Every finding on record at York North Skilled Nursing and Rehabilitation CTR

Based on resident and staff interviews, observations, and completion of a test tray for one meal, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures. Findings include: Review of facility provided Test Tray Evaluation form, not date marked, read in part, cold foods should be less than or equal to 45 degrees Fahrenheit (F), and hot foods should be greater than 140 degrees F. During an interview with Resident 41 on March 24, 2026, at 9:42 AM, she revealed her food is always served cold. Interview with Resident 106 on March 24, 2026, at 10:03 AM, revealed he said the food is cold. During a group interview with Residents 6, 35, 37, 44, 57, and 66 on March 25, 2026, at 10:08 AM, they expressed concerns with the food, including that it is always served cold. There was a 14-minute lapse between the time the food cart was competed in the kitchen and test tray temperatures were obtained. Test tray temperatures were taken by Employee 17 (Food Service Director) at 1:14 PM.Test tray temperatures included:Macaroni and cheese 127 degrees F, not palatable for temperatureStewed tomatoes 112 degrees F, not palatable for temperatureColeslaw 47 degrees FCookie was served at room temperatureMilk 50 degrees, not palatable for temperatureOrange juice 59 degrees F, not palatable for temperatureCoffee 150 degrees F Interview with Employee 17 on March 24, 2026, at 1:20 PM, revealed the steam table was functioning and the pan of macaroni and cheese was [NAME] out of the oven not long ago. Further, she thought both would've registered a higher temperature and felt the milk should've been colder. During an interview with the Nursing Home Administrator on March 24, 2026, at 1:30 PM, no further information was provided regarding the test tray results. 28 Pa. Code 201.14. Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in four nourishment pantries (A, B, Medbridge, and C stations).Findings include: Review of facility policy, titled Food Storage: Cold Foods, dated February 2023, read, in part, all foods will be stored in wrapped or in a covered container, labeled and dated. Observation March 23, 2026, at 9:20 AM, in the walk-in refrigerator revealed: one 5l pound American cheese package was open and not date marked. At that time, Employee 17 (Food Service Director) stated that the cheese was opened that morning. Observation in the dish room on March 23, 2026, at 9:23 AM, revealed the fan in the window opening on the clean side of the dish machine, the ceiling, and ceiling vents above the tray line contained a light grey fuzzy substance. At that time, an interview with Employee 17 revealed that maintenance is responsible for cleaning the fan and ceiling vents. During an interview with the Nursing Home Administrator (NHA) on March 24, 2026, it was revealed that the fan and vents aren't on a routine cleaning schedule. Observation in the A station nourishment pantry on March 23, 2026, at 9:37 AM, revealed there was dried yellow and red liquid in the microwave. In the refrigerator, there was a half of a submarine sandwich marked with a resident name but was not date marked, and one stromboli without a resident identifier or a date. At that time, interview with Employee 17 revealed she didn't know who was responsible for cleaning the microwaves in the nourishment pantries, and both items should contain a resident identifier and be marked with a date. Observation in the Medbridge nourishment Pantry on March 23, 2026, at 9:43 AM, revealed there was dried food in the microwave. Observation in the B station nourishment pantry on March 23, 2026, at 9:46 AM, revealed there was a lunch bag that contained a salad, meal, yogurt and energy drink. At that time, Employee 17 confirmed that the lunch bag wasn't a resident's and that staff shouldn't store anything in the resident refrigerator. Observation in the C station nourishment pantry on March 23, 2026, at 9:49 AM, revealed one thawed vanilla nutritional shake (the product should be used within 14 days of it being thawed) that didn't contain a pull or use by date, and one energy drink not marked with an identifier. At that time, Employee 17 revealed she wasn't able to determine when the shake was thawed and felt the energy drink belonged to a staff member. Observation during tray line service on March 24, 2026, at 12:11 PM, revealed Employees 18, 19, and 20 had a bear and were working in the kitchen without wearing a beard covering. At that time, Employee 17 revealed that the facility policy required a beard net if facial hair was at a particular length. The surveyor asked for the policy but didn't receive it. Employees 18 and 20 had a bear that was 1-1/2 to 2 inches long. Interview with the NHA on March 24, 2026, at 1:30 PM, it was revealed that food should be stored within professional standards, staff food shouldn't be stored in nourishment refrigerators, and resident food should be labeled with an identifier and date marked. At that time, the NHA was made aware of concern with facial hair not being covered, and no further information was provided. 28 Pa code 211.6(f) - Dietary Services

Based on review of the RAI manual (Resident Assessment Instrument- A standardized guide used in nursing homes and long-term care facilities to assess residents health, functional status, and care needs), clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 32 residents reviewed (Residents 1 and 25).Findings include: Review of RAI Manual guidance for section H revealed: H0100: Appliances (cont.)Coding Tips and Special Populations Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only and not as an ostomy (H0100C). Review of Resident 1's clinical record revealed diagnoses that included Traumatic Brain Injury (TBI-Damage to the brain resulting from a sudden external physical assault, such as a blow to the head, fall, or projectile [Resident 1 experienced a fall from a barn roof]) and Tracheostomy (an opening in the neck where a tube is inserted directly into the trachea [windpipe] to deliver oxygen). Review of Resident 1's admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident's physical, mental or psychosocial needs) dated October 6, 2025, revealed Resident 1 has a BIMs of 0, indicating cognitive skills are severely impaired. Further review of Resident 1's admission MDS revealed Section H.- Bladder and Bowel, subsection H0300 Urinary Incontinence was marked with a 2, indicating the Resident was frequently incontinent of urine instead of being marked with a 3 indicating the Resident was always incontinent of urine. A review of Resident 1's Quarterly MDS dated [DATE], revealed Section H.- Bladder and Bowel, subsection H0300 Urinary Incontinence was marked with a 2, indicating the Resident was frequently incontinent of urine instead of being marked with a 3 indicating the Resident was always incontinent of urine. Subsection HO400 Bowel was marked with a 2, indicating the Resident was frequently incontinent of bowel movements instead of being marked a 3 indicating the Resident was always incontinent of bowel movements. During an interview with Employee 14 (Licensed Practical Nurse) on March 25, 2026, at approximately 12:30 PM, Employee 14 confirmed that Resident 1 had always been incontinent of bowel and bladder since admission to the facility. During an interview with the Nursing Home Administrator (NHA) on March 25, 2026, at 11:00 AM, the NHA said the MDS should be accurate and reflect the Resident's status and that modifications to both MDS's will be entered in the system. Review of Resident 25's clinical record revealed medical diagnoses that included flaccid neuropathic bladder (bladder dysfunction caused by nerve damage where the bladder muscle cannot contract and results in urine retention, overfilling and constant overflow dribbling) and depression (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Review of Resident 25's care plan revealed a focus area Use of Suprapubic indwelling urinary catheter, with a start date of April 3, 2024. Review of Resident 25's Quarterly MDS with ARD of January 2, 2026, revealed under Section H Bladder and Bowel - Subsection H0100 C, Resident 25 was marked yes for an Ostomy, indicating he had an ostomy. During interview with Employee 15 (Clinical Reimbursement Coordinator) on March 26, 2026, at 10:27 AM, she expressed that this was incorrect documentation, as Resident 25 had a suprapubic catheter and does not have an ostomy. She revealed that this will be corrected and submitted under Modification for MDS Quarterly with ARD date of January 2, 2026. Follow up interview with NHA and Director of Nursing on March 26, 2026, at 11:48 AM, the NHA revealed she would expect Resident 25's MDS Assessments to be coded accurately. 28 Pa. Code 211.5 (f) Medical Records28 Pa. Code 211.5(d)(3)(5) Nursing services

Based on observations, policy review, and staff interviews, it was determined that the facility failed to ensure that its corridors were equipped with firmly secured handrails on both sides in two of the seven resident halls observed (400 and 500 Halls). Findings Include: Review of the facility's policy, titled Safe and Homelike Environment, revised November 14, 2025, read, The resident/patient has the right to a safe, clean, comfortable and homelike environment. An observation in the 500 hall on March 25, 2026, at approximately 12:00 PM, revealed that the handrail affixed on the left side of the hall was loose to touch. An observation in the 400 hall on March 25, 2026, at 1:25 PM, revealed that the handrail affixed on the right side of the hall, near the therapy gym, was loose to touch. An interview with the Maintenance Director on March 25, 2026, confirmed that the loose handrails have been secured by his staff. An interview with the Nursing Home Administrator, on March 26, 2026, at 11:30 AM, confirmed that the handrails should be securely affixed to the walls and that the maintenance department will continue to conduct environmental rounds. 28 Pa. Code 201.18 (b) (1) Management

