Armstrong Rehabilitation And Nursing Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings Include: Review of the facility policy Missing Resident / Elopement Procedures dated 8/8/25, defined elopement: Occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. This can include locations within the building. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses of bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and moyamoya disease (progressive cerebrovascular disorder where the internal carotid arteries narrow, reducing blood flow to the brain and causing strokes, TIAs (mini-strokes), or hemorrhage). Review of Section C: Cognitive Patterns revealed Resident R1 had moderate cognitive impairment. Review of Resident R1's Elopement Risk Assessments completed revealed:9/8/25: Not an elopement risk.10/17/25: Elopement Risk12/27/25: Not an elopement risk. Review of the physician's orders indicated Resident R1 was ordered an electronic monitoring bracelet (electronic bracelet usually worn either on the resident or on their wheelchair that alarms when near doorways connected to the monitoring system) on 2/10/25; and remained a current order. Review of Resident R1's plan of care for Resident exhibits behavior symptoms such as wandering, suicidal ideations initiated 10/22/25, revised on 11/3/25, with the goal of The resident's safety will be maintained and included interventions of:-Check placement of Wanderguard (electronic monitoring bracelet).-Distract resident from wandering by offering pleasant diversions.-Provide a Wanderguard. Review of a progress note dated 3/19/26, 3:45 p.m. At 1545 (3:45 p.m.) writer was informed by activities aide that the resident could not be found post cooking club activity. @1547 (3:47 p.m.) code white was called as resident was not found in any of the nearby rooms or restrooms. After code white was called all employees responded appropriately and were actively searching for resident. @1553 (3:53 p.m.) resident was found outside, in a nearby alley, safely on the berm as to avoid traffic, attempting to go to [NAME] (local convenience store), as she does when she goes on LOAs (leaves of absence) w/ her family. Resident was safely escorted back to facility and up to the third floor where her nurse proceeded to check her vitals and do a head-to-toe assessment assisted by CNA (nurse aide). The LPN (licensed practical nurse) & aide reported directly to writer afterwards, as writer was on the phone w/ [nurse practitioner]., and together we informed NP that vital signs are stable, and no skin alterations or injuries were found. Resident was in no distress, had no complaints of pain, but was tearful as she stated, she was not trying to cause any trouble. Additionally stated in this progress note was resident was dressed appropriately. No new orders were given from NP (nurse practitioner). Writer then called residents RP (responsible party), her mother, to inform her of the incident, there was no answer. Writer then called a second time, still with no answer, and left a message for [Resident R1's mother] to please return call as soon as possible but did inform that the resident was safe. All clear was called @ 1614 (4:14 p.m.). Review of a progress note dated 3/19/26, at 4:20 p.m. indicated, @1600 (4:00 p.m.) resident was escorted back to 3rd floor, able to self-propel in wheelchair to her room, and asked if we could do a head-to-toe assessment as well as vital signs. The resident agreed and the CNA helped writer w/ assessment. Wanderguard noted to be in place on L wrist, and the alarm did sound when resident returned to 3rd floor. Resident alert & oriented x3 w/ no obvious injuries noted. Resident w/ no c/o pain or discomfort but is tearful and feels as though she is in trouble. Writer reassured resident that we are simply happy she is safe, educated resident on the risks of leaving the floor/facility, to which she verbalized understanding. Resident has not had exit seeking behavior this week prior to elopement this evening. Review of an undated employee statement written by Activities Aide Employee E1 indicated, On March 19th I was transporting residents from the 1st floor to 2nd and 3rd. As I was getting them from the dining room to the elevator [Resident R1] had left the 1st floor from sitting at the elevator waiting to go back to her room on 3rd floor. Review of a second undated statement written by Activities Aide Employee E1 indicated, On Thursday March 19th I was taking residents on the elevator back upstairs after an activity. The elevator only holds four people at a time. I had to leave some residents. I dropped the residents off on the third floor. Came back to the first and [Resident R1] was not there, just the other residents. I went to other staff to get help finding her and they found her at [NAME]. She had taken the outdoor elevator. Review of an employee statement dated 3/19/26, Environmental Services (EVS) Employee E2 stated, At approximately 3:30 pm on 3-19-2026 l, [EVS Employee E2], was on the first floor and saw [Resident R1] and another resident but I can't recall whom sitting by the A side elevator, waiting to be taken up from the activity. I walked through the green hallway to retrieve something and came back to the A side to find [Resident R1] gone and assumed she had been taken back to her floor. About 5 minutes later the activities aide, [Employee E1] came back to the elevator asking if I had seen [Resident R1] and instantly we both realize she has managed to make for an exit. I went to the basement first to alert other people to be on the lookout and then ran out of C-side side door to the outside and headed toward family counseling. I then turn right down the alley to go around the building, swing wide into our parking lot to see if I see her and that's when I run into the Dietary supervisor [Employee E3], and the transport coordinator [Employee E4], and I tell them I saw three gentleman around an suv and because I'm a suspicious person, I was worried they loaded her and were blocking her from view. So the three of us head over and politely ask if they'd seen her, per [Employee E4's] less suspicious mind and bless 'em they had seen her and pointed down [NAME]. The three of us begin to sprint because we don't see her in sight still. Halfway down [NAME], in the alley to [NAME], we see [Resident R1], we call out to her and she stops moving. We caught up to her and brought her back to the facility. Review of an employee statement (incorrectly dated 8/19/25), NA Employee E3 stated, I was coming out of the bathroom when the LPN notified me that [Resident R1] was missing. I notified the other aide on the floor and I went to the first floor. I then went outside. When [LPN Employee E4] and I meet we went opposite ways outside. I ask the dietary people if they seen [Resident R1] they said no. Both [LPN Employee E4] and I didn't see her outside. I went to the fourth floor next. I was alerted she was found. When she came back up I helped the LPN Employee E4 with the body check. Review of an employee statement dated 3/19/26, LPN Employee E4 indicated, I was informed by Activities that they could not locate [Resident R1]. I immediately notified my aides and went to notify RN (Registered Nurse) Supervisor. [Employee E3] and I both went outside to look for her and searched inside the building. [Employees E5 and E6] found her. Upon her return all vitals found to be stable and body check was clear. Review of an employee statement dated 3/19/26, Transportation Employee E5 indicated, Announcement went out over intercom stating code white. I went to go look for resident with staff, went outside searching, and asked fellow bystanders if they saw a woman in a wheelchair. They said yes and pointed in the direction she went. Staff and I went in that direction and found her in the alley way beside [NAME]. Staff and I safety returned her to the facility. When she returned to facility we took her to supervisor on duty, and the supervisor stated to take her to her floor. Staff and I returned her to her floor and told her nurse she was back. Review of an employee statement dated 3/19/26, Dietary Manager Employee E6 indicated, I saw Activities taking residents to the elevator. I asked if they needed help, they said yes. took [Resident R6, R7, R8, and R9] to the line outside the elevator. [Resident R9] was the last resident after I took her to the line I went to HR's office. I heard Code [NAME] over the intercom. Went to the Kitchen to instruct my employees to search and watch the basement. When I found out it was [Resident R1] missing, I went outside to search. [Employee E5] from transports and [Employee E2] from housekeeping joined me and ran down the alley saw three men in the parking lot asked them, did you see a woman in a wheelchair with dirty blond hair? They said yes, she went that way pointing down toward Water St. So, we ran down the road looking down at the alleys and saw her in the alley behind [NAME]. Ran up to her and asked where she was going. She said [NAME]. Pushed [Resident R1] back to the building and took her to 3bc nursing station for the LPN to evaluate. Review of an employee statement dated 3/19/26, Activities Aide Employee E7 indicated, Activity concluded approx. 3:00 p.m. [Employee E1] began transporting 2nd floor residents to elevator. I stayed in dining room. Once 2nd floor residents were returned, we began 3rd floor resident transporting. I would take residents down C hall where [Employee E1] would meet. [Employee E1] would take up the elevator. Manager [Employee E6] in hallway, I asked if she could help. She pushed a few residents to [Employee E1], when she returned, I'd take someone over. The final two residents [Resident R8 and R10] are unable to propel self, were by the elevator. [Employee E1] came over and asked if I took [Resident R1] up, which I did not on my turn. I pushed other residents on elevator with [Employee E1] and asked her to let me know. I proceeded to double check dining room and restroom. After approx. 15 minutes I did not hear form [Employee E1] or 3rd floor or a code page, I misguidedly assumed all was OK, and left for the day. Shortly after, [Employee E1] called to tell me a code was called and [Resident R1] was found outside. Review of information submitted to the Pennsylvania Department of Health state agency on 3/19/26, indicated, Resident admitted from a personal care home. At time of admission, resident did have a positive elopement risk screening, indicating that she desires to leave the facility. At this time, resident was ordered a Wander guard which remains on her person. She resides on the third floor of the facility. Resident does have a standing Leave of Absence order and does leave the facility on outings frequently with her family. There is no evidence that she has attempted to leave the facility unattended since admission. Resident is alert and oriented with a BIMS of 15. She is aware of her surroundings and environment. While waiting to return to her home unit after group activity, resident left the elevator area and went to the elevator that leads to the parking lot, as this is where she exits when she goes on leave of absence with her family. She indicates she did this because she wanted to go to [NAME], a frequent place she visits with her family when out on a leave of absence. Resident was noted as missing at 1546 (3:46 p.m.), code white was immediately called. Staff started to search premises when an unknown individual outside indicated that they saw a female in a wheelchair wheeling not far past the facility toward a nearby [NAME]. Staff proceeded up the alley way adjacent to the back of the facility and noted this resident to be wheeling up the side of the road, out of the line of direct traffic, safely in the berm area. Staff approached resident and resident indicated she just was going to [NAME]. Staff wheeled resident back to the facility without incident. Upon arrival to facility, nursing staff completed a head-to-toe assessment of residents with negative findings. Resident was tearful indicating she did not want to cause trouble or get anyone in trouble; she just wanted to go to [NAME]. During an interview on 3/23/26, at 3:15 p.m. NA Employee E6 and LPN Employee E4 confirmed their above statements. NA Employee E6 stated that Resident R10 pointed to the elevator when asked where Resident R1 was. At this time, LPN Employee E4 displayed the elopement binder present at the nurse's station. Review of the elopement binder displayed by staff were ten residents documented as an elopement risk (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). During an interview on 3/23/26, at approximately 3:25 p.m. the Activities Director was asked if the Activities Department had an elopement binder for use by their staff. The Activities Director stated she believed there was one, but did not know where it was. A list of the residents who were at risk for elopement was found and produced at approximately 4:00 p.m. The Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for residents on 3/23/26, at 4:08 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 4:09 p.m. The facility plan of correction was accepted on 3/23/26, at 6:30 p.m. to include:The resident was returned to the facility. Full body assessment was completed with no negative findings. Resident is alert and oriented and indicated she just wanted to go to [NAME] where she frequently goes out on Leave of Absence with her family. Physician and family were notified. Resident care plan will be updated to include that resident will be supervised at all times outside of her living unit. Her LOA order already states that she cannot be unsupervised. Immediately, Nursing Home Administrator completed on Elopement/Accidents and Hazards (attached) with Activities Staff that residents coming to the first floor dining room for activities that have a Wanderguard device or deemed at risk for elopement will not be unsupervised at any time, before, during or after the activity until they are returned safely to their respective living area. Immediately, whole house education on Elopement/Accidents and Hazards (attached) was initiated and completed. Elopement assessments were completed on current residents, which are under evaluations in the resident medical chart, elopement binders were verified for accuracy and completion. Activities on the first floor will be continued; however, the following plan has been implemented to ensure resident safety and decreased risk of elopement: Facility leadership, including Social Services Director, admission Director, Human Resources Director, LPN Unit Manager, Infection Preventionist, Business Office Manager, Appointment Scheduler, Staff Scheduler, Director of Rehabilitation, Medical Records, and Maintenance Director will assist during large group activities planned for the first floor dining room to ensure direct supervision support. Leadership will support activities staff in transporting residents to/from first floor dining room where the activity is taking place as well as provided additional supervision during the activity. Activity Director will verbalize the need for help in morning standup meeting as well as provide a sign-up sheet for leadership to secure. At no time will residents with Wanderguard device or residents at risk of elopement be left unsupervised. 4 people will be needed: one in room, one transporting in the hallway, one transporting the elevator, and one observing the hallway.Facility has reduced the number of activities in the first-floor dining room to the larger, primary activities such as auction, birthday party, cooking club, special events.Once all residents are in the dining room on first floor, the door will be closed. A bell has been placed on the door to alert staff if someone is attempting to open the door.Other activities will be modified to be completed on the resident floors in the dayrooms. Activities such as Church and Resident Council that are smaller integrated activities, will be scheduled in the 3A dayroom moving forward.New residents admitting will be evaluated for elopement. Discussion of findings will occur during the morning meeting process. If resident is deemed an elopement risk, elopement binders will be updated, Wanderguard will be placed, and interdisciplinary team will all be made aware for resident safety. Audits of group activities occurring in the first-floor dining room will be completed by Nursing Home Administrator for proper supervision of residents twice per week for two weeks, then once per week for two weeks, then weekly for two months. here have been no large group activities since the date of this occurrence to audit. Audits will begin with the next large group activity. All education, updates to care plan, modifications to activities will be completed by Wednesday, 03/25/2026. Audits will begin with next large group activity, scheduled for Wednesday 03/25/2026. Review of Resident R1's clinical record confirmed that Resident R1's responsible party and the nurse practitioner were notified on 3/19/26, at 3:45 p.m. and new interventions were placed in the plan of care. Review of clinical records on 3/24/26, confirmed the facility completed whole-house education to 116 of 116 staff members. A total of 98 of 116 confirmed education via signing the education in-service sheet. 20 of 116 staff members were educated via phone. 2 of 20 have returned to the facility and signed in-service sheet prior to the start of their shift. All other staff members will be required to verify they were educated via signing the in-service education sheet prior to the start of their next shift. During in-person interviews conducted on 3/24/26, 34 of 34 verified they were educated on the elopement procedure and to not leave residents unsupervised. Review of education documents indicated that on 3/19/26, the Nursing Home Administrator educated the activity staff members that when residents are brought to activities on the first floor from the third floor, at no time during the activity or after the activity should these residents be unattended. This includes when residents are transported to/from the elevator to go to the dining room and accompanied by activities staff to ensure their safety. During 32 staff interviews completed on 3/24/26, beginning at approximately 9:45 a.m. confirmed all staff had received education on elopement prevention and actions to take if a resident leaves the facility. During an interview on 3/25/26, at approximately 10:00 a.m. the Activities Director was asked if Activities staff had previously been provided education on ensuring the safety of residents at risk for elopement, to which she responded, Not really, probably during orientation. During observations on 3/24/26, the elopement binders were confirmed to be updated as of 1:00 p.m. Review confirmed that 94/94 elopement assessments were completed. 10/94 residents were identified at risk for elopement. The Immediate Jeopardy was removed on 3/24/26, at 2:56 p.m. when the action plan implementation was verified. During an interview on 3/25/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of two residents left unsupervised. This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of the facility's job descriptions, employee attendance information, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility.Review of the facility provided Director of Nursing (DON) job description, undated, indicated that the DON position purpose was, Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Included in the listing of Required Qualifications was Current unrestricted license as a Registered Nurse in practicing state. Information reported to the State Department of Health indicated that Registered Nurse Employee E1 started as the DON for the facility on 1/15/26. Review of facility provided Stand-Up sheets 2/2/26, through 3/23/26, failed to include documentation that the DON was present and acting in the capacity as Director of Nursing on 23 of 36 business days: Monday, 2/2/26: The DON was documented as not present in the building.Tuesday, 2/3/26: Stand-Up sheet not signed by the DON, unknown if present.Wednesday, 2/4/26: Stand-Up sheet not signed by the DON, unknown if present.Thursday, 2/5/26: The DON was documented as not present in the building.Friday, 2/6/26: The DON was documented as not present in the building. Monday, 2/9/26: The DON was documented as present in the building.Tuesday, 2/10/26: The DON was documented as not present in the building.Wednesday, 2/11/26: The DON was documented as not present in the building.Thursday, 2/12/26: The DON was documented as not present in the building.Friday, 2/13/26: The DON was documented as not present in the building. Monday, 2/16/26: The DON was documented as present in the building.Tuesday, 2/17/26: The DON was documented as present in the building.Wednesday, 2/18/26: The DON was documented as present in the building.Thursday, 2/19/26: The DON was documented as present in the building.Friday, 2/20/26: The DON was documented as not present in the building. Monday, 2/23/26: No Stand-Up sheet available.Tuesday, 2/24/26: The DON was documented as present in the building.Wednesday, 2/25/26: No Stand-Up sheet available.Thursday, 2/26/26: No Stand-Up sheet available.Friday, 2/27/26: No Stand-Up sheet available. Monday, 3/2/26: The DON was documented as present in the building.Tuesday, 3/3/26: The DON was documented as not present in the building.Wednesday, 3/4/26: The DON was documented as present in the building.Thursday, 3/5/26: Stand-Up sheet not signed by the DON, unknown if present.Friday, 3/6/26: The DON was documented as present in the building. Monday, 3/9/26: The DON was documented as not present in the building.Tuesday, 3/10/26: DON documented as arriving late.Wednesday, 3/11/26: Stand-Up sheet not signed by the DON, unknown if present.Thursday, 3/12/26: The DON was documented as present in the building.Friday, 3/13/26: No Stand-Up sheet available. Monday, 3/16/26: The DON was documented as not present in the building.Tuesday, 3/17/26: The DON was documented as not present in the building.Wednesday, 3/18/26: No Stand-Up sheet available.Thursday, 3/19/26: The DON was documented as not present in the building.Friday, 3/20/26: The DON was documented as not present in the building. Monday, 3/23/26: The DON was documented as not present in the building. Two additional Stand-Up sheets were present, undated, both documented that the DON was not present in the facility. Review of facility-provided employment information, the Assistant Director of Nursing had a final employment date of 2/16/26. Thereafter, no additional registered nurse was placed in an Interim Director of Nursing Position. During an interview on 3/23/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the DON was not currently in the building and was using paid time off through her last day of employment on 3/24/26. During an interview with the Nursing Home Administrator on 3/25/26, at approximately 1:15 p.m. confirmed that there was no documented evidence that Registered Nurse Employee E1 worked 35 or more hours a week in the facility in the capacity as DON. 28 Pa Code 201.3 Definitions.28 Pa Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code 211.12(b)(c)(d) Nursing Services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the building unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care. Review of the facility-provided Director of Nursing (DON) job description indicated, Planning, organizing, developing and directing the overall operations of the Nursing Service Deportment in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Based on findings identified in this report, the facility failed to prevent the failed protect residents from exiting the facility unsupervised. The NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 3/25/26, at approximately 12:30 p.m. the NHA and current DON confirmed that facility administration failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the building unsupervised. This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility staff failed to follow a physician order for a Bi-pap machine (used to facilitate breathing during sleep for certain types of sleep apnea. Sleep apnea is a condition that causes breathing to stop and start several times during sleep. A bi-pap machine pushes air into the lungs with two settings a higher pressure when you inhale and a lower pressure when you exhale) for one of three residents (discharged Resident R1).Findings include: Review of facility policy admission Orders last reviewed8/8/25, indicated A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. The orders should allow facility staff to provide essential care to the residents consistent with the resident's mental and physical status on admission. Review of the facility policy Oxygen Administration last reviewed 8/8/25, indicated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident's goals and preferences. Types of delivery systems include but not inclusive to Bi-level Positive Pressure Airway Pressure (BiPap) mask this mask is part of a system that is capable of generating two adjustable pressure levels during inhalation and exhalation. Review of the clinical record indicated discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/23/25, indicated diagnoses of with the diagnosis of cancer, high blood pressure and Chronic Obstructive pulmonary disease (COPD- lung condition that restricts breathing). Review of discharged Resident R1's physician order dated 11/12/25, indicated BiPap at hours of sleep at present parameters at bedtime and remove per schedule. The order start date was 11/13/25. Review of discharged Resident R1's physician order dated 11/13/25, indicated BiPap at hours of sleep at present parameters for 45% - 6.0 centimeters (CM) water (H2O) and remove per schedule. Review of discharged Resident R1's Treatment Administration Record (TAR) for November 2025, indicated three occurrences of physician ordered treatment for the BiPap was not provided 11/12/25, 11/19/25, and 11/20/25. During an interview completed on 3/18/26, at 3:10 p.m. Upon asking Registered Nurse RN Employee E1 concerning discharged Resident R1's Bi pap orders Stated The BiPap was not put on until 11/13/25, the orders were put in on 11/12/25, however, it was not scheduled until the 11/13/25. Upon asking RN Employee E1 what a 9 meant on the TAR for 11/19/25, and 11/20/25, stated see nursing note when asked about the nursing notes confirmed there were not any to coincide with the BiPap not being used on 11/19/25, and 11/20/25, and that the facility staff failed to follow a physician order for a Bi-pap machine for one of three residents (discharged Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).Findings include: Review of facility's policy dated 7/1/25, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within a specific timeframe; immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital. The facility failed to report the allegation of neglect within 24 hours to the local state field office. During an interview on 2/25/26, at 12:37 p.m. the Director of Nursing confirmed allegations of neglect must be reported to the appropriate agencies within 24 hours. During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of five residents (Resident R1).Findings include: Review of facility's policy dated 7/1/25, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Registered Nurse, Employee E1's signed job description dated 11/4/25, revealed major duties and responsibilities include ensuring policies and procedures are complied with by nursing personnel assigned, participates in the admission, discharge, and transfers of residents as required, assesses for changes in resident's status, notifying the physician and resident family or representative and documenting according, prepares and administers medications as per physicians' orders and observes for adverse effects as indicated. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26. Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of facility documents revealed RN, Employee E1 was the RN, Supervisor on duty from 7 a.m. to 7 p.m. Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. I did not see her go to his room at all. NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 he couldn't come back here while the ambulance workers were there. Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, I already know what he wants. LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 Do you think I should send him out if he wants sent out? LPN, Employee E3 responded Yes and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out. RN Supervisor then went to feed resident. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current. Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital. During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview. During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's Discharge Transition Packet dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days. During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital. During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels. During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted , their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified. During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it. During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to protect resident from neglect for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10 (a) (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).Findings include: Review of facility Bowel Routine Policy last reviewed 7/1/25, indicated each resident will have routine bowel elimination. The purpose is to address the resident's individual needs with respect to routine bowel movements, initiate appropriate strategies and interventions, and monitor and evaluate resident outcomes. Give Milk of Magnesia 30 ml if no bowel movement in 72 hours (Day 3 without a bowel movement), if ineffective give Dulcolax Suppository. Administer fleet enema if Dulcolax Suppository is ineffective. Call physician if fleet enema is ineffective. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26. Review of Resident R1's clinical record for 2/12/26, failed to reveal Resident R1 had a bowel movement. Review of Resident R1's physician order dated 2/12/26, indicated to administer 30 milliliter (ml) Milk of Magnesia Suspension 7.75 % (Magnesium Hydroxide) by mouth as needed for constipation, if no bowel movement in 48 hours. Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Dulcolax Suppository 10 MG (Bisacodyl) suppository rectally as needed for constipation if Milk of Magnesia is ineffective. Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Fleet Enema 7-19 GM/118ML (Sodium Phosphates) applicatorful rectally as needed for constipation, if no bowel movement after Dulcolax suppository. Review of Resident R1's February 2026 Medication Administration Record (MAR) failed to include evidence the resident's medications were administered as ordered on 2/12/26. Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. I did not see her go to his room at all. NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 he couldn't come back here while the ambulance workers were there. Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, I already know what he wants. LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 Do you think I should send him out if he wants sent out? LPN, Employee E3 responded Yes and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current. During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview. During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's Discharge Transition Packet dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days. During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital. During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels. During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted , their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified. During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it. Review of Resident R1's Hospital Discharge Summary on 2/25/26, revealed the resident was hospitalized from [DATE], to 2/17/26 for a rectal fecal impaction, severe constipation, requiring oral laxatives, disimpacting and soap suds enema. During an interview on 2/25/26, at 12:27 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum QAPI program. Review of RN Employee E3's personnel file indicated a hire date of 10/1/23, and failed to include QAPI training between 10/1/24, and 10/1/25. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include QAPI training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include QAPI training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include QAPI training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include QAPI training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on QAPI for five of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Infection Control for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Infection Prevention, and Control Program. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Infection Control training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Infection Control training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Infection Control training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Infection Control training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on Infection Control for four of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Compliance and Ethics for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Compliance and Ethics Program. Review of RN Employee E3's personnel file indicated a hire date of 10/1/23, and failed to include Compliance and Ethics training between 10/1/24, and 10/1/25. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Compliance and Ethics training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Compliance and Ethics training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Compliance and Ethics training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Compliance and Ethics training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on Compliance and Ethics for five of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility admission packet, facility policy, clinical records, observation, and staff interviews it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two residents (Resident R3 and R44).Findings include: Review of the facility admission Packet policy dated 5/28/21, indicated the facility shall protect and promote the rights of each resident that include the right to a dignified existence, self-determination, communication with and access to, persons and services inside and outside the facility. Review of the facility Catheter Care policy dated 10/13/25 indicated that the facility will ensure that residents indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/25, indicated diagnoses of depression, neurogenic bladder (nerve damage that interrupts bladder control), quadriplegia (a paralysis that affects all body limbs). Section H - Bowel and Bladder H0100A indicated an indwelling catheter. Review of Resident R3's care plan dated 11/19/25, indicated the resident has an indwelling urinary catheter related to neurogenic bladder. During an observation on 12/8/25, at 11:15 a.m. Resident R3's catheter draining bag was observed hanging on his bed frame without a privacy cover applied. During an interview on 12/8/25, at 11:20 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed Resident R3's catheter draining bag did not have a privacy cover and that the facility failed to ensure that care was provided in a way that maintained Resident R3's dignity. Review of Resident R44's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated diagnoses of high blood pressure, cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section GG Functional Abilities GG0130 Eating was coded as a 1, indicating resident is dependent and the helper does all of the effort. Resident does none of the effort to complete the activity. Review of Resident R44's physician orders dated 7/11/25, indicated resident is total assist with self-feeding to promote nutritional intake. Review of Resident R44's care plan on 12/8/25, at 11:50 a.m. indicated resident is total assist with self-feeding to promote nutritional intake. During an observation on 12/8/25, at 11:55 a.m. two staff members were passing lunch trays on the unit. Nurse Aide Employee E12 placed Resident R44's lunch tray on the bedside table in front of her and then left the room to continue passing lunch trays. During an interview on 12/8/25, at 12:01 p.m. LPN Employee E9 confirmed the above findings, and that resident should have been assisted with lunch when the lunch tray was delivered. During an interview on 12/8/25, at 2:45 p.m. Director of Nursing confirmed that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two residents (Resident R3 and R44). Pa. Code: 211.10 (c)(d) Resident care policies. Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to post complete contact information for State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit as required, and failed to post a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation on three of three floors (First Floor, Second Floor, and Third Floor).Findings include: During observations completed on 12/9/25, of the First Floor, Second Floor, and Third Floor, postings of the contact information for State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit failed to include email addresses for the above agencies as required, and also failed to include a statement that the resident may file a complaint with the State Survey Agency During interview, on 12/9/25, at 2:20 p.m., the Nursing Home Administrator confirmed that the facility failed to post complete contact information for State Survey Agency, Adult Protective Services, and Medicaid Fraud Unit, and failed to post a statement that the resident may file a complaint with the State Survey Agency as required, on three of three floors. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(e) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of four residents reviewed (Resident R3, and R64).Findings include: A review of the facility Residents' Rights Regarding Treatment and Advance Directives policy dated 10/13/25, indicated that the facility will support and facilitate a resident's right to request, refuse or discontinue medical or surgical treatment and to formulate advance directives. On admission, the facility will determine if the resident has executed an advance directive and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information on formulating advance directives.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/25, indicated diagnoses of depression, neurogenic bladder (nerve damage that interrupts bladder control), quadriplegia (a paralysis that affects all body limbs). A review of the clinical record failed to reveal an advanced directive or documentation that Resident R3 was given the opportunity to formulate an Advanced Directive. Review of Resident R64's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R64's MDS dated [DATE], indicated diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), muscle weakness, and cancer (uncontrolled growth and division of abnormal cells). A review of the clinical record failed to reveal an advanced directive or documentation that Resident R64 was given the opportunity to formulate an Advanced Directive. During an interview on 12/10/25, at 1:50 p.m. Social Worker Employee E15 confirmed that the facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive for two of four residents reviewed (Resident R3, and R64). 28 Pa. Code: 201.29(b) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews it was determined that the facility failed to develop a person-centered care plan with interventions for one of three residents reviewed (Resident R7).Findings include: Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/7/25, included diagnoses of suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide), schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms). Review of the plan of care for mood and behavior indicated the, a focus goal and intervention section: the focus was suicidal ideations with a goal section that failed to include a goal for suicidal ideations, and interventions that said, I use plastic silverware. No other interventions were documented in the plan of care or in the clinical record. Review of the clinical record progress notes indicated:12/5/25: alerted by Nurse Aide that Resident R7 wished she was not here anymore. Stated that she had no purpose here anymore. This writer notified RN on duty. After dinner was alerted that resident tried to stab herself with a plastic fork and expressed that she did now want to be alive anymore. 12/6/25: Staff just informed this nurse that Resident R7 tried to cut herself with a plastic spoon. During an interview on 12/11/25, at 3:05 p.m. the Director of Nursing and Nursing Home Administrator were informed that the facility failed to develop a person-centered care plan for Resident R7 that included interventions to assist with suicidal ideations. Pa. Code 201.24 (c ) (4) admission policy 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R8).Findings include: Review of facility policy Pressure Injury Prevention and Management dated 10/13/25, indicated the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injury. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a pressure injury risk assessment on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. The goals and preferences of a resident and/or authorized representative will be included in the plan of care. Interventions will be documented in the care plan and communicated to all relevant staff. Interventions on a resident's plan of care will be modified as needed. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's clinical record progress notes dated 9/17/25, at 9:57 a.m., revealed new skin issue reported - Resident (R8) seen by wound team for consult. Resident (R8) found to have a S3PI (stage 3 pressure injury = full-thickness skin loss, potentially extending into the subcutaneous tissue, and may present with undermining and tunneling) to coccyx (commonly referred to as the tailbone), noted that resident (R8) has had a decline in overall condition. Review of Resident R8's clinical record wound consultant note dated 9/17/25, indicated that on the coccyx, a linear shaped open wound with moist pink tissue at base, minimal drainage. Edges unattached, peri wound intact. No odor, no warmth, no erythema. Measurement 1.5 x 0.5 x 0.2 cm (centimeters). Coccyx S3PI. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/25, indicated diagnoses Chronic obstructive pulmonary disease (progressive lung disease characterized by airway inflammation and damage, leading to symptoms such as shortness of breath, chronic cough, and mucus production), diabetes mellitus (chronic condition characterized by high levels of glucose in the blood due to the body's inability to produce or effectively use insulin), and bipolar disorder (mental health condition that causes extreme mood swings). Section M - Skin Condition, M0300C indicated a 1 = Number of Stage 3 pressure ulcers. Review of physician order dated 9/17/25, indicated SSD (silver sulfadiazine) External Cream 1%, apply to coccyx topically two times a day for wound care. Review of Resident R8's clinical record reviewed on 12/9/25, failed to reveal weekly wound documentation since wound was identified on 9/17/25. During an interview on 12/9/25, at 1:03 p.m., Wound Care Licensed Practical Nurse (WCLPN) Employee E22 revealed that Resident R8's S3PI on coccyx is healed, and that there is no weekly wound documentation in clinical record regarding coccyx skin breakdown from 9/17/25, to current date. Review of the clinical record failed to indicate that a Braden Scale for Predicting Pressure Sore Risk has been updated since 3/19/25, when Resident R8 was identified at moderate risk for skin breakdown. Review of plan of care for pressure ulcer development, initiated 2/20/25, updated 9/25/25, indicated that Resident R8 has a stage 3 to coccyx 9/16/25. During an interview on 12/11/25, at 9:00 a.m., the Director of Nursing (DON) confirmed that a Braden Scale for Predicting Pressure Sore Risk had not be completed for Resident R8 since 3/19/25; confirmed that the facility failed to document weekly on Resident R8's coccyx pressure injury; and failed to update Resident R8's care plan timely related to current skin status. During an interview on 12/12/25, at 2:45 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of four residents (Resident R8). 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview it was determined that the facility failed to provide adequate supervision for one of three residents with mental health concerns to prevent attempts of suicide (Resident R7). Findings include: Review of facility policy Accidents and Supervision dated 10/13/25, indicated: The resident environment will remain free as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. Revie of facility policy Suicide ideation or attempt), dated 10/13/25, indicated: Plan of care for a resident after suicide ideation or attempt is to focus on immediate safety, comprehensive mental health evaluation, collaborative safety planning, and ongoing emotional support and monitoring. Immediate intervention: Ensure safety Do not leave the resident alone. One - on - One observation by a staff member until a professional evaluation is completed or risk is lowered. Remove any lethal means. Immediately search the resident's surroundings and remove any items that could be used for self-harm ( e.g. sharp objects, call bell cord, belts). Medical attention. Ensure that the resident receives immediate medical care for any physical injuries resulting from the attempt. Emergency contacts. Notify the MD immediately. Notify the crisis team and emergency contact person. Involve mental health professionals. Arrange for an urgent screening and comprehensive evaluation by mental health professional. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7 Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/7/25, included diagnoses of suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide), schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms). Review of clinical record progress notes indicated the following: 12/5/25: alerted by Nurse Aide that Resident R7 wished she was not here anymore. Stated that she had no purpose here anymore. This writer notified RN on duty. After dinner was alerted that resident tried to stab herself with a plastic fork and expressed that she did now want to be alive anymore. 12/6/25: Staff just informed this nurse that Resident R7 tried to cut herself with a plastic spoon. During an interview on 12/10/25, at 2:20 p.m. Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that on 12/5/25 and 12/6/25 Resident R7 experienced suicidal ideations. During an interview on 12/12/25, at 1:40 p.m. NHA were informed that the facility failed to provide adequate supervision to prevent attempts of suicide for Resident R7. 28 Pa. Code 211.10 (d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility policy, clinical record review and staff interview, it was determined that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of three residents (Resident R8) records reviewed.Findings include: Review of facility's policy Nutritional Management, dated 10/13/25, indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/2/25, indicated diagnoses Chronic obstructive pulmonary disease (progressive lung disease characterized by airway inflammation and damage, leading to symptoms such as shortness of breath, chronic cough, and mucus production), diabetes mellitus (chronic condition characterized by high levels of glucose in the blood due to the body's inability to produce or effectively use insulin), and bipolar disorder (mental health condition that causes extreme mood swings). Section M - Skin Condition, M0300C indicated a 1 = Number of Stage 3 pressure ulcers. During an interview on 12/11/25, at 9:32 a.m., Registered Dietitian (RD) Employee E21 revealed that a comprehensive nutritional assessment (form Nutrition Assessment V.3) is completed on admission/readmission, annually, and with a significant change in condition. Review of Resident R8's clinical record failed to reveal that a comprehensive nutritional assessment (form Nutrition Assessment V.3) was completed that addressed Resident R8's current nutritional status related to Stage 3 pressure ulcer by updating nutrient needs, evaluating laboratory/diagnostic values, and evaluating overall need for additional nutritional interventions for pressure ulcer repair based on information submitted on Significant Change MDS assessment dated [DATE]. Review of current nutritional plan of care initiated 2/22/5, updated 10/20/25, failed to indicate a nutritional focus/concern, goals, and interventions to address Resident R8's stage 3 pressure ulcer as identified in MDS dated [DATE]. During an interview on 12/11/25, at 10:00 a.m., RD Employee E21 confirmed that a comprehensive nutritional assessment was not completed as required for a Significant Change MDS assessment dated [DATE], which addressed Resident R8's change in nutritional needs due to a Stage 3 pressure ulcer, and failed to update Resident R8's care plan to reflect current skin breakdown. During an interview on 12/12/25, at 2:45 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to accurately assess the nutritional status and failed to update an individualized care plan to address the resident's specific nutritional concerns for one of three residents (Resident R8) records reviewed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.12(d)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R3 and R65). Findings include: Review of facility policy Oxygen Administration dated 10/13/25, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Change oxygen tubing weekly and as needed. Keep delivery devices covered in plastic bag when not in use. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/24/25, indicated diagnoses of depression, neurogenic bladder (nerve damage that interrupts bladder control), quadriplegia (a paralysis that affects all body limbs). Review of a physician's orders dated 12/1/25, indicated to administer oxygen two liters per minute for shortness of breath as needed. During an observation on 12/8/25, at 10:55 a.m. Resident R3 was lying in bed. The oxygen concentrator was located beside the bed with the nasal cannula (a thin tubing that delivers oxygen from the oxygen concentrator to the nose) laid over top, not stored in a bag. During an interview on 12/8/25, at 11:20 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed that the nasal cannula was not stored in a bag when not in use, as required. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of depression, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of physician's orders dated 6/6/25, indicated to administer Ipratrpium-Albuterol (a medication used to treat respiratory diseases) via nebulizer (a machine that delivers medication through inhalation) every four hours if needed. During an observation on 12/8/25, at 11:05 a.m. Resident R65 was lying in bed. The nebulizer machine and tubing were lying on bedside table. The tubing was not dated and was not stored in a bag. During an interview on 12/8/25, at 11:25 a.m. LPN Employee E9 confirmed that the nebulizer tubing failed to have a date on it and was not stored in a bag when not in use, as required. During an interview on 12/8/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for two of four residents (Resident R3 and R65). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, personnel records and staff interviews it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA) (NA Employees E4, E5, E6, E7, and E8).Findings include: Review of NA Employee E4's personnel record indicated a hire date of 9/19/11. Review of NA Employee E5's personnel record indicated a hire date of 9/21/18. Review of NA Employee E6's personnel record indicated a hire date of 2/26/23. Review of NA Employee E7's personnel record indicated a hire date of 8/27/23. Review of NA Employee E8's personnel record indicated a hire date of 10/2/23. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employees E4, E5, E6, E7, and E8. During an interview on 12/9/25, at 1:57 p.m. Human Resources Employee E10 confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides as required. 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical documentation and staff interview it was determined that the facility failed to provide sufficient and timely social services to one of three residents reviewed (Resident R7).Findings include: Review of facility policy dated 10/13/25, Behavioral Health Services indicated:It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.Review of facility policy dated 10/13/25, Suicide ideation or attempt indicated: Plan of care for a resident after suicide ideation or attempt is to focus on immediate safety, comprehensive mental health evaluation, collaborative safety planning and ongoing emotional support and monitoring. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - a periodic assessment of resident care needs) dated 11/7/25, included diagnoses of suicidal ideation (when you think about, consider or feel preoccupied with the idea of death and suicide), schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) and anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms). Review of Resident R7 clinical record indicated: Therapeutic evaluation in 10/16/25, where clinician ended therapy services. Review of clinical record from October 2025 to December 2025 failed to show additional therapy services. 12/5/25: alerted by Nurse Aide that Resident R7 wished she was not here anymore. Stated that she had no purpose here anymore. This writer notified RN on duty. After dinner was alerted that resident tried to stab herself with a plastic fork and expressed that she did now want to be alive anymore. 12/6/25: Staff just informed this nurse that Resident R7 tried to cut herself with a plastic spoon. During an interview on 12/11/25, at 12:43 p.m. Social Worker Employee E15 indicated:Resident R7 had a known history of suicidal ideations and attempts- that Resident R7 had expressed to Social Worker Employee E7 that she was experiencing a recurring dream that scared her and the Social Worker Employee E7 described as potential trauma. Social Worker Employee E7 was aware that therapy had ended in October and besides medication management (which did not take place between October thru December 2025) Resident R7 was not receiving clinical therapeutic services. During an interview on 12/11/25, at 2:31 p.m. Contractor Clinical Therapist Employee E24 indicated that she had discharged Resident R7 due to cognitive decline. When asked what the cognitive decline change was - Contractor Clinical therapist Employee E24 indicated that she wasn't communicating with the clinical and that's why she discharged her. Contractor Clinical Therapist Employee E24 asked if anything had happened to Resident R7. No documentation was noted of the facility contacting the clinical therapist or CRNP for psychotropic medication monitoring. During an interview on 12/11/25, at 3:50 p.m. nursing staff indicated the following:Resident R7 did experience a dream which scared her - and she was consistent with talking about the dream. During an interview on 12/12/25, at 1:42 p.m. Nursing Home Administrator was informed that the facility failed provide sufficient and timely social services to one of three residents reviewed (Resident R7). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 211.16(a)(1)Social services. 28 Pa. Code 201.29(a) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observation, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R36). Findings include: Review of facility Medication Administration policy dated 10/13/25, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: - Right resident- Right drug- Right dose- Right route- Right time- Right documentation Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/25, indicated diagnoses of arthritis, depression, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of a physician order dated 12/1/25, indicated to inject eight units of Insulin Aspart (a medication used to treat high blood sugar) subcutaneously (under the skin) with meals. During an interview on 12/11/25, Nurse Aide Employee E11 stated that breakfast trays are usually on the unit at 7:55 a.m. During a med pass observation on 12/11/25, at 9:42 a.m. Licensed Practical Nurse (LPN) Employee E18 gave Resident R36 eight units of Insulin Aspart. During an interview on 12/11/25, at 9:45 a.m. LPN Employee E18 stated, I'm late with her medicine. It is ordered with meals. I should have given it with her breakfast. During an interview on 12/11/25, at 2:45 p.m. Director of Nursing confirmed that the facility failed to ensure that Resident R36 received her medication as ordered and that residents were free of significant medication errors for one of five residents reviewed (Resident R36) as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in three of five medication rooms (Second Floor (2C) Medication Room, Third Floor (3A) Medication Room, and Third Floor (3C) Medication Room) and failed to properly store medication in two of three medication carts (3BC Medication Cart and 2BC Medication Cart). Findings include:
Review of facility policy Medication Storage dated [DATE], indicated that medications will be stored in the medication rooms according to the manufacturer's recommendations. All medications rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed.
