Every finding on record at Yorkview Nursing and Rehabilitation

Based on clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident receives adequate supervision and assistance to prevent falls based on individual needs for one of four resident's reviewed (Resident 2), which resulted in actual harm for Resident 2 as evidenced by a fall with a femur fracture.Findings Include: Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure), difficulty walking and contracture of the left and right knees. Review of Resident 2's interdisciplinary plan of care revealed a problem area that read risk of ADL self-care performance deficit. ADL's (Activities of Daily Living) described as self-care tasks an individual does daily that include eating, bathing, dressing, getting out of bed or a chair. The plan of care continued, Bed Mobility- Max Assist x 2. Max Assist of 2 is described as when a patient needs maximal physical help from 2 people in order to complete a task. Review of Resident 2's Kardex (a concise patient care summary detailing a patient's daily care plan), read Bed Mobility-Max Assist of 2. Review of the facility's incident report, dated July 7, 2026, read [Resident 2] rolled out of his bed onto the floor while [Nurse Aide-Employee 2] was giving him.care. The incident report continued, [Resident 2] complained of pain in his right ankle, R[ight] knee and his R[ight] hip area. After assessment it was determined that the resident needed to be sent o hospital for further assessment. Review of Employee 2's statement regarding Resident 2's fall revealed I was giving care to resident, and he was lying on his side. The resident rolled out of the bed he stated the bed was inflating and that his body could not adjust to the bed inflating [in] the inflation caused him to fall from his bed. Review of Resident 2's statement, post fall, read She came to change me and rolled me away from her. Her mistake was not bringing in 2 people. Review of Resident 2's hospital clinical record information revealed an assessment with diagnoses that included closed right distal femur fracture. The assessment also read Patient was seen and evaluated at the Emergency Department. Sustained a closed right distal femur fracture after fall off his bed earlier today. Additional review of the hospital clinical record revealed Resident 2 required surgical intervention while hospitalized to repair the fracture. An interview with the Nursing Home Administrator (NHA) on July 21, 2026, at 8:54 AM, revealed Employee 2 did not follow Resident 2's plan of care and should have had another staff person to help with providing care to Resident 2. The interview confirmed Employee 2 was not eligible to return to work at the facility at that time. The interview with the NHA also revealed Employee 2 stated that she did not know why she didn't get help with assisting Resident 2 in his bed. During the onsite visit on July 21, 2026, at 9:00 AM, the NHA confirmed the facility initiated and provided the facility's plan of correction that was put into place as a result of the facility's investigation into the fall, with a completion date of July 10, 2026. Review of the facility's document, titled Past Non-Compliance read, Resident to be provided with 2 assists during care, as per Care Plan. Review of current resident will be completed to ensure resident with air mattresses who require 2 assist are receiving 2 assist during care as per plan of care. Nursing staff will utilize the resident Kardex to identify plan of care and resident needs. Education will be provided to nursing staff to ensure use of Kardex and the plan of care is being followed. Observations of residents with air mattresses requiring 2 assist will be completed to ensure 2 assist are provided daily for 5 days, weekly for 2 weeks, monthly for two months. Facility documentation also revealed:Facility-wide staff training, beginning on July 8, 2026, with the topic 2 assist with care.Facility-wide auditing by Administration and monitoring of residents observed with 2 assist audits, beginning July 9, 2026. Prior to the abbreviated survey, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent falls based on individual needs, resulting in harm for Resident 2 as evidenced by a closed distal right femur fracture. The facility's plan of correction was reviewed during the survey. Review of facility documentation revealed that on July 8- 9, 2026, the facility had initiated education for staff and audits to ensure compliance by July 10, 2026, During the abbreviated survey on July 21, 2026, staff interviews, resident interviews, resident record review, and observations revealed no concerns with adequate supervision and assistance to prevent falls. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on facility policy review, clinical record review, review of facility investigation documentation, review of hospital documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident the right to be free from neglect for one of four residents reviewed (Resident 2), which resulted in actual harm for Resident 2 as evidenced by a fall with a femur fracture.Findings Include: Review of the facility's policy, titled Abuse, read, in part, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. The policy continued, Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy also defined serious physical injury as an injury that causes a person severe pain, significantly impairs a person's physical functioning, either temporarily or permanently. Review of the nurse aid job description revealed the purpose of the position was, to provide each of your assigned residents with daily nursing care and service in accordance with the resident's assessment and care plan . Duties and Responsibilities of a nurse aid included, Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors. Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure), difficulty walking, and contracture of the left and right knees. Review of Resident 2's interdisciplinary plan of care revealed a problem area that read risk of ADL self-care performance deficit. ADL's (Activities of Daily Living) described as self-care tasks an individual does daily that includes eating, bathing, dressing, getting out of bed or a chair. The plan of care continued, Bed Mobility- Max Assist x 2. Max Assist of 2 is described as when a patient needs maximal physical help from 2 people in order to complete a task. Review of Resident 2's Kardex (a concise patient care summary detailing a patient's daily care plan), read Bed Mobility-Max Assist of 2. Review of the facility's incident report, dated July 7, 2026, read [Resident 2] rolled out of his bed onto the floor while [Nurse Aide-Employee 2] was giving him.care. The incident report continued, [Resident 2] complained of pain in his right ankle, R[ight] knee and his R[ight] hip area. After assessment it was determined that the resident needed to be sent to hospital for further assessment. Review of Employee 2's statement regarding Resident 2's fall revealed I was giving care to resident, and he was lying on his side. The resident rolled out of the bed he stated the bed was inflating and that his body could not adjust to the bed inflating [in] the inflation caused him to fall from his bed. Review of Resident 2's statement, post fall, read She came to change me and rolled me away from her. Her mistake was not bringing in 2 people. Review of Resident 2's hospital clinical record information revealed an assessment with diagnoses that included closed right distal femur fracture. The assessment also read Patient was seen and evaluated at the Emergency Department. Sustained a closed right distal femur fracture after fall off his bed earlier today. Additional review of the hospital clinical record revealed Resident 2 required surgical intervention while hospitalized to repair the fracture. An interview with the Nursing Home Administrator (NHA) on July 21, 2026, at 8:54 AM, revealed Employee 2 did not follow Resident 2's plan of care and should have had another staff person to help with providing care to Resident 2. The interview confirmed Employee 2 was not eligible to return to work at the facility at that time. The interview with the NHA also revealed Employee 2 stated that she did not know why she didn't get help with assisting Resident 2 in his bed. Prior to the abbreviated survey, the facility failed to ensure each resident the right to be free from neglect, resulting in harm for Resident 2 as evidenced by a closed distal right femur fracture. During the onsite visit on July 21, 2026, at 9:00 AM, the NHA confirmed the facility initiated and provided the facility's plan of correction that was put into place as a result of the facility's investigation into the fall, with a completion date of July 10, 2026. Review of the facility's document, titled Past Non-Compliance read, Resident to be provided with 2 assists during care, as per Care Plan. Review of current resident will be completed to ensure resident with air mattresses who require 2 assist are receiving 2 assist during care as per plan of care. Nursing staff will utilize the resident Kardex to identify plan of care and resident needs. Education will be provided to nursing staff to ensure use of Kardex and the plan of care is being followed. Observations of residents with air mattresses requiring 2 assist will be completed to ensure 2 assist are provided daily for 5 days, weekly for 2 weeks, monthly for two months. Facility documentation also revealed:Facility-wide staff training, beginning on July 8, 2026, with the topic 2 assist with care.Facility-wide auditing by Administration and monitoring of residents observed with 2 assist audits, beginning July 9, 2026. The facility's plan of correction was reviewed during the survey. Review of facility documentation revealed that on July 8- 9, 2026, the facility had initiated education for staff and audits to ensure compliance by July 10, 2026, During the abbreviated survey on July 21, 2026, staff interviews, resident interviews, resident record review, and observations revealed no concerns with neglect. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate services, equipment, and assistance to increase range of motion and/or prevent further decrease in range of motion for one of one residents reviewed (Resident 7).Findings include: Review of facility policy, titled Restorative Nursing Services dated July 2017, indicated, in part, Residents will restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course or stay pr when discharged from rehabilitative care. Review of Resident 7's clinical record revealed diagnoses that included muscle weakness and contractures (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of the right and left hand. Observations of Resident 7 on June 23, 2026, at 10:40 AM; June 24, 2026, at 12:58 PM; June 25, 2026, at 9:44 AM and 1:15 PM, revealed bilateral hand splints in a basin near her bedside. Review of Resident 7's physician orders revealed an order for bilateral hand/wrist splint check skin every shift, dated September 7, 2025. Further review of orders failed to reveal an order for a wearing schedule of the splints. Review of Resident 7's care plan revealed a care plan focus for Requires assistance/potential to restore to maximum level of function for Mobility, dated March 28, 2025, but there were no interventions regarding splinting programs. Review of Resident 7's clinical record revealed that she had received Occupational Therapy (OT) from March 23, 2026, through April 29, 2026. Review of Resident 7's Occupational Therapy Discharge summary dated [DATE], indicated in the section titled Short-Term Goals that Resident 7 was able to tolerate wearing bilateral resting hand splints for six hours daily. In addition, the section titled Discharge Recommendations, indicated that staff were educated on donning and doffing splints and completing skin checks; that Resident 7 had an order for hand splints; and that a Restorative Splint and Brace Program was established for bilateral resting hand splints daily. Review of the Restorative Education Form provided by the facility for Resident 7's splint program revealed that one Licensed Practical Nurse and two nurse aides were educated that the goal was for Resident 7 to wear her bilateral resting hand splints daily up to eight hours a day. Additionally, staff were to provide passive range of motion to fingers, wrists, and elbows flex and extend prior to donning splints because Resident 7 was totally dependent on staff for splint donning/doffing and hygiene. Review of Resident 7's clinical record to include the Treatment Administration Records and Nurse Aide Task Documentation failed to reveal any documentation of Resident 7 wearing her bilateral resting hand splints; however, it was noted that nurses were completing the ordered bilateral hand/wrist splint skin check every shift. During an interview with the Nursing Home Administrator and Director of Nursing (DON) on June 25, 2026, at 1:33 PM, the DON confirmed that there was no order indicating Resident 7's splint wearing schedule and that there was no documentation to provide that Resident 7's splints were applied. She also confirmed that she would expect the restorative program to be initiated in April 2026 when OT discharged her from services. