temperatures. -Hydration Stations were placed in the resident's common areas by the culinary staff on July 9, 2024. -Additional portable cooling systems were installed appropriately in the affected resident rooms on July 10, 2024. -The maintenance director re-tested affected rooms after proper installation of portable cooling systems and rooms were confirmed to be within appropriate range. -Facility temperatures will be checked every shift to ensure that they are within appropriate range along with resident interviews to ensure that they are comfortable with the current temperatures. -If the facility room affected does not meet and maintain the appropriate temperatures the facility will initiate the emergency plan to include closure of the affected rooms and mandated movement of residents to functioning rooms. -A contract was entered into with HVAC company to ensure continuous operation of the central cooling system on July 10, 2024. -A part for the non-operational chillers required for repair was ordered on July 9, 2024, and is scheduled to be installed on Friday, July 12, 2024. Once installed and operational, the second chiller requiring repair/ cleaning will be taken out of service and repaired as well as cleaned. -An Ad Hoc QAPI meeting was held on July 10, 2024 to discuss the events surrounding the facility's failure to ensure that the temperatures in the facility were maintained between 71-81 degrees Fahrenheit, to identify the root cause, and to initiate improvements to the facility's processes and procedures regarding ensuring that temperatures are appropriately maintained in the facility, the facility has a plan in place when temperatures are not maintained and to ensure that the central cooling system has a routine maintenance plan in place to address cleaning of the system and routine maintenance and repairs to ensure that the system remain in operational status. -The Southeastern Pennsylvania Healthcare Coalition was notified via phone on July 10, 2024. A review of air temperature audits was completed on July 11, 2024, revealed that air temperatures on the Second and Third floor were maintained below 81 degrees. Observation on July 11, 2024, between 2:30-3:30 p.m. revealed that portable air conditioners units were placed at each resident room. It was confirmed that a signed contract was secured by the facility with an HVAC company for the extended of 3 years. Following verification of the implementation of the immediate action plan, review the Immediate Jeopardy was lifted on July 11, 2024, at 3:37 p.m. Refer to F908 s 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy, facility documentation, review of clinical records, interviews with staff and the resident, it was determined that the facility did not ensure residents were free from verbal abuse which resulted in actual harm to Resident R14 who was verbally abuse by a nursing staff for one of 16 residents reviewed. (Resident R14) Findings Include: Review of facility policy titled Abuse Prevention Program dated January 1, 2022 reads, Our residents have the right to be free from abuse, neglect, misappropriation or resident property and exploitation. Review of the admission record for Resident R14 incident he was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Unspecified abnormalities of gait, muscle weakness, polydipsia (an urge to drink too much associated with dry mouth or throat), acute kidney failure and anemia. Review of Resident R14's admission Minimum Data Set (MDS resident assessment of care needs) dated August 19, 2023, revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating that the resident's cognition was intact. Review of facility documentation submitted to the State Agency on January 19, 2024 revealed that on January 14, 2024, Employee E15 was in the doorway of Resident R14's room and nurse aide, Employee E22 approached Employee E15 and asked what the resident was requesting. Employee E15 said that the resident was requesting water but he was on fluid restrictions. Employee E22 asked the nurse and the nurse said that the resident could have a small cup of water. Upon Employee E22 returning to Resident's R14's room with water, Employee E22 heard Employee E15 calling resident names. The facility substantiated the allegation of verbal abuse. Review of facility grievance form from January 15, 2024, involving Resident R14 and nurse aide Employee E15. Grievance form summary of concern reads, Resident said his nurse has been calling me all types of names. Resident also said she was rough with him and she refused to give him ice and water. Review of facility witness statement form Licensed nurse, Employee E21 revealed, This nurse overheard [nurse aide, Employee E15] and [nurse aide, Employee E22] disagreeing as they were both coming down the hallway. [Resident R14] requested water and [nurse aide Employee E15] told [nurse aide, Employee 22] he could not have water due to restrictions. Nurse aid Employee E15 can been seen going into the resident's room and nurse aid Employee E22 was standing at the nurse's station we could hear nurse aide, [Employee E15] yelling at [Resident R14[ about the water. [Nurse aide, Employee E22] approached the nurses station asking could she give Room . [Resident R14]water. This nurse informed her so could do so with supervision, one small cup only. [Nurse aide, Employee E22] from the low side informed this nurse, that [nurse aide, Employee E1]5 told her not to give him water. I then encourage [nurse aide, Employee E22] to give the resident water no one can refuse him water if he is asking. [Nurse aide, Employee E15] told me I do not work here you do not tell me because I am with him every day he has a restriction. [Nurse aide, Employee E15] told [nurse aide, Employee E22] do not go on my side telling me what to do who are you nobody you are an ugly Muslim and you lie on me. This nurse encouraged both ladies to calm down and write statements to give to the supervisor. [Nurse aide, Employee E22] told [nurse aide Employee E15] that she was wrong for cursing at the patient, and she should be fired for all the abuse and wrong doing she does and that she was tired of it. [Nurse aide, Employee E22] was crying she appeared very emotional. [Nurse aide, Employee E15] told [nurse aide, Employee E22] she can go to h*** and report me all you want you will see nothing will happen you will get fired first you ugly Muslim you are evil. [Nurse aide, Employee E15] went to [Resident R14's room] asking him why did he lie I could hear her yelling. She returned to the nurse station telling his nurse I can not tell her what to do you are not staff only agency and a license practical nurse nobody. As the supervisor was approaching asking to talk in the lounge [nurse aide, Employee E15] followed behind me still yelling and calling me names. [Nurse aide, Employee E15] went into the patient room and for the third time she could be seen by this nurse pulling the sheet off the patient[ Resident R14]. [Resident R14] stated, She, she threw my water on me and my cup is on the floor. [Resident R14] appeared afraid and uncomfortable. [nurse