Review of facility Insulin Storage policy dated [DATE], indicated that insulin must be stored securely in a locked area. Follow specific instructions for opened insulin vials/pens. Often good at room temperature for 28 days. Insulin vials/pens must be dated on the date they are initially used.
During a medication cart review (3BC Medication Cart ) on [DATE], at 12:40 p.m. the following were observed:
(2) Lantus (a medication used to treat high blood sugars) vial with an opened date marked [DATE].
Insulin Lispro (a medication used to treat high blood sugars) vial with an opened date marked [DATE].
Lantus pen with an opened date marked [DATE].
Lispo vial with an opened date marked [DATE].
Insulin Aspart (a medication used to treat high blood sugars) vial with an opened date marked [DATE].
Lantus vial with an opened date of [DATE].
Novolog (a medication used to treat high blood sugars) was missing an opened and expired date.
Lantus vial with an opened date marked [DATE].
Lispro vial with an opened date marked [DATE].
During an interview on [DATE], at 12:53 p.m. Licensed Practical Nurse (LPN) E13 confirmed the above findings and confirmed that they were expired.
During a medication cart review (2BC Medication Cart ) on [DATE], at 1:20 p.m. the following were observed:
Lantus vial with an expiration date marked [DATE].
Lantus vial with an opened date marked [DATE].
During an interview on [DATE], at 1:35 p,m, Registered Nurse Employee E14 confirmed the above findings and confirmed that they were expired.
During an observation on [DATE], at 10:16 a.m. of the Second Floor (2C) Medication Room the following was observed:
-(2) Gallons of opened undated Natural Spring Water
-(1) Spedi Catheter Internment French 16 Expired [DATE]
-(1) IV Tubing Administration Set Expired [DATE]
-(3) IV Connecting Tubing 20' Length, 3/16' Diameter Expired [DATE]
-(2) Gold Blood Tubes Expires [DATE]
-(2) Blood Collection Set Expired [DATE]
-(1) 300 milligram (mg) Bottle Fish Oil Expired 6/25
-(3) 50 mg Bottle Zinc Expired 7/25
-(1) Saccharomyces Boulardii Probiotic Expired 9/25
-(1) 1000 mg Bottle B12 Expired [DATE]
-(2) 500 mg Bottle Vitamin C Expired 11/25
During an interview on [DATE], at 10:18 a.m. LPN Employee E19 confirmed the above items were expired.
During an observation on [DATE], at 10:29 a.m. of the Third Floor (3A) Medication Room the following was observed:
- (1) 50 mg Bottle Zinc Expired 7/25
-(1) 325mg Bottle of Iron Expired 8/25
During an interview on [DATE], at 10:30 a.m. LPN, Employee E16 confirmed the above items were expired.
During an observation on [DATE], at 10:36 a.m. of the Third Floor (3C) Medication Room the following was observed:
-(1) Secondary Administration Set Expired [DATE]
-(1) 400 mg Bottle Fish Oil Expired 7/25
-(3) IV Administration Set Expired [DATE]
-(1) 500 mg Bottle Vitamin C Expired 11/25
During an interview on [DATE], at 10:40 a.m. LPN, Employee E13 confirmed the above items were expired.
During an interview on [DATE], at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly store medications and/or biologicals in three of six medication rooms.
28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility financial documents, interviews with residents, resident's families, and staff it was determined that the facility failed to pay bills in a timely manner.Findings include: Review of the Nursing Home Administrator job description indicated: position purpose: leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Resident R57 was admitted to the facility on [DATE]. Review of Resident R57 Minimum Data Set (MDS - a periodic assessment of resident needs) dated 11/14/25, indicated diagnosis of cerebral palsy (group of condition that affect movements and posture. I caused by damage that occurs to the developing brain, most often before birth) anxiety disorder (involve repeated episodes of sudden feelings of intense anxiety and or fear or terror), and abnormalities of gait (abnormal walking pattern). During an observation on the 2nd floor nursing unit on 12/11/25, at 329 p.m. Resident R57 Indicated they wanted to talk with a surveyor. Resident R57 with Resident R57 Family Member on the video screen and Nurse Aide in to help with communicating with Resident R57 - stated that he wanted to know why he couldn't go to his eye appointment. Resident R57 Family member wife expanded to say - they had made an original appointment in October that needed to be canceled but re-made his eye appointment for Friday - the facility cancelled it. The appointment was for eye surgery due to resident not being able to see well out of his eye. Resident R57 Family Member indicated that the eye appointment was cancelled due to facility not having transportation. During an interview on 12/12/25, at 10:24 a.m. Scheduler Employee E23 indicated the following: Scheduler Employee E23 is responsible for setting up appointments for residents for transportation and for taking residents who are in wheelchairs and able to walk independently/with cane/wheeled walker to appointments. Per Scheduler Employee E23 the appointment was cancelled by the facility and the reason for cancelling was due to the transportation company not being paid by the facility. Scheduler Employee E23 indicated that this has happened before, but this was the longest period of time (no exact date provided). Review of facility documentation: Optimal transport contract:This non-emergency wheelchair/stretcher transportation services agreement: Optimal transport is equipped and qualified to provide Non-Emergency Wheelchair/Stretcher transportation services to health care providers and assisted living facilities. Article 4- charges and billing - Optimal transport will invoice [NAME] Rehabilitation and Nursing monthly in accordance with the Fee schedule. Payment [NAME] Rehabilitation and nursing agree to pay Optimal Transport 100% of set rates. Review of facility documentation from October of 2025 to December 2025 indicated: 12 appointments being cancelled due to transportation not being available including Resident R57. During an interview on 12/12/25, at 2:00 p.m. Nursing Home Administrator confirmed that the facility failed to pay the transportation vendor in a timely manner. 28 Pa. Code 201.14 (a)( c) Responsibility of licensee28 Pa. Code 201.18(b)(1)( e)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, review of clinical record, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to failing to use Personal Protective Equipment (PPE) appropriately in Droplet Isolation (a type of isolation that requires a gown, gloves, N95 (a respirator mask), and eye protection, which created the potential for the cross-contamination and the spread of diseases and infections for four out of four resident rooms (Rooms 301, 304, 305, and 312), failed to clean residents rooms appropriately after isolation was discontinued for three of three rooms (rooms [ROOM NUMBER]), and failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires (an infection of the lungs caused by bacteria, commonly spread by water) for 12 of 12 months.Findings Include:Review of facility Infection Prevention and Control Risk Assessment Procedure policy dated 10/13/25, indicated the facility documents a risk assessment that utilizes an all-hazard approach. This risk assessment will be used for prioritizing activities of the facility's infection prevention and control program. Review of facility Personal Protective Equipment policy dated 10/13/25, indicated the facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Review of facility Complete Room Cleaning policy dated 10/13/25, indicated when cleaning a complete room, the room should be emptied and ready for cleaning. Starting in a clockwise rotation, clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room. Review of facility Water Management Program policy dated 10/13/25, indicated the facility will establish water management plans for reduction the risk of legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards. During an interview on 12/8/25, at 9:33 a.m. Infection Preventionist (IP) Employee E20 confirmed that Covid-19 (a respiratory infection) was present on the third floor. During a tour of the third floor, yellow signs were hung outside of several rooms that indicated Standard Precaution - Airborne - Contact - Droplet Isolation. Prior to entering the room, clean hands, wear gown, N95, eye protection, and gloves. During multiple tours of the unit on 12/8/25, the following were observed with rooms that had isolation signs: - Nurse Aide (NA) Employee E11 was in a droplet isolation room with only a surgical mask on.- Licensed Practical Nurse (LPN) Employee E9 was in a droplet isolation room with a gown, gloves, and a surgical mask on.- NA Employee E12 exited a droplet isolation room and failed to discard N95 mask and was going into a non-isolation room with the N95 on. The State Agency (SA) requested the N95 be removed to prevent further spread of viruses.- NA Employee E111 was in a droplet isolation room with only a surgical mask on (Second time).- A family member stopped at nurses' station to talk to LPN Employee E9. The visitor had a mask on, however LPN Employee E9 failed to educate visitor prior to entering a droplet isolation room as to what should be worn to protect themselves.- NA Employee E11 was in a droplet isolation room with only a surgical mask (Third time).- NA Employee E12 was in a droplet isolation room with just a surgical mask and gloves on. During an interview on 12/8/25, at 12:10 p.m. LPN Employee E9 stated, I should have told the visitor she needed a gown, eye wear and gloves on as well as her mask before she visited resident while we were talking. During an interview on 12/8/25, at 12:15 p.m. LPN Employee E9, NA Employee E11 and NA Employee E12 confirmed that the appropriate PPE were not used in droplet isolation rooms, and a visitor was not educated on the appropriate PPE to be worn prior to entering a droplet isolation room to prevent the spread of Covid-19 during a visit. During an interview on 12/9/25, at 11:33 a.m. IP Employee E20 stated that three Covid-19 isolation rooms (rooms [ROOM NUMBER]) were discontinued due to residents testing negative for Covid-19 on this date. During a tour and observation on 12/9/25, at 1:10 p.m. residents in rooms [ROOM NUMBER] were lying in bed. During an interview on 12/9/25, at 1:17 p.m. Housekeeper Employee E17 stated that the rooms were cleaned after the isolation was discontinued. When asked, Were the residents in those rooms out of bed during the deep clean?, Housekeeper Employee E17 stated No, they were still in bed. During an interview on 12/9/25, at 1:21 p.m. Housekeeper Employee E17 stated that when a room is deep cleaned after an isolation order was discontinued that residents should be out of bed so that beds, mattresses, and bedframes can be disinfected with cleaner and that bedding should be laundered. During an interview on 12/9/25, at 2:15 p.m. Nursing Home Administrator and Director of Nursing confirmed that the facility failed to maintain proper infection control practices related to failing to use PPE appropriately in Droplet Isolation which created the potential for the cross-contamination and the spread of diseases and infections for four out of four resident rooms (Rooms 301, 304, 305, and 312), and failed to clean residents rooms appropriately after isolation was discontinued for three of three rooms (rooms [ROOM NUMBER]). During an interview on 12/11/25, at 10:07 a.m. the Nursing Home Administrator (NHA) stated he was unable to provide the facilities Legionella water management plan that included monitoring or auditing of facility for potential Legionella and failed to provide mapping of high opportunity areas where Legionella could be found in the facility water pipes. During an interview on 12/11/25, at 10:13 the NHA confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionnaires for 12 of 12 months. 28 Pa. Code: 211.10(d) Resident Care Policies.28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Effective Communication for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, E8, and Licensed Practical Nurse (LPN Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Effective Communication. Review of RN Employee E3's personnel file indicated a hire date of 10/1/23, and failed to include Effective Communication training between 10/1/24, and 10/1/25. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Effective Communication training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Effective Communication training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Effective Communication training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Effective Communication training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 1:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on Effective Communication for five of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff Development.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Resident Rights for six of seven staff members (Nurse Aide (NA) Employee E4, NA Employee E5, NA Employee E6, NA Employee E7, NA Employee E8, and Licensed Practical Nurse (LPN) E9). Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Resident Rights. Review of NA Employee E4's personnel file indicated a hire date of 9/19/11, and failed to include Resident Rights training between 9/19/24, and 9/19/25. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Resident Rights training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Resident Rights training between 2/26/24, and 2/26/25. Review of NA Employee E7's personnel file indicated a hire date of 8/27/23, and failed to include Resident Rights training between 8/27/24, and 8/27/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Resident Rights training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Resident Rights training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on Resident Rights for six of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of seven staff members (Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Abuse, Neglect, and Exploitation Prevention. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Abuse, Neglect, and Exploitation training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Abuse, Neglect, and Exploitation training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Abuse, Neglect, and Exploitation training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Abuse, Neglect, and Exploitation training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation for four of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

Based on review of personnel records, and staff interview it was determined that the facility failed to ensure that three of five sampled Nurse Aides (NA) received a minimum of 12 hours of in-service education per year (NA Employees E5, E6, and E8).Findings include: Review of facility nurse aide training records revealed that NA Employee E5 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E5 had received a minimum of 12 hours of in-service training yearly. Review of facility nurse aide training records revealed that NA Employee E6 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E6 had received a minimum of 12 hours of in-service training yearly. Review of facility nurse aide training records revealed that NA Employee E8 did not receive 12 hours of in-service training in the last year. The facility was unable to provide documented evidence that NA Employee E8 had received a minimum of 12 hours of in-service training yearly. During an interview on 129/25, at 2:00 p.m. Human Resources Employee E10 confirmed that the facility did not have evidence that NA Employee E5, E6, and E8 received the required 12 hours of yearly in-service training 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(c) Staff Development.