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy reviews, clinical record review, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of one resident reviewed (Resident 7).Findings include: Review of facility policy, titled Gastrostomy [G-tube: a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach]/Jejunostomy [J-tube: a flexible feeding tube placed through the abdominal wall and into the small intestine which allows nutrition to be placed directly into the small intestine bypassing the stomach] Site Care, dated October 2011, revealed, in part, Verify that there is a physician's order for this procedure. The person completing this procedure should record the following information in the resident's medical record: date and time procedure was performed; the name and title of the individual who performed the procedure; how the resident tolerated the procedure; if the resident refused the procedure, the reason why and intervention taken; and the signature and title of the person recording the data. Review of facility policy, titled Enteral Tube Feeding via Continuous Pump, dated November 2018, revealed, in part, Verify placement of tube. If anything suggests improper tube positioning, do not administer feeding or medication. Notify the charge nurse or physician. The person performing this procedure should record the following information: date and time the procedure was performed; verification of tube placement; amount and type of enteral feeding; the average fluid intake per day; the name and title of the individual(s) who performed the procedure; all assessment date obtained during the procedure; how the resident tolerated the procedure; if the resident refused the procedure, the reason why and intervention taken; and the signature and title of the person recording the data. Review of Resident 7's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) with hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) of the right dominant side, and dysphagia (difficulty swallowing) of the oropharyngeal phase (initiating a swallow). Review of Resident 7's clinical record revealed the following orders: NPO (nothing by mouth), dated August 6, 2025; enteral feeding every shift for dysphagia Jevity 1.5 at 95ml (milliliter) per hour until 1200 ml infused with 30 ml of free water flush every hour while feeding administered with start time of 10:00 PM, dated January 26, 2026; flush feeding tube with 150 ml of water every four hours dated August 6, 2025; enteral feed every day shift record the total volume infused, dated January 26, 2026; enteral feeding check for residual every shift and if over 100 ml hold feeding and notify physician, dated August 6, 2025; and oral care every six hours for NPO status, dated August 6, 2025. Further review of orders failed to reveal an order for gastrostomy tube placement verification prior to starting enteral feeding or site care to be completed every shift. Review of Resident 7's care plan revealed a care plan focus for Resident requires a tube feeding related to dysphagia to meet all nutrition and hydration needs, dated March 26, 2025. Interventions included but were not limited to g-tube care every shift dated March 26, 2025; and provide local care to G-tube site as ordered dated January 12, 2026. Review of Resident 7's Medication and Treatment Administration Records from August 2025, through June 2026, failed to reveal any documentation that G-tube site care was administered every shift or that residual feeding was checked and amount noted. In addition, it was noted that the ordered every four hour water flushes were not always documented that Resident 7 received a total of 150 mls of water; and there were two different areas for nursing staff to document amount of feeding infused and the amount infused did not consistently match ordered amount, nor did the two entries consistently match each other. During a staff interview with Employee 5 (Registered Dietician) on June 25, 2026, at 11:30 AM, Employee 5 indicated that she has not referred to Resident 7's Medication Administration Records to see what tube feeding amounts or water flush amounts were administered when assessing Resident 7's nutritional status. She said that she only read Resident 7's nurses' progress notes, which indicated that Resident 7 was receiving her feeding and tolerating it. She further said that if she had looked at the administration records, she would have seen the documentation concerns. Review of Resident 7's clinical record nursing progress notes revealed multiple notes, which indicated that Resident 7's tube placement was confirmed by air auscultation, tube feeding infusing without difficulty, no residual noted, and G-tube site without signs or symptoms of infection; however, there was not a note noted for every shift of every day. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on June 26, 2025, at 1:00 PM, the DON confirmed that g-tube site care and residual checks should be completed every shift and documented in the clinical record. She indicated that she would expect all documentation of Resident 7's enteral feedings and water flushes to be a true and accurate reflection of what she received in accordance with the physician's order or additional documentation as to why the ordered amounts of enteral feeding or water flushes were not administered. 28 Pa. Code 201.18 Management.28 Pa. Code 211.10 (c)(d)Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed (Resident 108).Findings Include: Review of facility policy, titled End-Stage Renal Disease, Care of a Resident with with a revision date of September 2010 revealed, in part, 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: b. how information will be exchanged between the facilities. Review of Resident's 108's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 108's physician orders revealed the following orders for dialysis treatments three times a week on Monday/Wednesday/Friday, dated May 8, 2025. Review of Resident 108's care plan revealed a care plan focus for dialysis with interventions that included keep open communication with dialysis center, dated April 29, 2025. Review of Resident 108's dialysis treatment communication sheets revealed the following dialysis communication sheets were missing: March 16, 20, 23, 25, and 27, 2026;April 15, 17, 20, 24, 27, and 29, 2026;May 4, 8, 18, and 22, 2026; andJune 1, 10, 19, and 22, 2026. Review of Resident 108's Medication Administration Records for March, April, May, and June (2026) revealed that she went to dialysis on the aforementioned dates. During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on June 26, 2025, at 12:44 PM, the DON confirmed that dialysis communication sheets for the aforementioned dates were not present in Resident 108's clinical record and that dialysis consult sheets should be completed with each dialysis treatment and kept in the clinical record. She further indicated that she had contacted the dialysis center and they would be faxing over the missing communication sheets. 28 Pa Code 211.5(f) Medical records.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of select document review, resident and staff interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable and at appetizing temperatures.Findings include: Interview with Resident 91 on June 23, 2026, at 11:49 AM, revealed meals are not served hot. Interview with Resident 103 on June 23, 2026, at 10:14 AM, revealed the hot food is cold, and no condiments are served with sandwiches. Interview with Resident 108 on June 23, 2026, at 11:15 AM, revealed she did not like the food at the facility because it did not taste good. Interview with Resident 157 on June 23, 2026, at 12:29 PM, revealed the Resident doesn't like the taste of the food and doesn't get enough to eat. During tray line observation, at 12:05 PM, one pan of Chicken [NAME] was pulled from the warmer and placed in a hot well on the tray line. At that time the food temperature was 155 degrees. Interview with Employee 6 (Food Service Director) at that time revealed that one of the bays on the plate warmer wasn't functioning. A test tray completed on June 24, 2026, revealed adequate portions size, and the food was palatable for taste and texture for a regular diet; however, the temperature of the chicken alfredo with noodles, Italian blend vegetable and mandarin oranges weren't palatable for temperature. The test tray was placed on a meal cart and delivered to the 700-unit with other trays being delivered at that time; 18 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 6 took temperatures of the food items at the time the test tray was served for evaluation, at 12:31 PM. The following were the recorded highest temperatures: Chicken [NAME] with Noodles- 139 degrees FItalian Blend Vegetables- 135 degrees FMandarin Oranges - 58 degrees F (per Employee 6 the Mandarin oranges were to be served cold)coffee - 135 degrees Fmilk - 46 degrees F At the time of the test tray evaluation the plate was barely warm to the touch. Interview with Employee 6 at the time of the test tray evaluation revealed the food temperatures should be sufficient; as the hot food was within the standard on the facility test tray evaluation form. Interview with the Nursing Home Administrator on June 26, 2026, at 11:00 AM, revealed food temperatures were within parameters of the facility test tray evaluation form. It was also revealed there is a current work order, waiting approval, to fix the plate warmer. 28 Pa. Code 201.14(a) - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on clinical record review and staff interviews, it was determined that the facility failed to follow physician orders for obtaining weights and notification of weight changes for two of 33 residents reviewed (Residents 98 and 108).Findings include: Review of Resident 98's clinical record revealed diagnoses that included chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and hypertension (high blood pressure). Review of Resident 98's physician orders revealed an order for daily weights and to call with weight gain of two pounds (lbs) in 24 hours or five lbs in one week, dated January 10, 2026. Review of Resident 98's February 2026 Medication Administration Record (MAR) revealed that there was no daily weight documented on February 7, 16, 17, 21, and 23, 2026. In addition, on February 15, 2026, Resident 98 weighed 170.5 lbs, and on February 18, 2026, weighed 175.8 lbs; a weight gain of 5.3 lbs. Review of Resident 98's progress notes failed to reveal any documentation that Resident 98's physician was made aware of the weight gains. Review of Resident 98's March 2026 MAR revealed that there was no daily weight documented on March 16, 23, 27, 29, and 30, 2026. On March 13, 2026, Resident 98's weight was documented as not being obtained because shower door would not open. In addition, on March 1, 2026, Resident 98 weighed 170.6 lbs and on March 2, 2026, weighed 173 lbs; a weight gain of 2.4 lbs. On March 3, 2026, Resident 98 weighed 172 lbs and on March 4, 2026, weighed 174.2 lbs; a weight gain of 2.2 lbs. On March 17, 2026, Resident 98 weighed 170.9 lbs and on March 18, 2026, weighed 173.4 lbs; a weight gain of 2.5 lbs. Review of Resident 98's progress notes failed to reveal any documentation that Resident 98's physician was made aware of the weight gains. Review of Resident 98's April 2026 MAR revealed that there was no daily weight documented on April 5, 19, and 24, 2026. In addition, on April 7, 2026, Resident 98 weighed 170.4 lbs and on April 8, 2026 weighed 172.6 lbs; a weight gain of 2.2 lbs. On April 22, 2026, Resident 98 weighed 173.2 lbs and on April 23, 2026, weighed 177 lbs; a weight gain of 3.8 lbs. Review of Resident 98's progress notes failed to reveal any documentation that Resident 98's physician was made aware of the weight gains. Review of Resident 98's May 2026 MAR revealed that there was no daily weight documented on May 1 or 9, 2026. On May 14, 2026, Resident 98's weight was documented as not being obtained because scale was out of order. Review of Resident 98's June 2026 MAR revealed that there was no daily weight documented on June 5, 2026. In addition, on May 31, 2026, Resident 98 weighed 176 lbs and on June 1, 2026, weighed 178 lbs; a weight gain of 2 lbs. On June 2, 2026, Resident 98 weighed 178 lbs and on June 3, 2026, weighed 180 lbs; a weight gain of 2 lbs. On June 24, 2026, Resident weighed 173.6 lbs and on June 25, 2026, weighed 178 lbs; a weight gain of 4.4 lbs. Review of Resident 98's progress notes failed to reveal any documentation that Resident 98's physician was made aware of the weight gains. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 25, 2026, at 1:27 PM, the DON confirmed that she would expect a resident's weight to be obtained as ordered and all appropriate follow-up with physician be completed and documented accordingly. Review of Resident's 108's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 108's physician orders revealed an order for daily weights and to notify physician of 4 lbs or greater weight gain dated May 1, 2025. Review of Resident 108's March 2026 MAR revealed that there was no daily weight documented on March 5, 7, 12, 15, 22, 23, 28, and 30, 2026. On March 23 and 30, 2026, documentation indicated that Resident 98's weight was not obtained because she was sleeping. No additional attempts to weigh Resident 98 were documented for these dates. Review of Resident 108's April 2026 MAR revealed that there was no daily weight documented on April 2, 4, 12, 18, 22, 23, and 27, 2026. Review of Resident 108's May 2026 MAR revealed that there was no daily weight documented on May 1, 6, 8, 9, 10, 13, 17, 24, 25, and 28, 2026. On May 23 and 30, 2026, documentation indicated that Resident 98's weight was not obtained because she was sleeping. No additional attempts to weigh Resident 98 were documented for these dates. Review of Resident 108's June 2026 MAR revealed that there was no daily weight documented on June 17 and 21, 2026. On June 17, 2026, documentation indicated that Resident 98's weight was not obtained because she was sleeping. No additional attempts to weigh Resident 98 were documented for that date. During a staff interview with the NHA and DON on June 26, 2026, at 10:43 AM, the DON confirmed that she would expect a resident's weight to be obtained as ordered. 