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that its residents who require dialysis receive such services consistent with professional standards of practice for one of two residents reviewed for dialysis services (Resident 45).Findings Include: Review of the facility's policy, titled Dialysis Guidelines, dated June 2017, read, Both the center and the dialysis facility are responsible for shared communication regarding patients receiving dialysis services. The Hemodialysis Communication Form is to be used. Collaborative communication includes . timely mediation administration, physician/treatment orders, laboratory values, and vital signs. Review of Resident 45's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end-stage renal disease (the final stage of kidney failure where the kidneys function at less than 15% of normal capacity). Review of Resident 45's physician's orders revealed that the Resident required renal dialysis on Monday, Wednesday, and as needed. Renal dialysis is defined as a life-sustaining medical treatment that filters wastes, toxins, and excess fluid from the blood when the kidneys have failed. Review of Resident 45's Hemodialysis Communication Record Form dated March 6, 2026, revealed the dialysis center did not complete the area titled post-dialysis weight. Review of Resident 45's Hemodialysis Communication Record Form dated March 9, 2026, revealed the dialysis center did not complete the following areas: Blood Pressure, Pre-dialysis weight, post-dialysis weight, Medication Given During Hemodialysis, and Pulse. An interview with the Director of Nursing on March 26, 2026, at 10:18 AM, confirmed that the missing documentation on the communication forms should have been completed. 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who need respiratory care are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for respiratory care (Resident 9). Findings include: Review of facility policy, titled Respiratory Equipment/Supply Cleaning/Disinfection last reviewed December 16, 2024, read, in part, Cleaning and disinfection of respiratory equipment is performed by a respiratory therapist, licensed nurse, or equipment technician. Disinfection is performed on all equipment on a scheduled basis and upon discontinuation from service and between patients. Purpose: To remove microorganisms from the surfaces of equipment. Review of Resident 9's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- an ongoing respiratory condition caused by damage to the lungs) and muscle wasting and atrophy (gradual loss of muscle mass and strength). Review of Resident 9's physician orders revealed orders for:Ipratropium-Albuterol Inhalation Solution, 1 vial inhale orally every 6 hours for SOB (shortness of breath)/wheezing, with a start date of March 23, 2026. Supply oxygen at 1-4 liter per minute via nasal cannula (device that supplies oxygen through the nose). May titrate at 1 liters per minute every 3 minutes to maintain a pulse ox greater than 90 as needed for shortness of breath, with a start date of March 23, 2026. Review of Resident 9's comprehensive care plan revealed a focus area At risk for respiratory complications related to COPD, SOB, wheezing, with an intervention for administer aerosol as ordered indicated and administer oxygen as per physician order. Interview with Resident 9 on March 24, 2026, at 9:35 AM, revealed she was sick and wanted to see a doctor, she then let out a wet cough. Observation in Resident 9's room on March 24, 2026, at 9:35 AM, revealed she had a nebulizer machine at her bedside (a piece of medical equipment that a person with a respiratory condition can use to administer medication directly and quickly to the lungs). Further observation in her room revealed her nebulizer mask was laying out on her bedside table on top of her box of tissues, her nebulizer tubing was on the floor, the tubing was dated March 23, 2026, and her oxygen tubing from her oxygen concentrator to her nasal cannula in her nose was laying across the floor. Observation in Resident 9's room on March 24, 2026, at 12:34 PM, revealed her nebulizer mask and tubing were now bagged, but the tubing had the same date of March 23, 2026, indicating it had not been changed since being on the floor. Further observation revealed her oxygen tubing remained touching the floor and the bag used for storage of the equipment was also touching the floor. Observation in Resident 9's room on March 25, 2026, at 9:42 AM, revealed her nebulizer tubing was in a bag, but it was touching the floor and remained dated March 23, 2026. Further observation revealed her oxygen tubing remained touching the floor between her oxygen concentrator and her nasal cannula in her nose. During an interview with the Director of Nursing on March 25, 2026, at 10:09 AM, the surveyor revealed the concern with the storage of Resident 9's oxygen and nebulizer tubing, as well as her nebulizer mask. He revealed he would expect respiratory equipment to be stored and utilized to prevent contamination with microorganisms. 28 Pa. Code 211.11(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 7).Findings include: Review of facility policy, titled Restorative Nursing last revised August 7, 2023, read, in part, Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. Purpose: to promote the patient ability to adapt and adjust to living as independently as safely as possible. Implement the restorative nursing program according to the specifics on the care plan. Review of Resident 7's clinical record revealed diagnoses that included deforming dorsopathy (a spinal disorder characterized by abnormal curvature or structural deformities of the vertebral column, which can lead to pain, mobility issues, and neurological complications) and abnormalities of gait and mobility (abnormal manner or pattern of walking and mobility from issues affecting the brain, spinal cord, muscles, or joints). Interview with Resident 7 on March 25, 2026, at 9:44 AM, revealed she has only been up to walk with her walker in the hallway 2-3 times since she has been discharged from therapy and it would be nice to walk every day. Review of Resident 7's physical therapy Discharge summary dated [DATE], revealed Discharge Recommendations & Program Details: plan to refer to restorative ambulation program to provide supervision and support for progression of longer distance ambulation using rolling walker on unit to attend activities as needed. Review of Resident 7's care plan revealed a focus area Restorative Ambulation: Patient demonstrates a deficit in ambulation with an intervention for Goal: Patient will walk throughout the unit at least two times per day, with a start date of February 16, 2026. Review of Resident 7's restorative nursing documentation revealed it was marked not applicable on February 25, 26, 27, and 28, 2025; and was also marked not applicable on March 1-5, 7-16, 18, and 21-23, 2025. Email correspondence with the Director of Nursing (DON) March 25, 2026, at 3:23 PM, he revealed Her restorative program is titled incorrectly but with the right direction which nurse aides can see on the POC (point of care) documentation. This could be causing confusion for the nurse aides as this resident does not have a prosthesis. This was locked and unable to be corrected, so we did resolve and updated today. Review of Resident 7's Restorative Program POC documentation revealed it had been updated to note Correction RNP: walk 100-150 ft. Further review of Resident 7's restorative program POC documentation revealed it was marked not applicable in the evening of March 25, 2026, after the DON had corrected the POC task. During an interview with the DON on March 26, 2026, at 10:08 AM, he revealed he would have to follow up to see why the program continued to be marked as not applicable. He further revealed his expectation that restorative programs would be implemented and entered correctly into the electronic health system. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and interviews, it was determined that the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of 30 residents reviewed (Resident 92). Findings include: Review of Resident 92's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), altered mental status, anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), and anisocoria (unequal pupil sizes). During an interview with Resident 92 on March 23, 2026, at 11:02 AM, she stated the Eye Doctor was in about a month ago and asked how her the new glasses were working and she stated she hadn't received them. It was revealed, and the surveyor observed, that her glasses were missing the right lens and nose piece, and the left lens was severely scratched. The Resident stated that not having glasses affects her quality of life because she can't see to read or do activities that she enjoys, and she must sit close to the television to watch it. She can't watch the television when she is lying in bed. It was revealed that she has been in the facility a year and has been asking for new glasses because they were severely scratched; and since admission the lens fell out and couldn't be found, and then the nose piece fell off. Further clinical record review documented Resident 92 was admitted on [DATE], current payor source was private pay. Resident 92's care plan included the Resident had vision impairment, macular degeneration, dry eyes, date initiated January 3, 2025, and revised on February 11, 2026. Interventions included to place glasses within reach in a consistent place and encourage use and consultation with physician for vision evaluation, date-initiated January 3, 2025, and to administer eye medication as ordered, date initiated May 12, 2025. Eye care consult dated January 23, 2026, read, in part, dry eyes, glaucoma (damage to the optic nerve) suspected both eyes, pseudophakia (lens implant) both eyes, hyperopia (distant objects are usually seen clearly but close objects appear blurry) and presbyopia (inability to focus on close objects) both eyes, and follow up in 3-4 months, new glasses recommended and to be delivered upon approval; encourage use of glasses for distance and reading. Interview with Nursing Home Administrator (NHA) and Employee 3 (Registered Nurse Coordinator) on March 24, 2026, at 1:15 PM, it was revealed the bill for the glasses was sent to Resident 92's daughter and must be paid prior to the glasses being delivered. Employee 2 (Director of Social Services) was asked to follow up with the daughter. Further review of clinical record revealed Resident 92's daughter wasn't allowed in the facility or to have contact with Resident 92, and that if contact was made the police should be called. Interview with the NHA on March 25, 2026, at 9:46 AM, revealed there was a history of exploitation by the daughter. The Resident has a guardian that was assigned to her. Employee 16 (Business Office Manager) sent the bill to the guardian and the guardian failed to complete the form/paid the bill. It was revealed that Employee 16 reached out to the guardian on March 24, 2026; the form was completed and the bill was paid. Interview with Employee 16 on March 25, 2026, at 10:15 AM, it was revealed the bill came in the end of last month, she couldn't provide an exact date, and it was mailed to the guardian. Employee 16 stated she usually emails bills from consultants, but she didn't. It was confirmed she reached out to the guardian March 24, 2026, and the guardian revealed they never received the bill. She stated that she reached out to the eye Doctor to get another copy of the bill, and she sent it to the guardian on March 24th, 2026. The guardian signed the paperwork, paid the bill, and the paperwork was sent to the eye Doctor. In the presence of the surveyor, Employee 16 called the Eye Doctor's office, and it was revealed the initial bill was mailed to the facility February 4, 2026. 28 Pa code 211.12(d)(5) Nursing Services