aide, Employee E15] was asked to leave the patient room for safety reasons and privacy to talk to the nurse. [nurse aide, Employee E15] used prejudice/harmful words about my religious beliefs attacking my work ethic as well. [Licensed nurse, Employee E8] encouraged [nurse aide, Employee E15] to leave. She refused until the end of shift. Review of facility witness statement form completed January 14, 2024, from nurse aide, Employee E22 read, I was done my last round at 10:15 p.m. so I decided to go see why room [ROOM NUMBER] light had been going off for hours. Once I got to the room, nurse aid Employee E15 was sitting outside the room. I asked her why his light was going off and she said he want some water. But he on fluid restriction. I went into the room anyway. When I got in the room the patient said he wanted water but she was not going to give me none. That when I asked the charge nurse if he can have some water she told me yes but a small cup. I pour the cup of water and was on my way down to the room [ROOM NUMBER] when I heard nurse aid Employee E15 call the resident all kinds of name, (mother f**, if he reported her just see) that's when I went in the room to give him his water, told nurse aid Employee E15 to step out of the room. That's when I told her she can not talk to him like that. I reported her to the charge nurse that's when she told me I was ugly because I am Muslim. Review of facility witness statement form completed January 14, 2024, from Licensed nurse, Supervisor, Employee E8, While sitting in the nurse's office approximately 10:30 p.m. I heard a commotion in the hallway. I immediately went onto the unit and observed the charge nurse Employee E21 and nurse aid Employee E15 going/arguing back and forth with one another. I asked what is going on and spoke with each staff member assigned to the second floor. Nurse aide Employee E22 reported to me that she witness nurse aid Employee E15 cursing at Resident R14 and talking loud to the resident. I asked nurse aid Employee E15 to get her things she have to leave, because it's been reported to me that she cursed at the resident. At that time nurse aid Employee E15 attempted to go int to the resident room. I told [Employee E15] not to go in the room and she went in the room anyway. After [Employee E15] left the room. I spoke with resident he stated she spilled my water, I don't know why she doesn't like me. When I left the resident room and went to the nurse's station. The CNA [Employee E15] went back to resident's room. I asked her to leave and if she didn't leave. I told her I will call the police. Staff left the building, after that. Interview held with Licensed nurse, Supervisor, Employee E8 on February 21, 2024, at 1:31 p.m. Licensed nurse, Employee E8 stated she was unsure of the exact time the incident with Resident R14 and nurse aide Employee E15 started. Licensed nurse, Employee E8 stated, Towards the end of shift I heard commotion. I go down the hallway and see the nurse and nurse aid Employee E15 arguing on the floor. I took the nurse into the break room and got her story about what was going on. I then got nurse aide Employee E15 into the break room to get her story. I told her there was an allegation of abuse and she had to leave. I told her she could call and talk to the Director of Nursing in the morning. Not long after she was still here and she wouldn't leave. She was down the unit hallway towards where her bags were. She wasn't leaving right away she was in the hallway and she may have tried to go near the room again after she got her stuff. She left a little after 11:00 p.m. because the next shift was coming in and was asking what was going on. I'm not going to say she left immediately because it was hard to get her to leave, I had to tell her I was going to call the police. Interview with nurse aide, Employee E22 on February 23, 2024, at 3:38 p.m. revealed nurse said that Resident R14 could have a small cup. [Employee E15] was inside room and she overheard Employee E15 calling the resident names. I then was able to get [Employee E15] out of the room and she started to call me names. This all happened around 10:30 p.m. and it was hard to get her off of the floor. There were staff from the second shift coming in asking what happened because I was upset. Interview conducted with Resident R14 on February 23, 2024, at 9:41 a.m. confirmed that the resident was involved in verbal abuse situation. The resident stated, that aide was rude to me so they fired her. Interview with the Director of Nursing on February 22, 2024, at approximately 1:30 p.m. stated that Employee E15 did not returned to work at the facility and was terminated from employment. Interview with Nursing Home Administrator, Employee E1 on February 22, 2024, at 2:10 p.m. confirmed the above findings. The facility failed to ensure that Resident R14 was free from verbal abuse which resulted in actual harm to Resident R14 who called a derogatory name by nurse aide, Employee E15. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.10 (c) (d) Resident Care policies 28 Pa. Code 211.12 (d) (1)(2)(3)(5) Nursing services

Based on review of clinical records, policies and procedures, facility documentation and interviews with residents and staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to fulfill their essential job duties related to enforcing the regulatory requirements to the level of health care and safety of the residents and to the protection of residents rights, constituting Substandard Quality of Care. Findings include: Review of the job description for the Nursing Home Administrator dated February 6, 2017, revealed that the administrator's essential duties and responsibilities included: Establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident's need in compliance with federal, state and local requirements, and to establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Review of the job description for the Director of Nursing dated January 25, 2016, revealed that the Director of Nursing's essential job duties and responsibilities included: To provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Based on the findings of an annual Recertification and State Licensure survey, and an Abbreviated survey in response to two complaints completed on April 11, 2017, which identified multiple areas of regulatory non-compliance, it was determined that the administrator and the director of nursing failed to fulfill the essential duties and responsibilities of their positions, contributing to Substandard Quality of Care. Refer to F281, F309, F314, F325, R333, and F441. 42 CFR 483.70 Effective Administration/Resident Well-Being Previously cited 06/14/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/14/16, 08/12/16 28 Pa. Code 201.18(b)(1) Management Previously cited 05/09/16, 06/14/16, 06/24/16, 08/12/16 28 Pa. Code 201.18(b)(3) Management Previously cited 11/19/15, 06/14/16, 06/24/16, 08/12/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(d)(j) Resident rights 28 Pa. Code 211.12(c) Nursing services Previously cited 04/02/15, 05/09/16