28 Pa. Code 201.18 Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 39 residents reviewed (Residents 7, 20, 94, and 108). Findings Include: Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, reviewed [DATE], read, The interdisciplinary team reviews and updates the care plan. Review of Resident 7's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) with hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) of the right dominant side and muscle weakness. Review of Resident 7's physician orders revealed an order for Cardiopulmonary Resuscitation dated February 19, 2026. Review of Resident 7's care plan revealed a care plan focus for Resident has an advanced directive of Do Not Resuscitate dated [DATE]. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 10:41 AM, the DON confirmed that the care plan should have been revised in February 2026 when Resident 7's order was changed from Do Not Resuscitate to Full Code per Resident 7's Representative request. Further review of Resident 7's care plan revealed a care plan focus for Resident has a pressure ulcer, dated [DATE]. Further review of Resident 7's clinical record that she currently did not have a pressure ulcer. Her clinical record indicated that she had an arterial ulcer, which resolved on [DATE]. During a staff interview with the NHA and DON on [DATE], at 1:33 PM, the DON confirmed that Resident 7's care plan should have been revised when the wound resolved. Review of Resident 20's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and advanced cataracts (later stages of lens clouding that significantly impair vision and daily activities, often requiring surgical interventions for restoration of sight).An observation of Resident 20, on [DATE], at 12:50 PM, in the dining room, revealed the Resident eating her lunch meal. The observation revealed that Resident 20 was experiencing difficulties in locating her cup of lemonade and her ice cream. Resident 20 stated I don't want to drink his, referring to her neighbor at the table. Review of Resident 20's most recent vision consult, dated [DATE], revealed the presence of advanced cataracts and read, Surgery is not indicated as pt. [patient] is poor candidate.Review of Resident 20's interdisciplinary plan of care failed to include her low vision and advanced cataracts.The interdisciplinary plan of care revealed an intervention, dated [DATE], that read Wears glasses. Keep clean and in good repair.Continued observations of Resident 20 revealed her to not wear glasses.An interview with the DON on [DATE], confirmed Resident 20 no longer wears glasses and the care plan would be updated regarding the low vision. Review of Resident 94's clinical record revealed diagnoses that included diabetes (a condition where the body is unable to regulate blood glucose levels) and chronic kidney disease (gradually impaired kidney function, often without early symptoms, and can lead to serious complications like heart disease and kidney failure if untreated). Review of Resident 94's care plan revealed a focus are of: the Resident has an advanced directive of full code, with an intervention of: CPR (Cardiopulmonary Resuscitation) will be performed as needed, initiated [DATE]. Review of Resident 94's Physician Orders for Life-Sustaining Treatment (POLST- is a medical order that ensures a seriously ill person's treatment preferences are followed in emergencies), dated [DATE], revealed that if Resident 94 is found pulseless and not breathing, she wishes to be a DNR (Do Not Resuscitate, a medical order instructing healthcare providers not to perform CPR if a person's heart or breathing stops). Review of Resident 94's physician order revealed an order for, DNR (DO NOT RESUSCITATE), started [DATE]. An interview with the DON on [DATE], at 10:45 AM, revealed that Resident 94's care plan should have been updated to reflect her preference for DNR status. Review of Resident 108's clinical record revealed diagnoses that included end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats), and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 108's care plan revealed a care plan focus for Resident has a pressure ulcer, dated [DATE]. Review of Resident 108's clinical record failed to reveal that she had a pressure ulcer. During a staff interview with the NHA and DON on [DATE], at 10:43 AM, the DON confirmed that Resident 108 had not had a pressure ulcer in quite some time and that her care plan should have been revised when the pressure ulcer resolved. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, 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 for three of five pantry refrigerators (subacute, F- east, and [NAME] II) and lack of hand hygiene during the Lunch meal on June 24, 2026.Findings include: Review of facility policy, titled Food Storage, revised February 15, 2020, read, in part, food storage areas shall be clean at all times, house supplements will be dated at the time of receiving and again on thawing. Unserved leftovers shall be labeled, dated, and stored for a period not to exceed three days. Review of facility policy, titled Bare Hand Contact with Food and use of Plastic Gloves, revised July 2023, red, in part, plastic gloves will be worn when handling food directly with hands. Staff will utilize good hygiene practices and techniques. Gloved hands are considered a food contact surface that can get contaminated or soiled and must be changed after touching your face or a contaminated surface. Single use gloves should be discarded when soiled. Hands are to be washed when donning and doffing plastic gloves. Review of facility policy, titled Food from Outside sources, not dated, read, in part, visitors/family member will label food and beverages with the resident's name, room number and date that is was [NAME] into the facility. Observation in the Subacute nourishment pantry on June 23, 2026, at 9:47 AM, in the freezer was a half- eaten strawberry milk shake and fruit yogurt bowl, not date marked or marked with a resident identifier. In the refrigerator, there was one 32 oz container honey thick milk, open with contents partially removed not date marked with an open or use by date. Interview at that time with Employee 6 (Food Service Director) revealed resident items should be marked with a resident identifier and date marked. Observation in the F-east and west nourishment pantry on June 23, 2026, at 9:55 AM, revealed two bowls of apple sauce weren't date marked, and there was a clear liquid an inch and a half deep in the left lower bin, and the bottom shelf had a dried tan liquid. Interview at that time, with Employee 6 revealed the applesauce should be marked with a date, and the refrigerator should be clean. Observation in the [NAME] II nourishment pantry on June 23, 2026, at 9:59 AM, in the refrigerator there were two -strawberry mighty shakes, thawed not marked with a pull or use by date (the product is to be used within 14 days of thawing), and one 32 oz carton med pass 2 open with contents partially removed, not marked with an open or use by date. Interview at that time with Employee 6 revealed open items should be dated with an open or use by date. It was revealed that the mighty shakes are pulled from the freezer, the case is marked with a date when pulled, and the shakes are placed on resident meal trays for consumption. Interview with the Nursing Home Administrator (NHA) on June 26, 2026, at 11:00 AM, revealed open items should be dated with an open or use by date, resident items should be marked with a resident identifier and date marked, and refrigerators should be clean. Observation during the lunch meal on June 24, 2026, at 12:00 PM, revealed Employee 7 (Dietary Aide), with a gloved hand, opened the proofing box, retrieved a hamburger roll, then touched the roll to her bare arm and closed the proof box. Employee 7 then reached into the pan of hamburgers with the same glove hand to retrieve a hamburger, placed it in the bun, and served the sandwich on the tray line, without completing hand hygiene. Additional observation at 12:12 PM, revealed Employee 8 (Dietary Aide), with a gloved hand, utilizing serving utensils to serve soup and puree items on the left end of steam table. During a break in service, the Employee was observed to pick her teeth and inside her mouth, and rubbing her nose with a gloved hand, did not change gloves or completed hand hygiene and returned to serving (touching utensils) for the soup and puree items. At that time, Employee 6 confirmed that both Employees should've changed their gloves and completed hand hygiene. Interview with the NHA on June 26, 2026, at 11:00 AM, revealed both staff members should've changed gloves and completed hand hygiene. 28 Pa code 211.6 - Dietary Services

Based on policy review, facility documents, observations, and resident and staff interviews, it was determined there is greater than 14 hours between the evening meal and breakfast the following day. The facility failed to provide and offer a nourishing snack (food from the basic food groups, either singly or in combination with each other) outside of the scheduled meal service times in accordance with resident's needs and agreement from the resident group.Findings include: Review of facility policy, titled Food and Nutrition Services, not date marked, read, in part, nourishing snacks are available to the residents. Residents may request snacks as desired, or snacks may be scheduled between meals to accommodate the residents' typical eating patterns. All residents are offered a nourishing evening snack. Review of facility provided document Meal Cart Delivery Times form, not dated, read, in part, A-wing is the first cart served at dinner between 4:15 PM and 4:25 PM and the last cart served is C-wing between 6:20 PM and 6:25 PM. The first unit served breakfast is A-wing between 7:15 AM and 7:25 AM and the last cart served is C-wing between 9:15 AM and 9:20 AM. A time span of 15 hours between dinner and breakfast. Review of facility provided document Unit Snack par level sheet documented the following snacks are stocked on each unit (par level amount/amount stocked): fudge cookies (3), oatmeal cookies (3), lemon cookies (3), potato chips (3), pretzels (3), peanut butter crackers (4), chocolate chip cookies (3), graham crackers (6), saltines (10), and animal crackers(4). Observations on June 23, 2026, between 9:45 AM and 10:15 AM, in the following nourishment pantries/nursing units, revealed: subacute, B and C wing, F east and west wing, and [NAME] II wing the snack bins contained graham crackers and cookies, and no observed peanut butter crackers or nourishing snacks in the refrigerators. Interview on June 23, 2026, at 10:00 PM, with Employee 6 (Food Service Director) revealed snacks are delivered to the nursing units daily, and sandwich(es) are stored in the Registered Nurse Supervisor refrigerator in the event there is a new admission that arrives after dinner or per resident request. Observations in the medication storage room refrigerators on June 24, 2026, at 2:00 PM, in B and C wing, and at 2:15 PM in subacute; and on June 25, 2026, at 10:50 AM in A wing, and at 10:55 AM in [NAME] 2; revealed there were no nourishing snacks observed. Observation in the Registered Nurse (RN) Supervisor office refrigerator on June 26, 2026, at 9:00 AM, no sandwiches were observed. At that time, interview with Employee 11 (RN Supervisor) it was revealed that sandwiches are stored in the nursing refrigerators on individual nursing units. During resident group meeting on June 24, 2026, at 11:30 AM, Residents 116, 141, 186, 189, and 205 indicated that they do not get offered bedtime snacks and that when they ask for them, they are told none are available. Review of Resident 91's clinical record documented diagnoses that included history of gastric sleeve surgery. Interview with Resident 91 on June 23, 2026, at 11:49 AM, revealed she had gastric sleeve surgery (a minimally invasive weight-loss procedure). She eats small meals, and she is hungry between meals and at night. She does ask staff for snacks and is told they don't have any. Review of Resident 91's physician orders included a regular diet, starting date January 14, 2026. Review of Resident 91's meal intake documentation May 27th, 2026, through June 25th, 2026, revealed 25 to 75% intake. Review of physician note dated March 3, 2026, read, in part, Resident was seen for acute visit per staff and the Resident's request. She reportedly has been complaining of increased episodes of nausea and reportedly has a poor oral intake. Resident with a history of remote gastric bypass surgery and gastrointestinal complaints in the past. Current medication list was reviewed and there has been no recent addition to her medications. Increased gastrointestinal complaints and nausea reported by the Resident during March 2026 visit. Medication timing was adjusted along with the discontinuation of her as needed Percocet (opioid used to treat moderate to severe pain), aspirin, and losartan (medication used to treat high blood pressure). In addition, a Proton Pump Inhibitor (medication that decreases stomach acid). The surveyor requested Resident 91's tray tickets for June 23, 2026, breakfast, lunch and dinner, via email to the Nursing Home Administrator (NHA) on June 26, 2026, at 9:00 AM. The Surveyor was provided tray tickets for the dinner meal June 26th and 27th, 2026, which documented Resident 91 would be provided a ham sandwich and a peanut butter and jelly sandwich. Review of Meal Cart Delivery Form, dinner is delivered to the F east unit between 4:50 PM to 5:00 PM; therefore, Resident 91 would receive her requested evening snack with her dinner meal. Interview with Resident 157 on June 23, 2026, at 12:29 PM, revealed he doesn't like the taste of the food and doesn't get enough to eat. When he asks for a snack, he is usually told they don't have any. Email communication from the NHA on June 24, 2026, at 2:38 PM, in response to the group meeting concern, that snacks are not offered at bed time and that when they ask for a snack are told none are available, it was revealed that snacks are delivered to the units every other day or as needed. Interview with the NHA on June 26, 2026, at 11:15 AM, revealed snacks are purchased and delivered to the units on evening shift, and staff do call to requested additional snacks as needed. It was also revealed that sandwiches are stored in the RN supervisor office refrigerator. 