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 30 residents reviewed (Residents 6, 45, and 81).Findings Include: Review of facility policy, titled Person-Centered Care Plan, reviewed [DATE], revealed, The Center must develop and implement a person-centered care plan for each patient/resident consistent with patient rights, measurable objectives, and timeframes to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. Review of Resident 6's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), protein calorie malnutrition, Multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), and end stage kidney disease (loss of kidney function). Interview with Resident 6 on [DATE], at 9:00 AM, revealed he does smoke when he is on leave of absence and doesn't store his smoking supplies in the facility. Smoking assessments completed to ensure safety documented: [DATE], independent smoking is allowed off site of the facility; [DATE], and February 13,2026, Resident not allowed to smoke. Review of Resident 6's physician orders included leave of absence (LOA) orders: may go LOA independently with medication start date [DATE], end date [DATE]; may go LOA with Responsible Party and medications and may go to the end of the drive independently, start date February 31, 2025, on hold starting [DATE], and discontinued [DATE]; and may go LOA with Responsible Party with medications start date [DATE]. Review of Resident 6's care plan documented the Resident may not smoke per smoking evaluation, date initiated and revised on February 17, 2025; and the Resident may smoke independently per smoking evaluation, date initiated [DATE]. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 11:37 AM, revealed the care plan should be updated to reflect the current smoking and leave of absence status. Review of Resident 45's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and end-stage renal disease (the final stage of kidney failure where the kidneys function at less than 15% of normal capacity). Review of Resident 45's physician's orders revealed the Resident to be a full code status. Full Code status is a medical directive indicating that, in the event of a cardiac or respiratory arrest, all possible life-saving interventions should be performed to save the patient's life, including CPR. CPR- cardiopulmonary resuscitation is an emergency, life-saving procedure performed when a person's breathing or heartbeat has stopped, such as during cardiac arrest, drowning, or choking. It combines chest compressions (pushing hard and fast on the chest) and rescue breaths to maintain oxygenated blood flow to vital organs. Review of Resident 45's interdisciplinary plan of care revealed documentation that read Code Status. DNR created February 20, 2026. A DNR- is a do-not-resuscitate status that directs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing or heart stops. It ensures a natural death, typically used by patients with terminal illnesses, allowing them to forgo unwanted life-saving procedures. An interview with the DON on [DATE], at 11:57 AM, revealed that the DNR care plan was incorrect and has been updated to a full code status. Review of Resident 81's clinical record revealed diagnoses that included diabetes (a condition where the body is unable to regulate blood glucose levels) and gastroesophageal reflux disease (GERD, when stomach acid flows back up into the esophagus). Review of the progress note dated [DATE], at 4:18 PM, revealed that Resident 81's daughter had the desire for Resident 81 to be discharged to her house after renovations were completed. Review of Progress note dated [DATE], at 11:26 AM, revealed that a conversation was had with Resident 81 about transitioning to a lower level of care and that Resident 81 was resistant to even talking about leaving the facility because she feels safe here. Review of the progress note dated [DATE], at 10:46 AM, revealed a conversation was held with Resident 81 about a possible discharge to an independent living facility and that Resident 81 was agreeable with that. An interview with the NHA on [DATE], at 11:15 AM, revealed that Resident 81's care plan should have included her choice for discharge or long-term care at the facility to help alleviate any confusion. 28 Pa. Code 211.12(d)(5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident was informed in advance of the risks and benefits of psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 3). Findings Include: Review of the facility's policy, titled Health Care Decision Making, reviewed June 12, 2025, read, It is the right of all patients/residents to participate in their own healthcare. The policy continued, Health care decision making refers to consent, refusal to consent, or withdrawal of consent of health care, treatment, service, or a procedure to maintain, diagnose, or treat a patient's physical or mental condition. Review of Resident 3's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and depression (a common, serious mood disorder characterized by persistent sadness, low mood, and a loss of interest in activities). Review of Resident 3's physician orders revealed the medication Zoloft 50 MG give one tablet by mouth 1 time a day for Depression, ordered December 5, 2025. Review of the facility's form, titled Psychotropic Medication Administration Disclosure read, It is important that you are fully informed about psychotropic medications. If you have any questions regarding the information contained herein, please direct them to your attending physician or psychiatrist. Continued review of the disclosure form revealed that neither Resident 3 nor his Representative was informed of the risks and/or benefits of the antidepressant medication Zoloft. An interview with the Director of Nursing on March 26, 2026, confirmed that the disclosure form was not signed and that the medication was not reviewed with Resident 3 when ordered by the Resident's physician. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure its residents receive treatment and care in accordance with professional standards of practice and the person-centered, comprehensive plan of care for one of four residents reviewed (Resident 3). Findings Include:Review of the facility's policy, titled Medication Administration, dated 2007, read, in part, Medications are administered in accordance with written orders of the prescriber.Review of Resident 3's physician orders revealed diagnoses that included Atrial Fibrillation (an irregular and very rapid heart rhythm that can lead to blood clots, stroke, and heart failure) and anxiety (characterized by intense worry, fear, or panic that interferes with daily life, often involving physical symptoms like a racing heart or sweating).Review of Resident 3's Medication Administration Record (MAR), dated December 1-31, 2025, revealed an order that read Amiodarone HCL Oral Tablet 200 MG .Give 1 tablet by mouth two times a day for A-Fib [Atrial Fibrillation] . start on 12/24/25.Review of Resident 3's clinical record revealed a consultation report, dated January 6, 2026, from the heart and vascular provider. The provider recommendations read as follows: Amiodarone 200 mg qd [once daily].Review of Resident 3's MAR, dated January 1-31, 2026, revealed nursing staff administered the Amiodarone 200 MG's two times a day after the Resident's changed order from the heart and vascular provider dated January 6, 2026.Continued review of Resident 3's clinical record revealed nursing communication to Resident 3's provider, dated January 16, 2026, that read Amiodarone should only be once a day-please update.Based on that documentation, staff did not update Resident 3's dosage to once per day between January 6 and 16, 2026, and continued to administer the medication twice per day.An interview with the Director of Nursing on January 20, 2026, at approximately 2:30 PM, confirmed Resident 3's medication should have been changed to once per day beginning January 6, 2026, per the physician's order.28 Pa. Code 211.12 (d) (1) (2)(5) Nursing services

Based in review of facility policy, documentation provided by the facility, clinical record review, and staff interviews, it was determined that the facility failed to protect the resident's right to be free from involuntary seclusion by a staff member (Resident 1).Findings include: Review of the facility policy and procedure, titled Abuse Prohibition, revised October 24, 2022, read, in part, the Center prohibits abuse, mistreatment, involuntary seclusion. Involuntary seclusion is definition included confinement of a resident to their room against the resident's will. Anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to her/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. Initiate an investigation within 24-hours of an allegation of abuse that focuses on whether it occurred, clinical examination for signs of injuries, causative factors. Ensure that documentation of witnessed interviews was included. Review of Resident 1's clinical record revealed that the Resident was admitted on [DATE], with diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), anxiety (a feeling of worry, nervousness, or unease), and fracture of left clavicle. Review of Resident 1's care plan included a focus area for resistive to care related to difficulty adjusting to facility, cognitive loss/dementia, initiated July 22, 2025. Interventions included, if Resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure, initiated July 22, 2025. Additional focus areas included Resident has impaired cognitive function or thought processes related to dementia, initiated July 16, 2025. Interventions included to explain all care and reason for performing the care before initiating; allow extra time after speaking for resident to process thoughts and respond; allow Resident to make daily decisions, break down tasks to support short-term memory deficits and provide cueing/assistance as needed, and re-direct using external cues as needed, initiated July 16, 2025. Resident is at risk for injury or complications related to the use of anticoagulant (blood thinner) therapy, initiated July 16, 2025. Review of the facility reported incident revealed an incident on July 22, 2025, at 1:30AM. Statements provided by Employees 1 (Nursing Assistant), 3 (Licensed Practical Nurse), and 4 (Licensed Practical Nurse) revealed they heard banging down the hall. Employee 1 went to investigate and found Employee 2 (Nursing Assistant) holding Resident 1's door to her room shut. Resident 1 was heard yelling to be let out of her room and banging on the door. Employee 2 admitted to holding the door closed and stated that the Resident was upset and Employee 2 was scared. Further review of staff interviews from Employees 1, 3, and 4 documented after the incident, revealed Resident 1 stated she was being held hostage in her own home. The facility's initial investigation failed to include documentation of an interview with Employee 5 (Registered Nurse [RN] Supervisor) who worked night shift on July 21st into 22nd, 2025. Further review of the facility investigation documented Employee 1 reported the allegation to Employee 6 (Registered Nurse Unit Manager) on the following day shift on July 22nd, 2025, at 8:00 AM. Surveyor interview with Employee 6 on July 28, 2025, at 7:00 AM, it was revealed that she worked day shift on July 22nd, 2025, and at the start of her shift Employee 1 was upset and informed her of an incident that occurred at 1:30 AM between Employee 2 and Resident 1. It was confirmed that Employee 5 did not initiate an investigation or do an assessment on Resident 1. Employee 6 completed a full body assessment on Resident 1 and no injuries or bruising were noted, and the Resident didn't recall the incident. It was