Based on review of facility policy and documents, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for five of seven staff members (Registered Nurse (RN) Employee E3, Nurse Aide (NA) Employees E5, E6, and E8, and Licensed Practical Nurse (LPN) Employee E9).Findings include: Review of facility policy Training Requirements dated 8/13/25, indicated that it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under contractual arrangement, and volunteers, consistent with their expected roles. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program, Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment. Training content includes at a minimum Behavioral Health. Review of RN Employee E3's personnel file indicated a hire date of 10/1/23, and failed to include Behavioral Health training between 10/1/24, and 10/1/25. Review of NA Employee E5's personnel file indicated a hire date of 9/21/18, and failed to include Behavioral Health training between 9/21/24, and 9/21/25. Review of NA Employee E6's personnel file indicated a hire date of 2/26/23, and failed to include Behavioral Health training between 2/26/24, and 2/26/25. Review of NA Employee E8's personnel file indicated a hire date of 10/2/23, and failed to include Behavioral Health training between 10/2/24, and 10/2/25. Review of LPN Employee E9's personnel file indicated a hire date of 5/24/23, and failed to include Behavioral Health training between 5/24/24, and 5/24/25. During an interview on 12/9/25, at 12:59 p.m. Human Resources Employee E10 confirmed that the facility failed to provide Behavioral Health training on for five of seven staff members as required. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a) Staff development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility provided documents, clinical record review, and staff interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Residents R1). This was identified for past non-compliance for Resident R1.Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed 10/13/25, indicated the facility is to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/11/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affect memory, thinking and interfere with daily life), and impulse disorder. Review of Resident R1's progress note dated 10/24/25, at 10:24 a.m. revealed that Resident R1 was complaining of increased hip pain. Hospice was consulted for further orders. New order was obtained for an X-ray. Family updated. Review of Resident R1's progress note dated 10/25/25, at 10:24 a.m. revealed X-ray results received. Acute displaced fracture of left proximal femur noted. Hospice notified and will call physician. At 2:46 p.m. Resident R1 was sent to Acute care hospital for evaluation and treatment.During an interview on 12/3/25, at 11:59 a.m. the Director of Nursing (DON) stated that she was made aware of the fracture and arrived at facility after receiving notification of event to start an investigation. DON stated that witness statements were gathered, and staff interviews were conducted. We didn't know he had a previous fall on 10/23/25, or that the Alleged Perpetrator Licensed Practical Nurse (LPN) Employee E1 threw him back to bed after he fell out of bed. While gathering statements and conducting an investigation, Activity Aide Employee E2 came up to me and described an incident that happened concerning Resident R1. Review of a written statement indicated that Activity Aide Employee E2 stated the following: I was in the room with another resident. I turned around and Resident R1 fell out of bed. I ran to get a nurse. LPN Employee E1 was who I got. I told her that Resident R1 had just fallen. LPN Employee E1 said Again, He's always falling. I don't know where his aide was and sat there. I asked her if she wanted me to help. LPN Employee E1 said I suppose. We went to the room. I took him under his right arm to lift him, and she grabbed the back of his pants and threw him on to the bed. LPN Employee E1 just walked out of the room. I stayed there to see if he was alright. I asked him if he was ok. He just shook his head yes. During a review of Resident R1's clinical record failed to include a fall from bed or any notification or documentation of incident. Review of documentation provided by the facility indicated that LPN Employee E1 was suspended pending investigation and was terminated on 11/4/25. The facility implemented a plan of correction that included the following: - Facility initiated whole house audits on 10/25/25, of all incidents/risk for any indications of abuse.- Facility initiated whole house audits on 10/25/25, of all residents for concerns of abuse/neglect.- Facility initiated whole house education on 10/25/25, on abuse/neglect, and reporting requirements.- Education initiated on 10/25/25, and provided to all nursing staff on assessing residents' post fall, proper notification, and monitoring.- Facility will audit 15 residents weekly for signs and symptoms of abuse by examination or interview, to be completed weekly for three weeks and then monthly for two months.- QAPI (Quality Assurance Performance Improvement) was conducted on 10/25/25. During an interview on 12/4/25, at 10:35 a.m. LPN Employee E3 stated she was educated on abuse, neglect, falls and reporting. We call for the Registered Nurse (RN) so they can assess the resident before getting them off the floor. I would not pick them up and not report a fall. During an interview on 12/4/25, at 10:47 a.m. LPN Employee E4 stated, I would get the RN supervisor. Don't move the residents unless they are in a position of getting hurt. I don't know if they had a break or injury so I would not move them. The facility has demonstrated compliance with the above since 10/25/25. Information was verified via review of Plan of Correction binder. During an interview on 12/4/25, at 12:15 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are protected from abuse or neglect and fall protocols. During an interview on 12/4/25, at 12:20 p.m. the Nursing Home Administrator, and Director of Nursing confirmed the facility failed to protect residents from neglect for one of three residents (Residents R1). 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.28 Pa. Code 211.10(a)(c.)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, a facility tour, and staff and resident interview it was determined that the facility failed to implement transmission-based precautions and test for scabies for two of four residents (Residents R1 and R2).Findings include:The facility Head Lice and Scabies Exposure and Treatment policy dated 7/2/25 and last reviewed 10/13/25, indicated it is the policy of the facility to ensure residents who contract scabies are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. Human scabies is caused by the human itch mite. It is contagious and can be transmitted by direct prolong skin contact with an affected person. Proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. The nurse will assess the resident who complaints of signs and symptoms of scabies (such as itching, scratching, papular rash, or burrows). The nurse will notify the practitioner of the findings to obtain a treatment regimen for the specific infestation. The infested resident will be placed in a single occupancy room away from to her residents to avoid transmission. Staff will follow appropriate transmission based precautions, including PPE, when providing care to affected residents. Staff or residents who may have had potential contact with affected residents should be assessed for signs of scabies. Review of the facility's report submitted to the Department of Health on 8/20/25, revealed two separate residents and three staff members have developed a rash of unknown cause. Rash an petechiae appearance with small raised bumps that are itchy. PPE provided and worn by all staff members while rash is present. The report failed to include the resident or staff member names. Review of the facility's August Infection Surveillance tracking revealed Resident R3 and Resident R4 were being treated with Ivermectin (treatment for scabies), and symptoms of itching began on 8/19/25. Review of Resident R1's admission record indicated the resident was admitted on [DATE], and readmitted on [DATE]. Review of Resident R1's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/24/25, indicated she had diagnoses that included high blood pressure, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and retention of urine. Review of Resident R1's progress note dated 9/25/25, revealed the resident had a raised rash noted on the left side of trunk, under axillary area to hip. Right side of trunk, petechiae noted mid rib area. Review of Resident R1's follow up note entered by Certified Registered Nurse Practitioner (CRNP), Employee E1 dated 9/29/25, revealed Resident R1 was evaluated for a rash. Resident R1 had a generalized rash on their torso, appears to have scratched at it also. The rash was described as a macular rash with linear excoriations. Review of Resident R1's progress note dated 10/12/25, revealed the resident was picking and scratching at bilateral upper extremities. Review of Resident R1's progress note dated 10/20/25, revealed the resident continues to scratch at both arms, chest, and armpits. Residents bedding had to be changed due to it being covered with blood. Review of Resident R1's physician orders from 9/29/25, to 10/21/25, failed to include an order for a skin scraping to rule out scabies or contact precautions. During an interview on 10/21/25, at 10:31 a.m. Licensed Practical Nurse, Employee E2 was asked if they had a concern for scabies in the facility. LPN, Employee E2 responded Yes, I have concerns, I actually had them. LPN, Employee E2 indicated Resident R1 and R2 have been itching like crazy.During an observation on 10/21/25, 10:51 a.m. Resident R1 was observed sleeping in bed in a double occupancy room. A visible rash was observed on the resident's left shoulder. A scabbed area was observed on the resident's right forearm and right ring finger. No contact precautions signage was observed posted at the entrance of Resident R1's door. During an interview on 10/21/25, at 10:53 AM Nurse Aide, Employee E3 stated Resident R1 itches all the time. NA, Employee E3 also indicated Resident R2 was complaining of a rash. Review of Resident R2's admission record indicated the resident was admitted on [DATE]. Review of Resident R2's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/13/25, indicated she had diagnoses that included rash and other nonspecific skin eruption, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and depression. Review of Resident R2's progress note dated 9/10/25, revealed the resident stated they feel itchy, states they developed a rash. A slight red, rash noted on bilateral upper extremities, abdomen, and back, patchy areas. Review of Resident R2's physician orders from 9/29/25, to 10/21/25, failed to include an order for a skin scraping to rule out scabies or contact precautions.During an interview and observation on 10/21/25, at 10:56 a.m. Resident R2 was observed in a room with two other roommates. Resident R2 had a visible raised rash on both arms and upper thighs, abdomen, and back. Resident R2 stated the rash started about a month ago on their upper thighs. Resident R2 stated no scapings have been completed to rule out scabies, although they were told it would be completed. Resident R2 was observed itching their back and scratching their arms during the interview. Contact isolation signage was not observed at the entrance of the resident's door. During an interview on 10/21/25, at 12:16 p.m. Infection Preventionist (IP), Employee E4 confirmed there was a possible outbreak of scabies in August 2025. Resident R3 and R4 were treated. IP, Employee E4 stated signs and symptoms of scabies include a rash and itching and contact precautions must be implemented because we do not want that to spread. IP, Employee E4 stated they were aware Resident R1 was itching and that they were on hospice and confirmed Resident R1 was never tested for scabies. IP, Employee E4 stated I am unsure why Resident R1 was not tested. IP, Employee E4 indicated they were unaware Resident R2 was itching. During an interview on 10/21/25, at 2:35 p.m. information was disseminated to the Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to implement transmission-based precautions and test for scabies for two of four residents (Residents R1 and R2).28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.28 (b)(1)(e)(1) Management.28 Pa Code: 211.10 (d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for two of four residents (Resident R1 and R2).Findings include: Review of Resident R1's admission record indicated the resident was admitted on [DATE], and readmitted on [DATE]. Review of Resident R1's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/24/25, indicated she had diagnoses that included high blood pressure, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and retention of urine. Review of Resident R1's progress note dated 9/25/25, revealed the resident had a raised rash noted on the left side of trunk, under axillary area to hip. Right side of trunk, petechiae noted mid rib area. Review of Resident R1's follow up note entered by Certified Registered Nurse Practitioner (CRNP), Employee E1 dated 9/29/25, revealed Resident R1 was evaluated for a rash. Resident R1 had a generalized rash on their torso, appears to have scratched at it also. The rash was described as a macular rash with linear excoriations. Review of Resident R1's progress note dated 10/12/25, revealed the resident was picking and scratching at bilateral upper extremities. Review of Resident R1's physician order dated 10/15/25, indicated to administer 25 milligram (mg) of hydroxyzine HCL, one tablet by mouth every eight hours as needed for itching. Review of Resident R1's progress note dated 10/20/25, revealed the resident continues to scratch at both arms, chest, and armpits. Residents bedding had to be changed due to it being covered with blood. Review of Resident R1's October 2025 Medication Administration Record revealed the resident did not receive 25 mg hydroxyzine HCL for itching from 10/15/25, to 10/20/25. During an interview on 10/21/25, at 1:38 p.m. Licensed Practical Nurse (LPN), Employee E5 confirmed Resident R1 was ordered hydroxyzine for itching and the facility failed to administer the medication as ordered. During an interview on 10/21/25, at 10:31 a.m. LPN, Employee E2 indicated Resident R1 and R2 have been itching like crazy. During an observation on 10/21/25, 10:51 a.m. Resident R1 was observed sleeping in bed in a double occupancy room. A visible rash was observed on the resident's left shoulder. A scabbed area was observed on the resident's right forearm and right ring finger. During an interview on 10/21/25, at 10:53 AM Nurse Aide, Employee E3 stated Resident R1 itches all the time. NA, Employee E3 also indicated Resident R2 was complaining of a rash and itching. Review of Resident R2's admission record indicated the resident was admitted on [DATE]. Review of Resident R2's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 9/13/25, indicated she had diagnoses that included rash and other nonspecific skin eruption, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and depression. Review of Resident R2's progress note dated 9/10/25, revealed the resident stated they feel itchy, states they developed a rash. A slight red, rash noted on bilateral upper extremities, abdomen, and back, patchy areas. Review of Resident R2's physician order dated 9/23/25, indicated to apply hydrocortisone external 1% topical cream to left arm every 12 hours as needed for rash. The order was discontinued on 9/24/25. Review of Resident R2's physician order dated 10/15/25, indicated to apply hydrocortisone external 1% topical cream to affected areas every 12 hours as needed for rash. A total of 22 days after it was discontinued. Review of Resident R2's physician order dated 10/15/25, indicated to administer 25 milligram (mg) of hydroxyzine HCL, one tablet by mouth every eight hours as needed for itching. Review of Resident R2's October 2025 Medication Administration Record revealed the resident did not receive 25 mg hydroxyzine HCL for itching as ordered from 10/15/25, to 10/21/25. During an interview and observation on 10/21/25, at 10:56 a.m. Resident R2 had a visible raised rash on both arms and upper thighs, abdomen, and back. Resident R2 stated the rash started about a month ago on their upper thighs. Resident R2 indicated staff do nothing to help with the itching. Resident R2 was observed itching their back and scratching their arms during the interview. During an interview on 10/21/25, at 1:38 p.m. Licensed Practical Nurse (LPN), Employee E5 confirmed Resident R2 was ordered hydroxyzine for itching and the facility failed to administer the medication as ordered. During an interview on 10/21/25, at 2:35 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to provide medications as ordered by the physician for two of four residents (Resident R1 and R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record and staff interview it was determined that the facility failed to ensure that in preparation for a room change each resident/responsible party received written notice, including the reason for the change before the resident room was changed for one of three residents (Resident R1).Findings include: Review of facility policy Notification of Changes dated 7/1/25, indicated the purpose of this policy is to ensure the facility promptly informs the resident, physician, and notifies the resident's representative when there is a change requiring notification. Circumstances requiring notification include accidents, significant changes, the need to change treatment, a transfer or discharge, and a notice of room change. Review of Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/13/25, indicated diagnosis of anxiety (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and muscle weakness. Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R1's BIMS score was a 12 indicating Resident R1 was moderately impaired. Review of Resident R1's clinical record progress notes indicated on 7/15/25, that Resident R1 was transferred to the third floor with limited access to the elevator. Resident R1 was moved from second floor, resident is not happy at the moment, but willing to try this change. Review of Resident R1's clinical record failed to indicate that responsible party was notified of room change on 7/15/25. During an interview on 8/18/25, at 2:52 p.m. admission Employee E1 stated that Resident R1 had to be moved for safety reasons and did not ask/give options to the resident's responsible party prior to move. During an interview on 8/18/25, at 3:15 p.m. Director of Nursing confirmed that the facility failed to ensure that in preparation for a room change each resident/responsible party received written notice, including the reason for the change before the resident room was changed for one of three (Resident R1). 28 Pa. Code 201.29(a)(c.3)(1) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of six residents (Resident R1).Findings include: Review of the facility Elopements and Wandering Residents dated 7/1/25, indicated the facility ensures that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care addressing the unique factors contributing to wandering or elopement risk. The facility shall implement interventions to reduce risks and modify interventions when necessary. Review of Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/13/25, indicated diagnosis of anxiety (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and muscle weakness. Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R1's BIMS score was a 12 indicating Resident R1 was moderately impaired. Review of Resident R1's Elopement Evaluation Form dated 7/22/25, indicated resident wanders through facility or prior residence, but does not leave interior setting. Elopement score was 13, indicating resident is a risk for elopement. During a review of Resident R1's progress note dated 7/15/25, indicated the following: - Received a phone call from dietary director that Resident R1 helped himself into the kitchen and took a tray and a few cups back to the second floor with him. She advised me that he always goes into the kitchen and has been told multiple times that he was not permitted in there due to safety concerns. To prevent injury or accident at this time, Resident R1 was transferred to the third floor with limited access to the elevator. During an interview on 8/18/25, Dietary Manager Employee E2 stated that on 7/15/25, employee was sitting in her office and observed Resident R1 head towards the kitchen. He asked for a tray and two coffee mugs. Resident R1 stated he wanted to show his roommate how to put his finished tray onto the food cart like he does. Dietary Manager Employee E2 educated resident that was not a good idea and escorted resident back to unit. During a review of Resident R1's clinical record, the facility failed to have a physical assessment completed of resident upon return to unit, and the physician and the resident's responsible party were not made aware of incident on 7/15/25.During an interview on 8/18/25, at 11:57 a.m. Director of Nursing (DON) confirmed that Resident R1 has a history of wandering, he did go into an area that was not designated for residents, and that the resident was identified in the area by a dietary staff member who escorted resident back to the nursing unit. During an interview on 8/18/25, at 2:30 p.m. DON confirmed that the facility failed to provide adequate supervision to prevent elopement and failed to complete proper assessments and notifications after an incident occurs for one of six residents (Resident R1). 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for one of six residents identified as high risk for wandering/elopement (Residents R1). Findings included: Review of the facility Care Plan Revisions Upon Status Change dated 7/1/25, indicated this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Review of the facility Elopements and Wandering Residents dated 7/1/25, indicated the facility ensures that residents who exhibit wandering behavior and are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered care addressing the unique factors contributing to wandering or elopement risk. The facility shall implement interventions to reduce risks and modify interventions when necessary. Review of Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 clinical record MDS (minimum data set a periodic assessment of resident needs) dated 6/13/25, indicated diagnosis of anxiety (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), (are a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and muscle weakness. Resident R1's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R1's BIMS score was a 12 indicating Resident R1 was moderately impaired. Review of Resident R1's Elopement Evaluation Form dated 7/22/25, indicated resident wanders through facility or prior residence, but does not leave interior setting. Elopement score was 13, indicating resident is a risk for elopement. Review of Resident R1's care plan revised on 7//22/25, indicated resident exhibits wandering. Intervention included: - Administer medication as ordered- Initiate psychiatric evaluation as needed- Initiate psychology evaluation as needed Review of Resident R1's care plan did not identify any resident person-centered interventions and/or goals specific to the resident in the wandering care plan. During an interview on 8/18/25, at 1:46 p.m. Director of Nursing confirmed the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for one of six residents identified as high risk for wandering/elopement (Residents R1). 28 Pa. Code 201.24(e)(1)(5) Admissions Policy28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration for one of two residents reviewed (Resident R1) which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1.
Findings include:
Review of the facility's Registered Nurse (RN) job description indicated the RN will prepare and administer medications as ordered by the physician.
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed:
-
Right resident
-
Right drug
-
Right dose
-
Right route
-
Right time
-
Right documentation
Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and, weakness.
Review of Resident R1's progress note dated 5/24/25, at 10:56 a.m. indicated that Resident R1 had been given the wrong medications that included amiodarone (medication used to regulate abnormal heart rhythms). Resident did not receive his own medications. Resident is complaining of mild chest pain and shortness of breath which started after med was given. Diagnosis, Assessment/Plan: Failure in dosage during medical care. This is an acute new problem. Condition is guarded given multiple meds including amiodarone, now symptomatic will send to ER (Emergency Room) for close monitoring. Orders: Transfer to emergency department for med error with amiodarone and complaints of chest pain and shortness of breath.
Review of Resident R1's clinical record revealed that resident was not ordered amiodarone.
Review of a written statement dated 5/24/25, indicated that Registered Nurse (RN) Employee E1 stated the following: I went into the room to give medication and gave the wrong medication to Resident R1. I realized at once I made a mistake. I assessed patient and got vitals and called for supervisor. I didn't realize it was 3 person room at this time. I try to double check myself.
Review of documentation provided by the facility indicated that RN Employee E1 was suspended pending investigation, and opted to resign.
The facility implemented a plan of correction that included the following:
·
Facility initiated education on 5/24/25, for all nursing staff including Registered Nurse's (RN's), and Licensed Practical Nurses (LPN's) for Safe Medication Administration. All nurses completed training and a quiz to demonstrate their understanding.
·
Reviewed RN Employee E1's file to ensure she had received education on Safe Medication Administration prior to the incident. This was verified to have been completed 2/12/25.
·
Evaluated all other residents on the same unit as Resident R1 to observe for adverse effects, which included obtaining vitals every four hours for 24 hours.
·
Ensured resident photos are up to date in the Electronic Charting System, which was completed on 5/28/25.
·
Audit medication carts starting 6/2/25.