28 Pa. Code 201.14(a) - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to ensure a resident's comprehensive care plan was implemented for one of 39 residents reviewed (Resident 1).Findings include: Review of the facility's policy, titled Care Plans, Comprehensive Person Centered, reviewed January 2026, read, in part, The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's Dementia with late onset (an irreversible, progressive decline in mental abilities severe enough to interfere with daily life), persistent atrial fibrillation (an irregular and often very rapid heart rhythm), intracardiac thrombosis (a blood clot that forms in one of the four chambers of the heart), and long term (current) use of anticoagulants (a substance that prevents or slows down the blood's ability to clot). Review of the Minimum Data Set (MDS- periodic assessment tool) dated June 5, 2026, revealed that Resident 1 was on anticoagulant medication. Review of Resident 1's physician orders revealed an order for Eliquis (anticoagulant) 5 mg twice a day related to atrial fibrillation. Review of Resident 1's care plan failed to include a focus area for the use of an anticoagulant medication or monitoring for bleeding. During a staff interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 26, 2026, at 10:35 AM, the DON revealed that care plan input comes from the Interdisciplinary Care Team, Unit nurse, DON, Therapy, and MDS Coordinator, but nursing in general is responsible for initiating and updating. During a staff interview with NHA and DON on June 26, 2026, at 12:55 PM, the NHA and DON revealed expectations for Care Plans to be up to date for monitoring resident care needs. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing service

Based on review of facility policy, record review, observations, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers by ensuring heel lifting boots were worn for one of three residents reviewed for pressure ulcers (Resident 92).Findings Include: Review of facility policy, titled Skin and Wound Management System, revised September 2022, revealed, preventative intervention will be implemented for residents identified at risk, as appropriate, for example beds, wheelchair cushions, nutrition, incontinence, therapy, etc. Review of Resident 92's clinical record revealed diagnoses that included trans ischemic attack (TIA- a temporary blockage of blood flow to the brain) and muscle weakness (weakness in the muscles not explained by any medical diagnosis). Observation of Resident 92 on June 23, 2026, at 11:03 AM, revealed Resident 92 lying in bed. At that time, Resident 92's heel offloading boots were lying on the floor beside her wheelchair. Resident 92 was not wearing heel offloading boots. Observation of Resident 92 on June 25, 2026, at 9:56 AM, revealed Resident 92 lying in bed. At that time, Resident 92's heel offloading boots were sitting in her wheelchair near the foot of her bed. Resident 92 was not wearing heel offloading boot. Review of Resident 92's physician orders revealed an order to apply bilateral heel offloading boots at all times when in bed, starting October 16, 2026. Review of Resident 92's care plan revealed a focus area of: The Resident has limited physical mobility related to TIA, with an intervention of bilateral heel offloading boots for positioning/contracture management, with a revision date of April 13, 2026. Interview with the Director of Nursing on June 26, 2026, at 10: 45 AM, that she would expect the Resident to be wearing the boots as ordered. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical records review, observations, and staff interview, it was determined that the facility failed to ensure that the resident environment was free of accident hazards by providing bilateral fall mats for one of two Residents reviewed for falls (Resident 49).Findings include: Review of facility policy, titled Falls Management System, last revised September 2022, revealed, The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall. The updated plan will be reviewed and revised as indicated by the Falls Management Team at the meeting. Documentation of implementation will be in accordance with accepted standards of clinical record keeping as outlined in Federal and State regulations and industry standards of practice. Review of Resident 's clinical record revealed diagnoses that included repeated falls (two or more falls within 12 months) and hemiplegia (paralysis on one side of the body). Observation of Resident 49 on June 23, 2026, 11:24 AM, revealed the Resident 49 lying in bed. On the floor on the left side of Resident 49's bed was a singular fall mat. Observation of Resident 49 on June 26, 2026, 9:56 AM, revealed the Resident 49 lying in bed. On the floor on the left side of Resident 49's bed was a singular fall mat. Review of Resident 49's physician orders failed to reveal an order for fall mats at Resident 49's bedside. Review of Resident 49's care plan revealed a focus area of: the Resident is at risk for falls, gait/balance problems related to stroke, with an intervention of bilateral fall mats, initiated on April 30, 2024. Further review of Resident 49's care plan revealed a focus area of: the Resident has a potential for falls, with an intervention of bilateral wedges and floor mats to both sides of the bed, revised March 28, 2024. Interview of the Director of Nursing on June 26, 2026, at 10:35 AM, revealed that Resident 49 should have had bilateral fall mats on the floor at his bedside. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to properly label medications in one of six medications carts reviewed ([NAME] 2) and one medication storage room (Subacute Care); and failed to discard expired medications in one of four medication storage rooms observed (Subacute Care).Findings include: Review of facility policy, titled Medication Labeling and Storage, reviewed January 2026, revealed, in part, Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated. Review of facility policy, titled Medication Labeling and Storage, reviewed January 2026, revealed, in part, If the facility has discontinued outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation of [NAME] 2 medication cart with Employee 10 (Licensed Practical Nurse) on June 25, 2026, at 11:00 AM, revealed a Humalog Kwik insulin pen belonging to Resident 141 was opened, but not dated. Employee 10 confirmed that Resident 141's Humalog insulin pen should have been dated with an open date when opened. Observation of Subacute Care medication storage room on June 24, 2026, at 2:15 PM, with Employee 9 (Registered Nurse) revealed an opened Apisol Injectable 5/0.1 ml multi-dose vial opened but not dated. During an immediate staff interview with Employee 9, Employee 9 confirmed the vial was opened and not dated. Observation of medication storage room Subacute Care unit on June 24, 2026, at 2:15 PM, with Employee 9, revealed a bottle of Vitamin D3 50 mcg with an expiration date of March 2025; a bottle of Vitamin C 500 mg with an expiration date of April 2026; a bottle of Aspirin 325 mg with an expiration date of May 2026; a bottle of Melatonin 1 mg with a best by date of April 2024; and a bottle of Melatonin 1 mg with best by date of March 2025. During an immediate interview with Employee 9, the Employee confirmed the medications were expired and properly disposed of them. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on June 26, 2026, at 12:5 PM, the NHA confirmed that she would expect medications to be labeled and stored properly, and that she expected medications to be discarded when expired according to policy or manufacturer guidelines. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of facility policies, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide residents with food that accommodates resident allergies, intolerances, and preferences for one of 39 residents reviewed (Resident 157).Findings include: Review of facility policy, titled Food and Nutrition Services, not date marked, read, in part, reasonable efforts will be made to accommodate resident choices and preferences. Each resident will be provided with a well-balanced diet taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct mis is provided for each resident. Review of facility policy, titled Fluid Restriction, not dated, read, in part, a fluid restriction is put in place to limit the amount of fluid that is consumed each day. In addition to beverages, foods may be considered liquids. Anything that is liquid or melts at room temperature must be counted in the allotted fluids (i.e. ice cream). Review of Resident 157's clinical record documented diagnoses that included obesity class 3 (severely over wight based on your weight relative to your height), hemiplegia (total or partial paralysis of one side of the body caused by brain or spinal cord damage) left non-dominant side, and anxiety (feelings of tension, worried thoughts). Interview with Resident 157 on June 23, 2026, at 12:29 PM, revealed he doesn't like the taste of the food and doesn't get enough to eat. Review of the menu for June 23, 2026, lunch included Vegetable soup, ham steak, green beans, corn, ice cream and beverages. Review of Resident 157's meal ticket for lunch on June 23, 2026, read: Heart Healthy Diet, 360 milliliter (ml) flid restriction, no corn; and documented the Resident was to receive vegetable soup, saltine crackers, ham steak, green beans, alternate vegetable, ice cream, milk and coffee. Observation of Resident 157's meal tray revealed he received vegetable soup, saltine cracker, ham steak, green beans and ice cream. An alternate for corn, milk, and coffee wasn't provided. At that time, Resident 157 stated to the Surveyor he would like alternate vegetable and milk to drink. The Surveyor did inform nursing staff at the time of Resident 157's request. Resident 157's Physician orders included: heart healthy diet, start date December 4, 2025; Fluid Restriction 1500 ml total per 24 hrs. as follows: Dietary Department: 1080 ml on meal trays (breakfast 360 ml, lunch 360 ml, dinner 360 ml), Nursing Department: 420 ml (Day shift 180 ml, Evening shift 150 ml, Night sift 90 ml), start date December 4, 2025. Interview with Employee 5 (Registered Dietitian) on June 26, 2026, at 12:00 PM, revealed Resident 157 should've received an alternate item for the corn. She also stated that she would speak with Resident 157 regarding his fluid restriction and obtain his preferences for fluids when the menu is above the physician ordered allotted amount for a particular meal. During an interview with Nursing Home Administrator (NHA) on June 26, 2026, at 12:45 PM, the NHA was informed of the concern with Resident 157 not receiving an alternate vegetable in place of the corn, and the food items on the meal tray met the Resident's fluid allotment for the meal, which did not include a beverage to drink. No further information was provided. 28 Pa. Code 201.14(a) - Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on facility documents, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a nutritionally adequate meal for one of one meal observed (May 18, 2026, lunch meal). Findings include: Review of the facility Long Term Care Diet Manual- Regular Diet, not dated, read, in part, regular diet is to receive 3 ounces of protein at lunch. Review of the production sheets (guidance for dietary staff regarding portion size and number of servings required for each menu item) documented to serve three chicken tenders. Observation on May 18, 2026, at 12:30 PM, during lunch meal service revealed residents were served two chicken tenders as the main entree. Interview with Employee 10 (Food Service Director), at 1:40 PM, revealed the serving for the main entree should be two chicken tenders. The surveyor asked for the portion of chicken to be weighed, and Employee 10 revealed a scale wasn't available to obtain the weight of the chicken. Review of the Diet Manual and production sheets with Employee 10, at 1:50 PM, he stated that three chicken tenders should've been served. Interview with the Nursing Home Administrator (NHA) on May 18, 2026, at 2:24 PM, it was revealed that the production sheet should be followed to ensure the appropriate size serving is provided. Review of Resident 6's clinical record documented diagnoses that included Alzheimer's disease (a progressive brain disorder affecting memory and the ability to carry out simple daily tasks) and dysphagia (difficulty swallowing). Review of resident 6's physician orders included mechanical soft (chopped texture) texture diet, start date June 4, 2025. During the lunch meal service on May 18, 2026, at 12:09 PM, Resident 6 was served carrots, ground chicken tenders, pudding, ice cream, juice; however, she wasn't served her peanut butter and jelly sandwich or extra gravy or sauce per her meal ticket. At that time interview with Employee 11 (Nursing Assistant) confirmed Resident 6 should've received a peanut butter and jelly sandwich and extra gravy or sauce. Observation and interview on May 18, 2026, at 12:15 PM, with Employee 10 (Food Service Director) it was confirmed that Resident 6 should've received a peanut butter and jelly sandwich and extra gravy. Interview with the NHA on May 18, 2026, at 2:24 PM, it was revealed that Resident 6 should've been served items per the tray ticket. Pa code 211.6 - Dietary Services