further revealed that Resident 1 does sundown starting around 7 PM. She is confused and she may yell and be resistant to care, however, she can usually be redirected by speaking in a calm reassuring voice, and you must remind her repeatedly of things. Statement provided by Employee 5 on July 28, 2025, at 12:31 PM, via electronic message stated that Employee 1 reported that Resident 1 was sundowning becoming belligerent, threatening to call the police and stating that she was being held hostage and making other accusations, which is normal behavior for this Resident. Staff was managing the behaviors. Later in the shift, Employee 1 commented that Employee 2 was holding the door closed, he didn't specify which door was held closed. Employee 2 was at the unit's cafe doors when Employee 1 made the statement. Employee 5 sated that it wasn't reported to her that the Resident's room door was held shut, and she assumed Employee 2 was holding the door to the cafe closed to keep Resident 2 out. During an interview with the Director of Nursing on July 28, 2025, at 9:00 AM, it was revealed that Employees 1 and 3 should've informed Employee 5, and a RN assessment should've been completed once the Resident had calmed down. 28 Pa. code 201.14(a) Responsibility of Licensee 28 Pa. code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen. Findings include: Review of facility policy, Food and Nutrition Services Use By Dating Guidelines, dated [DATE], read, in part, frozen shakes use by date of 14 days once thawed - use labels for individual items when removed from the carton. Bulk items in large quantities such as flour, sugar and food thickener - use by date six months when opened and transferred to a storage bin. Review of facility policy, Food and Nutritional Services Personal Hygiene, effective date [DATE], read, in part, facial hair coverings are used to cover all facial hair. Observations at the three-compartment sink on February 10, 2025, at 9:30 AM, the test strips expired [DATE]. Upon testing sanitizer solution in the third sink, which was in use, it registered 0. The temperature log at the three-compartment sink was documentation of dish machine temperatures for wash and rinse water, and didn't contain documentation of pH levels for sanitizer. During an interview with Employee 6 on February 10, 2025, at 9:30 AM, it was revealed that the test strip was the incorrect type of strip, and that the facility had ordered the correct test strips. Observation at the three-compartment sing on February 11, 2025, at 12:00 PM, revealed a new container of test strips. The sanitizer solution in the third sink was tested and registered 0. The temperature log at the three-compartment sinks documented dish machine temperatures. During an interview with Employee 5 on February 11, 2025, at 12:00 PM, it was revealed there should be a log for the three-compartment sink. Observation in the dry storeroom on February 10, 2025, at 9:18 AM, the following cereal was stored in bulk containers and wasn't date marked: corn flakes, raisin bran, cheerios, and rice Krispies. During an interview with Employee 6 on February 10, 2025, at 9:18 AM, it was revealed the containers of cereal should be date marked. Observation in the reach-in refrigerator near the receiving area on February 10, 2025, at 9:26 AM, the following nutritional shakes were thawed and not date marked with a thaw or pulled date: 20 vanilla, 43 strawberry. The nutritional shake product is delivered frozen and are to be used within 14 days of thawing. During an interview with Employee 6 on February 10, 2025, at 9:26 AM, it was revealed that the aforementioned nutritional shakes were delivered Thursday (February 6th, 2025), the case was put in the refrigerator when they are delivered, and the facility goes through them by the next delivery. Observation on February 11, 2025, at 11:58 AM, in the reach-in refrigerator near the receiving area, 3 vanilla nutritional shakes not date marked. Observation on February 10, 2025, at 9:21 AM, the ceiling and vent over the prep area and tray line, grate on the front of the vent hood over the grill, and the wall fan on the clean side of the dish room contained a black fuzzy substance. During an interview with Employee 6 on February 10, 2025, at 9:22 AM, it was revealed that maintenance is responsible for cleaning the aforementioned areas. Observation in the prep area on February 10, 2025, at 9:32 AM, there were three plastic bags that contained the ends of white sliced bread that were not date marked. During an interview with Employee 6 on February 10, 2025, at 9:32 AM, it was revealed that the bags of bread should be date marked. Observation in the prep area on February 11, 2025, at 12:03 PM, the bulk container of sugar was not date marked, had a scoop stored inside the bin and the lid to the bin was not securely closed; the bulk container of flour was not date marked and the lid wasn't securely closed; and the bag of thickener inside the cardboard box was not securely closed. During an interview with Employee 5 on February 11, 2025, at 12:07 PM, it was revealed that the scoop shouldn't be stored in the sugar, the flour and sugar should be date marked, and the aforementioned containers should be securely closed. Observation on tray line February 11, 2025, at 11:50 AM, three male employees had a beard and mustache that were working on tray line without a facial hair restraint. During an interview with Employee 5 on February 11, 2025, at 11:50 AM, it was revealed he was unsure of the facial hair restraint policy at the facility. Interview with the Nursing Home Administrator on February 12, 2025, at 1:51 PM, revealed the aforementioned items should be date marked, the scoop not stored in the container of sugar, a log of the three-compartment sink is required to include use of the correct test strips, staff should wear correct hair restraints, and the ceiling and vents and fan should be clean. 28 Pa code 211.6(f) - Dietary Services

Based on observation, policy review, review of facility documentation, and resident and staff interviews, it was determined that the facility failed to provide sufficient dining services staff to ensure that resident meals and nourishments were served timely during two of three meals observed (February 11 and 12, 2025). Findings include: Review of facility policy Snacks, Nourishments, Supplements, and Pantry Stock, effective May 1, 2023, read, in part, Food and Nutrition Services delivers snacks to nursing stations at specified times. Resident interviews during the initial pool process revealed resident concerns with meals being served late. Review of Food Committee meeting minutes for October 2024 and November 2024, revealed concerns for meals being served late especially on the weekends, and that the food cart may sit in the hallway for 20 minutes before trays are being passed out. There were concerns with snacks not being offered at the November 2024 meeting. Documented meal service times are as follows: breakfast 7:10 AM - 8:20, lunch 11:35 AM - 12:45 PM, dinner 5:00 PM - 6:15PM. Observation of lunch meal service on February 11, 2025, the A nursing unit first food cart was delivered 45 minutes late, scheduled 12:25 PM and delivered at 1:13 PM, tray pass started at 1:18 PM. Employee 5 went to Heritage unit to request nursing staff from that unit pass trays on A nursing unit. During an interview with Employee 5 on February 11, 2025, at 12:00 PM, it was revealed that three employees called off for day shift in Dietary. Review of cart delivery time records revealed the following dates the last meal cart was delivered late to the unit 55 minutes or more: February 1, 2025, breakfast; February 2, 2025, breakfast and lunch; February 5, 2025, dinner; February 6, 2025, dinner; and February 11, 2025, lunch and dinner. Observation on February 12, 2025, the 10:00 AM, snacks/nutritional supplements were delivered as followed: C nursing station 12:35 PM - nutritional supplements for the following residents: 17, 60, 80, 83, 96, 109 , and 128. B nursing station 12:37 PM - nutritional shakes for the following residents: 22, 29, 78, 116, 119, and 132, resident 57 an oatmeal cookie. A nursing station 12:43 PM - nutritional shake for resident 27, and milk and fruits for Resident 8. During an interview with Employee 7 (Licensed Practical Nurse) on February 12, 2025, at 12:43 PM, it was revealed that Dietary was notified that the 10:00 AM snacks/nourishments weren't delivered, and they were just delivered to the units. During an interview with the Nursing Home Administrator (NHA) on February 13, 2025, at 1:00PM, it was revealed that the number of staff scheduled to work in Dietary daily depends on the number of staff available. It also was revealed that in previous months there were multiple open Dietary positions, and within the past several weeks many positions have been filled. Surveyor informed the NHA that 10:00 AM snacks/nourishments were delivered to the nursing stations late on February 12, 2025. 28 Pa code 201.18(b)(3)(e)(6) Management

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for four of seven residents reviewed for nutrition (Residents 90, 117, 131, and 252). Findings include: Review of the facility policy, titled NSG244 Weights and Heights last reviewed December 2024, revealed that patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Review of Resident 90's clinical record revealed diagnoses that included hypertension (high blood pressure) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 90's weights summary task revealed the Resident was not weighed in September 2024, October 2024, November 2024, and January 2025. Review of Resident 90's September 2024 MAR (Medication Administration Record) revealed the monthly weights order was marked as completed, however, no weight was recorded. Review of Resident 90's October 2024 MAR revealed the monthly weights order was marked as refused. Review of Resident 90's November 2024 MAR revealed the monthly weights order was marked as completed, however, no weight was recorded. Review of Resident 90's December 2024 MAR revealed there were no weights obtained as ordered for monthly weights starting on the 1st for 7 days, with an active date of December 1, 2024. Review of Resident 90's January 2025 MAR revealed there were no weights obtained as ordered for monthly weights starting on the 1st for 7 days, with an active date of December 1, 2024. Review of Resident 117's clinical record revealed diagnoses that included syncope (fainting) and cardiomyopathy (a disease of the heart muscle). Review of Resident 117's clinical record revealed a discontinued physician's order to weigh every day shift every 1 month starting on the 1st for 7 days, with a start date of November 1, 2024, and discontinued date of December 8, 2024. Review of Resident 117's clinical record revealed a current physician's order to weigh every day shift every 1 month starting on the 1st for 7 days and every day shift every Monday for 4 weeks, with an active date of December 9, 2024. Review of Resident 117's December 2024 MAR revealed Resident 117 was not weighed on December 1, 2, 3, 4, 5, or 7th, 2024, per physician's order. Review of Resident 117's December 2024 MAR revealed Resident 