Based on observation, review of clinical records, facility policies and procedures, and facility documentation, and interviews with staff, it was determined that the facility failed to obtain physician's orders related to care and maintenance of intravenous (IV) catheters, prescribed dose of IV nutritional solution, oxygen administration, dressing changes, and assessment of surgical skin incisions/drains; failed to follow physician's orders related to the monitoring of blood sugar levels, the monitoring of urinary and drainage output, and the monitoring of pulse oximetry levels; failed to clarify physician's orders related to medications and prescribed therapeutic diets; and failed to assess and monitor residents, with timely notification to the physician, after a significant change in medical condition, for 9 of 20 residents reviewed (Residents R11, R17, R24, R37, R52, R56, R57, CL1 and CL2) on both floors of the facility, including both nursing units. This failure resulted in actual harm to two residents (Residents R11 and R57) and constituted Substandard Quality of Care (SQC). Findings include: Review of Resident R57's clinical record revealed that the resident had [DIAGNOSES REDACTED]. The resident's initial admission to the facility was on February 20, 2017, and the resident was readmitted to the facility from the hospital on the following dates: March 11, 2017, March 28, 2017, and March 30, 2017. Review of Resident R57's physician's orders dated March 30, 2017 and signed by the physician on April 1, 2017 instructed the nurses to monitor the resident's blood sugar via a fingerstick before meals and at bedtime (four times a day). The same physcian's orders instructed the nurses to monitor the resident's blood sugar before meals only (three times a day). Review of Resident R57's MAR (Medication Administration Record) for April, 2017 revealed that the documentation to verify that the resident's blood sugar was documented by the nurses in two different areas on the MAR - three times a day (before meals) which was noted with the start date of March 31, 2017, and four times a day (before meals and at bedtime) which also noted a start date of March 31, 2017. Further review of Resident R57's MAR for April 2017 revealed that the physician's order directing that blood sugar checks were to be completed, four times a day, was removed from the MAR indicated [REDACTED] Review of Resident R57's clinical record revealed no documentation that blood sugar monitoring via an Accucheck device (a machine to test blod sugars) was done at bedtime on April 9, 2017. Review of Resident R57's progress note dated April 10, 2017, at 5:14 a.m. revealed that on April 10, 2017, at 4:31 a.m. the nursing supervisor was called to the unit because Resident R57 was unresponsive and the Accucheck that was taken revealed the resident's blood sugar was 59. [MEDICATION NAME] (a medication used to treat low blood sugar) was given to Resident R57 and the Accucheck was taken again and the resident's blood sugar was 51. The progresss note stated, . All attempts taken to revive resident to no avail. Resident R57 was given [MEDICATION NAME] again and the Accucheck was too low to register on the Accucheck device. 911 was called and Emergency Medical Services arrived on April 10, 2017, at 4:50 a.m. and continued attempts to revive the resident and the resident was taken to the hospital. The resident remained at the hospital on April 11, 2017, which was the last day of the survey. An interview with Employee E12, Nurse Supervisor, on April 11, 2017, at 10:00 a.m. confirmed that the physician's orders dated April 1, 2017, for blood sugar monitoring, to include at bedtime, was removed from the MAR indicated [REDACTED]. Further, Employee E12 confirmed that Resident R57 had a low blood sugar on April 10, 2017, at 4:31 a.m. and that the Nursing Supervisor was called to the unit because Resident R57 was unresponsive, the Accucheck taken at the time was 59 and the resident was transferred to the hospital via emergency transport services. Resident R57 experienced harm related to the facility not performing blood sugar monitoring as ordered. Review of the clinical record for Resident R11 revealed hospital documentation indicating that the resident was living alone and was independent prior to admission to the hospital on March 3, 2017, for right fifth toe pain and was diagnosed with [REDACTED]. On March 6, 2017, the resident had surgery for [REDACTED]. Hospital documentation revealed that during the resident's admission in the hospital, Resident R11 received [MEDICATION NAME] (a blood thinning medication) 5000 units subcutaneously (SQ - injection through the skin) and aspirin 81 milligrams (an over the counter medication used for blood thinning). Hospital documentation additionally stated that there were some concerns that the resident did not have the capacity to make their own decisions and was evaluated by professional psychiatric services on March 21, 2017, where it was deemed that the resident did not have this capacity. A review of the nursing progress notes revealed that Resident R11 was admitted from the hospital to the facility on [DATE], at 7:00 p.m. with admitting [DIAGNOSES REDACTED]. Review of the physician's orders revealed that Resident R11 was to receive aspirin 81 mg daily, starting on April 1, 2017. Review of the physician's orders for April 2017, revealed that the resident was non-weight bearing for the right lower extremity (leg). Review of a nursing progress note dated April 1, 2017, at 4:58 a.m. revealed that during the night, Resident R11 was trying to ambulate to the bathroom without assistance, stating his doctor said he can walk with a walker, resulted in popping 2 sutures and blood everywhere. The nursing progress note further revealed the foot wound was cleaned and a new dressing reapplied by the Licensed Nurse. There was no documentation in the nursing progress notes that a Registered Nurse reassessed the resident's foot to determine if the bleeding had stopped or if any further bleeding had occurred, and there was no documentation in the nursing progress notes that the resident's physician was contacted regarding this change in clinical condition. Review of the facility Physician communication sheet, (an internal facility form, not part of the clinical record, used to document when and why a physician is contacted by the facility staff) dated April 1, 2017, with no time documented, revealed, Awaiting return call (from Resident R11's physician). Further review of the Physician communication sheet revealed no documentation regarding what time the message was left with the physician's office/answering service about Resident R11's change in status of, Patient walking 2 sutures popped, no documentation regarding if the staff attempted to call the physician again and no documentation if or when the physician responded to the call. Review of the Medication Administration Record [REDACTED]popping 2 sutures and blood everywhere. Review of an SBAR (Situation-Background-Assessment-Recommendation) Communication Form, dated April 1, 2017, revealed that the