·
Randomly observe Medication Pass to ensure 6 Rights of medication administration are being completed prior to medication administration, which began on 5/27/25.
·
QAPI (Quality Assurance Performance Improvement) conducted 5/24/25.
During an interview on 7/1/25, at 9:50 a.m. LPN Employee E2 verified that he had received education on Safe Medication Administration and was able to verbalize understanding, adding You have to double check.
During an interview on 7/1/25, at 9:56 a.m. RN Employee E3 verified that she had received education on Safe Medication Administration and was able to verbalize understanding, adding I check the orders at least twice, as well as the photo in the chart.
During an interview on 7/1/25, at 10:06 a.m. LPN Employee E4 verified that she had received education on Safe Medication Administration and was able to verbalize understanding. She added that all residents have an updated picture in their chart, and that you have to look at their picture to make sure you have the right person.
The facility has demonstrated compliance with the above since 5/24/25. Information was verified via review of Plan of Correction binder.
During an interview on 7/1/25, at 1:42 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration.
During an interview on 7/1/25, at 3:08 p.m. the Nursing Home Administrator, and Director of Nursing confirmed the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration, which resulted in harm for Resident R1.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1.
Findings include:
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed:
-
Right resident
-
Right drug
-
Right dose
-
Right route
-
Right time
-
Right documentation
Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and, weakness.
Review of Resident R1's progress note dated 5/24/25, at 10:56 a.m. indicated that Resident R1 had been given the wrong medications that included amiodarone (medication used to regulate abnormal heart rhythms). Resident did not receive his own medications. Resident is complaining of mild chest pain and shortness of breath which started after med was given. Diagnosis, Assessment/Plan: Failure in dosage during medical care. This is an acute new problem. Condition is guarded given multiple meds including amiodarone, now symptomatic will send to ER (Emergency Room) for close monitoring. Orders: Transfer to emergency department for med error with amiodarone and complaints of chest pain and shortness of breath.
Review of Resident R1's clinical record revealed that resident was not ordered amiodarone.
Review of a written statement dated 5/24/25, indicated that Registered Nurse (RN) Employee E1 stated the following: I went into the room to give medication and gave the wrong medication to Resident R1. I realized at once I made a mistake. I assessed patient and got vitals and called for supervisor. I didn't realize it was 3 person room at this time. I try to double check myself.
Review of documentation provided by the facility indicated that RN Employee E1 was suspended pending investigation, and opted to resign.
The facility implemented a plan of correction that included the following:
·
Facility initiated education on 5/24/25, for all nursing staff including Registered Nurse's (RN's), and Licensed Practical Nurses (LPN's) for Safe Medication Administration. All nurses completed training and a quiz to demonstrate their understanding.
·
Reviewed RN Employee E1's file to ensure she had received education on Safe Medication Administration prior to the incident. This was verified to have been completed 2/12/25.
·
Evaluated all other residents on the same unit as Resident R1 to observe for adverse effects, which included obtaining vitals every four hours for 24 hours.
·
Ensured resident photos are up to date in the Electronic Charting System, which was completed on 5/28/25.
·
Audit medication carts starting 6/2/25.
·
Randomly observe Medication Pass to ensure 6 Rights of medication administration are being completed prior to medication administration, which began on 5/27/25.
·
QAPI (Quality Assurance Performance Improvement) conducted 5/24/25.
During an interview on 7/1/25, at 9:50 a.m. LPN Employee E2 verified that he had received education on Safe Medication Administration and was able to verbalize understanding, adding You have to double check.
During an interview on 7/1/25, at 9:56 a.m. RN Employee E3 verified that she had received education on Safe Medication Administration and was able to verbalize understanding, adding I check the orders at least twice, as well as the photo in the chart.
During an interview on 7/1/25, at 10:06 a.m. LPN Employee E4 verified that she had received education on Safe Medication Administration and was able to verbalize understanding. She added that all residents have an updated picture in their chart, and that you have to look at their picture to make sure you have the right person.
The facility has demonstrated compliance with the above since 5/24/25. Information was verified via review of Plan of Correction binder.
During an interview on 7/1/25, at 1:42 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration.
During an interview on 7/1/25, at 3:08 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were free from any significant medication errors for one of two residents, which resulted in harm for Resident R1.
28 Pa Code: 201.18 (b)(1)(3) Management
28 Pa Code: 211.10 (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, national accepted guidelines for Pressure Ulcers, and staff interview, it was determined that the facility failed to accurately assess pressure ulcers for one of three residents (Resident R2).
Findings include:
The facility policy Wound Treatment Management reviewed 12/3/24 indicated to promote wound healing of various wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards or practice and physician orders. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 5/22/25, indicated that Resident R2 had diagnoses that included thrombophilia(a condition where the blood has an increased tendency to clot), chronic embolism and rhabdomyolysis(condition where damaged muscle tissue breaks down, releasing its contents into the bloodstream).
Review of the clinical admission assessment dated [DATE], indicated that Resident R2 has a stage 2 pressure ulcer on coccyx, unstageable pressure ulcer right medial ankle and a blister left heel.
Review of physician orders dated 6/26/25 indicated Resident R2 did not have orders for these skin impairment's until 4/9/25.
During an interview on 7/1/25, at 2:30 p.m. the Director of Nursing confirmed the facility failed to accurately assess pressure ulcers for one of three residents as required.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for two of four residents (Resident R4 and Resident R5).
Findings include:
Review of facility's policy dated 11/27/24, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Review of Resident R4's admission record indicated resident was admitted to facility on 1/27/25, with the diagnosis of chronic pain, hemiplegia (paralysis of one side of the body), and weakness.
Review of Residents R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated the diagnoses were current.
Review of Resident R4's care plan dated 3/23/25, revealed the resident was at risk for alternation in nutrition and hydration. Interventions included to assist as needed, encourage food and fluid as ordered.
Review of Resident R4's Kardex (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on 6/10/25, revealed the resident required assistance with meals as needed.
Review of undated facility documentation titled Total Feeds on 6/10/25, revealed Resident R4 must be fed for meals.
During an interview on 6/10/25, at 12:32 p.m. Nurse Aide, Employee E2 was asked how to know which residents require assistance with meals. NA, Employee E2 stated It will populate a task, each person says set up, assist, or supervision.
During an observation on 6/10/25, at 12:32 p.m. the lunch cart arrived to the 2C nursing unit.
During an observation on 6/10/25, at 12:33 p.m. staff began passing trays to residents on the unit.
During an interview on 6/10/25, at 12:52 p.m. Resident R4 stated they don't come in to help. Resident R4 stated I asked NA, Employee E4 to put in my dentures and NA, Employee E4 wouldn't do it. Resident R4 stated I don't eat much, if I could feed myself, I would. That's why I am drinking Ensure. Resident R4's dentures were observed on the bed side dresser, not in reach of the resident.
During an observation on 6/10/25, at 1:02 p.m. NA, Employee E4 was observed picking up trays and placing them back on the lunch tray cart.
During observations completed on 6/10/25, from 12:21 p.m. to 1:03 p.m. Resident R4's door was closed. No staff member entered Resident R4's room.
During an interview on 6/10/25, at 1:04 p.m. NA, Employee E4 confirmed Resident R4 was not offered their meal tray once the cart arrived to the floor. NA, Employee E4 confirmed Resident R4's dentures were not put in.
During an interview on 6/10/25, at 1:07 p.m. Registered Nurse (RN), E3 indicated the nurse aides are expected to offer the residents meal once it arrives to the unit.
During an interview completed on 6/10/25, at 11:11 a.m. the Assistant Director of Nursing, Employee E1 confirmed that the facility failed to protect Resident R4 from neglect.
Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, diabetes (occurs when your blood sugar is too high).
Review of Resident R5's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses were current. Resident R5's Brief Interview for Mental Status (BIMS) assessment revealed the resident had a BIMS of 15, cognitively intact.
During an interview on 6/10/25, at 11:50 a.m. Resident R5 was sitting in a wheelchair in the resident's common area and stated there is not enough staff. Resident R5 stated I have to wait a long time when I put on my call bell, I have to be put on a bed pan, I have to wait a while to be put on, then I already go in my pants. Resident R5 stated when I sit in the dayroom, I pee my pants and have to sit in it. Resident R5 stated staff puts me in the day room a little before lunch, then I sit there until after dinner mostly every day. Resident R5 stated this occurs five out of seven days a week and by the time the brief is changed it is soak and wet. Some aides tell me, just go in the dayroom and poop and pee in your pants.
Review of Resident R5's June 2025 Documentation Survey Report v2 on 6/10/25, revealed the resident was incontinent of bladder on the following dates:
-6/1/25, at 11:57 a.m.
-6/2/25, at 8:56 a.m.
-6/7/25, at 8:02 a.m.
-6/8/25, at 10:23 a.m.
-6/10/25, at 2:38 p.m.
A further review of Resident R5's June 2025 Documentation Survey Report v2 failed to include evidence the resident was toileted on the night shift on 6/2/25, 6/5/25, and 6/7/25. The following was documented.
-6/1/25, Resident R5 was toileted at 11:56 a.m. then at 6:38 p.m. a total of 6 hours and 42 minutes later.
-6/2/25, Resident R5 was toileted at 8:56 a.m. then at 6:03 p.m. a total of 9 hours and 7 minutes later.
-6/3/25, Resident R5 was toileted at 9:03 a.m. then at 7:59 p.m. a total of 10 hours and 56 minutes later.
-6/4/25, Resident R5 was toileted at 11:42 a.m. then at 5:19 p.m. a total of 5 hours and 37 minutes later.
-6/5/25, Resident R5 was toileted at 9:56 a.m. then at 6:29 p.m. a total of 5 hours and 37 minutes later.
-6/6/25, Resident R5 was toileted at 7:57 a.m. then at 4:53 p.m. a total of 8 hours and 56 minutes later.
-6/7/25, Resident R5 was toileted at 9:12 a.m. then at 8:01 p.m. a total of 10 hours and 49 minutes later.
-6/8/25, Resident R5 was toileted at 10:23 a.m. then at 7:36 p.m. a total of 9 hours and 13 minutes later.
-6/9/25, Resident R5 was toileted at 6:16 a.m. then at 4:53 p.m. a total of 10 hours and 37 minutes later.
During an interview on 6/10/25, at 5:10 p.m. the Nursing Home Administrator confirmed that the facility failed to protect resident from neglect for two of four residents (Resident R4 and Resident R5).
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.10 (a) (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy, job descriptions, and resident and staff interviews, it was determined that the facility failed to have sufficient staff to provide nursing services including toileting for three of seven residents reviewed (Residents R5, R6, and R7).
Findings include:
Review of the facility's Activities of Daily Living (ADLs) policy dated 11/27/24, indicated care and services such as transferring and toileting will be provided. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good grooming and personal hygiene.
Review of the facility's undated Certified Nursing Assistant job description revealed major duties and responsibilities include performing activities of daily living (ADL) for residents in accordance with care plans and established policies and procedures, assist nursing staff in carrying out toileting program activities, and complete flow sheets daily to indicate the specified task was done. Additional tasks included to treat all residents with dignity and respect, and to follow appropriate safety and hygiene measures at all times to protect residents an themselves.
During an interview on 6/10/25, at 10:58 a.m. Registered Nurse (RN), Employee E8 was asked if they had a concern for staffing. RN, Employee E8 stated the facility uses a lot agency that is unreliable. RN, Employee E8 stated I work once a week. RN, Employee E8 was asked if they have to stay later than there scheduled shift on the days they work and RN, Employee E8 stated I have to stay later to document and due to not having enough staff to fill the spots.
During an interview on 6/10/25, at 11:18 a.m. Nurse Aide (NA), Employee E9 was asked if they had a concern for staffing and replied, the only real problem is night shift. NA, Employee E9 stated generally there is only one aide per unit. I feel a longer wait time for residents occurs when short staffed, anywhere from 15 to 30 minutes, maybe a little longer depending on the situation.
Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, diabetes (occurs when your blood sugar is too high).
Review of Resident R5's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses were current. Resident R5's Brief Interview for Mental Status (BIMS) assessment revealed the resident had a BIMS of 15, cognitively intact.
During an interview on 6/10/25, at 11:50 a.m. Resident R5 was sitting in a wheelchair in the resident's common area and stated there is not enough staff. Resident R5 stated I have to wait a long time when I put on my call bell, I have to be put on a bed pan, I have to wait a while to be put on, then I already go in my pants. Resident R5 stated when I sit in the dayroom, I pee my pants and have to sit in it. Resident R5 stated staff puts me in the day room a little before lunch, then I sit there until after dinner mostly every day. Resident R5 stated this occurs five out of seven days a week and by the time the brief is changed it is soak and wet. Some aides tell me, just go in the dayroom and poop and pee in your pants.
Review of Resident R5's June 2025 Documentation Survey Report v2 on 6/10/25, revealed the resident was incontinent of bladder on the following dates:
-6/1/25, at 11:57 a.m.
-6/2/25, at 8:56 a.m.
-6/7/25, at 8:02 a.m.
-6/8/25, at 10:23 a.m.
-6/10/25, at 2:38 p.m.
A further review of Resident R5's June 2025 Documentation Survey Report v2 failed to include evidence the resident was toileted on the night shift on 6/2/25, 6/5/25, and 6/7/25. The following was documented.
-6/1/25, Resident R5 was toileted at 11:56 a.m. then at 6:38 p.m. a total of 6 hours and 42 minutes later.
-6/2/25, Resident R5 was toileted at 8:56 a.m. then at 6:03 p.m. a total of 9 hours and 7 minutes later.
-6/3/25, Resident R5 was toileted at 9:03 a.m. then at 7:59 p.m. a total of 10 hours and 56 minutes later.
-6/4/25, Resident R5 was toileted at 11:42 a.m. then at 5:19 p.m. a total of 5 hours and 37 minutes later.
-6/5/25, Resident R5 was toileted at 9:56 a.m. then at 6:29 p.m. a total of 5 hours and 37 minutes later.
-6/6/25, Resident R5 was toileted at 7:57 a.m. then at 4:53 p.m. a total of 8 hours and 56 minutes later.
-6/7/25, Resident R5 was toileted at 9:12 a.m. then at 8:01 p.m. a total of 10 hours and 49 minutes later.
-6/8/25, Resident R5 was toileted at 10:23 a.m. then at 7:36 p.m. a total of 9 hours and 13 minutes later.
-6/9/25, Resident R5 was toileted at 6:16 a.m. then at 4:53 p.m. a total of 10 hours and 37 minutes later.
Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of high blood pressure, diabetes, and cardiac arrythmia (irregular heart rate).
Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/6/25, indicated diagnoses were current.
Review of Resident R6's care plan revealed the resident required an assist of two staff members for toileting.
During an interview on 6/10/25, at 11:30 a.m. Resident R6 stated They won't help me when I need it. Resident R6 stated At night, it's terrible here. Resident R6 stated Last night I had to wait a half hour. I got out of bed myself, it's so hard to get someone. I wheeled myself out. I took myself to bathroom. I waited forever to get back in bed. Resident R6 indicated every night I wait more than 30 minutes to use the bathroom. The resident stated the call light is turned on, they come in and say they have to get someone else, then they turn off the call light, then I still wait, and typically I fall asleep. Resident R6 stated there is only one aide on floor on overnights.
Review of the clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of high blood pressure, diabetes, and depression.
Review of Resident R7's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/24/25, indicated diagnoses were current.
Review of Resident R7's care plan dated 9/27/24, stated to encourage resident to sit on toilet to evacuate bowels if possible.
During an interview on 6/10/25, at 11:37 a.m. Resident R7 stated it can take staff a long time to respond to call bells. The resident stated I need assistance with reconnecting the oxygen tubing when going to the bathroom. Resident R7 indicated they have soiled themselves waiting to go to the bathroom. Resident R7 was asked how often that occurs and stated It happens a lot.
During an interview on 6/10/25, at 1:11 p.m. the Assistant DIrector of Nursing (ADON), was notified of the concerns realted to Resident R5, R6, and R7 not being toileted timely.
During an interview on 6/10/25, at 5:10 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient staff to provide nursing services including toileting for three of seven residents reviewed (Residents R5, R6, and R7).
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1)(4)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of three residents (Resident R5).
Findings include:
Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, diabetes (occurs when your blood sugar is too high).
Review of Resident R5's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses were current.
Review of Resident R5's physician order dated 5/23/25, indicated to consult dermatology for ongoing rash.
Review of Resident R5's clinical record revealed on 5/27/25, Medical Doctor, Employee E4 seen the resident for a monthly follow up. The resident was complaining of their chronic rash, that is getting worse. The resident's skin was observed to have a rash present, hands are scaly, very dry. It was indicated a skin scraping was completed of the resident's left hand. A dermatologist consult has been ordered.
Review of Resident R5's clinical record revealed on 5/30/25, Certified Registered Nurse Practitioner (CRNP), Employee E5 evaluated the resident for follow up of the rash. The rash was negative for scabies. Ongoing rash/pruritus to abdomen and left arm. It was indicated the resident was agreeable to a dermatologist appointment.
During an interview on 6/10/25, at 3:42 p.m. Resident R5 was observed with a rash on their face, upper chest, and arms. Resident R5's hands were visible dry and scaly. Resident R5 stated They don ' t know what it is. Resident R5 stated the rash had be ongoing for three weeks.
Review of Resident R5's clinical record on 6/10/25, failed to reveal evidence dermatology was consulted for Resident R5's ongoing rash as ordered. A total of 18 days since Resident R5 was ordered a dermatology consult.
During an interview on 6/10/25, at 3:48 p.m. Scheduler, Employee E6 was asked if dermatology had been consulted for Resident R5. Scheduler, Employee E6 stated I do handle appointments, and not that I am aware of. Scheduler, Employee E6 confirmed the facility failed to timely consult dermatology as ordered.
During an interview on 6/10/25, at 5:10 p.m. the Nursing Home Administrator confirmed the facility failed to schedule an appointment for outside services in a timely manner for one of two residents reviewed (Resident R5).
28 Pa. Code 211.12(d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for eight of 49 resident rooms (209, 212, 218, 219, 221, 302, 303, and 305).
Findings Include:
Review of the facility policy Safe and Homelike Environment indicated the facility will provide a safe, clean, comfortable, and homelike environment. The facility will provide and maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit.
Observations conducted on 6/10/25, from 2:32 p.m. to 2:59 p.m. with the Maintenance Director, Employee E7 revealed the following air temperatures:
2nd floor Nursing Floor
-room [ROOM NUMBER]-82.2 of degrees Fahrenheit
-room [ROOM NUMBER]-81.5 of degrees Fahrenheit
-room [ROOM NUMBER]-82.4 of degrees Fahrenheit
-room [ROOM NUMBER]-82.8 of degrees Fahrenheit
-room [ROOM NUMBER]-82.8 of degrees Fahrenheit
3nd floor Nursing Floor
-room [ROOM NUMBER]-83.5 of degrees Fahrenheit
-room [ROOM NUMBER]-82.0 of degrees Fahrenheit
-room [ROOM NUMBER]-82.4 of degrees Fahrenheit
During an interview on 6/10/25, at 5:11 p.m. the Nursing Home Adminstrator confirmed the facility failed to ensure comfortable air temperature levels were provided for eight of 49 resident rooms (209, 212, 218, 219, 221, 302, 303, and 305).