117 was not weighed on December 9, December 16 or 23, 2024, per physician's order. Review of Resident 117's weight summary task revealed there was not a weight obtained for Resident 117 in January 2025 or February 2025. Review of Resident 117's clinical record revealed a Progress note written by the Dietitian on January 2, 2025, at 3:23 PM, that stated, in part, Resident 117 had a significant weight gain noted of 10% in the past 6 months. No weight comparison available for the past 3 months. Review of Resident 131's clinical record revealed diagnoses that included hypertension (high blood pressure) and type 2 diabetes (occurs when your blood sugar is too high). Review of Resident 131's clinical record revealed the Resident was admitted to the facility on [DATE]. Review of Resident 131's clinical record revealed a current physician's order to be weighed every evening shift every Saturday for 4 weeks and every evening shift every 1 month starting on the 1st for 1 day, with an active date of January 4, 2025. Review of Resident 131's January 2025 MAR revealed the Resident was not weighed on January 4, 2025, and was marked as a refusal on January 11, 2025. Review of Resident 131's February 2025 MAR revealed no weight has been obtained. Review of Resident 131's comprehensive care plan revealed a focus area that the Resident is at nutritional risk, with an intervention to weigh per facility policy/orders and alert dietitian and physician to any significant loss or gain, with an initiated date of January 3, 2025. During an interview with the Director of Nursing (DON) on February 13, 2025, at 10:40 AM, she revealed she would have expected Residents 90, 117, and 131 to have been weighed as ordered per the physician's orders. Review of Resident 252's clinical record revealed diagnoses that included type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood into the cells for nourishment) and chronic pain syndrome (condition that is characterized by persistent pain that last more than three to six months). Review of Resident 252's clinical record revealed that Resident 252 was admitted to the facility from the hospital on January 30, 2025. Review of Resident 252's physician orders revealed an order dated January 30, 2025, for staff to, Weigh every evening shift every [Monday] for 4 weeks. Review of Resident 252's clinical record revealed that the only documented weight that was obtained by facility staff was on January 30, 2025. Review of Resident 252's Medication Administration Record (MAR - documentation tool utilized to record when physician orders were performed and by whom) revealed there was no documentation by facility staff that Resident 252's weight was obtained for Monday, February 3, 2025, nor Monday, February 10, 2025, as provided in the MAR. During a staff interview on February 13, 2025, at approximately 10:50 AM, the DON revealed staff should have been completing and documenting a weight assessment for Resident 252 as ordered by the physician. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 33 residents reviewed (Residents 14, 90, and 252). Findings include: Review of the clinical record for Resident 14 revealed diagnoses that included hospice status (end of life) and chronic diastolic congestive heart failure (a condition where the heart muscle becomes stiff, preventing it from properly filling during the resting phase [diastole]). Further review of the clinical record for Resident 14 revealed hospice status was initiated January 17, 2025, and the physician orders dated February 2025, failed to reveal a physician order for hospice status. During an interview with the Director of Nursing (DON) on February 12, 2025, 10:00 AM, the DON was informed there was no physician order for hospice status upon review of all orders for January 2025 and February 2025. The DON stated the Resident contacted hospice herself to enroll. The DON was questioned about the requirement for the physician to write an order for hospice status, but the DON was unable to provide that information. During an interview on February 12, 2025, at approximately 1:00 PM, the DON was able to provide a fax, dated February 11, 2025, and timed 10:27 AM, that was obtained from the hospice service that provided an order for hospice and certification of hospice status. The DON confirmed that the order and certification was sent to hospice from the Attending physician but the facility never received a copy. The DON agreed that the hospice orders should have been entered on January 17, 2025, when hospice status was effective. Review of Resident 90's clinical record revealed diagnoses that included hypertension (high blood pressure) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 90's comprehensive care plan revealed a focus area that she is at risk for alteration in skin integrity and potential for skin tears, bruises, abrasions, excoriation, and pressure ulcers, with a revision date of June 27, 2023; and the following interventions: Geri-leg to left lower extremity, revised on June 10, 2024, and Geri-sleeve to right arm, revised on June 10, 2024. Review of Resident 90's Kardex (a tool for organizing and providing a readily accessible summary of patient information) revealed a skin care section that included Geri-leg to left lower extremity and Geri-sleeve to right arm. Observation of Resident 90 on February 11, 2025, at 12:58 AM, revealed her sitting in the Activities Dining Hall on the 200's hall, sitting in her wheelchair, not wearing a Geri-leg on their left lower extremity or a Geri-sleeve on their right arm. Observation of Resident 90 on February 12, 2025, at 11:13 AM, revealed her sitting in the Activities Dining Hall on the 200's hall, sitting in her wheelchair, not wearing a Geri-leg on her left lower extremity or a Geri-sleeve on her right arm. During an interview with the DON on February 13, 2025, at 10:32 AM, revealed Resident 90's Geri-sleeves were in the wash and new ones were obtained. DON revealed she would have expected Geri-leg and Geri-sleeve to have been worn on Resident 90 as care planned. Review of Resident 252's clinical record revealed diagnoses that included type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood into the cells for nourishment) and chronic pain syndrome (condition that is characterized by persistent pain that last more than three to six months). Review of Resident 252's physician orders revealed that upon admission Resident 252, an order for Percocet (combination drug that contains oxycodone and acetaminophen) 5-325 mg (five milligrams of oxycodone and 325 milligrams of acetaminophen) one tablet as-needed every four hours as needed for pain for one day (until January 31, 2025). Starting on January 31, 2025, Resident 252's as-needed Percocet 5-325 mg order was one tablet by mouth every 12 hours as-needed for pain. Review of Resident 252's Medication Administration Record (MAR - documentation tool utilized to record when physician orders were performed and by whom) revealed that staff documented the following: January 30, 2025, at 6:51 PM, staff documented administration of the as needed Percocet 5-325 mg for a documented pain level of 0 (no pain). February 1, 2025, at 7:53 PM, staff documented administration of the as needed Percocet 5-325 mg for a documented pain level of 0 (no pain). February 2, 2025, at 9:25 PM, staff documented administration of the as needed Percocet 5-325 mg for a documented pain level of 0 (no pain). February 4, 2025, at 5:15 PM, staff documented administration of the as needed Percocet 5-325 mg for a documented pain level of 0 (no pain). February 8, 2025, at 4:00 PM, staff documented administration of the as needed Percocet 5-325 mg for a documented pain level of 0 (no pain). Review of Resident 252's clinical record for the administrations failed to reveal documented rationale(s) for administering the as-needed Percocet when it was documented that Resident 252 was not experiencing pain at the time of administration. During a staff interview on February 13, 2025, at approximately 10:50 AM, the DON revealed that it was the facility's expectation that staff administer as needed medications in accordance with the physician's order and physician ordered indication. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents' dependent on staff for assistance with these activities of daily living for two of two residents reviewed for activities of daily living (Residents 112 and 117). Findings include: Review of Resident 112's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and chronic heart failure (when the heart muscle does not pump blood as well as it should). During an interview with Resident 112 on February 10, 2025, at 9:51 AM, revealed the Resident does not always receive showers on their shower days. Resident 112 revealed her shower days are on Wednesdays and Saturdays, but due to short staff, Saturday showers often get missed. Resident 112 revealed she did not receive a shower as scheduled for this previous Saturday (February 8, 2025). Review of the facility's grievance log revealed Resident 112 filed a grievance on January 6, 2025, relating to not receiving showers. Further review of the grievance revealed the full concern was that Resident 112 was not receiving showers, especially on Saturdays. The grievance was marked as confirmed, and the correction action included staff education. The grievance was resolved on January 21, 2025, with the Resident being satisfied with the corrective action taken and included a statement that Resident 112 has seen an improvement with receiving showers. Review of Resident 112's comprehensive care plan revealed an ADL (Activities of Daily Living) focus area with an intervention to assist to bathe/shower as needed, initiated on March 14, 2024, and an intervention that she prefers early AM shower, initiated on March 14, 2024. Review of Resident 112's Kardex (a tool for organizing and providing a readily accessible summary of patient information) revealed a bathing section that included Resident 112's tub/shower schedule is on Saturday and Wednesdays during the day, she prefers early AM showers, and she requires setup assistance. Review of Resident 112's tub/shower task for the past 30 days revealed she did not receive a shower on January 18 and 22, 2025; and February 8, 2025. Review of Resident 117's clinical record revealed diagnoses that included syncope (fainting) and cardiomyopathy (a disease of the heart muscle). During an interview with Resident 117 on February 10, at 10:10 AM, revealed she does not always receive showers on their scheduled shower day. Resident 117 revealed that she prefers to take showers, and that staff do not ask what her preference is. Review of Resident 117's comprehensive care plan revealed an ADL focus area with an intervention to assist to bathe/shower as needed, with an initiation date of August 25, 2023, and an intervention that it is important to the resident to choose between a tub bath, shower, bed bath, or sponge bath and to please ask her, with an initiation date of December 31, 2024. Review of Resident 117's tub/shower task revealed her shower schedule is on Mondays and Thursdays. Further review of Resident 117's tub/shower task for the past 30 days revealed she did not receive a shower on February 3, 6, and 10, 2025. Review of Resident 117's GG-bathing task for the past 30 days revealed she received a bed bath on February 3, 6, and 10, 2025. During an interview with the Director of Nursing on February 13, 2025, at 10:40 AM, revealed she would have expected Resident 112 and Resident 117 to have received showers to their preference, as scheduled. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three of 37 residents reviewed (Residents 10, 14, and 57). Findings Include: Review of the facility's policy, titled Person-Centered Care Plan, revised October 24, 2022, read, A comprehensive person-centered care plan must be developed for each patient. Review of the clinical record for Resident 10, revealed clinical diagnoses that included neurogenic bladder (a condition that occurs when the nervous system's connection to the bladder is disrupted), diabetes mellitus (the body has trouble controlling blood sugar), pneumonia (lung infection), and three Stage 4 chronic pressure ulcers (wounds that extend deep in the tissue, exposing muscle, tendon, or bone and a high risk of infection). Further review of Resident 10's clinical record revealed Resident 10 was required to have enhanced barrier precautions (EBP-infection control precaution measures) due to his internal devices supra pubic catheter (external bladder catheter), ostomy (abdominal site for excretion of waste), and chronic wounds. On February 11, 2025, there was no care plan to indicate EBP for Resident 10. An interview with the Director of Nursing (DON) on February 12, 2025, at 11:58 AM, confirmed that Resident 10 should have a care plan for EBP. Review of the clinical record for Resident 14 on February 11, 2025, revealed diagnoses that included hospice status (end of life) and chronic diastolic congestive heart failure (a condition where the heart muscle becomes stiff, preventing it from properly filling with blood during the resting phase [diastole]). Review of Resident 14's interdisciplinary plan of care revealed no hospice care plan was developed for hospice care and services when services were implemented on January 17, 2025. During an interview with the DON on February 12, 2025, at 11:58 AM, the DON agreed that a care plan for hospice should have been developed. A review of Resident 57's clinical record revealed diagnoses that included chronic kidney disease (CKD-a condition in which the kidneys gradually lose their ability to filter waste products from the blood. This leads to a buildup of toxins in the body, which can damage other organs and affect overall health.) and chronic pain syndrome (a condition characterized by persistent or recurring pain that lasts for more than 3 months. It is not a specific disease but rather a symptom that can result from various underlying causes). Review of Resident 57's physician orders revealed an order for hospice services dated August 26, 2024. Review of Resident 57's interdisciplinary plan of care revealed none developed or implemented regarding Resident 57's hospice care and services. An interview with the DON on February 12, 2025, at 11:58 AM, revealed Resident 57's interdisciplinary plan of care was fixed and a hospice care plan was developed and added to the plan of care. 28 Pa. Code 211.12(d)(1)(3)Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for three of four resident records reviewed regarding hospitalization s (Residents 37, 66, and 121). Findings include: Review of the clinical record for Resident 37 on February 11, 2025, revealed clinical diagnoses that included obstructive uropathy (a condition that causes a retention of urine), diabetes mellitus (the body has trouble controlling blood sugar). Further review of Resident 37's clinical record revealed transfers to the hospital on June 20, 2024, and October 24, 2024. The surveyor requested copies of the transfer, bed hold, and Ombudsman notification. The Ombudsman notification and bed hold notices were provided, however, the transfer notice provided failed to include a statement of the resident's appeal rights and the name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman. During an interview on February 13, 2025, at 11:00 AM, with the NHA, the NHA revealed that the facility changed transfer forms and failed to include all of the required information on the current form being used for transfer notice. Review of Resident 66's clinical record revealed diagnoses that included congestive heart failure (the heart doesn't pump blood as well as it should). Further review of Resident 66's clinical record revealed a transfer to the hospital on May 27, 2024. Surveyor requested a copy of the transfer notice on February 11th and 12th, 2025, it wasn't provided. During an interview on February 13, 2025, at 11:00 AM, with the NHA, it was revealed that the facility didn't have the transfer form for Resident 66 transfer. Review of Resident 121's clinical record revealed diagnoses that included type two diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 121's clinical record revealed that on September 18, 2024, and February 7, 2025, Resident 121 was transferred to the hospital due to acute medical changes. Review of Resident 121's clinical record revealed no evidence that the Resident and/or Resident's Representative was provided with a written notice of transfer for the hospital transfers on September 18, 2024, and February 7, 2025. Review of an electronic communication from the NHA on February 12, 2025, at 1:26 PM, revealed that NHA confirmed the facility staff did not provide Resident 121 nor Resident 21's Representative with a written notice of transfer. During a staff interview on February 13, 2025, at approximately 12:50 PM, the NHA revealed it was the facility's expectation to provide a written notice of transfer when they are transferred to the hospital. Review of submitted example of the facility's written transfer notice revealed that the transfer notice did not include the following required elements: A statement of the resident's appeal rights, nor the required contact information for the entity responsible for receiving such requests. Information on how to obtain an appeal form, assistance with completing the form and assistance with submitting the appeal hearing request. The required contact information for the Office of the State Long-Term Care Ombudsman. The required contact information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. The required contact information for the agency responsible for the protection and advocacy of individuals with mental disorder(s). During a staff interview on February 13, 2025, at approximately 12:50 PM, the NHA confirmed that the written transfer notice should include information that is required. 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on observation, policy review, and staff interviews, it was determined that the facility failed to maintain a safe environment that supports infection prevention and control for five of 33 residents reviewed (Residents 10, 37, 108, 113, and 119). Findings include: Review of the facility's infection control policy required residents colonized or infected with multi-resistant drug organisms (MDRO), have chronic wounds, or an internal device require enhanced barrier precautions (EBP). EBP is an infection control intervention designed to reduce the transmission of novel or multi-drug resistant organisms. The facility requires EBP signage be placed that directs staff to wear personal protective equipment (PPE) during high contact resident activities. Review of the clinical record for Resident 10 on February 11, 2025, revealed clinical diagnoses that included neurogenic bladder (a condition that occurs when the nervous system's connection to the bladder is disrupted), diabetes mellitus (the body has trouble controlling blood sugar), pneumonia (lung infection), and three Stage 4 chronic pressure ulcers (wounds that extend deep in the tissue, exposing muscle, tendon, or bone and a high risk of infection). Further review of Resident 10's clinical record revealed he had internal devices that include an ostomy (prosthetic device that collects waste from a surgically created opening in the abdomen, called a stoma) and a supra pubic catheter (medical device that drains urine from the bladder through the abdominal wall. Observation on February 11, 2025, failed to reveal any PPE cart or signage to indicate the Resident was required to have EBP. There was one PPE cart sitting in a small alcove in the hall where Resident 10 resides with a droplet precautions sign laying on the top of the cart. There was no droplet precautions signage posted. During interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on February 12, 2025, at 12:30 PM, both agreed that both EBP and droplet precautions signage should be posted and PPE should be immediately available. When this surveyor ask about the cart location and droplet signage, the DON responded that Resident 10 was on droplet precautions due to a diagnoses of pneumonia (lung infection). A review of Resident 10's clinical record revealed he was receiving an antibiotic for the pneumonia until February 12, 2025. Review of the clinical record for Resident 37 on February 11, 2025, revealed clinical diagnoses that included obstructive uropathy (a condition that causes a retention of urine) and diabetes mellitus (the body has trouble controlling blood sugar). Further review of Resident 37's clinical record and observation revealed presence of a supra pubic catheter (an internal medical device that drains urine from the bladder through the abdominal wall). Observation on February 11, 2025, at 10:30 AM, failed to reveal any PPE cart or signage to indicate the Resident was required to have EBP. There was one PPE cart sitting in a small alcove in the hall where Resident 37 resides, with a droplet precautions sign laying on the top of the cart. This cart was 4 rooms away from Resident 37's room. During interview with the NHA and DON on February 12, 2025, at 12:30 PM, both agreed that both EBP signage should be posted and PPE should be immediately available. Review of Resident 108's clinical record revealed diagnoses that included discitis (inflammation of the of the soft tissue between vertebrae of the back typically caused by a bacterial infection) and hypertension (elevated/high blood pressure). Review of Resident 108's clinical record revealed that Resident 108 had the following health related concerns, which indicated the need for enhanced barrier precautions: A non-healing pressure ulcer (wound of the skin) of the left ischium (part of the bone that makes up the hip). Placement of a PICC line (peripherally inserted central catheter - tube inserted into a large vein of the upper arm that travels and terminates in the large vein above the heart). Indwelling internal urinary catheter (tube inserted into the body and to the bladder to facilitate the evacuation of urine). Observations of Resident 108's room on February 10, 11, and 12, 2025, revealed Resident 108's rooom had no indication that Resident 108 was on enhanced barrier precautions, nor was PPE made available at Resident 108's room. During a staff interview on February 13, 2025, at approximately 10:50 AM, the