resident's change in condition was that the sutures to the right 5th toe amputation dehisced with bone protruding from the wound, and that another physician (not the resident's attending physician) was notified on April 1, 2017, at 9:00 a.m. with orders to send Resident R11 to the hospital. Review of a nursing progress note dated April 1, 2017, at 1:03 p.m. completed by Employee E13, Licensed Practical Nurse/Wound Nurse, revealed that Resident R11 was received in bed and per the report, the resident was noncompliant with non-weight bearing to the right lower extremity order and had opened his sutures. The note further stated, Ace wrap removed and dressing opened, right foot incision dehisced (wound ruptures along surgical incision) and wide open with exposed bone. The note indicated that a phone call was made to another physician, an order was received by that physician to send the resident back to the hospital for surgical evaluation of the foot wound, and that an ambulance was called and the resident was transported back to the hospital. Further review of the clinical record for Resident R11 revealed no documentation that the facility staff assessed and monitored the resident's condition after discovery of the wound dehiscence and bleeding as documented on April 1, 2017, at 4:58 a.m. and no documentation regarding when the resident's physician was initially contacted with this change in condition. There was no documentation indicating if the physician responded to the notification of the change in condition, no documentation if any other attempts were made by the staff to contact the physician, and no documentation regarding the specific time period between when the resident's change in condition was discovered to when the resident was transferred back to the hospital. An interview with the Director of Nursing on April 11, 2017, at approximately 1:30 p.m. confirmed there was no documentation of adequate nursing assessment and monitoring of Resident R11's acute and significant change in clinical condition and no documentation of timely response by the physician. This failure of nursing staff to identify a significant change in clinical condition and failure of prompt notification to the physician caused actual harm to Resident R11, a resident at high risk for bleeding from history of anticoagulant use (blood thinning medications) and high risk for injury related to the resident's inability to make sound judgements as indicated in the hospital documentation. Review of facility policy, PICC (Peripherally Inserted Central Catheter-PICC - a tube inserted into a vein used for long-term use) Line Care, dated May 14, 2016, revealed that PICC line catheter information must be included as part of the resident's clinical record including catheter insertion date and length of catheter. The policy further indicated that the dressing over the PICC line would be changed weekly, and that the external length of the catheter (portion outside the skin) would also be measured weekly to ensure correct length. If staff determined any symptoms of catheter movement, misposition or any obvious change in length, the policy stated that staff were required to stop using the PICC line until an X-ray could be obtained to verify placement. Review of the clinical record for Resident R56 revealed that the resident was admitted to the facility from an acute care hospital on March 31, 2017, with [DIAGNOSES REDACTED]. Review of the admission physician's orders, dated March 31, 2017, instructed staff to administer [MEDICATION NAME]-Sulbactam ([MEDICATION NAME] - an IV antibiotic medication) 3 grams, every six hours, via the PICC line, for the abdominal abscess. Review of another admission physician's order, dated March 31, 2017, indicated that Resident R56's PICC line was 35 centimeters (cm) in length. Review of a hospital Central Line Insertion Procedural Note located in the resident's clinical record revealed that Resident R56's PICC line was inserted on March 31, 2017, had a total length of 35 cm, with an external length of 0 cm, and that the chest X-ray was not yet available, indicating that proper PICC line placement had not been established and was not safe to use until placement could be confirmed. Further review of the clinical record revealed no documentation regarding if the PICC line placement was confirmed and was safe for the facility's use, and no documentation that the external length of the catheter was assessed by nursing upon the resident's admission. Review of a nursing progress note dated April 6, 2017, at 8:34 a.m. revealed the dressing over the resident's PICC line was changed by the Licensed Nurse, and that the external length of the catheter was 10 cm. Review of another nursing progress note dated April 6, 2017, at 6:55 p.m. revealed the external length of the catheter was 13 cm. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no documentation that the staff acknowledged the 10 cm change in external length as documented on April 6, 2017, at 8:34 a.m. and the 13 cm change in external length as documented on April 6, 2017, at 6:55 p.m., revealed no documentation that the resident's physician was notified to obtain clarification and guidance regarding the ongoing use of the PICC line (if an X-ray was required to evaluate safe usage), and there was no documentation that the resident's infusions were stopped until the physician could be notified regarding the changes in the external length of the catheter. These findings were confirmed in an interview with the Director of Nursing at approximately 12:30 p.m. on April 7, 2017. Review of the clinical record of Resident R24 revealed that the resident was admitted to the facility on [DATE], from an acute care hospital with [DIAGNOSES REDACTED]. Review of the physician's orders for Resident R24, dated April 1, 2017, to April 30, 2017, instructed the nursing staff to administer TPN (Total [MEDICATION NAME] Nutrition - a method of feeding that bypasses the gastrointestinal tract and fluids are given into a vein to provide most of the body needs) Electrolyte (minerals in the body that have an electric charge) Solution and to be given at 131 ml (milliliters) per hour intravenously at bedtime for 12 hours (9:00 p.m. to 9:00 a.m.). The same order also stated that 25 units of Regular insulin was to be, added by RN (Registered Nurse) prior to hanging. Review of a hospital, Peripherally Inserted Central Catheter (PICC) record located in the resident's clinical record revealed that Resident R24's PICC line was located in the upper right arm, was inserted on March 24, 2017, and had a total length of 39 centimeters, with an external length of 0 centimeter. The hospital record also documented that the PICC line was assessed daily until Resident R24 was transferred and admitted to the facility on [DATE]. Further review of the resident's record revealed that the placement of the resident's PICC line, including the external length of the PICC line and confirmation of proper placement of the PICC line (X ray placement verification is required to ensure safe usage), was not verified and/or confirmed