Based on observation, clinical record review, staff interviews, and policy review, it was determined that the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of the five residents observed (Resident 5).Findings Include: Review of the facility's Dignity policy, dated August 2009, read, in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy continued, Staff shall maintain an environment in which confidential clinical information is protected. Review of Resident 5's clinical record revealed an admission date of May 16, 2026. Review of Resident 5's interdisciplinary plan of care revealed diagnoses that included trauma related to PTSD (Post-Traumatic Stress Disorder - a serious mental health condition that can develop after an individual experiences or witnesses a traumatic event) and depression (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest). An observation of Employee 5 (Social Worker) on May 18, 2026, at 10:33 AM, revealed interactions with Resident 5, including the Brief Assessment for Mental Status (BIMS -is designed to quickly assess cognitive function in elderly patients, particularly in long-term care or nursing home settings. It helps caregivers track memory and thinking changes over time and determine if additional support or further evaluation for dementia is needed), and an interview that included the PHQ-9 (a questionnaire that measures how often a person has been bothered by 9 symptoms of depression over the past two weeks). Resident 5 was questioned about her mood, appetite, concentration, feeling down, depressed, or hopeless, and her ability to recall and repeat words. An immediate interview with the Employee, at 10:34 AM, revealed she assessed Resident 5 in the hallway, in the presence of other residents, staff, and visitors, as Resident 5 had a recent fall and was not in her room. An interview with Employee 3 (Director of Social Services) on May 18, 2026, at 12:18 PM, confirmed that it is not best practice to interview residents in the hall regarding their cognitive and mood status. A final interview with the Nursing Home Administrator on May 18, 2026, at 12:43 PM, confirmed awareness of Employee 5's assessment of Resident 5 in the hall and that the assessment was not best practice. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior for two rooms on two of nine units (Units B and C). Observation in Resident 7's room on May 18, 2026, at 10:17 AM, revealed the multiple slats on the blinds were broken off or bent, dried food was observed around and under the bed. Observation in Resident 8's room on May 18, 2026, at 10:45 AM, revealed the papers, used cups, dried liquid, red and brown and dried food particles ground into the floor, and the floor note to contain a hazy film. Interview with Nursing Home Administrator on May 18, 2026, at 2:40 PM, revealed that when blinds need to be replaced, a work order should be submitted, and that Resident 8 likes to keep food in his room. 28 Pa. Code 201.18 (e)(1)(2.1) Management

Based on review of select grievances, observation, staff interview, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures at one of one meal observed.Findings include: Review of grievance submitted on April 30, 2026, on behalf of Resident 6, documented milk on top of the food cart for two hours not in ice, and family was concerned that milk would be reused. Resolution documented that milk should've been on ice and staff were educated. Review of facility provided Test tray evaluation form, not dated, read, in part, hot entree, starch and vegetable should be greater than 135 degrees Fahrenheit (F), cold entree less than 41 degrees F, and dessert less than 41 degrees or greater than 135 degrees F. Observation on May 18, 2026, at 9:26 AM, revealed the breakfast cart was delivered to C unit and the milk on top of the food cart was not on ice. A test tray was completed on May 18, 2026. Employee 10 (Food Service Director) took temperatures of the food items at the time the test tray was served for evaluation (11:35 AM). The following were the recorded highest temperatures: Chicken tenders 102 [NAME] fries 97 FColeslaw 66 F Fruit cocktail 74 F- was served at room temperatureMilk 60 F Interview with Employee 10 on May 18, 2026, at 1:20 PM, revealed the temperatures of all items were not as they should be, the hot items should've been warmer and the cold items cooler. Interview with Nursing Home Administrator on May 18, 2026, at 2:40 PM, stated that the temperatures should be within an acceptable temperature range. 28 Pa. Code 201.14.(a) Responsibility of licensee28 Pa code 211.6 - Dietary Services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Medication Ordering and Receiving from Pharmacy read Medications and related products are received from the dispensing pharmacy on a timely basis. The policy continued, Timely delivery of new orders is required so that medication administration is not delayed. Review of Resident 2's clinical record revealed diagnoses that included asthma (a chronic, long-term lung disease that causes inflammation and narrowing of the airways, making breathing difficult) and chronic pain due to trauma (a complex condition where the nervous system becomes sensitized, often causing pain to persist long after injuries heal). Review of Resident 2's census information revealed an admission date to the facility of March 17, 2026. Review of Resident 2's physician's orders revealed the following orders dated March 17, 2026:1. Advair HFA Inhalation Aerosol 230-21 MCG/ACT (Fluticasone-Salmeterol) 2 puff inhale orally every morning and at bedtime for asthma.2. Pregabalin capsule 100 MG Tab [also known as Lyrica] take 1 capsule by mouth 3 times daily for pain.3. Celecoxib [also known as Celebrex] give 200 MG by mouth 2 times a day for arthritis.4. Amphetamine Dextroamphetamine [also known as Adderall] 30 mg: Give one tablet every morning and at bedtime for ADHD. A review of Resident 2's interdisciplinary progress notes revealed that documentation on those medications was marked not available on March 17, 2026. An interview with the Director of Nursing on March 31, 2026, confirmed the medications documented as not available had not been received by the facility's contracted pharmacy in order to administer to Resident 2 as ordered by the physician. 28 Pa. Code 211.9 (a) (1) (d) Pharmacy services28 Pa. Code 211.12 (d) (1) (5) Nursing services

Based on review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, review of residents' clinical records, as well as staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that CPR was provided in accordance with physician's orders and the resident's CPR declaration resulting in death for one of eight residents reviewed (Resident 1). Findings Include: Review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, recently revised [DATE], reads If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. The policy continues Instruct a staff member to call 911 and also notify the Supervisor who will then call/direct the 'code.' Instruct a staff member to retrieve emergency equipment. Verify or instruct a staff member to verify .the code status of the individual. Initiate the basic life support (BLS) sequence of events. Cardiopulmonary Resuscitation (CPR) is defined as an emergency lifesaving procedure performed when the heart stops beating. Also, CPR incudes the manual application of chest compressions and ventilations to patients in cardiac arrest, done in an effort to maintain viability until advanced help arrives. The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. Review of Resident 1's clinical record revealed diagnoses including hypertensive heart disease with heart failure (heart disease that occurs due to high blood pressure) and ischemic cardiomyopathy (the heart's inability to pump blood properly due to damage to the heart muscle). Review of Resident 1's physician orders revealed CPR-Full Code status dated [DATE]. Full Code is defined if a person's heart stops beating and/or they stopped breathing , all resuscitation procedures will be provided to keep them alive. The process can include chest compressions, intubation and defibrillation and is referred to as CPR. Continued review of Resident 1's clinical record revealed a document titled Decision of Agent or Representative Regarding CPR Status of Incompetent Resident, dated [DATE]. Review of the document revealed an electronic signature dated [DATE], whereby Resident 1's Healthcare Agent marked the area reading I authorize [Resident 1] to have CPR. Review of Resident 1's interdisciplinary progress notes revealed documentation by the Licensed Practical Nurse (Employee 8), on [DATE], that reads At 0400 [ 4 o'clock AM] nursing assistant notified writer of pt [patient] not looking like himself. Writer assessed pt, upon assessment pt with a faint pulse and [NAME] stokes respirations [atypical pattern of breathing involving deep breathing followed by shallow breathing]. Nurse supervisor called and made aware of pt change in condition, code status of being a full code , and to report to the floor immediately. Pt still had pulse at the time of the RN [Registered Nurse Supervisor- Employee 1] arrival. RN supervisor took over assessment. Gave instructions to call MD [Medical Doctor] . Did not indicate CPR at that time. While on phone with MD [on call Certified Registered Nurse Practioner-CRNP] RN informed me pt had lost pulse. MD [CRNP] update of RN findings at the time. RN to assess of no apical pulse follow death process and facility policy. 0415 RN supervisor pronounced pt at 0415. Review of Employee 1's witness statement, dated [DATE] revealed When the LPN [Employee 8] relayed the message from the doctor I understood that to mean-no CPR. Review of Employee 8's witness statement, dated [DATE] continued to describe the incident As I was still on the phone [Employee 1] looked at her watch and said he's gone and pronounced him at 4:15 AM saying she doesn't feel a pulse anymore. Then I asked the on call doctor what should we do he is a full code. On call said there isn't much we can do. You can call the family and treat it like a normal death. Review of the witness statement provided to the Director of Nursing (DON), by the Certified Registered Nurse Practioner (CRNP), dated [DATE] revealed I was told that resident was dead with no pulse. I asked if recently sick at all. LPN stated no he was found to be dead, but earlier in the shift he was walking around wandering the unit and was restless at the beginning of the night. Staff placed him into a broda chair around 2 AM. I told the LPN have the RN assess him to make sure he had no apical pulse. If no apical pulse, proceed with the death and follow facility protocol. Interviews with the Nursing Home Administrator (NHA) and the DON, on [DATE] at 2:18 PM, revealed Employees 1 and 8 did not follow facility policy by neglecting to provide CPR to Resident 1 per physician order and Resident/Representative direction at the time of Resident 1's change in condition. The interviews also revealed Employees 1 and 8 did not call a code blue in order for additional facility personnel to respond for assistance, and also failed to contact 911 for advanced emergency services per facility policy. The interviews also revealed Employees 1 and 8 were educated and disciplined on [DATE] and Employee 1's employment with the facility has been terminated. Employee 8 has not returned to employment with the facility at the time of the survey and remains under suspended status. Prior to the onsite investigation, the facility failed to provide emergency cardiopulmonary resuscitation to Resident 1 with a full code status, which resulted in harm to the Resident. The NHA and DON were notified of the Immediate Jeopardy on [DATE], at 3:50 PM. An Immediate Plan of Correction was requested. The Immediate Plan of Correction was immediately provided by the NHA, which was accepted. Review of documents and actions provided by the facility and reviewed onsite to address the Immediate Jeopardy include: a facility wide sweep conducted by DON/designee for all residents' verification of accurate code status and orders on [DATE]. All licensed nursing staff were educated on the facility CPR policy by Assitant Director of Nursing /Staff development RN on [DATE]. Education will continue prior to start of each shift for licensed nursing staff as follows: DON/Designee will conduct code blue drills each shift x 1 week. 3x a week for 1 month and month x 3 months for the facility's Quality Assurance and Performance Improvement Committee to address any trends or patterns. The facility's education and audits were reviewed during the onsite survey. Licensed staff performing duties on each resident hall were interviewed during the onsite survey regarding the facility's CPR policy/procedure and demonstrated knowledge and understanding. The Immediate Jeopardy was lifted on [DATE] at 4:46 PM and the deficient practice was found to be past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(2)(3)(e)(1) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, review of facility provided documentation, resident interview and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan for each resident, and provide services to maintain the resident's highest practicable physical well-being, resulting in harm, for one of three residents reviewed (Resident 1). Findings Include: Review of the facility's job description for Nursing Assistants, most recently revised March 22, 2018, summarizes the position as follows: The person holding this position is delegated the responsibility of carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations .: Also, Meets total health needs of residents. And, Assists with the development and review of resident care plans. Review of the facility's Care Plan Kardex policy for Nursing Assistants, reads nursing assistants will have access to the resident's care plan through the use of the