DON revealed that Resident 108 should have been placed on enhanced barrier precautions. Review of Resident 113's clinical record revealed diagnoses that included hypertension and history of VRE (Vancomycin-resistant enterococci) in urine (a type of bacteria called enterococci that have developed resistance to many antibiotic). Review of Resident 113's comprehensive care plan revealed a focus area relating to history of VRE in urine, initiated on April 12, 2024, with an intervention for Infection precautions: enhanced barrier precautions (contact/gloves), initiated on April 12, 2024. Observation on February 10, 2025, at 10;35 AM, and February 11, 2025, at 9:54 AM, failed to reveal an PPE signage to indicate Resident 113 was required to have EBP. During an interview with the DON on February 11, 2025, at 1:50 PM, revealed that Resident 113 should have a sign posted outside of their door to indicate the Resident was on EBP. Review of Resident 119's clinical record revealed diagnoses that included type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and atrial fibrillation (irregular heart beat). Review of Resident 119's clinical record revealed that Resident 119 had the following health related concerns, which indicated the need for enhanced barrier precautions: Suprapubic urinary catheter (tube surgically inserted through an opening of the abdomen that is placed into the bladder to facilitate the removal of urine). Multiple wounds to Resident 119's left great toe and left second toe. Observations of Resident 119's room on February 10, 11, and 12, 2025, revealed Resident 119's room had no indication that Resident 108 was on enhanced barrier precautions, nor was PPE made available at Resident 119's room. During a staff interview on February 13, 2025, at approximately 10:50 AM, the DON revealed that Resident 119 should have been placed on enhanced barrier precautions. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility failed to ensure that interventions were put into place to prevent accident hazards resulting in a fall with fractures for one of four residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included [CONDITION(S)] (a group of lung diseases that make it hard to breathe and get worse over time), Peripheral Vascular Disease (a slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel which may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels) and Cerebral Vascular Accident ([CONDITION(S)]) (stroke-a loss of blood flow to part of the brain, which damages brain tissue which is caused by blood clots and broken blood vessels in the brain) with left-sided [CONDITION(S)] (muscle weakness or [CONDITION(S)]). Review of Resident 1's Quarterly Minimum Data Set (MDS- comprehensive assessment tool) dated February 3, 2021, revealed that section G0100. Activities of Daily Living (ADL) Assistance on line A. Bed Mobility was coded as 3. Extensive assistance which translates into the resident needing 3. Two + persons physical assist. Review of line B. Transfer revealed he was coded 4. Total dependence which translates to resident needing 3. Two + persons physical assist. Review of Resident 1's Care Plan revealed the care focus area of ADL self care deficit related to [CONDITION(S)] with Left [CONDITION(S)] with Date Initiated: 02/28/2017, with goal Will receive assistance necessary to meet ADL needs and associated Interventions/Tasks of ADL Assist: Two person assist with ADL's-false accusations. Additional care Focus area noted for At risk for falls due to history of falls, unsteady gait' with noted Date Initiated: 02/28/2017 and associated Interventions/Tasks of FALL RISK with noted Date Initiated 01/10/2017. Review of Resident 1's care Kardex (active prior to March 30, 2021) (utilized by Nursing Aides to identify residents' daily care needs) revealed Category of ADL's/Restorative Care with Intervention of ADL assist: Two person assist with ADL's - false accusations and the Category of SAFETY for which Interventions revealed FALL RISK (FYI). Review of the fall Investigation Report dated March 30, 2021, revealed in the section titled, Timeline of Events CNA was doing am care on resident and she turned to get a wash rag. When she turned back, resident was sliding oob (out of bed) as written by Registered Nurse (RN) 1. Review of the section titled Summary of Critical Information Obtained During Investigation revealed Bariatric ( an extra heavy-duty and extra wide bed that is able to accomodate persons with a higher weight capacity than standard models designed to safely accommodate larger individuals in hospitals, clinics, rehab centers or at home) bed in place-Bed inspected and no defects noted and 2 assist with care-For false accusations. Review of section Conclusions revealed Intervention: 2 assist with all care. During the time of the fall, Resident 1 was being cared for by Temporary Nurse Aid (TNA) 1. (A temporary nurse aid has completed training but has not passed the state's competency exam). Review of TNA 1's statement regarding the fall on March 30, 2021, at 6:00 AM revealed During routine care, resident was lying on left side in bed, I was standing by the bed on the left side (opposite of resident, who was facing away from me) when the mattress dipped down, and then slid off the bed, taking the resident with it and onto the floor. No other statements were provided. During an interview with Resident 1 on September 15, 2021, at 2:20 PM, Resident was asked if he remembered how the fall happened. Resident 1 quickly responded she pushed me. Resident 1 was then asked if he thought it was on purpose. His voice dropped, making it hard to hear him. It appeared he stated he was uncertain. Additional questioning provided no additional answers regarding this. As a result of the fall, Resident 1 suffered harm in the form of a Fracture of Lower End of Right Femur (thigh bone), Displaced Fracture of Upper End of Right Humerus (upper arm), Fracture of Left Fibula Shaft (outside bone of lower leg), Non-displaced Fracture of Left Wrist and Scapholunate (ligament) injury to right hand. Review of TNA 1's select personnel documents revealed that on May 18, 2020, she was given a Coaching/Counseling form for Failure to carry out health and safety rules by rolling a resident away from her instead of toward her causing the resident to slide off of the side of the bed and for failure to Maintain appropriate safety measures toward self and others by following the bed positioning policy of gently rolling the patient towards you to turn a resident onto his/her side. Continued review of TNA 1's personnel documents revealed Employee Warning Notice with Discharge box checked. Reason for Notice was noted with checked box for Violation of Work rule commitment. Form section titled Describe the action that made it necessary to prepare this notice with comments indicated of Comply with all health and safety rules, including rules prohibiting unsafe acts that jeopardize the health and safety of others, or result in serious injury. On March 30, 2021-you were suspended for a resident fall that resulted in serious injury. Additional section on form revealed Termination- work rule violation. This form was dated April 2, 2021 and signed by the Director of Nursing. On September 17, 2021, the Nursing Home Administrator and Director of Nursing were made aware of the noted concerns. No additional information was provided by facility to specifically identify what caused/contributed to Resident 1's fall. Review of all incident investigation documents, progress notes, and event report failed to reveal acknowledgment that resident's care plan and care kardex had not been followed in regards to him needing assist of two persons for ADL's care prior to his fall. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, review of facility policies, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure placed the facility in an Immediate Jeopardy situation for one of five nursing units (MedBridge unit). In addition, it was determined that the facility failed to properly disinfect reusable equipment between residents for one of five nursing units observed (MedBridge unit) and failed to offer the COVID-19 immunization for one of 30 residents reviewed (Resident 110). Findings Include: Review of facility policy titled, COVID-19 Clinical Monitoring and Measures Plan, dated December 3, 2020, revealed, Place any patient diagnosed in the facility with COVID-19 in transmission based (airborne-droplet) precautions. Review of CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes most recently updated March 29, 2021, revealed Ideally a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. However, in some circumstances (e.g., memory care units) keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection do not need to be placed into an airborne infection isolation room (AIIR) but should be cared for by HCP [healthcare personnel] using a N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Review of Pennsylvania Health Alert Network (PA-HAN) 530, with the Subject: Long-term Care Facility Guidance for Testing and Cohorting: Response to an Outbreak and Residents with Exposure to COVID-19 dated October 7, 2020, revealed that residents needed to be cohorted (grouped together) to separate units in three zones, based on test results: - COVID-19 positive residents (Red Zone): residents with a positive test and still within the parameters for transmission-based precautions. - Potentially exposed residents (Yellow Zone): residents with a negative COVID-19 test who remain asymptomatic but were within 14-days of possible exposure to COVID-19. - Unexposed (Green Zone): any residents in the facility who were not tested and were thought to be unexposed to COVID-19. - Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Pennsylvania Health Alert Network (PA-HAN) 563, dated April 9, 2021, with the Subject: UPDATE: Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic revealed, Place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room with the door closed. HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. Observation of the MedBridge unit on April 18, 2021, at 9:28 AM revealed signage on the resident room doors stating Isolation Full PPE. N95, Face shield, gown, gloves. Multiple observations made on April 18, 2021, from 9:28 AM-1:00 PM revealed Registered Nurse (RN) 1 wearing a surgical mask and face shield. RN 1 was observed multiple times entering resident rooms, which were designated yellow rooms, while wearing the surgical mask, not a N95 mask. Multiple observations made on April 18, 2021, from 9:28 AM-1:00 PM revealed Nurse Aide (NA) 1 wearing a N95 mask but no face shield. NA 1 was observed entering multiple resident rooms which were designated yellow rooms, not wearing a face shield in the rooms. During an interview with RN 1 on April 18, 2021, at 2:55 PM, RN 1 stated she was provided training on the use of PPE. RN 1 stated that in a yellow room, it is required to wear a N95 mask, face shield and gown and that the gown is to be removed prior to leaving the room. RN 1 stated that in a red room, it is required to wear a N95 mask, face shield, and gown, and upon exiting the red room, remove the gown. When RN 1 was asked if