at the time of the resident's admission to the facility. Review of the nursing progress note of April 7, 2017, at 10:07 a.m. revealed that the resident had a double lumen (two ports) PICC to the right upper extremity, that the dressing over the resident's PICC line was changed and was clean, dry, and intact, and that the external catheter length measured 10 centimeters, with a circumference of the resident's right upper arm (measurement of size of resident's arm where PICC line is located) of 22 centimeters. Review of the nursing progress note of April 7, 2017, at 3:11 p.m. indicated that a chest X-ray was ordered by the resident's physician to verify the PICC line placement and it was confirmed to be in place over the superior vena cava (large vein carrying [MEDICATION NAME] blood back to the right side of the heart). As noted above, Resident R24 was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. During an interview with the Director of Nursing on April 6, 2017, at approximately 2:30 p.m. it was confirmed that the external length of the PICC line was not measured and the proper placement of the PICC line was not confirmed until April 7, 2017, that the resident was admitted to the facility on [DATE], and the TPN Electrolyte Solution was administered for three days without proper placement of the PICC line confirmed. Review of the clinical record of Resident R17 revealed that the resident was admitted to the facility on [DATE], from an acute care hospital with [DIAGNOSES REDACTED]. Review of the physician's orders for Resident R17 dated April 1, 2017, to April 30, 2017, instructed the nursing staff to administer [MEDICATION NAME] Solution Reconstituted (an antibiotic) 3.375 grams intravenously for an infection (inflammation of the small and large intestines) every 8 hours for 4 days (administered April 4, 2017, to April 8, 2017). Review of hospital documentation PowerPICC card located in resident's clinical record revealed that Resident R17 had a PICC line in place which was inserted on April 3, 2017, and had a length of 35 centimeters. Further review of the resident's record revealed that the placement of the resident's PICC line located in the right upper extremity, including the external length of the PICC line and confirmation of proper placement of the PICC line was not verified and/or confirmed at the time of the resident's admission to the facility. Review of the nursing progress note of April 7, 2017, at 9:10 a.m. revealed that Resident R17 had a double lumen (two ports) PICC to the right upper extremity, that the site was clean, dry, and intact, and that the external catheter length measured 11 centimeters with an arm circumference (measurement of resident's arm where PICC line is located) of 18 centimeters. Review of the nursing progress note of April 7, 2017, at 3:06 p.m. revealed that a chest X-ray to confirm proper placement of the PICC line was ordered by the resident's physician, and it was confirmed to be in place over the superior vena cava (the large vein carrying [MEDICATION NAME] blood back to the right side of the heart). Resident was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was administered intravenously for a total of twelve doses by the facility prior to obtaining confirmation of the placement of the PICC line and the proper measurement of the length of the PICC line. An interview with the Director of Nursing on April 6, 2017, at approximately 2:30 p.m. confirmed that the length of the external PICC line was not measured and proper placement was not verified. Review of the clinical record for Resident CL2 revealed that the resident was admitted to the facility from an acute care hospital on January 14, 2017, with [DIAGNOSES REDACTED]. Review of the admission physician's orders, dated January 14, 2017, instructed the staff to administer [MEDICATION NAME] (an IV antibiotic medication) 1.25 grams, once a day, via the PICC line, for the right knee infection. Review of a nursing progress note dated January 14, 2017, indicated that Resident CL2's PICC line was 46 cm in length. Review of another nursing progress note dated January 26, 2017, at 1:33 p.m. revealed that Resident CL2's PICC line was noted, on the floor and the, measurements for PICC line was 40 cm and that (sic) what was on the floor, the resident's physician was made aware and arrangements were being made to send the resident to the hospital for insertion of a new PICC line. Review of an undated Witness Report Form from a facility staff member (Nursing Assistant-NA) regarding Resident CL2's PICC line, revealed that the NA was changing the resident for therapy, another NA came in to assist, and the resdient was transferred into a chair. The statement further revealed that the NA went back into Resident CL2's room and the resident's family members told the NA that the resident's PICC line came out, the family showed it to the NA, and the PICC line was in the resident's nightgown. Review of another undated Witness Report Form from a facility staff member, a Licensed Practical Nurse - LPN, the author of the nursing progress note dated January 26, 2017, at 1:33 p.m., stated that the LPN went into the resident's room and observed the PICC line on the floor. Review of nursing progress notes revealed that Resident CL2 was sent to an acute care hospital on January 27, 2017, where the PICC line was successfully reinserted, approximately 24 hours after the resident's PICC line was found on the floor. Further review of the clinical record revealed no documentation that when the PICC line was found completely dislodged from Resident CL2's arm on January 26, 2017, at 1:33 p.m. and when the resident's physician was notified of the dislodgement by the LPN, that the 6 cm catheter length discrepancy (46 cm length documented upon admission and 40 cm length documented upon dislodgement discovery by the nurse) was included in the communication to the physician. An interview with the Director of Nursing on April 10, 2017, at approximately 1:50 p.m. confirmed that there was no documentation regarding how Resident CL2's PICC line may have become dislodged and no documentation that the resident's physician was made aware of a 6 cm catheter length discrepancy. Review of the clinical record for Resident R56 revealed nursing documentation indicating the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on April 6, 2017, at approximately 12:15 p.m. with Employee E4, Licensed Practical Nurse, of the right upper quadrant abdominal abscess drain revealed a dry dressing over the catheter insertion site dated 4/4. Upon Employee E4's removal of the dressing dated 4/4, the catheter was visible with a drain sponge (special type of dressing to fit around a drain) around the catheter. Further review of the clinical record for Resident R56 revealed no physician's order related to care and assessment of the skin around the resident's abdominal drain and if it did or did not require a dressing. Interview with the Director of Nursing directly after the observation confirmed there were no physician's orders related to care and assessment of the resident's