Kardex. Kardex categories include Safety-fall prevention equipment . any other device, equipment, intervention required by the resident to keep them safe. The policy also reads Transfers-method of transfer (lift, self, one or two person). Review of Resident 1's August 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Contractures are defined as permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff. Review of Resident 1's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated June 27, 2021, reveals under Section C- Cognitive Patterns the Brief Interview for Mental Status (BIMS) score documented as 15/15, which denotes intake cognition. Review of Resident 1's interdisciplinary plan of care revealed under the activities of daily living (ADLS- the tasks of every day living to include eating, dressing, getting in or out of a bed or chair, taking a bath or shower and using the toilet), Resident 1's transfer interventions include the use of a Hoyer Lift (Lift- an assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) and 2 assists. The care plan was created on March 26, 2019. Review of information dated August 11, 2021, submitted by the facility revealed On 8/10/21 at 3:39 PM, R1 [Resident 1] voiced complaints of pain in .right leg and leg being twisted during transfer on the previous shift. The information also revealed Resident 1's physician placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Continued review of the facility submitted information revealed the x-rays to show fractures of left and right lower extremities. The physician ordered splints to both lower extremities and a follow up office appointment. Based on information provided and staff interview the facility began an investigation into the injuries caused to Resident 1's lower right and left extremities. Review of the investigation revealed Resident 1's nursing assistant (NA 1) , on the prior evening shift, transferred R 1 [Resident 1] without getting assistance. Also, R1 [Resident 1] is non ambulatory (not able to walk) and a 2 assist hoyer transfer. Review of the facility's documentation titled Point of Care Audit Report reveals NA 1 documented providing ADL cares to Resident 1, on the evening of August 9, 2021, including hygiene and transfers. The investigation continued and revealed NA 1 was suspended during the investigation and identified as the perpetrator. Review of NA 1's written statement, dated August 11, 2021, reveals While doing care I hoyered resident in bed because she was insisting she wanted to be in bed. couldn't find any help so she was hoyered in bed by me. An interview with Resident 1, on August 16, 2021, at 9:16 AM revealed she recalled the incident with NA 1 and stated she [NA 1] didn't know what she was doing. Resident 1 demonstrated during the interview NA 1 lifting her under her arms. Resident 1 stated to NA 1 you're hurting me, get another person, please stop. Resident 1 stated NA 1 did not listen. Review of the facility's Education Counseling form, completed by the Director of Staff Development (RN 1), dated August 12, 2021, reads NA 1 transferred Resident [Resident 1] to bed with hoyer and alone. Resident [Resident 1] is a 2 transfer hoyer lift. Resident [Resident 1] stated she [NA 1] did not use lift properly. Also, Care Plan not utilized. An interview with RN 1, on August 16, 2021, at 10:51 AM revealed NA 1's statement of the incident/transfer was not found to be credible based on Resident 1's description of NA 1 transferring her with the use of her arms only. An additional interview with the Nursing Home Administrator, on August 16, 2021, at 11:00 AM confirmed NA 1's contract with the facility had been terminated and the facility substantiated the neglect investigation identifying NA 1 as the perpetrator of the injuries caused to the lower extremities of Resident 1 based on NA 1 not following the care plan specifically created for the care and services to be provided to Resident 1 in a safe and person-centered manner. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.10 (a)(c)(d) Resident care policies 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing services

Based on clinical record review, select policy review, facility provided documentation review, resident interview and staff interview, it was determined that the facility failed to ensure each resident the right to be free from neglect resulting in the physical harm of one of three residents reviewed. (Resident R1). Findings Include: Review of the facility's abuse policy, most recently revised November 2017, defines abuse as the infliction of injury, unreasonable confinement, intimidation or punishment, with resulting harm, pain or mental anguish or deprivation by a caretaker of goods and services that are necessary to attain or maintain physical, mental or psychosocial well-being. Neglect is specifically defined by the policy as Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's job description for Nursing Assistants, most recently revised March 22, 2018, summarizes the position as follows: The person holding this position is delegated the responsibility of carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations .: Also, Meets total health needs of residents. And, Assists with the development and review of resident care plans. Review of the facility's Care Plan Kardex policy for Nursing Assistants, most recently revised in February 5, 2012, reads nursing assistants will have access to the resident's care plan through the use of the Kardex. Kardex categories include Safety-fall prevention equipment . any other device, equipment, intervention required by the resident to keep them safe. The policy also reads Transfers-method of transfer (lift, self, one or two person). Review of Resident 1's August 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Contractures are defined as permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff. Review of Resident 1's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated June 27, 2021, reveals under Section C- Cognitive Patterns the Brief Interview for Mental Status (BIMS) score documented as 15/15, which denotes intake cognition. Review of Resident 1's interdisciplinary plan of care revealed under the activities of daily living (ADLS- the tasks of every day living to include eating, dressing, getting in or out of a bed or chair, taking a bath or shower and using the toilet), Resident 1's transfer interventions include the use of a Hoyer Lift (Lift- an assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) and 2 assists. The care plan was created on March 26, 2019. Review of information dated August 11, 2021, submitted by the facility reveals On 8/10/21 at 3:39 PM, R1 [Resident R1] voiced complaints of pain in .right leg and leg being twisted during transfer on the previous shift. The information also revealed Resident R1's physician placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Continued review of the facility submitted information reveals the x-rays to show fractures of left and right lower extremities. The physician ordered splints to both lower extremities and a follow up office appointment. Based on information provided and staff interview the facility began an investigation into the injuries caused to Resident 1's lower right and left extremities. Review of the investigation revealed Resident R1's nursing assistant (NA 1) , on the prior evening shift, transferred R R1 [Resident R1] without getting assistance. Also, R1 [Resident R1] is non ambulatory (not able to walk) and a 2 assist hoyer transfer. Review of the facility's documentation titled Point of Care Audit Report reveals NA 1 documented providing ADL care to Resident R1, on the evening of August 9, 2021, including hygiene and transfers. The investigation continued and revealed NA 1 was suspended during the investigation and identified as the perpetrator. Review of NA 1's written statement, dated August 11, 2021, reveals While doing care I hoyered resident in bed because she was insisting she wanted to be in bed. couldn't find any help so she was hoyered in bed by me. An interview with Resident R1, on August 16, 2021, at 9:16 AM revealed she recalled the incident with NA 1 and stated she didn't know what she was doing. Resident R1 demonstrated during the interview NA 1 lifting her under her arms. Resident R1 stated to NA 1 you're hurting me, get another person, please stop. Resident R1 stated NA 1 did not listen. Review of the facility's Education Counseling form, completed by the Director of Staff Development (RN 1), dated August 12, 2021, reads NA 1 transferred Resident [Resident R1] to bed with hoyer and alone. Resident [Resident R1] is a 2 transfer hoyer lift. Resident [Resident R1] stated she [NA 1] did not use lift properly. Also, Care Plan not utilized. An interview with RN 1, on August 16, 2021, at 10:51 AM revealed NA 1's statement of the incident/transfer was not found to be credible based on Resident R1's description of NA 1 transferring her with the use of her arms only. An additional interview with the Nursing Home Administrator, on August 16, 2021, at 11:00 AM confirmed NA 1's contract with the facility had been terminated and the facility substantiated the neglect investigation identifying NA 1 as the perpetrator of the injuries caused to the lower extremities of Resident R1 based on NA 1 not following the care plan specifically created for the care and services to be provided to Resident R1 in a safe and person-centered manner. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 201.29 (j) Resident rights 28 Pa. Code 211.10 (a) (c) (d) Resident care policies 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12 (c) (d) ( 1) ( 2) ( 5) Nursing services

Based on policy review, clinical record review and staff interview, it was determined that the facility failed to provide safety interventions that are necessary to avoid physical harm which resulted in a laceration to the forehead and lip after a fall for one of three residents reviewed (Resident 1) and failed to ensure that safety interventions were in place during transportation in a wheelchair for one of three sampled residents (Resident 2). Findings include: Review of the facility's current policy titled Managing Falls and Fall Risks with a revision date of January 2016, stated that the interdisciplinary team will identify and implement interventions to try to minimize serious consequences of falling. Review of the clinical record for Resident 1 revealed diagnoses that included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills) and hypertension (elevated blood pressure). Resident 1 had a fall from bed on October 10, 2020. New interventions after the fall included a concave air mattress. On March 1, 2021, at 9:30 AM Registered Nurse (RN) 1 entered Resident 1's room to administer medications and found the resident laying on the floor beside the bed. Upon assessment, Resident 1 was noted with a large circular hematoma (bruise) on the forehead with blood dripping from the center of the laceration (cut). Resident 1's left upper lip was also swollen and had a small abrasion above the lip. Further assessment revealed that Resident 1's blood pressure was 206/90 (normal 120/80). The physician was notified and new orders were received to send the resident to the emergency room for evaluation. Resident 1 returned to the facility on [DATE], at 4:20 PM. An assessment of the resident's forehead revealed a laceration and hematoma. The laceration measured 1 cm x 0.2 cm. New treatment orders were initiated to cleanse area with normal saline solution and cover with Band-Aid every day and as needed. Resident 1 also had a laceration above the lip and new orders were received for [MEDICATION(S)] (antibiotic) 300 mg four times a day for 5 days. Upon investigation into the fall, it was discovered that the resident's fall care plan included interventions for crash mats (cushioned floor mat) on both sides of the bed. The crash mats were not in place at the time of the fall. Nurse Aid (NA) 1 was taking care of Resident 1 at the time of the fall. NA 1 said in a statement on March 3, 2021, I left the residents head of the bed up. The floor mats were not in place. I knew they were supposed to be there. I did ask a nurse to get the floor mats, I cannot recall who I asked. NA 1 was given a written warning on March 3, 2021 for not ensuring the Kardex was followed. During an interview with the Nursing Home Administrator and the Director of Nursing on March 10, 2021, at 1:40 PM, they confirmed that the fall mats were not in place and should have been. Review of the clinical record for Resident 2 revealed diagnoses that included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills) and urinary tract infection. Resident 2 had an appointment outside of the facility on February 24, 2021. The facility staff transported the resident from the facility to the appointment. The resident's care plan stated that the resident uses leg rests on the wheelchair for transport to activities and to the dining room. When Resident 2 was transported to the appointment, the leg rests were not put on the wheelchair. When leg rests are not on a wheelchair, it requires the resident to lift their legs and hold their feet up while being pushed in the wheelchair, which is a safety hazard. The Nursing Home Administrator confirmed on March 12, 2021, at 3:48 PM that the leg rests were not put on Resident 2's wheelchair. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/8/21, 10/24/19, 2/5/19, 11/1/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/8/21, 11/1/18. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/24/19. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/8/21, 10/24/19, 4/10/19, 11/1/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/24/19, 11/1/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/8/21, 10/24/19, 8/9/19, 4/10/19, 11/1/18.