it was appropriate to wear a surgical mask in the hallway, she stated that when she's sitting at the desk charting it is okay to be wearing a surgical mask. On April 18, 2021, at 3:15 PM NA 1 was observed walking through the hall wearing a N95 mask but no face shield. During an interview with NA 1 at this time, when asked if she was provided PPE training, she stated, yes. She stated that in a yellow room it is required to wear a N95 mask, face shield, and gown. In a red room, it is required to wear a N95 mask, face shield, and gown. NA 1 was asked if it was required to also wear a face shield in the hallway and she stated yes but that she did not have a face shield on all day. Observation of the MedBridge unit on April 18, 2021, at approximately 11:00 AM revealed Resident 54's door open with a sign on Resident 54's door which stated, Isolation Full PPE. N95, Face Shield, Gown, Gloves. Keep door closed. Change gowns between rooms. Further observation failed to reveal any signage stating if Resident 54's room was in a yellow or red zone. During an interview with RN 1 on April 18, 2021, at 11:03 AM RN 1 stated that Resident 54 had tested positive for COVID-19 on April 12, 2021. Review of facility's line list [a document for tracking COVID infections] revealed that Resident 54 was tested for COVID-19 on April 8, 2021, as part of facility wide routine testing of residents. Resident 54 was asymptomatic. Review of Resident 54's clinical record revealed that results came back positive for COVID-19 on April 12, 2021, and Resident 54 was moved to a room on MedBridge unit at that time. Additional observations on April 18, 2021, at 12:00 PM and 12:35 PM revealed that Resident 54's door remained open. At 12:35 PM, RN 2 was observed entering Resident 54's room to deliver Resident 54's lunch tray and left the door open while doing so. After delivering the tray, RN 2 removed her gown and gloves, exited Resident 54's room, performed hand hygiene, and walked down the hallway to retrieve silverware for Resident 54. Resident 54's door remained open. As RN 2 came back to Resident 54's room with the silverware, RN 2 started donning the gown as she was entering the room and approaching Resident 54. Observation revealed RN 2's gown was only half on as she was handing Resident 54 the silverware. RN 2 then finished putting the gown on and closed Resident 54's door while she remained in the room to assist Resident 54 with lunch. Observations on April 18, 2021, at 3:00 PM revealed the same isolation sign on the door. No additional sign was observed noting if the room was a yellow room or red room. At that time, when asked how staff know that a room is a red room verses a yellow room since the isolation signs are the same, RN 1 stated that the staff are told at the change of shift meeting. On April 18, 2021, at 4:19 PM the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that an immediate jeopardy existed due to failing to follow infection control guidelines from the CDC and the PA DOH to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic and that a corrective action plan was required. The IJ template was provided to the NHA at this time. On April 18, 2021, at 8:35 PM an acceptable corrective action plan was approved which included the following interventions: Immediate Actions: 1. Appropriate signage was placed on Resident 54's room to include COVID positive status. 2. The facility implemented the, COVID-19 Enhanced Clinical Measures and Monitoring, process on April 18, 2021, at 5:00 PM 3. Nurse Aide 1 (facility staff member without appropriate eye wear) was immediately re-educated on the, PPE usage guide on April 18, 2021, at 5:30 PM by phone. 4. Resident 54 had appropriate signage placed on the outside of the room to include COVID positive status on April 18, 2021, at 4:35 PM. 5. All facility staff including all departments who work at ManorCare York North were educated on the, PPE usage guide including the use of eye wear and masks by the Director of Nursing/designee on April 18, 2021, starting at 5:00 PM to be completed by April 19, 2021. 6. All facility staff including all departments who work at ManorCare York North were educated on the, COVID-19 Enhanced Clinical Measures and Monitoring process on April 18, 2021 at 5:00 PM by the Director of Nursing/designee through April 19, 2021. 7. Utilizing Airborne Infection Isolation Precautions, COVID positive patients will be placed in appropriate isolation per the Company infection control practice guideline, Infection Control Guidelines Chapter 2 Practice Guidelines to ensure appropriate isolation practices are in place for COVID positive patients. Like Residents: 1. A comprehensive review of other residents currently residing in the facility who have tested positive for COVID have been reviewed to ensure appropriate signage is in place for isolation precautions on April 18, 2021, by the Director of Nursing/designee. However, there are no additional COVID positive residents currently. System Revision: 1. Utilizing the PPE usage guide - All facility staff including all departments who work at ManorCare York North will be educated prior to their shift on the PPE usage guide by the Director of Nursing/designee on or before April 19, 2021, at 5:00 PM. On-going monitoring: 2. PPE donning/doffing competencies which include information on how to gather the appropriate PPE, putting on the gown, mask, face shield and gloves as well as removal of these items. This will be completed by the Director of Nursing/designee on 5 facility nursing employees/day x 5 days to ensure compliance. Audits will then continue weekly x 4 weeks. Results will be reviewed with Quality Assessment and Assurance. 3. Utilizing the COVID-19 Tracker the facility will audit COVID-19 positive rooms daily x 5 days to ensure appropriate signage is available on the doors of positive residents. Audits will then continue weekly x 4 weeks. Results will be reviewed with Quality Assessment and Assurance. Observation on April 18, 2021, at approximately 6:00 PM revealed Resident 54's door was closed with signs hanging on the door, indicating it was a COVID positive, red zone room. Observations throughout the day on April 19, 2021, revealed Resident 54's door was closed with signs hanging on the door, indicating it was a COVID positive, red zone room. Interviews with multiple staff members on April 19, 2021, revealed that they received education on PPE usage and on the COVID-19 Enhanced Clinical Measures and Monitoring process. On April 19, 2021, at 3:02 PM the NHA was made aware that the Immediate Jeopardy was removed. Review of facility's infection control manual under, Chapter 2-Practice Guidelines with an issue date of May 2013 revealed, Disinfect reusable equipment between patients (e.g. glucometers, lifts, scissors, blood pressure cuffs, etc.) with an EPA-registered disinfectant or hypochlorite solution. Observation on the MedBridge unit on April 18, 2021, at 12:26 PM revealed NA 1 removing the Hoyer lift (an assistive device that allows people to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) from Resident 267's room, which was a designated yellow room, and taking it into Resident 270's room, which was also a designated yellow room. NA 1 was not observed cleaning the lift in between resident uses. On April 20, 2021, at 1:55 PM the NHA and the DON were made aware that the Hoyer lift was not cleaned appropriately between resident uses. Review of Resident 110's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident 110 on April 18, 2021, at 2:15 PM he revealed that he had been in the facility since November, wanted the COVID vaccination, had been told by his doctor that he was OK to get the vaccination, but that he hadn't been able to get the vaccination. During an interview with the DON on April 20, 2021, at 9:00 AM she revealed that Resident 110 was not eligible for the COVID vaccination when it was offered in January 2021, because he was COVID recovered and was still symptomatic. She also revealed that they missed offering it to him at the February 2, 2021, clinic but that it would be offered to him at the next vaccination clinic the facility is able to schedule. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. Previously cited 1/8/21, 8/26/20. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/4/21, 8/26/20, 7/18/19, 8/30/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/8/21, 8/26/20, 7/18/19, 8/30/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 8/26/20, 7/18/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/18/19. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 1/8/21, 8/26/20, 7/18/19. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/26/20, 7/18/19. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/14/21, 1/8/21, 8/13/20, 7/18/19, 8/30/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/18/19, 8/30/18.

Based on clinical record and facility policy review, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents received adequate supervision and assistance to prevent an accident which resulted in harm from a fall with a dislocated shoulder for one of 34 residents reviewed (Resident 44). Findings include: Review of Resident 44's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 44's current care plan revealed a focus area for self care deficit due to ambulatory dysfunction with an intervention to transfer with one person assist using a gait belt (belt placed around a person that is used to transfer people from one position to another, from one thing to another or while ambulating people that have problems with balance). Review of facility incident report dated (MONTH) 25, 2019, revealed Resident 44 experienced a fall on this date. Further review of incident report revealed that Resident 44 was assisted to the bathroom by (Nurse Aide) (NA) 3 . NA 3 assisted resident back to bed and began caring for resident's roommate. While this was occuring, Resident 44 returned to the bathroom independently. As she was returning to her bed, she bumped into her wheelchair and fell on to the ground dislocating her right shoulder. Review of NA 3's witness statement dated (MONTH) 25, 2019, revealed that she was not aware of Resident 44's transfer status since she did not check resident's Kardex (guide for care available to nursing staff) prior to care, saw resident get up to go to the bathroom, but did not intervene or ask resident to wait for assistance. During an interview with the Director of Nursing on (MONTH) 18, 2019, at 1:06 PM she confirmed that NA 3 did nothing to prevent the fall. She also revealed the expectation that NA 3 should have been aware of Resident 44's transfer status since she provided care to the resident just prior to the fall. The facility failed to ensure that residents received adequate supervision and assistance to prevent an accident which resulted in harm from a fall with a dislocated shoulder for Resident 44. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(c) Staff development 28 Pa. Code 201.20(d) Staff development 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.5(F) Clinical records 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(a) Nursing services 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services .