skin around the resident's abdominal drain. Review of the clinical record of Resident R24 revealed that the resident was admitted to the facility on [DATE], from an acute care hospital with [DIAGNOSES REDACTED]. Review of the facility's admission nursing assessment dated [DATE], at 2:28 p.m. revealed in the the Skin Assessment, Section 19(e), that Resident R24 had, on the abdomen, an undescribed area with 18 staples, approximately six inches. Review of the hospital Inpatient Discharge Summary indicated that Resident R24 presented with severe abdominal pain and underwent an exploratory laparotomy (involves a large incision through the abdominal wall into the abdominal cavity for abdominal exploration) on March 19, 2017, with subsequent [DIAGNOSES REDACTED]. Review of the clinical record for Resident R24 revealed that there was no physcian's order obtained to assess the resident's abdominal incision, including the 18 staples, and there was no physician's order to complete wound care. During an interview on April 10, 2017, at approximately 1:30 p.m. the Director of Nursing confirmed that there was no order obtained regarding care of the resident's abdominal incision. Review of the clinical record of Resident R17 revealed that the resident was admitted to the facility on [DATE], from an acute care hospital with [DIAGNOSES REDACTED]. bag appliance), history of bladder and bilateral (both sides) [MEDICAL CONDITION]. Review of the facility's, Admission Nursing Assessment dated April 3, 2017, with no time noted on the documentation, revealed in the Skin Assessment, Section 19(e) that Resident R17 had a mid-line abdominal incision of 20 centimeters with 17 staples, a right abdominal upper quadrant incision of 1.2 centimeters, and opened areas on the coccyx (lower back): one area 2.1 centimeters, and the second 1.5 centimeters. Review of the nursing progress notes, dated April 3, 2017, at 10:57 a.m. stated that the resident was a new admission, that there was the presence of a surgical area on the abdomen with a mid-line incision with staples present. The same nursing progress note also stated that there was an opened area to the coccyx. Review of the hospital History and Physical for Resident R17, revealed that abdominal surgery was completed on March 24, 2017, to repair the perforation of the bowel with resultant [MEDICAL CONDITION]. Review of the clinical record for Resident R17 revealed that a physician's order was not obtained to assess the resident's abdominal incisions, including the 17 staples, and there was no physician's order to complete wound care. Further review of the record revealed that there was no physcian's order to administer care to the opened area on the coccyx. During an interview on April 6, 2017, at approximately 11:30 a.m. the Director of Nursing confirmed that no order was obtained to administer wound care to the resident's abdominal incisions and the opened area of the coccyx. Review of Resident Cl1's closed clinical record revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a less severe form of [MEDICAL CONDITION]) following a Cerebral Infarction (stroke - occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients). A review of Resident CL1's physician's orders revealed an order, initiated on February 14, 2017, and continued through the resident's discharge from the facility on March 15, 2017, for Zinc Oxide Cream 12% (used to prevent skin breakdown) to apply to bilateral buttocks topically every shift. Review of Resident CL1's Medication Administration Record [REDACTED]. An interview on April 10, 2017, at 12:00 p.m. with the Director of Nursing (DON), confirmed that the resident's Zinc Oxide Cream 12% was not documented as being administered on the 7:00 a.m. to 3:00 p.m. shift on the following days: March 1, 2, 4, 5, 6, 8, and 9, 2017. Review of the clinical record for Resident R56 revealed nursing documentation indicating that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record for Resident R56 revealed a physician's order, dated April 1, 2017, instructing the staff to monitor the drainage from the resident's right upper quadrant abdominal abscess drain, and to document the output (amount of fluid draining from the abdomen) every shift. Review of the Treatment Administration Record (TAR) on April 6, 2017, revealed no documentation of the quantity (volume-amounts) of abscess drainage per the physician's order. Review of nursing progress notes revealed documentation on April 2, 2017, at 6:47 p.m. of 400 ml. drainage output, and on April 4, 2017, at 2:52 p.m. 100 ml. drainage output. Further review of the clinical record revealed no other documented abdominal catheter drainage outputs for Resident R56. An interview with Employee E12, a Licensed Practical Nurse Unit Manager, on April 10, 2017, at approximately 1:30 p.m. confirmed there was no documentation of abscess drainage amounts every shift per physician's order. Observation on April 7, 2017, at approximately 11:00 a.m. revealed that Resident R37 had a [MEDICAL CONDITION] (trach tube - a tube inserted through the neck to assist with breathing) attached to [MEDICAL CONDITION], connected to 2 liters of oxygen. Review of Resident R37's clinical record revealed that the resident was admitted to the facility on [DATE], with [MEDICAL CONDITION] room air (did not require oxygen) related to a prior gunshot wound with T2/T3 [MEDICAL CONDITION] ([MEDICATION NAME] vertebra T2/T3 located in the mid-back area causing paralysis of the lower half of the body). Review of a physician's order dated April 5, 2017, instructed staff to check oxygen saturations (using a pulse oximetry meter-medical device used to obtain oxygen levels in

Based on observations of care and services, review of clinical records, and interviews with staff, it was determined that the facility failed to assess, monitor and evaluate the nutritional status for one of 20 residents reviewed which resulted in one resident not being provided with adequate nutritional care that resulted in actual harm to the resident (Resident R5). Findings include: Review of both a quarterly Minimum Data Set assessment (MDS - a report of care need) dated March 25, 2017, and a Medicare 60-day MDS assessment dated [DATE], for Resident R5 revealed that the resident was severely cognitively impaired and totally dependent on staff for the activities of daily living (bed mobility, transfers, eating toilet use dressing and personal hygiene). The MDS revealed [DIAGNOSES REDACTED]. The assessments listed this resident as 64 inches tall and weighing 107 pounds. Nutritional approaches were an abdominal PEG (Percutaneous Endoscopic Gastrostomy Tube - a tube passed into a resident's stomach through the abdominal wall, most commonly used to provide a means of feeding when oral intake is not adequate) and a mechanically altered diet (a diet with foods or liquids having a change in texture). The assessment also indicated that Resident R5 had a Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis or damage to the muscle, bone or supporting structures). The measurements recorded for the dimensions of the