Based on review of the clinical record, facility incident reports, and staff interviews, it was determined that the facility failed to implement established interventions to prevent accidents for one of four residents reviewed (Resident 1) resulting in a fall with harm in the form of a hematoma, skin tear, and bruising to Resident 1. Findings include: Review of the facility policy titled, Abuse Identification most recently revised in (MONTH) (YEAR), describes neglect as Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's Nursing Service Manual revealed a policy statement reading, in part, nursing assistants will have access to a resident's care plan through the use of the Kardex. Kardex categories include the method of transfer of a resident and the level of assistance needed. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's Physical Therapy Discharge Summary, dated (MONTH) 18, 2019, revealed a recommendation that reads Patient is to be discharged from skilled PT (physical therapy) services on this date while waiting for new socket for L (left) prosthetic leg. He will require extensive assists x 2 for slide board transfers. Review of Resident 1's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated (MONTH) 28, 2019, revealed under functional status, that Resident 1 was coded as requiring extensive assistance with two plus persons, physical assist. Extensive assistance is described as resident involved activity; staff provide weight-bearing support. Transfers are described as how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Review of a facility provided report dated (MONTH) 5, 2019, at 07:35 AM revealed the following staff description of an incident: Res (Resident) found on L (left) side between A & B bed. Res found face down onto floor laying on R (right) shoulder with RA (right arm) behind res. LA (left arm) in front of him palm down on floor, face turned to R (right) and facing window. The report described Resident 1, fell while being transferred. Further review of the report revealed a witness statement submitted by Nurse Aide (NA) 1 that reads, I was transferring (resident) with the slide board to get him up for the day, when he fell forward out of his chair and on to the floor hitting his head. Additional review of the report reveals NA 1 was attempting to transfer Resident 1 from his bed to his wheelchair and NA 1 did not follow Resident 1's care plan. Review of Resident 1's interdisciplinary progress notes, dated (MONTH) 4, 2019, at 1:35 PM revealed a health status that read, hematoma 4x4 cm R forehead/temple area ice applied. Skin tear R (right) hand 1x1 cm . bruise R (right) hand 2x2. An interview with the Director of Nursing (DON), on (MONTH) 1, 2019, at 12:32 PM confirmed NA 1 did not follow Resident 1's plan of care resulting in a fall with injuries. The facility failed to implement established interventions to prevent accidents for one of four residents reviewed (Resident 1) resulting in a fall with harm in the form of a hematoma, skin tear, and bruising to Resident 1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 11/3/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 2/5/19, 11/1/18, 2/1/18, 11/3/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/1/18, 2/1/18, 11/3/17. 28 Pa. Code 201.18(b)(3)(e)(1) Management. Previously cited 2/1/18, 11/3/17. 28 Pa. Code 201.29(a) Resident rights. Previously cited 11/3/17. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 11/1/18, 11/3/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/10/19, 11/1/18, 11/3/17. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 11/3/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/1/18, 11/3/17.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the highest practicable well-being for residents regarding timely assessments for one out of five residents reviewed (Resident 1). Findings include: Review of the clinical record revealed that Resident 1 had [DIAGNOSES REDACTED]. A review of Comment/Concern form (a form that a resident or family use to address issues related to the resident) dated October 7, 2015, revealed that Resident 1's husband had visited her on October 4, 2015, and expressed his concern to staff that Resident 1 was hallucinating and had a strong smell. The concern form states that the staff told him, she would be fine and that the resident had the odor for several days. The husband expressed his concern to his daughter via a phone call later that day. She subsequently called the facility and requested that a supervisor evaluate the resident immediately. Review of Problem or Issue to be Addressed Form (a form used to inform the physician of a concern with the resident) dated October 4, 2015 at 2:00 p.m., and completed by LPN 1 (Licensed Practical Nurse), stated that the, resident exhibiting mental status change, Afebrile (without a fever), visual hallucinations, complaining of pain not relieved by prn (as needed) Oxy (a slang expression for [MEDICATION NAME], a pain relieving medication). Family states that previously the resident had these symptoms associated with a Urinary Track Infection. In an interview with LPN 1 on November 4, 2015 at approximately 1:00 p.m., she stated that she had made a note to the doctor as described above. She indicated that as she thought the resident's behavior was not that different, but did note that her pain was not relieved by the medications given. There was no documented evidence of vital signs (measurements reflecting essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) having been taken or an assessment being done at the time that she completed the Problem or Issue to be Addressed Form. Review of a progress note dated October 4, 2015 at 8:19 p.m., revealed that RN 1 (Registered Nurse) was called because of the resident's change in mental status. Vital signs were taken and the resident was noted to have odiferous (yielding an odor) urine and discharge and she complained of pain not relieved by pain meds. The physician was called and gave an order, dated October 4, 2015 at 8:10 p.m., to send the resident to the hospital. During an interview with RN 1 on November 4, 2015 at 11:30 a.m., she stated that she had received a call from the resident's daughter on October 4, 2015. The daughter requested that the resident be evaluated. RN 1 assessed the resident at 8:00 p.m., and placed the call to the physician for the order to send her to the hospital. The Problem or Issue to be Addressed Form described above, also indicated that on October 4, 2015 at 8:10 p.m., a verbal telephone order was given to send the resident to the hospital for evaluation and treatment, over 6 hours after the resident was noted to be exhibiting mental status changes as documented by LPN 1 on the Problem or Issue to be Addressed Form. RN 1 stated that this portion of the form (the section pertaining to the verbal telephone order) was completed by her. Review of the hospital records revealed that Resident 1 was admitted to the Intensive Care Unit (care provided for life threatening conditions) in septic shock (an extreme immune system response to an infection that has spread throughout the blood and tissues) secondary to the UTI. The discharge [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (a potentially life-threatening complication of an infection) and septic shock due to Escherichia coli (a type of bacteria commonly found in the gastrointestinal (GI) tract). An interview with the Director of Nursing on November 4, 2015 at approximately 1:30 p.m., confirmed that there was no evidence that the resident was assessed prior to RN 1's assessment on October 4, 2015 at 8:00 p.m. 42 CRF 483.25 Provide Care/Services for Highest Well Being. Previously cited 10/1/15, 4/9/15, 10/29/14, 11/22/13. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 10/29/14, 11/22/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/1/15, 9/2/15, 4/9/15, 10/29/14, 6/2/14, 11/22/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/1/15, 9/2/15, 6/19/15, 4/9/15, 10/29/14, 6/2/14, 11/22/13.

Based on a review of clinical records and staff interviews, it was revealed that the facility failed to ensure that the residents remained free of significant medication errors resulting in hospitalization for one of 7 residents reviewed (Resident 4). Findings include: A review of clinical records revealed that Resident 4 had multiple [DIAGNOSES REDACTED]. A review of facility documentation dated November 4, 2015 at approximately 9:45 a.m., revealed that Resident 4 was given another resident's medication on that date by RN 2 (Registered Nurse). The medications included the following: [MEDICATION NAME]/olmesrtan (used to treat high blood pressure) 10/320 milligrams (mgs.), [MEDICATION NAME] (a B vitamin) 5 mgs., [MEDICATION NAME] (an allergy medication) 10 mgs., [MEDICATION NAME] (a blood thinner) 75 mgs., Invokana (used to treat diabetes) 100 mgs., [MEDICATION NAME] (used for diabetes) 60 units, [MEDICATION NAME]/HCTZ/ [MEDICATION NAME] (used to treat high blood pressure and a diuretic) 37.5/25 mgs. (2 tablets), [MEDICATION NAME] (a heart medication) 6/25 mgs., [MEDICATION NAME] (a muscle relaxer) 10 mgs., [MEDICATION NAME] (used for [MEDICAL CONDITION] and pain cased by damage or disease to the nervous system) 300 mgs., and [MEDICATION NAME] (used to treat diabetes) 8 mgs. Following the administration of the above medications on November 4, 2015, Resident 4 was subsequently transferred to the hospital via 911 call made at 10:45 a.m., and admitted with [DIAGNOSES REDACTED]. Review of the facility policy titled, Administering Medications reviewed by the facility on May 15, 2015, indicated that the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Upon investigation by the facility, it was determined RN 2 had administered the medication without following the facility's policy and procedure for identifying the resident, prior to the administration of the medications. During an interview with the Director of Nursing on November 4, 2015 at 3:30 p.m., she confirmed the occurrence of the medication error. Refer F281 28 Pa. Code 211.12(a) Nursing services. Previously cited 10/1/15. 28 Pa. Code 211.12(c) Nursing services. Previously cited 6/2/14, 11/22/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/1/15, 9/2/15, 4/19/15, 10/29/14, 6/2/14, 11/22/13. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/1/15, 9/2/15, 6/19/15, 4/9/15, 10/29/14, 11/22/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/1/15, 9/2/15, 6/19/15, 4/9/15, 10/29/14, 6/2/14, 11/22/13.

Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional nurse (Registered Nurse) accurately dispensed and documented administration of medications in accordance with accepted professional standards for two of seven residents reviewed (Residents 4 and 5) one of whom experienced a change in condition. Findings include: Review of the Pennsylvania Nurse Practice Act for Registered Nurses §21.18, Standards of nursing conduct, revealed in section (a)(5), A registered nurse shall: Document and maintain accurate records. Also, section (b)(8) states, A registered nurse may not: Falsify or knowingly make incorrect entries into the patient's record or other related documents. A review of clinical records revealed that Resident 4 had multiple [DIAGNOSES REDACTED]. A review of the facility documentation dated November 4, 2015 at approximately 9:45 a.m., revealed that Resident 4 was given another resident's medication on that date by RN 2 (Registered Nurse). The medications included the following: [MEDICATION NAME]/olmesrtan (used to treat high blood pressure) 10/320 milligrams (mgs.), [MEDICATION NAME] (a B vitamin) 5 mgs., [MEDICATION NAME] (an allergy medication) 10 mgs., [MEDICATION NAME] (a blood thinner) 75 mgs., Invokana (used to treat diabetes) 100 mgs., [MEDICATION NAME] (used for diabetes) 60 units, [MEDICATION NAME]/HCTZ/ [MEDICATION NAME] (used to treat high blood pressure and a diuretic) 37.5/25 mgs. (2 tablets), [MEDICATION NAME] (a heart medication) 6/25 mgs., [MEDICATION NAME] (a muscle relaxer) 10 mgs., [MEDICATION NAME] (used for [MEDICAL CONDITION] and pain cased by damage or disease to the nervous system) 300 mgs., and [MEDICATION NAME] (used to treat diabetes) 8 mgs. Following the administration of the above medications on November 4, 2015, Resident 4 was subsequently transferred to the hospital at 10:45 a.m., and admitted with a [DIAGNOSES REDACTED]. Upon investigation by the facility, it was determined that RN 2 had administered the medication without identifying the resident, prior to the administration of the medications. RN 2 had not followed the facility's policy and procedure titled, Administering Medications reviewed by the facility on May 15, 2015, which indicated that the individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of Resident 5's quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated October 28, 2015, revealed that she is alert and oriented. On November 9, 2015 at 2:00 p.m., in an interview with Resident 5, she stated that she did not receive her medications on November 4, 2015, and had slept most of the day until she was awakened by a staff person late in the afternoon. A review of Resident 5's Medication Administration Record [REDACTED]. During an interview with the Director of Nursing on November 9, 2015 at 3:30 p.m., she confirmed that the medications were administered to the wrong resident (Resident 4) but had been documented as having been given to the correct resident (Resident 5). 42 CRF 483.20(k)(3)(i) Services Provided to Meet Professional Standards. Previously cited 10/29/14, 6/2/14, 11/22/13. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/9/15, 11/22/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 10/1/15, 9/2/15, 4/9/15, 10/29/14, 6/2/14, 11/22/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/1/15, 9/2/15, 6/19/15, 4/9/15, 10/29/14. 6/2/14, 11/22/13.