28 Pa. Code: 201.18(b)(3) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance, including eating and toileting for four of seven residents (Resident R4, R5, R6, and R7).
Findings include:
Review of the facility's Activities of Daily Living (ADLs) policy dated 11/27/24, indicated care and services such as eating, transferring, and toileting will be provided. A resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Review of the facility's undated Certified Nursing Assistant job description revealed major duties and responsibilities include performing activities of daily living (ADL) for residents in accordance with care plans and established policies and procedures, assist nursing staff in carrying out toileting program activities, and complete flow sheets daily to indicate the specified task was done. Additional tasks included to treat all residents with dignity and respect, and to follow appropriate safety and hygiene measures at all times to protect residents an themselves.
Review of Resident R4's admission record indicated resident was admitted to facility on 1/27/25, with the diagnosis of chronic pain, hemiplegia (paralysis of one side of the body), and weakness.
Review of Residents R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated the diagnoses were current.
Review of Resident R4's care plan dated 3/23/25, revealed the resident was at risk for alternation in nutrition and hydration. Interventions included to assist as needed, encourage food and fluid as ordered.
Review of Resident R4's Kardex (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) on 6/10/25, revealed the resident required assistance with meals as needed.
Review of undated facility documentation titled Total Feeds on 6/10/25, revealed Resident R4 must be fed for meals.
During an interview on 6/10/25, at 12:32 p.m. Nurse Aide, Employee E2 was asked how to know which residents require assistance with meals. NA, Employee E2 stated It will populate a task, each person says set up, assist, or supervision.
During an observation on 6/10/25, at 12:32 p.m. the lunch cart arrived to the 2C nursing unit.
During an observation on 6/10/25, at 12:33 p.m. staff began passing trays to residents on the unit.
During an interview on 6/10/25, at 12:52 p.m. Resident R4 stated they don't come in to help. Resident R4 stated I asked NA, Employee E4 to put in my dentures and NA, Employee E4 wouldn't do it. Resident R4 stated I don't eat much, if I could feed myself, I would. That's why I am drinking Ensure. Resident R4's dentures were observed on the bed side dresser, not in reach of the resident.
During an observation on 6/10/25, at 1:02 p.m. NA, Employee E4 was observed picking up trays and placing them back on the lunch tray cart.
During observations completed on 6/10/25, from 12:21 p.m. to 1:03 p.m. Resident R4's door was closed. No staff member entered Resident R4's room.
During an interview on 6/10/25, at 1:04 p.m. NA, Employee E4 confirmed Resident R4 was not offered their meal tray once the cart arrived to the floor.
During an interview on 6/10/25, at 1:07 p.m. Registered Nurse (RN), E3 indicated the nurse aides are expected to offer the residents meal once it arrives to the unit.
During an interview completed on 6/10/25, at 11:11 a.m. the Assistant Director of Nursing, Employee E1 confirmed that the facility failed to provide eating assistance for Resident R4.
Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, diabetes (occurs when your blood sugar is too high).
Review of Resident R5's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses were current. Resident R5's Brief Interview for Mental Status (BIMS) assessment revealed the resident had a BIMS of 15, cognitively intact.
During an interview on 6/10/25, at 11:50 a.m. Resident R5 was sitting in a wheelchair in the resident's common area and stated there is not enough staff. Resident R5 stated I have to wait a long time when I put on my call bell, I have to be put on a bed pan, I have to wait a while to be put on, then I already go in my pants. Resident R5 stated when I sit in the dayroom, I pee my pants and have to sit in it. Resident R5 stated staff puts me in the day room a little before lunch, then I sit there until after dinner mostly every day. Resident R5 stated this occurs five out of seven days a week and by the time the brief is changed it is soak and wet. Some aides tell me, just go in the dayroom and poop and pee in your pants.
Review of Resident R5's June 2025 Documentation Survey Report v2 on 6/10/25, revealed the resident was incontinent of bladder on the following dates:
-6/1/25, at 11:57 a.m.
-6/2/25, at 8:56 a.m.
-6/7/25, at 8:02 a.m.
-6/8/25, at 10:23 a.m.
-6/10/25, at 2:38 p.m.
A further review of Resident R5's June 2025 Documentation Survey Report v2 failed to include evidence the resident was toileted on the night shift on 6/2/25, 6/5/25, and 6/7/25. The following was documented.
-6/1/25, Resident R5 was toileted at 11:56 a.m. then at 6:38 p.m. a total of 6 hours and 42 minutes later.
-6/2/25, Resident R5 was toileted at 8:56 a.m. then at 6:03 p.m. a total of 9 hours and 7 minutes later.
-6/3/25, Resident R5 was toileted at 9:03 a.m. then at 7:59 p.m. a total of 10 hours and 56 minutes later.
-6/4/25, Resident R5 was toileted at 11:42 a.m. then at 5:19 p.m. a total of 5 hours and 37 minutes later.
-6/5/25, Resident R5 was toileted at 9:56 a.m. then at 6:29 p.m. a total of 5 hours and 37 minutes later.
-6/6/25, Resident R5 was toileted at 7:57 a.m. then at 4:53 p.m. a total of 8 hours and 56 minutes later.
-6/7/25, Resident R5 was toileted at 9:12 a.m. then at 8:01 p.m. a total of 10 hours and 49 minutes later.
-6/8/25, Resident R5 was toileted at 10:23 a.m. then at 7:36 p.m. a total of 9 hours and 13 minutes later.
-6/9/25, Resident R5 was toileted at 6:16 a.m. then at 4:53 p.m. a total of 10 hours and 37 minutes later.
Review of the clinical record revealed that Resident R6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of high blood pressure, diabetes, and cardiac arrythmia (irregular heart rate).
Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/6/25, indicated diagnoses were current.
Review of Resident R6's care plan revealed the resident required an assist of two staff members for toileting.
During an interview on 6/10/25, at 11:30 a.m. Resident R6 stated They won't help me when I need it. Resident R6 stated At night, it's terrible here. Resident R6 stated Last night I had to wait a half hour. I got out of bed myself, it's so hard to get someone. I wheeled myself out. I took myself to bathroom. I waited forever to get back in bed. Resident R6 indicated every night I wait more than 30 minutes to use the bathroom. The resident stated the call light is turned on, they come in and say they have to get someone else, then they turn off the call light, then I still wait, and typically I fall asleep. It was indicated there is only one aide on floor on overnights.
A review of Resident R6's June 2025 Documentation Survey Report v2 on 6/10/25, failed to include evidence the resident was toileted for 14 of 27 shifts from 6/1/25, to 6/9/25.
Review of the clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of high blood pressure, diabetes, and depression.
Review of Resident R7's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 5/24/25, indicated diagnoses were current.
Review of Resident R7's care plan dated 9/27/24, stated to encourage resident to sit on toilet to evacuate bowels if possible.
During an interview on 6/10/25, at 11:37 a.m. Resident R7 stated it can take staff a long time to respond to call bells. The resident stated they need assistance with reconnecting the oxygen tubing when going to the bathroom. Resident R7 indicated they have soiled themselves waiting to go to the bathroom. Resident R7 was asked how often that occurs and stated It happens a lot.
A review of Resident R7's June 2025 Documentation Survey Report v2 on 6/10/25, failed to include evidence the resident was toileted for 12 of 27 shifts from 6/1/25, to 6/9/25.
During an interview on 6/10/25, at 5:10 p.m. the Nursing Home Administrator confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance, including eating and toileting for four out of seven residents (Resident R4, R5, R6, and R7).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(2.1) Management.

Based on a review of facility documents, observations, and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of two nursing floors (Second floor).
Findings include:
A review of facility policy Safe and Homelike Environment dated 12/3/24, indicated that residents are provided with a safe, clean, comfortable, and homelike environment.
During an observation on 3/5/25, from 10::10 a.m. through 10:20 a.m. the following was revealed:
-Second Floor C4 shower room, brown/rust colored ceiling tiles were noted
-Second Floor C3 bathroom an area of approximately 15 inches wide and four inches high of cracked and peeling plaster was noted on the wall.
-Second Floor Restroom across from nurses' station (far left) had brown stained ceiling tiles, and an area of approximately 24 inches across of chipped paint and plaster.
-Second Floor Restroom across from the nurses' station (middle) had an area of approximately 24 inches across of chipped paint and plaster.
-Second Floor Restroom across form the nurses' station (far right) had an area of approximately 18 inches across of chipped paint and plaster.
During an interview on 3/5/24, at 1:36 p.m. the Director of Nursing confirmed that the facility failed to create a home-like environment.
28 Pa. Code: 201.18(b)(3) Management
F

Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three of ten residents (Residents R1, R2, and R3).
Findings Include:
Review of the facility policy, Resident Showers dated 12/3/24, indicated residents will be provided showers as per request or as per facility schedule protocols and based on resident safety.
During an interview on 3/4/25, at 10:13 a.m. Resident R1 stated I didn't get a shower on Monday because they were low on staff. I am scheduled for showers on Mondays and Thursdays. Now I have to wait until Thursday. This isn't the first time this has happened. It happens a lot.
Review of Resident R1's clinical record revealed a nurses note dated 2/27/25, that stated the following Shower twice weekly on Monday and Thursday's daylight shift in the morning every Monday, Thursday. Client requesting to be a daylight shower Unable to shower due to having 51 residents to 4 Nas (nurse aides) and 2 nurses for the second floor.
During an interview on 3/5/25, at 10:18 a.m. Nurse Aide Employee E1 stated All us aides are tired of working short. Showers are getting missed and there is no time to do anything extra.
During an interview on 3/5/25, at 10:35 a.m. Resident R2 stated I don't always get showers. It depends on how much staff they have.
During an interview on 3/5/25, at 10:47 a.m. Resident R3 replied Not always, when she was asked if she was getting showers.
Review of clinical record revealed that Resident R3 has a physician's order dated 7/8/24, to shower twice weekly on Tuesday and Friday on the night shift (Wednesday and Saturday Mornings).
Review of clinical record revealed Shower Tasks was not completed for Resident R3 on 2/12/25, 2/15/25, 2/19/25, and 2/22/25.
During an interview on 3/5/25, at approximately 1:30 p.m. the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three of ten residents.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code: 201.20(a) Staff development.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, facility documents, resident interview, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1).
Findings include:
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed:
-
Right resident
-
Right drug
-
Right dose
-
Right route
-
Right time
-
Right documentation
Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included influenza (flu- a viral infection of the nose, throat, and lungs), resistant hypertension (uncontrolled high blood pressure), and weakness.
Review of Resident R1's progress note dated 2/1/25, at 10:00 a.m. indicated that Resident R1 had been given the wrong medication, and that family and physician were made aware.
Review of Resident R1's progress note dated 2/1/25, at 1058 a.m. indicated that Resident R1 Mistakenly received medication for her roommate (Resident R2), and that vital signs were being monitored every shift for three days.
Review of Resident R2's clinical record revealed that her scheduled medications that morning included amlodipine besylate 5 milligrams (mg) (a medication used to treat high blood pressure), furosemide 20 mg (a water pill that prevents the body from absorbing too much salt, causing it to be passed in the urine), and potassium chloride extended release 20 milliequivalents (a mineral supplement used to treat low amounts of potassium in the blood).
Review of Resident R1's clinical record revealed that she was not ordered any of the above medications.
Review of a written statement dated 2/4/25, indicated that Registered Nurse (RN) Employee E1 Did not realize that there were two residents in the room as the curtain was pulled and there was a new admission.
During an interview on 2/6/25, at 11:10 a.m. Resident R1 confirmed that she had received Resident R2's medication by mistake. Resident R1 stated that although she is fine now, the event was scary.
During an interview on 2/6/25, at 2:17 p.m. RN Employee E1 stated that she was responsible for giving Resident R1 the wrong medication, and that she did not see that there were two residents in the room as the curtain was pulled on the other side which obstructed her view of Resident R2. RN Employee E1 stated that she realized her mistake immediately.
During an interview on 2/6/25, at 2:22 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were free from any significant medication errors for one of two residents. (Resident R1).
28 Pa. Code 201.29 (j) Resident rights.
28 Pa Code: 201.18 (b)(1)(3) Management
28 Pa Code: 211.10 (d) Resident care policies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of two residents reviewed (Resident R1).
Findings include:
Review of the facility's Registered Nurse (RN) job description indicated the RN will prepare and administer medications as ordered by the physician.
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed:
-
Right resident
-
Right drug
-
Right dose
-
Right route
-
Right time
-
Right documentation
Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included influenza (flu- a viral infection of the nose, throat, and lungs), resistant hypertension (uncontrolled high blood pressure), and weakness.
Review of Resident R1's progress note dated 2/1/25, at 10:00 a.m. indicated that Resident R1 had been given the wrong medication, and that family and physician were made aware.
Review of Resident R1's progress note dated 2/1/25, at 1058 a.m. indicated that Resident R1 Mistakenly received medication for her roommate (Resident R2), and that vital signs were being monitored every shift for three days.
Review of Resident R2's clinical record revealed that her scheduled medications that morning included amlodipine besylate 5 milligrams (mg) (a medication used to treat high blood pressure), furosemide 20 mg (a water pill that prevents the body from absorbing too much salt, causing it to be passed in the urine), and potassium chloride extended release 20 milliequivalents (a mineral supplement used to treat low amounts of potassium in the blood).
Review of Resident R1's clinical record revealed that she was not ordered any of the above medications.
Review of a written statement dated 2/4/25, indicated that Registered Nurse (RN) Employee E1 Did not realize that there were two residents in the room as the curtain was pulled and there was a new admission.
During an interview on 2/6/25, at 11:10 a.m. Resident R1 confirmed that she had received Resident R2's medication by mistake. Resident R1 stated that although she is fine now, the event was scary.
During an interview on 2/6/25, at 2:17 p.m. RN Employee E1 stated that she was responsible for giving Resident R1 the wrong medication, and that she did not see that there were two residents in the room as the curtain was pulled on the other side which obstructed her view of Resident R2. RN Employee E1 stated that she realized her mistake immediately.
During an interview on 2/6/25, at 2:22 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services to meet the accepted standards of practice as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observations and staff interview, it was determined the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units (Second, and Third Floor).
Findings include:
Observation by the facilities entrance bulletin board had required postings posted, however residents would be required to descend a staircase consisting of nine steps to view the postings and climb back up nine step to get back to the Main Floor.
Observation on the nursing care units on the second and third floor failed to include information on how to apply for Medicare and Medicaid.
During an interview on 12/19/24, at 1:39 p.m. Nursing Home Administrator confirmed that the facility failed to post above required information where it is easily accessible to residents to refer to, if needed, on two of two nursing units (Second and Third Floor).
28 Pa. Code: §201.29(i) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide timely dental services for one of two residents reviewed (Resident R45).
Findings include:
Review of facility policy Dental Services dated 12/3/24, indicated the facility is to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services includes services needed to treat and episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist.
Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/26/24, indicated diagnoses of high blood pressure, muscle weakness, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression, and decrease in functional abilities).
Review of a physician order dated 11/26/24, indicated dental consult ASAP (as soon as possible), for abscess (a swollen area within body tissue, containing an accumulation of pus)/infection.
Review of Resident R45's care plan dated 11/27/24, indicated the resident is on antibiotic therapy related to dental abscess.
Review of a progress note dated 11/26/24, at 8:14 a.m. completed by Licensed Practical Nurse (LPN) Employee E20 stated, During morning medication pass, noted philtrum area (space between nose and upper lip) to be swelled and tender to touch. Client opened mouth and noted a sore on the top left side of mouth. Client is able to chew food/eat/drink. Educated client if she I having difficulty eating/chewing to let staff know so diet can be changed accordingly. Alerted Nurse Practitioners/physician and provided ice for area.
Review of a physician order dated 11/26/24, indicated to administer Clindamycin Phosphate 600 mg (milligrams) intravenously (through a vein) every 8 hours for dental infection for 7 days.
Review of a progress note dated 11/29/24, completed by Certified Registered Nurse Practitioner (CRNP) Employee E6 stated, Resident R45 seen today for follow up of dental infection, pain, and elevated blood sugar. Patient seen while resting in bed in NAD (no acute distress). Swelling to top lip much improved, no longer red or swollen. Patient reports pain is gone and she is feeling much better. IV (intravenous) antibiotics changed to PO (by mouth) for remainder of treatment. Assessment and plan for dental abscess/infection, discontinue IV start PO Clindamycin 300 mg QID (four times a day) x 5 days. Start Peridex (a germicidal mouthwash that reduces bacteria in the mouth) swish and spit mouth rinse BID (twice a day), dental consult, monitor worsening condition.
Review of a progress note dated 12/2/24, completed by CRNP Employee E6 stated, Resident R45 seen today for follow up of dental infection/abscess. Patient seen while resting in bed in NAD. She reports feeling much better. Denies any pain to upper lip/gum area. Swelling resolved. No difficulty eating or drinking at present. Upper gum area with small red, swollen area under lip, so symptoms of infection at present. Teeth remain decayed/chipped. Awaiting dental appointment.
Review of a progress note dated 12/4/24, completed by CRNP Employee E6 stated, Resident R45 seen today for follow up of dental abscess and diabetes. Patient seen while resting in bed in NAD. Swelling to upper lip resolved since antibiotics, now completed. Denies any further pain/discomfort. Assessment and plan for dental abscess/infection, completed Clindamycin with improvement in symptoms. Continue Peridex swish and spit mouth rinse BID. Dental consult pending for decayed teeth.
Review of a physician order dated 12/18/24, indicated to administer Augmentin 875 mg-125 mg give one tablet by mouth every 12 hours for dental infection for 7 days.
Review of a progress note dated 12/18/24, completed by CRNP Employee E7 stated, Resident R45 seen today while resting in bed in NAD. Lab and abdominal x-ray results. Labs indicated critical blood glucose at 465 and WBC (white blood count) elevated at 12.8. Was recently treated for dental infection with current elevated WBC of 12.8. Assessment and plan for leukocytosis (elevated WBC level) possible returning dental infection, start Augmentin 875 mg-125 mg BID for 7 days until 12/25.
Review of Resident R45's clinical record on 12/19/24, failed to indicate that Resident R45 received dental services as ordered.
During an interview on 12/19/24, at 12:41 p.m. [NAME] Clerk Employee E5 stated, The dentist is coming to the facility on January 8th, I have Resident R45 on the list to be seen. I was unable to get her an appointment anywhere outside of the facility because she was MA (medical assistance) pending at the time the dental consult order was written. She has insurance now. The dentist did come to the facility this month, but I was unable to put her on the list to be seen because she was MA pending.