unhealed pressure ulcer were 4.5 centimeter length by 3.0 centimeter width and 1.5 centimeter depth. Observations of Resident R5's wound at 10:00 a.m. on April 11, 2017, revealed a Stage IV pressure ulcer with serous drainage and the surrounding peri-wound was inflamed. Weight records reviewed revealed that Resident R5 was 115.7 pounds on September 19, 2016. On February 20, 2017, a weight of 103 pounds was recorded for Resident R5. This was a significant 10% weight loss for a six month period. Based on a height of 64 inches and a desirable body weight of 120 pounds, Resident R5 would need 1636 to 1909 calories a day to reach this desirable weight and 65 to 81 grams of protein per day for anabolism (constructive metabolism). Calculations of calorie and protein needs were based on the recommendations for persons at age fifty-one and older, Geriatric Nutrition, Guidelines for Working with Older Adults, 2012. Wound documentation recorded by the nursing staff for February 8, 2017, revealed that Resident R5 had a sacral (the triangular bone located at the base of the spine) pressure ulcer measuring 5cm length by 4.5 cm width by 1cm depth. On February 15, 2017, the nursing documentation indicated that Resident R5's pressure ulcer was 5cm length by 3 cm width by 1 cm depth with tunneling of 1.5 cm at seven o'clock. There was no documentation to indicate that the dietitian was notified of the non-healing pressure ulcer that deteriorated and increased in size. According to the Consultant Dietitians in Health Care Facilities, Nutrition Care of the Older Adult, 2004, Nutrition factors that contribute to skin breakdown include protein deficiency, which creates a negative nitrogen balance. Daily energy, protein and fluid needs for clients with pressure ulcers are increased. Residents with pressure ulcers require increased calories, protein and fluid to promote positive nitrogen balance or anabolism (body cells synthesize for tissue growth and repair). The most recent nutritional assessment dated [DATE], revealed that the Dietitian, Employee E18, indicated that a desirable body weight for Resident R5 was 120 pounds and that the resident's usual body weight was 124 pounds. The Dietitian noted that Resident R5's Body Mass Index (BMI - measurement used as one the parameters to determine nutritional status) was 18.36 and weight was 107 pounds, which placed this resident in a category of being underweight. The physician's orders [REDACTED]. The physician also ordered a pureed diet (foods that require no chewing) with honey thick liquids and a protein liquid supplement (30 ml) twice a day orally for Resident R5. The resident's nutritional care plan indicated that this resident was at nutritional risk. The goal for Resident R5 was to gain weight to the established desirable weight of 120 pounds. Resident R5's nursing care plan indicated that the resident would show signs of pressure ulcer healing. A review of the nursing documentation for the amount of foods eaten daily during breakfast, lunch and dinner revealed that Resident R5's by mouth intake was poor/inadequate less than 75% at each meal as documented from January 17, 2017, through April 4, 2017. There was no documentation to indicate that the nursing staff communicated the poor/inadequate by mouth intake to the Dietitian or the physician. There were no further nutritional assessments available for review for Resident R5. On April 5, 2017, Resident R5 was admitted to the hospital for further evaluation and diagnosed with [REDACTED]. A weight was recorded as 99 pounds for Resident R5 on April 10, 2017. Resident R5's weight recorded for October 2016 was 115 pounds. This represented a significant weight loss of greater than 10% over six months for Resident R5. Review of the clinical record for Resident R11 revealed nursing progress notes indicated that the resident was admitted to the facility from an acute care hospital on March 31, 2017, at 7:00 p.m. with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of nursing progress notes revealed that on April 3, 2017, during the morning medication pass, Resident R11 complained of a swollen hand and upon the nurse's assessment, the resident's left upper arm and hand and bilateral (both sides) lower legs and feet (lower extremities) were [MEDICAL CONDITION] (swollen). Another nursing progress note dated April 3, 2017, clarified that Resident R11 had plus three [MEDICAL CONDITION] (occurs when a finger is pressed into the skin, a deep indentation is seen that takes up to 30 seconds to resolve), the resident's physician was made aware, and ordered a one-time stat (as soon as possible) dose of [MEDICATION NAME] 80 mg orally. On April 5, 2017, Resident R11's morning weight was 395 pounds, with the resident's weight the day prior of 390 pounds (indicating a five pound weight gain in 24 hours). The resident's physician was notified and ordered [MEDICATION NAME] 80 mg. Review of the physician's interdisciplinary progress note dated April 5, 2017, revealed that Resident R11 was noted with [MEDICAL CONDITION] of the bilateral lower extremities up to the resident's thighs, that the resident had volume overload (too much fluid pooling in the legs) and indicated that the resident's [MEDICATION NAME] would be increased to 80 mg twice a day until a weight loss of five pounds was achieved. Review of a physician's orders [REDACTED]. Review of documented weights for Resident R11 revealed the following: April 3, 2017, 390 pounds; April 4, 2017, 390 pounds; April 5, 2017, 395.5 pounds; April 7, 2017, 395 pounds, and April 9, 2017, 395 pounds. Review of the nursing progress notes revealed that on April 6, 2017, the resident refused to be weighed. On April 8, 2017, the resident refused to be weighed stating, I can't do it, is too much. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record revealed no documentation that a weight was obtained or attempted on April 2, 2017; no documentation that the resident's physician was made aware of Resident R11's weight refusals on April 6, 8 and 10, 2017; no documentation that on the days when the resident refused to be weighed, that a weight was attempted any other time on those days, or that the resident was offered to be weighed by different means (by weight lift scale, seated scale, etc.); and no documentation that since admission to the facility on [DATE], that a nutritional assessment was performed by the facility's dietitian. An interview with Employee E18, a Registered Dietitian, on April 11, 2017, at approximately 9:30 a.m. confirmed there was no documentation that a nutritional assessment was completed for Resident R11. An interview with the Director of Nursing on April 11, 2017, at approximately 11:45 a.m. confirmed there was no documentation that Resident R11's weights were obtained daily as ordered by the physician, no documentation that the resident's physician was aware of the resident's weight refusals, and no documentation that facility staff made other attempts to obtain the weight after the resident refused. The facility failed to adequately assess and monitor Resident R11, a resident at high risk for weight variances due to [MEDICAL CONDITION] requiring treatment with diuretic medication, and high nutritional risk related to a bone infection of the right foot. The facility failed to ensure acceptable parameters of nutritional status were natianed for Residents R5 and R11, resulting in actual harm to Resident R5. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/14/16, 08/12/16 28 Pa. Code 201.18(b)(1) Management Previously cited 05/09/16, 06/14/16, 06/24/16, 08/12/16 28 Pa. Code 211.5(f) Clinical records Previously cited 04/02/15, 10/13/16 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 04/02/15, 05/09/16, 10/13/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 05/09/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 04/02/15, 05/09/16