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide care and services to one of 30 residents reviewed in regards to pain management (Resident 4), and in regards to notifying physician of holding a medication for two of 30 residents reviewed (Resident 4 and Resident 12). Findings include: Review of Resident 4's clinical record on September 28, 2015, at approximately 4:25 p.m., revealed [DIAGNOSES REDACTED]. Review of Resident 4's medication regimen revealed an order dated April 30th, 2015, last reviewed by the attending physician on September 30, 2015, for [MEDICATION NAME] extended release 50 mg every 24 hours for cardiovascular disease. Review of Resident 4's Medication Administration Record [REDACTED]. Review of nursing progress notes and clinical record revealed no note regarding the medication being held. During staff interview on September 30, 2015, at approximately 2:15 p.m., Director of Nursing revealed that the medication was held by the nurse due to Resident 4's heart rate being below 60 beats per minute. During staff interview on October 1, 2015 at approximately 11:00 a.m., Director of Nursing provided a physician's orders [REDACTED]. During staff interview Director of Nursing revealed that it is the facility's expectation that nursing staff alert the attending physician if a medication is not administered without a physicians order to do so. Review of Resident 4's medication regimen revealed an order, dated February 26, 2015, last reviewed by the attending physician on September 30, 2015, for [MEDICATION NAME] 650 mg twice a day for pain. Review of would care specialist evaluation dated September 15, 2015, revealed Resident 4 had a diabetic ulcer of the left lateral ankle. Review of Wound Care Specialist Evaluation, dated September 8, 2015, completed by Wound Specialist Physician 1, revealed that under section titled, Assessment and Plan, subsection titled, Pain Addressed stated, Oral [MEDICATION NAME] and 2% [MEDICATION NAME] gel, moist gauze packing to wound 30 minutes prior to wound physician visit. Review of wound progress note dated, September 15, 2015 revealed that the aforementioned section stated, Give [MEDICATION NAME] 30 minutes prior to wound dressing. Review of wound progress note, dated September 22, 2015, revealed the aforementioned section stated, Give [MEDICATION NAME] 30 minutes prior to wound dressing. During observation of wound care on September 29, 2015, Wound Specialist Physician 1 was observed applying topical [MEDICATION NAME] (local [MEDICATION NAME] for pain control). After application of the local [MEDICATION NAME], Wound Specialist Physician 1 a surgical excisional debridement of the muscle (using a scalpel to remove tissue) on the left lateral ankle wound. During the excisional debridement, Resident 4 was observed to exibit signs of pain (facial grimacing, and physical movement) and verbalized pain. After the procedure Resident 4 requested something stronger for the pain Resident 4 experiences during wound care. Wound Specialist Physician 1 questioned Resident 4 regarding current pain management. Resident 4 reported that she received [MEDICATION NAME] in the morning. Wound Specialist Physician 1 agreed to prescribing a stronger [MEDICATION NAME] for pain. At which time Registered Nurse 1 stated that she would assist the physician in securing an order for [REDACTED].>Review of Resident 4's clinical record on September 30, 2015, at approximately 11:00 revealed no new order for oral [MEDICATION NAME]. During staff interview on October 1, 2015 at approximately 1:10 p.m., Director of Nursing provided documentation that Resident 4 received oral [MEDICATION NAME] approximately 30 minutes prior to the wound procedure. During staff interview, Director of Nursing revealed there should have been an order for [REDACTED].>Review of Resident 12's clinical record revealed [DIAGNOSES REDACTED]. During an observation of a dressing change to Resident 12 on September 29, 2015 at 8:30 a.m., revealed the Wound Specialist Physician 1 a removed the old dressing and packing and RN 1 proceeded to pack the wound. Review of Resident 12's physician orders [REDACTED]. Interview with the Nursing Home Administrator and the Director of Nursing on October 1, 2015, at 11:00 a.m., confirmed the expectation the physician order [REDACTED]. 42 CFR 483.40(a) (1)(2) Quality of care 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, observation, and staff interview it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 2 of 34 residents reviewed (Residents 13 and 22). Findings include: Review of Resident 13's clinical record on October 26, 2014 at approximately 11:30 a.m., revealed a history of right [MEDICAL CONDITION] with surgical right hip replacement. Review of facility documentation revealed Resident 13 was to be transferred, at all times, via two person assist and a full body lift (Hoyer lift). Review of a statement written by Nursing Assistant 3 (NA 3), it was revealed that on September 9, 2014, NA 3 used a single-person standing lift with knowledge that a Hoyer lift should be used to transfer Resident 13. Following the transfer, Resident 13 complained of pain on multiple occasions and was treated with as-needed pain medication. Review of Nursing Progress Note dated September 10, 2014 revealed Resident 13 was unable to move the right knee and was experiencing right hip and thigh pain. An order was received to obtain an X-ray of the right leg which showed a [MEDICAL CONDITION] femur (long bone in the thigh). Resident 13 was subsequently sent to an emergency department for evaluation and treatment. During staff interview on October 28, 2014 at approximately 9:35 a.m., Nursing Home Administrator (NHA) acknowledged NA 3 used improper technique to transfer Resident 13 which resulted in a [MEDICAL CONDITION]. NHA revealed NA 3 should have followed the care plan which indicated Resident 13 should only be transferred using the Hoyer lift and two personnel. Review of Resident 22's clinical record on October 28, 2014, at approximately 1:30 p.m., revealed a [DIAGNOSES REDACTED]. Review of Resident 22's care plan revealed interventions for skin breakdown created and initiated on October 14, 2014; interventions included for Resident 22 to have a wedge (pillow) for positioning). During observation on October 29, 2014, at approximately 10:15 a.m., Resident 22 was observed in bed with eyes closed. The wedge pillow was observed setting on the bedside table. During a staff interview on October 29, 2014 at approximately 10:30 a.m., Nursing Assistant 5 (NA 5) it was revealed that an aide from hospice services was visiting earlier that morning and perhaps she had not replaced the wedge pillow. Review of a visit log revealed the hospice aide left Resident 22 at 9:15 a.m. on October 29, 2014. During staff interview on October 29, 2014 at approximately 11:50 a.m., NHA revealed the facility expectation was that the wedge pillow should have been in place, consistent with the plan of care. Pa Code: 211.12 (d)(1) Nursing Services

Based on observation, clinical record review, staff and resident interview and review of select facility policies, it was determined that the facility failed to ensure an environment free from accident hazards on one of nine nursing units (A Wing) and for four of 30 residents reviewed (Residents 148, 118, 125, 192). The facility also failed to implement interventions to prevent falls for one of 30 residents sampled (Resident 7). Findings include: The facility does not have a policy indicating that they maintain an environment free from accident hazards. During a group interview on November 20, 2013, at 10:30 AM nine residents voiced concern that the dietary department serves their foods and fluids on and in broken and chipped plates and mugs. Observation of the dietary department on November 20, 2013, 12:30 PM revealed that staff stored a broken, chipped glass plate under the steam table, ready and available with other dishes for use with resident meals. Interview with Employee 9, assistant cook, on the above noted date and time confirmed the finding. Observation of resident trays on A Wing (dementia unit), on November 21, 2013, at 12:00 PM revealed that dietary staff delivered resident trays to the unit on glass plates which they placed on a hot pellet (metal pellet made hot in an electric heating unit to keep plates warm) with only a thermal lid on top of the plate. Staff did not place the hot pellet inside a bottom thermal lid to prevent a resident or staff member from burning themselves from the hot exposed metal. Once nursing staff served residents their meals, staff stored the hot pellet on top of the food delivery cart, making it possible for confused residents to touch the pellets. Interview with Employee 8, regional food service director, on the above noted date and time confirmed this finding and could not provide documented evidence that dietary staff provide the bottom pellet to ensure resident and staff safety. Interview with Employee 10, licensed practical nurse, who was passing trays to residents on A Wing revealed that dietary staff never places the hot pellets in a bottom thermal and that the hot pellet is always exposed. Employee 10 confirmed that dietary staff does not provide nursing staff with oven mitts to protect themselves during meal distribution. The facility policy entitled, "Accident/Incident Reporting and Investigation," last reviewed August 2013, revealed that staff is to complete an Incident and Investigation Report form for all unexplained bruises or abrasions, all accidents or incidents resulting in injury or the potential for injury, and allegations of theft and/or abuse. Licensed staff is responsible to initiate and complete the Incident and Investigation Report form. Staff must complete a form for each resident involved in an incident and notify the resident's physician and family. An investigation is initiated within 24 hours of the discovery of a resident injury of suspicious or unknown origin or the allegation of abuse. The Accident/Incident Reporting and Investigation policy defines the following: An incident is any happening, which does not result in bodily injury or property damage. An accident is any happening that results in bodily injury other than abuse. Physical or mental mistreatment (abuse, actual or suspected) is considered an incident whether or not an actual injury occurred. Resident 192's nursing documentation dated September 8, 2013, at 10:15 PM revealed that at 7:30 PM staff called a registered nurse supervisor to F Wing West because Resident 192 was physically and verbally aggressive with staff, and requested to go home. Staff pushed Resident 192's wheelchair into her room, where she became verbally aggressive towards her roommate, with attempts to reach the roommate. Staff redirected Resident 192 from her roommate. Resident 192 began hitting, grabbing, and scratching staff. Staff moved Resident 192 into the hallway. While being pushed in her wheelchair, Resident 192 put her feet down, causing her to slide face first to the floor. Staff rolled her onto her back and noted a laceration above and below her right eye. Resident 192 was complaining of head and neck pain, though she continued to be physically aggressive to staff. Staff called 911 and Resident 192 was transferred to a local hospital. Nursing documentation on September 8, 2013, at 10:47 PM revealed that Resident 192 was admitted to the local hospital with fractures of the C1 and C2 cervical (neck) vertebrae. Review of Resident 192's Investigation Report dated September 8, 2013, confirmed that staff was with her at the time of the incident. The facility could not provide staff witness statements regarding this incident. Interview on November 22, 2013, at 7:55 AM with the Nursing Home Administrator, Employee 1, Assistant Nursing Home Administrator, and the Director of Nursing revealed that Employee 1 is the facility's incident/abuse coordinator. Employee 1 revealed that she investigates all incidents/abuse concerns and reports them to the appropriate agencies accordingly. Review of Resident 7's clinical record revealed that the facility admitted her on February 1, 2013. Documentation dated February 11, 2013, indicated that the facility assessed Resident 7 as being at significant risk of falls. An MDS (Minimum Data Set Assessment, an assessment tool completed at specific intervals to determine care needs) dated February 8, 2013, indicated that the facility assessed her as needing extensive assistance of two caregivers for toileting and transferring. Resident 7's Activities of Daily Living care plan dated February 18, 2013, indicated that Resident 7 needs one staff member to participate in toilet use. Documentation dated March 7, 2013, at 8:15 PM revealed that nursing staff found Resident 7 on the floor in her room. The facility indicated that they were going to place Resident 7 on a one to two hour toileting program. There was no evidence in Resident 7's clinical record to indicate that the facility assessed and/or monitored a toileting program for Resident 7 to determine effectiveness. Documentation dated March 15, 2013, at 6:15 PM revealed that nursing staff found Resident 7 on the floor in front of her bed. Again, the facility indicated that they would place Resident 7 on a one to two hour toileting program. There was no evidence in Resident 7's clinical record to indicate that the facility completed this. Documentation dated March 22, 2013, at 6:58 AM revealed that nursing staff found Resident 7 sitting on the floor in her room. The facility indicated that they were going to move Resident 7's room closer to the nurse's station. There was no evidence that the facility moved Resident 7's room because she remained in the same room throughout her stay. Documentation dated April 2, 2013, at 6:30 AM revealed that nursing staff found Resident 7 on the floor near her bedside commode. Review of the abuse/neglect allegation incident report dated April 2, 2013, indicated that one nurse aide transferred her to the bedside commode. The nurse aide left Resident 7 unattended on the bedside commode, and Resident 7 fell . Resident 7 sustained two fractures in her right arm and a fractured pelvis. Documentation provided by the facility dated April 5, 2013, indicated that it is facility practice to never leave a resident unattended when a resident is determined to be at "high risk for falls." Clinical record review for Resident 148 revealed communication to her physician dated October 6, 2013, reporting that staff found Resident 148 on the floor in her room. Resident 148 sustained a laceration above her left eye with a, "brush burn (abrasion)." Interview with the Director of Nursing and the Nursing Home Administrator on November 20, 2013, at 2:00 PM revealed that the facility was unable to provide an investigation regarding Resident 148's fall on October 6, 2013, during the onsite visit. Clinical record review for Resident 118 revealed nursing documentation dated October 19, 2013, at 1:15 AM indicating that at 10:50 PM staff arrived in Resident 118's room to find him lying on his right side on the floor. Staff noted multiple bruises on the right side of his body. Nursing documentation dated October 19, 2013, at 8:33 AM described the bruising as 3.9 cm (centimeters) by 3 cm purple bruise on his right lateral upper thigh and 4.9 cm by 3.4 cm bruise on his right upper arm. Resident 118's plan of care developed to address his high risk for falls listed bed and chair listed that alarms were initiated on September 29, 2013, to alert staff of attempts at unassisted transfers. Review of the facility's investigation of Resident 118's fall included a staff witness statement that she heard the resident talking loudly to himself, entered his room, and observed him on the floor. The investigation failed to obtain staff witness statements that indicated whether the bed alarm functioned at the time of the fall. Interview with Employee 1 and the Director of Nursing on November 21, 2013, at 2:00 PM confirmed that the facility's investigation did not include confirmation that the fall prevention intervention of the bed alarm was functioning at the time of Resident 118's fall. Clinical record review for Resident 125 revealed communication to her physician dated August 13, 2013, reporting her increased agitation, biting staff, and hitting. The facility admitted Resident 125 on June 21, 2013, with a [DIAGNOSES REDACTED]. Review of Resident 125's plans of care and target behavior tracking did not include Resident 125's potential for physical aggression complicated by her history of hallucinations. Interview with Employee 1 and the Director of Nursing on November 21, 2013, at 2:00 PM confirmed that Resident 125 did injure staff during the August 13, 2013, episode. The facility was unable to provide an incident investigation regarding Resident 125's assault on staff. 483.25(h) Accidents. Previously cited 4/29/13 28 Pa. Code 211.6(f) Dietary services. Previously cited 11/30/12 28 Pa. Code 211.10 (c) Resident care policies. Previously cited 11/30/12. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 11/30/12 and 11/12/13 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/30/12, 4/29/13, and 11/12/13