During an interview on 12/19/24, at 1:02 p.m. the Business Office Manager Employee E8 stated, Resident R45 was just recently approved for medical assistance. She did not have insurance coverage at the time of admission that I can recall.
During an interview on 12/20/24, at 1:59 p.m. the Nursing Home Administrator (NHA) stated, I left a message with our dental provider that comes into the facility. They stated they want payment the day of services, but we're going to have to work something out going forward. During this interview, the NHA confirmed that the facility failed to provide timely dental services for one of two residents as required.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.15 Dental services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents, and resident and staff interview, it was determined that the facility failed to provide specialized rehabilitative services for one of six residents (Resident R87).
Findings Include:
Review of the clinical record revealed that Resident R87 was admitted to the facility on [DATE].
Review of Resident 87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/3/24, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time).
Review of medical records revealed that Resident R87 had physician's orders for Physical Therapy (PT) Evaluation and Treatment as needed, and Occupational Therapy (OT) Evaluation and Treatment as needed, and a Speech Therapy (ST) Evaluation and Treatment as needed, all dated 11/26/24.
Review of medical record revealed a Rehabilitation admission Screen dated 11/26/24, indicated that Resident R87 was screened for PT, OT, and ST, however it was noted that Resident R87 was to be Screened only per NHA (Nursing Home Administrator). PT noted that Resident R87 is recommended for PT as she has had a decline in functional mobility as prior to admission she walked community distances without an assisted device, and now requires a front wheeled walker and is with limited distance. OT noted that Resident R87 is recommended for OT to promote activities of daily living and functional mobility and independence with positioning, seating, balance, safety, activity tolerance, general strength and decrease the risk of falls during functional tasks. High risk for falls. Wheelchair seating system recommended at this time.
During an interview on 12/16/24, at 11:37 a.m. Resident R87 indicated that she had not received any therapy, as the facility was filling out her insurance paperwork.
During an interview on 12/17/24, at 2:15 p.m. Rehabilitation Manager (RM) Employee E17 stated that the Resident R87 was not picked up by therapy as she did not have insurance.
During an interview on 12/18/24, at 10:17 a.m. Business Officer Manager (BOM) Employee E8 stated that Resident R87 had applied for medical assistance to pay for her stay upon admission, and that this this status was pending. BOM Employee E8 stated that it appears that she will be approved but confirmed that she has not started the therapy services that she was ordered.
During an interview on 12/18/24, at 1:44 p.m. RM Employee E17 stated that Resident R87 was screened only but not started on therapy services until a payer source was obtained.
During an interview on 12/18/24, at 1:46 p.m. NHA confirmed that the facility failed to administer therapy sources as ordered for Resident R87 and stated, I just told therapy to screen her.
28 Pa Code: 201.18(e)(1) Management.
28 Pa. Code: 211.10(c)(d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for three of six residents (Resident R17, R34, and R66).
Findings include:
A review of the facility policy Documentation in Medical Record dated 12/3/24, and previously dated 9/12/24, indicated that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure.
Review of Resident R17's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R17's clinical record indicated he was transferred out to the hospital on the following dates for respiratory distress.
-9/9/24
-9/15/24
-9/18/24
-9/28/24
-10/30/24
Review of Resident R17's clinical record on 12/17/24, at 9:30 a.m. failed to include Resident R17's hospital discharge summary from the above hospital stays.
During an interview on 12/18/24, at 1:46 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medical records were complete and accurately documented for Resident R17.
Review of the clinical record revealed that Resident R34 was admitted to the facility on [DATE] from a hospital.
Review of Resident 34's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), and pain.
Review of medical records revealed that Resident R34 had a physician's order dated 9/20/24, indicated to complete a CBC (Complete Blood Count- a group of blood tests that measure the number and size of the different cells in your body), and BMP (Basal Metabolic Panel- a blood test that measures the body's metabolism).
Review of medical records revealed that Resident R34 had a physician's order dated 12/4/24, indicated to complete a CBC, and BMP.
Review of medical records revealed that Resident R34 had a physician's order dated 12/9/24, indicated to complete a BMP, and an H and H level (a blood test that provides information about the oxygen-carrying capacity of the blood).
Review of medical records on 12/18/24, failed to reveal any hospital records, or lab results for Resident R34.
During an interview on 12/19/24, at 9:36 a.m. a request was made to Nursing Home Administrator (NHA) to provide Resident R34's hospital records and lab results.
During an observation, the Facility was unable to produce the requested documents for Resident R34 until 12/19/24, at 2:02 p.m.
During an interview on 12/19/24 at 2:45 p.m. NHA confirmed that the facility failed to make certain that medical records were complete and accurately documented for Resident R34.
Review of Resident R66's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R66's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).
Review of medical records revealed that Resident R66 had a physician's order dated 7/26/24, indicated a diagnostic mammogram (an x-ray image of the breast to screen for cancer) was ordered.
Review of medical records on 12/17/24, failed to reveal any hospital mammogram results for Resident R66.
During an interview on 12/17/24, at 1:33 p.m. a request was made to [NAME] Clerk Employee E5 to provide Resident R66's mammogram results.
During an observation, the Facility was unable to produce the requested document for Resident R66 until 12/19/24, at 2:15 p.m. in which it was faxed from the hospital.
During an interview on 12/20/24, at 1:33 p.m. the Director of Nursing confirmed that the facility failed to make certain that medical records were complete and accurately documented for Resident R66.
28 Pa. Code: 211.5(f)(g)(h) Clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis, and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two residents (Resident R12).
Findings include:
Review of the facility policy Providing End of Life Care dated 12/3/24, and previously dated 9/12/24, indicated that if a resident chooses hospice services (care for terminally ill residents) the plan of care will include the resident's underlying diagnoses. The facility will maintain communication with Hospice.
Review of the clinical record revealed that Resident R12 was admitted to the facility on [DATE].
Review of Resident 12's MDS (Minimum Data Set- periodic assessment of resident care needs) dated 11/15/24, indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), and hypokalemia (low potassium levels in the blood). Section O - Special Treatments, Procedures, and Programs indicated hospice care while a resident.
Review of Resident R12's clinical record revealed a physician order dated 11/12/24, for a referral for hospice services, but did not include a diagnosis related to the need of hospice services, or to admit the resident to hospice services.
Review of Resident R12's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to included contact information for the hospice agency and how to access the hospice's 24 hour on-call system.
During an interview on 12/19/24, at 11:45 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that the facility failed to obtain a diagnosis and order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for one of two hospice residents (R12).
28 Pa. Code 211.2(a) Physician services
28 Pa. Code 211.11(d) Resident care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R84)
Findings include:
A review of the facility policy Enhanced Barrier Precautions, last reviewed 12/3/24, indicated enhanced barrier precautions will be implemented for residents who have a wound.
Review of the Center for Disease Control How to Safely Remove Personal Protective Equipment (PPE) indicated all PPE is removed before exiting the patient room except a respirator, if worn. The first step of doffing PPE is removing the gown. Then the gloves are removed without contaminating your hands.
A review of the facility procedure Hand Hygiene last reviewed 12/3/24, indicated staff must perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Handwashing should take about 20 seconds and a clean towel is used to turn off the faucet.
Review of the admission record indicated Resident R84 was admitted to the facility on [DATE].
Review of R84's Minimum Data Set (MDS-periodic assessment of care needs) dated 10/22/24, included diagnoses of anemia (the blood doesn't have enough healthy red blood cells), cellulitis (infection of skin), and unstageable pressure ulcer (full-thickness skin and muscle loss, with slough (soft, yellowish, or white dead tissue) or eschar (black, hard dead tissue) obstructing the wound bed.)
Review of Resident 84's physician order dated 12/18/24, indicated to cleanse right medial and posterior thigh wounds with wound cleanser, apply alginate (highly absorbent wound care product from natural seaweed extracts) to wound base, add dry gauze to help pack wounds. Cover with abdominal pads.
During an observation of Resident R84's wound dressing change on 12/19/24, at 10:55 a.m. Licensed Practical Nurse, Employee E24 failed to wash her hands longer than 20 seconds and failed to use a barrier to turn off the faucet on four separate occasions. Nurse Aide, Employee E28 removed her gloves prior to removing her gown while doffing of PPE.
During an interview on 12/19/24, at 11:28 a.m. Licensed Practical Nurse Employee E24 confirmed the facility failed to implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R84).
28 Pa. code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, clinical records, group interview, and staff interviews, it was determined that the facility failed to inform residents in advance of the proposed care for two of seven residents (Resident R39 and Resident R66).
Findings include:
The facility policy Resident rights reviewed 12/3/24, indicated that the facility will support and facilitate a resident's right to request, refuse, and discontinue medical or surgical treatment. The facility will provide the resident information in a manner that is easy to understand.
During a group interview on 12/17/24, at 1:30 p.m. two of seven residents voiced concerns of not knowing in advance of when their appointments are.
During a group interview residents stated they used to get index cards prior to their appointment with who their appointment was for, date, and what time their appointment was for.
During a group interview residents voiced concern about not having enough time to prepare for an appointment and stated I'd like to know at least a day ahead so I know that I need to get ready instead of the same day, and I only know that I have an appointment because the staff will come in and say it's time to get ready for your appointment today.
During an interview on 12/18/24, at 2:32 p.m. [NAME] Clerk Employee E5 stated, I haven't figured out a process yet to notify the residents. I used to give them index cards but that didn't work.
During an interview on 12/18/24, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to inform residents in advance of the proposed care for two out of seven residents (Resident R39, and Resident R66).
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 211.12(d)(1) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interview, it was determined that the facility failed to accommodate resident needs and preferences for one of six residents (Resident 71).
Findings include:
Review of Resident R71's clinical record indicated he was admitted to the facility on [DATE], with diagnoses of depression, insomnia (difficulty falling or staying asleep), and orthostatic hypotension (a drop in blood pressure when you stand up, which can cause dizziness, fainting, and other symptoms).
Review of Resident R71's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R71's progress note dated 9/26/24, entered by Social Service Director, Employee E4 stated she attempted to order a free phone for the resident however was unable to complete the process as it required a debit card for a processing fee.
During an interview on 12/16/24, at 10:43 a.m. Resident R71 stated he asked the social worker to help him apply for a free phone. He stated it's been a while.
Review of Resident R71's clinical record failed to indicate any follow-up on obtaining Resident R71 a free phone as he requested.
During an interview on 12/17/24, at 9:47 a.m. Social Service Director, Employee E4 stated I have the application for phone, I still have to do one page.When asked about the debit processing fee, it was indicated the facility attempted to get him a free phone and a debit card was needed for a $2.50 processing fee. Social Service Director, Employee E4 confirmed the facility failed to accommodate resident needs and preferences for one of six residents reviewed (Resident R71).
28 Pa. Code 211.12(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three medication carts (2A Medication Cart).
Findings include:
Review of facility policy Confidentiality of Personal and Medical Records dated 12/3/24, indicated this facility honors the resident's right to secure and confident personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.
During an observation on 12/16/24, at 10:42 a.m. the 2A Medication Cart outside of resident room [ROOM NUMBER] was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.
During an interview on 12/16/24, at 10:43 a.m. Registered Nurse Employee E1 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required.
28 Pa. code: 211.5(b) Clinical records.
28 Pa. Code: 201.29(i) Resident Rights.
28 Pa. Code: 211.12(d)(3) Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R6) and failed to conduct a criminal background check prior to the start of employment for one of five staff (Dietary Employee E21).
Findings include:
Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. An immediate investigation is warranted when suspicion or abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. A background, reference, and credentials' check shall be conducted on potential employees. The facility will maintain documentation of proof the screening occurred.
Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].
Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/28/24, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).
Review of a facility Grievance/Concern Form dated 11/12/24, indicated the following: Physical Therapy performing quarterly eval at 2:00 p.m. and Resident R6 revealed that she was concerned today about her care. She had put her call light on between 11:00 a.m. and 11:30 a.m. and her aide came in prior to lunch and shut bell off, stating there were a lot of call bells on. Resident R6 communicated she needed changed. The aide did not return until 1:40 p.m. to change her.
Review of the Results of Action Taken section indicated the following: Staff interviewed and educated about shutting off call lights. Social Worker spoke to resident, explained staff was educated on care and call lights. Resident was pleased.
During an interview on 12/18/24 at 2:13 p.m. Social Services Director Employee E4 stated, I went up and talked to Resident R6 and she got really upset and started crying, she said she didn't want to get anyone in trouble. She seemed ok after that. I didn't report that as neglect.
During an interview on 12/19/24, at 2:13 p.m. Social Services Director Employee E4 confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for one of three residents (Resident R6).
Review of Dietary Aide, Employee E21's employee file on 12/19/24, at 2:24 p.m. revealed a start date of 10/22/24. Review of Dietary Aide, Employee E21's employee file failed to indicate a criminal background check was completed.
During an interview on 12/20/24, at 9:38 a.m. Director of Human Resources, Employee E22 confirmed the facility failed to conduct a criminal background check prior to the start of employment for one of five staff (Dietary Employee E21).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policy, facility grievance forms, group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from facility grievances and failed to respond to concerns in a timely manner for six out of six months (June 2024 through November 2024).
Findings include:
The facility policy Resident and Family Grievances dated 12/3/24, indicated that the facility will support each residents and family members right to voice grievances without discrimination, reprisal, or fear of discrimination. The grievance official is responsible for overseeing the grievance process. The written decision will include at a minimum:
- The date the grievance was received.
- The steps taken to investigate the grievance.
- A summary of the pertinent findings or conclusions regarding the resident ' s concern.
- A statement as to whether the grievance was confirmed or not confirmed.
- Any corrective action taken.
- The date the written decision was issued.
Review of facility provided grievance forms on 12/17/24, at 10:53 a.m. revealed that grievance forms were incomplete and residents or resident representatives were not made aware of the outcome of the filed grievance from June 2024 through November 2024.
During a group interview on 12/17/24, at 1:30 p.m. two of seven residents voiced a concern that the facility does not notify residents of the outcome of their grievance.
During an interview on 12/18/24, at 2:09 p.m. the Social Service Director Employee E4 confirmed that the facility failed to respond to concerns from facility grievances and failed to respond to concerns in a timely manner for six out of six months (June 2024 through November 2024).
28 Pa. Code 201.18(b)(1) Management

Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, Adult Protective Service information, Medicare Fraud Unit information, and how to file a complaint with State Agency on two of two nursing floors (Second and Third Floor).
Findings include:
Observation by the facilities entrance bulletin board had required postings displayed, however residents would be required to descend a staircase consisting of nine steps to view the postings and climb back up nine step to get back to the Main Floor.
Observation on the nursing care units on the second and third floor failed to include information on State Agency, Adult Protective Services, Medicare Fraud Unit, and how to file a complaint with State Agency.
During an interview on 12/19/24, at 1:39 p.m. Nursing Home Administrator confirmed that the facility failed to post above required information where it is easily accessible to residents to refer to, if needed, for two of two nursing floors (Second and Third Floor).
28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.18e Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of two residents (Resident R47, and R142).
Findings include:
A review of the facility Resident Rights Regarding Treatment and Advance Directives dated 12/3/24, and previously dated 9/12/24, indicated that upon admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.
Review of Resident R47's admission record indicated the resident was admitted to the facility 3/10/23.
A review of Resident R47's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/8/24, included diagnoses of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (a high level of fat particles in the blood).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R47 was given the opportunity to formulate an Advanced Directive.
A review of the medical record indicated Resident R142 was re- admitted to the facility on [DATE], with diagnoses that included high blood pressure, wound infection, and pain.
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R142 was given the opportunity to formulate an Advanced Directive.
During an interview on 12/17/24, at 12:53 p.m. Social Worker Employee E4 confirmed that the clinical record did not include documentation that Resident R47, and R142 were afforded the opportunity to formulate Advanced Directives.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to notify the family and/or physician of a change in condition in a timely manner for two of six residents (Resident R17 and R39).
Findings include:
Review of the facility policy Notification of Changes dated 12/3/24, indicated purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification such as a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health. This may include life threatening conditions, clinical complications, or a transfer of the resident from the facility.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure.
Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/1/24, indicated the diagnoses were current.
Review of Resident R17's progress note dated 10/30/24, at 10:29 p.m. indicated resident was using his stomach muscles to breath and had a red face. Resident blood pressure was 150/100, pulse 141 beats per minutes, respiration 40, temperature 100.8, and Spo2 83% on BIPAP. Resident was transferred to hospital.
Review of Resident R17's progress note dated 10/31/24, at 8:07 a.m. indicated a call was placed to hospital for an update. It was indicated the resident was being transferred to Intensive Care Unit with respiratory failure and elevated ammonia levels.
Review of Resident R17's progress note dated 11/1/24, at 11:22 a.m. indicated a call was placed to the resident's sister to make sure she knew resident was in the hospital. Sister upset that no call from facility was made to alert her. Please call sister with any updates.
During an interview on 12/19/24 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to notify the family of a change in condition in a timely manner for one of four residents (Resident R17).
Review of the clinical record indicated that Resident R39 was admitted to the facility on [DATE], with diagnoses of overactive bladder and kidney disease.
Review of the MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R39's progress note dated 12/1/24, indicated the resident was lethargic and weak. Did not eat breakfast. Saturated urine brief with red colored urine and urine in commode red as well. Resident was shaking and required an extensive two person assist for transfers. RN alerted and came to assess. Ordered sick tray for lunch, however resident has no appetite.
Review of Resident R39's progress note dated 12/1/24, at 12:15 p.m. indicated the provider was notified about residents' status. The nurse practitioner stated to monitor and assess the resident's vitals more frequently. It was indicated if changes occur to contact the provider.
Review of Resident R39's progress note dated 12/1/24, at 5:07 p.m. indicated resident was drowsy, fatigued and drifts to sleep while talking. Says she hurts all over, including her ears, throat, upper and lower extremities. She is shaky and dropped her water cup on the floor. Resident had loss of appetite. Bright red blood noted in urine after voiding. It was indicated the resident's daughter was notified in residents change in condition and requested for her to be sent to hospital for evaluation since she is concerned due to her rapid decline. Review of the resident's clinical record failed to reveal the resident's provider was notified as ordered.
During an interview on 12/20/24, at 9:24 a.m. Assistant Director of Nursing, Employee E14 confirmed the facility failed to notify a physician for a change in condition as ordered for one of six residents (Resident R39).
28 Pa. Code: 201.29(a)(b)(c)(d)(j)(m) Resident rights.
28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
28. Pa. Code: 211.10(a)(c)(d) Resident care policies.

Based on a review of facility documents and staff interview, it was determined that the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) form notice were provided timely for one of three residents (Resident R76).
Findings include:
Review of facility policy Advance Beneficiary Notices dated 12/3/24, indicated it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage. To ensure that the resident or representative had enough time to make a decision whether or not to receive the services and assume financial responsibility the notice shall be provided at least two days before the end of coverage.