Based on observations, interviews with residents, family members, facility staff, and a review of facility policy, it was determined that the facility failed to adequately monitor and maintain safe and comfortable air temperatures for all residents in the facility when outdoor temperatures exceeded 90 degrees Fahrenheit on July 18, 2013, and placed all of the residents in Immediate Jeopardy due to the danger of significant adverse consequences. Findings include: An initial tour of the facility on July 18, 2013, at 2:50 p.m., revealed that the second and third floors in the facility were extremely hot. During the tour of the occupied living area on the second floor in the facility, where all 36 residents resided, the room air felt extremely hot. The Maintenance Director was requested to obtain the facility's thermometer but could not produce one. During the tour, Employee E-3, the Maintenance Director confirmed that the windows in the facility are not designed to be opened and could only be opened in an emergent situation, and further stated that the facility's air conditioning was not efficient enough to cool the building in the extreme heat. The outside air temperatures were identified by the National Weather Service as 98 degrees Fahrenheit on July 18, 2013. Observations in room [ROOM NUMBER] and an interview with Resident R18 in this room on July 18, 2013, at 3:30 p.m., revealed that he has been in the facility since his admission on June 29, 2013. The resident stated that it has been very hot since then. The air temperature taken in this room by the surveyor and confirmed by Employee E3 was identified to be 88.0 degrees Fahrenheit with the window closed. Observations in room [ROOM NUMBER] and an interview with Resident R17 in this room on July 18, 2013, at 3:20 p.m., revealed that the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The resident stated that she has been "begging" for some type of relief from the heat in her room since her admission. Three fans were observed in her room, the window was closed and the air temperature was identified by the surveyor and Employee E3 to be 87 degrees Fahrenheit. Observations in room [ROOM NUMBER] and an interview with Resident R11 and her two adult daughters, on July 18, 2013, at 3:10 p.m., revealed that the resident was admitted to the facility on [DATE], from the hospital, where she was treated for [REDACTED]. Two fans were observed in room [ROOM NUMBER] and in the presence of Employee E3, the room air temperature was confirmed as 87.2 degrees Fahrenheit and the window was closed. Resident R11 and her two daughters further stated it has been this hot since their arrival, they did not know what to do and were ready to transfer the resident to another facility for fear of their mother's health. Observations in room [ROOM NUMBER] and an interview with Resident R36 on July 18, 2013, at 3:40 p.m., along with his spouse, revealed that he was readmitted to the facility on [DATE], and that two fans were offered. The window was observed to be closed, and even though fans were present, it was hot in the resident's room. The surveyor, the family, and Resident R36 on July 18, 2013 at 3:40 p.m. observed that the room air temperature when taken was 85.8 degrees Fahrenheit and the window was closed. During a tour of the second floor and a review of the resident roster, it was revealed that 11 residents (R2, R11, R17, R20, R23, R31, R32, R33, R35, R36 and R37) out of 36 residents had either heart or breathing problems and required oxygen concentrators (an electrical machine that produces supplemental oxygen). Six of the residents (R11, R17, R31, R32, R35, and R36) required continuous oxygen and the other five residents (R2, R20, R23, R33, and R37) required oxygen at night or as needed. This was confirmed in an interview with the Director of Nursing on July 18, 2013, at 4:00 p.m. A tour of the third floor on July 18, 2013, at 3:00 p.m., with the Nursing Home Administrator (NHA) and Employee E3 revealed a vacant third floor with many missing ceiling tiles, electrical wires hanging from the ceiling and disconnected equipment attached to the ceiling. An interview with the NHA and the Maintenance Director on July 18, 2013, at 3:10 p.m., revealed that the air conditioning system could not handle the extreme heat and their plan was to install Carrier PTAC Units (hotel style portable air conditioning/heating units) into the ceilings. An interview with the NHA on July 18, 2013, at 4:30 p.m., revealed that only seven of the 38 rooms on the third floor have the PTAC Units installed and that they required additional work and are non-functioning. During this same interview, it was revealed that the facility was not aware of the high temperatures in the resident rooms. A review of the facility's undated Temperature Monitoring Policy revealed that a maintenance staff member should do weekly random room checks. The policy indicated that if the temperature is found to be out of compliance with the 71-81 degree Fahrenheit range, the Maintenance Director must be notified immediately and that residents would be moved immediately to air conditioned portions of the building, resident body temperatures would be monitored and their physicians would be notified as necessary. An interview with Employee E3 on July 18, 2013, at 6:00 p.m., confirmed that the facility failed to check temperatures today and placed its focus on installation of the PTAC Units on the unoccupied third floor. The facility failed to monitor and maintain a temperature range of 71-81 degrees Fahrenheit during the current heat wave and failed to make timely interventions and increase monitoring of residents and the environment related to extreme air temperatures. This failure placed the residents at risk for health consequences from extreme temperatures and caused an Immediate Jeopardy situation for all the residents. On July 19, 2013 at 11:00 a. m., the Immediate Jeopardy was removed due to corrective actions that were implemented by the facility. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/19/12. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(3) Management. 28 Pa. Code 201.18 (b)(1) Management. Previously cited 11/19/12, 4/11/13. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 5/10/12, 11/19/12, 4/11/13. 28 Pa. Code 211.10(d) Resident care policies.