Review of Resident R76's admission record indicated the resident was admitted to the facility 10/23/24.
Review of Resident R76's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/30/24, included diagnoses of thyroid disorder (any dysfunction of the butterfly-shaped gland at the base of the neck), depression, and shortness of breath.
Review of the NOMNC form indicated services will end 10/31/24. Resident R76 signed the NOMNC on 10/31/24. The facility failed to issue the NOMNC in a timely manner.
During an interview on 12/17/24, at 12:53 p.m. the Social Service Director Employee E4 confirmed the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) form notice were provided timely for one of three residents (Resident R76).
28 Pa. Code 201.24 (b) admission Policy.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(2) Management.
28 Pa. Code 201.29(a) Resident Rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, reports submitted to the State, and staff interview, it was determined that the facility failed to report an allegation of neglect in the required timeframe one of three residents (Resident R6).
Findings include:
Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].
Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/28/24, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).
Review of a facility Grievance/Concern Form dated 11/12/24, indicated the following: Physical Therapy performing quarterly eval at 2:00 p.m. and Resident R6 revealed that she was concerned today about her care. She had put her call light on between 11:00 a.m. and 11:30 a.m. and her aide came in prior to lunch and shut bell off, stating there were a lot of call bells on. Resident R6 communicated she needed changed. The aide did not return until 1:40 p.m. to change her.
Review of the Results of Action Taken section indicated the following: Staff interviewed and educated about shutting off call lights. Social Worker spoke to resident, explained staff was educated on care and call lights. Resident was pleased.
During an interview on 12/18/24 at 2:13 p.m. Social Services Director Employee E4 stated, I went up and talked to Resident R6 and she got really upset and started crying, she said she didn't want to get anyone in trouble. She seemed ok after that. I didn't report that as neglect.
Review of incidents submitted to the State Agency of 12/19/24, at 10:00 a.m. did not include the neglect allegation involving Resident R6.
During an interview on 12/19/24, at 10:39 a.m. the Nursing Home Administrator (NHA) confirmed that Resident R6's allegation of neglect was not reported to the State Agency.
During an interview on 12/19/24, at 10:39 a.m. the NHA confirmed that the facility failed to report an allegation of neglect in the required timeframe one of three residents as required.
28 Pa. Code 201.14(a)(c.)(e.) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 201.20(b) Staff development.
28 Pa. Code 211.10(c.)(d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents (Resident R6).
Findings include:
Review of facility policy Abuse, Neglect, and Exploitation dated 12/3/24, indicated neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and repositioning. An immediate investigation is warranted when suspicion or abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].
Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/28/24, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).
Review of a facility Grievance/Concern Form dated 11/12/24, indicated the following: Physical Therapy performing quarterly eval at 2:00 p.m. and Resident R6 revealed that she was concerned today about her care. She had put her call light on between 11:00 a.m. and 11:30 a.m. and her aide came in prior to lunch and shut bell off, stating there were a lot of call bells on. Resident R6 communicated she needed changed. The aide did not return until 1:40 p.m. to change her.
Review of the Results of Action Taken section indicated the following: Staff interviewed and educated about shutting off call lights. Social Worker spoke to resident, explained staff was educated on care and call lights. Resident was pleased.
During an interview on 12/18/24 at 2:13 p.m. Social Services Director Employee E4 stated, I went up and talked to Resident R6 and she got really upset and started crying, she said she didn't want to get anyone in trouble. She seemed ok after that. I didn't report that as neglect.
During an interview on 12/19/24, at 10:39 a.m. the Nursing Home Administrator (NHA) confirmed that they did not perform an investigation of Resident R6's allegation of neglect.
During an interview on 12/19/24, at 10:39 a.m. the NHA confirmed that the facility failed to conduct a thorough investigation of an allegation of neglect for one of three residents as required.
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a )(c)(d) Resident Rights.
28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents, and resident and staff interview, it was determined that the facility failed to not distinguish between residents based on their source of payment when providing services that are required to be provided for two of twelve residents (Resident R45, and R87).
Findings Include:
Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/26/24, indicated diagnoses of high blood pressure, muscle weakness, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression, and decrease in functional abilities).
Review of a physician order dated 11/26/24, indicated dental consult ASAP (as soon as possible), for abscess (a swollen area within body tissue, containing an accumulation of pus)/infection.
Review of Resident R45's care plan dated 11/27/24, indicated the resident is on antibiotic therapy related to dental abscess.
Review of a progress note dated 11/26/24, at 8:14 a.m. completed by Licensed Practical Nurse (LPN) Employee E20 stated, During morning medication pass, noted philtrum area (space between nose and upper lip) to be swelled and tender to touch. Client opened mouth and noted a sore on the top left side of mouth. Client is able to chew food/eat/drink. Educated client if she I having difficulty eating/chewing to let staff know so diet can be changed accordingly. Alerted Nurse Practitioners/physician and provided ice for area.
Review of a physician order dated 11/26/24, indicated to administer Clindamycin Phosphate 600 mg (milligrams) intravenously (through a vein) every 8 hours for dental infection for 7 days.
Review of a progress note dated 11/29/24, completed by Certified Registered Nurse Practitioner (CRNP) Employee E6 stated, Resident R45 seen today for follow up of dental infection, pain, and elevated blood sugar. Patient seen while resting in bed in NAD (no acute distress). Swelling to top lip much improved, no longer red or swollen. Patient reports pain is gone and she is feeling much better. IV (intravenous) antibiotics changed to PO (by mouth) for remainder of treatment. Assessment and plan for dental abscess/infection, discontinue IV start PO Clindamycin 300 mg QID (four times a day) x 5 days. Start Peridex (a germicidal mouthwash that reduces bacteria in the mouth) swish and spit mouth rinse BID (twice a day), dental consult, monitor worsening condition.
Review of a progress note dated 12/2/24, completed by CRNP Employee E6 stated, Resident R45 seen today for follow up of dental infection/abscess. Patient seen while resting in bed in NAD. She reports feeling much better. Denies any pain to upper lip/gum area. Swelling resolved. No difficulty eating or drinking at present. Upper gum area with small red, swollen area under lip, so symptoms of infection at present. Teeth remain decayed/chipped. Awaiting dental appointment.
Review of a progress note dated 12/4/24, completed by CRNP Employee E6 stated, Resident R45 seen today for follow up of dental abscess and diabetes. Patient seen while resting in bed in NAD. Swelling to upper lip resolved since antibiotics, now completed. Denies any further pain/discomfort. Assessment and plan for dental abscess/infection, completed Clindamycin with improvement in symptoms. Continue Peridex swish and spit mouth rinse BID. Dental consult pending for decayed teeth.
Review of a physician order dated 12/18/24, indicated to administer Augmentin 875 mg-125 mg give one tablet by mouth every 12 hours for dental infection for 7 days.
Review of a progress note dated 12/18/24, completed by CRNP Employee E7 stated, Resident R45 seen today while resting in bed in NAD. Lab and abdominal x-ray results. Labs indicated critical blood glucose at 465 and WBC (white blood count) elevated at 12.8. Was recently treated for dental infection with current elevated WBC of 12.8. Assessment and plan for leukocytosis (elevated WBC level) possible returning dental infection, start Augmentin 875 mg-125 mg BID for 7 days until 12/25.
Review of Resident R45's clinical record on 12/19/24, failed to indicate that Resident R45 received dental services as ordered.
During an interview on 12/19/24, at 12:41 p.m. [NAME] Clerk Employee E5 stated, The dentist is coming to the facility on January 8th, I have Resident R45 on the list to be seen. I was unable to get her an appointment anywhere outside of the facility because she was MA (medical assistance) pending at the time the dental consult order was written. She has insurance now. The dentist did come to the facility this month, but I was unable to put her on the list to be seen because she was MA pending.
During an interview on 12/19/24, at 1:02 p.m. the Business Office Manager (BOM) Employee E8 stated, Resident R45 was just recently approved for medical assistance. She did not have insurance coverage at the time of admission that I can recall.
During an interview on 12/20/24, at 1:59 p.m. the Nursing Home Administrator (NHA) stated, I left a message with our dental provider that comes into the facility. They stated they want payment the day of services, but we're going to have to work something out going forward. During this interview, the NHA confirmed that the facility failed to provide required services for Resident R45.
Review of the clinical record revealed that Resident R87 was admitted to the facility on [DATE].
Review of Resident 87's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time).
Review of medical records revealed that Resident R87 had physician's orders for Physical Therapy (PT) Evaluation and Treatment as needed, and Occupational Therapy (OT) Evaluation and Treatment as needed, and a Speech Therapy (ST) Evaluation and Treatment as needed, all dated 11/26/24.
Review of medical record revealed a Rehabilitation admission Screen dated 11/26/24, indicated that Resident R87 was screened for PT, OT, and ST, however it was noted that Resident R87 was to be Screened only per NHA (Nursing Home Administrator). PT noted that Resident R87 is recommended for PT as she has had a decline in functional mobility as prior to admission she walked community distances without an assisted device, and now requires a front wheeled walker and is with limited distance. OT noted that Resident R87 is recommended for OT to promote activities of daily living and functional mobility and independence with positioning, seating, balance, safety, activity tolerance, general strength and decrease the risk of falls during functional tasks. High risk for falls. Wheelchair seating system recommended at this time.
During an interview on 12/16/24, at 11:37 a.m. Resident R87 indicated that she had not received any therapy, as the facility was filling out her insurance paperwork.
During an interview on 12/17/24, at 2:15 p.m. Rehabilitation Manager (RM) Employee E17 stated that the Resident R87 was not picked up by therapy as she did not have insurance.
During an interview on 12/18/24, at 10:17 a.m. BOM Employee E8 stated that Resident R87 had applied for medical assistance to pay for her stay upon admission, and that this this status was pending. BOM Employee E8 stated that it appears that she will be approved but confirmed that she has not started the therapy services that she was ordered.
During an interview on 12/18/24, at 1:44 p.m. RM Employee E17 stated that Resident R87 was screened only but not started on therapy services until a payer source was obtained.
During an interview on 12/18/24, at 1:46 p.m. NHA confirmed that the facility failed to administer therapy sources as ordered for Resident R87 and stated, I just told therapy to screen her.
28 Pa Code: 201.18(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents with facility-initiated transfers (Residents R18 and R47).
Findings include:
Review of facility policy Transfer and Discharge (Including AMA) dated 12/3/24, indicated for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information of the practitioner who was responsible for the care of the resident, resident representative information including contact information, advice director information, all other information necessary to meet the resident's needs, which includes but is not limited to resident status, diagnoses and allergies, medications, most recent relevant labs, diagnostic tests, treatments, special risks, and the resident's comprehensive care plan.
Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE].
Review of Resident R18's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/13/24, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and dependence on supplemental oxygen.
Review of Resident R18's clinical record revealed that the resident was transferred to the hospital on [DATE].
Review of Resident R18's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of Resident R47's admission record indicated the resident was admitted to the facility 3/10/23.
Review of Resident R47's MDS dated [DATE], included diagnoses of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (a high level of fat particles in the blood).
Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 4/16/24.
Review of Resident R47's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
During an interview on 12/20/24, at 1:38 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of two residents as required.
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of three resident hospital transfers (Residents R17, R18, and R47).
Findings include:
Review of facility policy Transfer and Discharge (Including AMA) dated 12/3/24, indicated during an emergency transfer/discharge, the facility will provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/1/24, indicated diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure.
Review of Resident R17's clinical record revealed the resident was transferred out to the hospital on the following dates:
-9/9/24
-9/15/24
-9/18/24
-9/28/24
-10/30/24
Review of Resident R17's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on the following dates:
-9/9/24
-9/15/24
-9/18/24
-9/28/24
-10/30/24
Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE].
Review of Resident R18's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and dependence on supplemental oxygen.
Review of Resident R18's clinical record revealed that the resident was transferred to the hospital on [DATE].
Review of Resident R18's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE].
Review of Resident R47's admission record indicated the resident was admitted to the facility 3/10/23.
Review of Resident R47's MDS dated [DATE], included diagnoses of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (a high level of fat particles in the blood).
Review of Resident R47's clinical record revealed that the resident was transferred to the hospital on 4/16/24.
Review of Resident R47's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 4/16/24.
During an interview on 12/20/24, at 1:38 p.m. the Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for three of three resident hospital transfers (Residents R17, R18, and R47).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for three of twelve residents (Residents R1, R17, and R91).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following:
Section A1500: Preadmission Screening and Resident Review (PASRR): code 1, yes if: PASSR Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.
Section A2105: Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person.
Section O0110G2: Special Treatments, procedures, and Programs: Check if resident received BiPAP (a device that helps to breathe).
Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's MDS dated [DATE], indicated diagnoses of anxiety (a feeling of worry, nervousness, or unease), Schizoaffective disorder (a mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and a mood disorder symptoms, such as depression and mania), and anoxic brain damage (occurs when the brain is deprived of oxygen, leading to damage or deal of brain cells).
Review of Resident R1's admission MDS dated [DATE], Question A1500 Preadmission Screening and Resident Review (PASRR) indicated yes the resident is currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
Review of Resident R1's annual comprehensive MDS dated [DATE], Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
During an interview on 12/19/24, at 11:54 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E2 stated, I checked with Social Work and once a resident is determined to be a Level II, it does not change, the annual MDS should have been coded as yes.
During an interview on 12/19/24, at 11:54 a.m. RNAC Employee E2 confirmed that the facility failed to make certain that resident assessments were accurate for Resident R1.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE].
Review of Resident R17's MDS dated [DATE], indicated diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure. Section O-Special Treatments, Procedures, and Programs C1. Oxygen Therapy and G1. Non-invasive Mechanical Ventilator was not checked and failed to indicate the resident was receiving oxygen and BIPAP therapy.
Review of Resident R17's active physician order dated 7/28/24, indicated to administer 2L oxygen continuously, every shift for oxygen therapy.
Review of Resident R17's physician order dated 10/7/24, entered by Nurse Practitioner, Employee E7 indicated the resident is to wear BIPAP (a mechanical breathing device that uses positive pressure ventilation to treat sleep apnea and other health conditions that affect your breathing) at night and any time during the day when sleeping. The settings were 12/8 with 4L oxygen.
During an interview on 12/20/24, at 12:18 p.m. the Director of Nursing confirmed the facility failed to make certain that resident assessments were accurate for Resident R17.
Review of the admission record indicated Resident R91 was admitted to the facility on [DATE].
Review of Resident R91's MDS dated [DATE], indicated the diagnoses of anemia (too little iron in the body causing fatigue), high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section A2105 was entered as 04, which indicated that resident R91 was discharged to a Short-Term General Hospital.
Review of progress notes dated 11/1/24, indicated that Resident R91 was discharged to home with family.
During an interview on 12/17/24, at 10:01 a.m. RNAC Employee E2 confirmed the facility failed to make certain that resident assessments were accurate for Resident R91.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on a review of the clinical record, resident council group, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four of four weeks (December 2024).
Findings include:
Review of facility policy Activities dated 12/3/24, indicated the facility is to provide an ongoing program to support residents in their choice of activities. Facility group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will include individual, small, and large group activities. Activities will be designed with the intent to;
- Enhance the resident's sense of well-being, belonging, and usefulness.
- Create opportunities of each resident to have a meaningful life.
- Promote or enhance physical activity.
- Promote or enhance cognition.
- Promote or enhance emotional health.
- Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence.
- Reflect residents ' interests and age.
- Reflect cultural and religious interest of the residents.
- Reflect choices of the residents.
During an interview on 12/16/24, at 10:03 a.m. Activity Director Employee E18 stated We are not having group activities because we have positive COVID-19 in the building.
During resident group on 12/17/24, at 1:30 p.m. four out of seven residents voiced concerns that the activities don't always meet their needs. Residents stated that the activity calendar can change, and activities don't take place, and they are unaware of when the changes are going to take place. Resident stated, I ' ve sat here waiting for an activity for awhile and then they will come in to tell me that its cancelled and BINGO has been cancelled for four weeks in a row now.
During resident group on 12/17/24, at 1:37 p.m. residents indicated that they would like to have group activities and that the only evening activity is on Thursdays. Resident stated, Evening activities would give us something to do.
A review of facility activity calendar dated December 2024, indicated that activities are scheduled until 3:00 p.m. and no evening activities are scheduled except for Thursdays.
A review of facility activity calendar dated December 2024, indicated that activites are subject to change without notice.
During an interview on 12/20/24, at 10:13 a.m. Activities Director Employee E18 confirmed that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for four of four weeks (December 2024).
28 Pa. Code: 201. 18(b)(3) Management.
28 Pa. Code: 207.2(a) Administrators Responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for five of 20 residents (Residents R17, R45, R47, R50, and R53).
Findings include:
Review of facility policy Hypoglycemia Management dated 12/3/24, indicated if the blood glucose reading is 70 mg/dL (milligram per deciliter) or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucoses as indicated, and notify the practitioner of the results as ordered.
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 mg/dL. If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR (Medication Administration Record) to identify medication to be administered.
Review of facility policy Blood Glucose Monitoring dated 12/3/24, indicated that facility is to perform blood glucose monitoring to diabetic residents as per physician's orders. Report critical test results to physician timely.
The facility policy Resident rights reviewed 12/3/24, indicated that the facility will support and facilitate a resident ' s right to request, refuse, and discontinue medical or surgical treatment. The facility will provide the resident information in a manner that is easy to understand.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of depression, anxiety, and insomnia (difficulty falling and/or staying asleep), and bipolar (a serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings).
Review of Resident R17's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R17's physician order dated 10/7/24, indicated to administer one capsule of 50 milligrams (mg) of Doxepin (an antidepressant medication used to treat depression, anxiety, and insomnia) at bedtime for bipolar disorder and depression.
Review of Resident R17's care plan dated 10/28/24, indicated the resident uses antidepressant and psychotropic medications medication due to depression and bipolar. Interventions indicated to administer medications as ordered by physician, consult with pharmacy and physician to consider dosage reduction when clinically appropriate.
Review of Resident R17's November 2024 Medication Administration Record (MAR) revealed 13 missed doses on the following dates.
-11/12/24 Not administered, awaiting delivery from Pharmacy.
-11/14/24 Per pharmacy, on order. Awaiting pharmacy deliver.
-11/15/24 Awaiting delivery from Pharmacy.
-11/17/24 Per pharmacy, on order.
-11/18/24 Per pharmacy, on order.
-11/19/24 Per pharmacy this remains on order.
-11/20/24 Unavailable
-11/21/24 MD notified pharmacy called, waiting for delivery.
-11/22/24 Awaiting delivery from pharmacy.
-11/25/24 On order at pharmacy.
-11/26/24 On order at pharmacy.
-11/27/24 On order at pharmacy.
-11/28/24 Waiting on pharmacy.
Review of Resident R17's December 2024 MAR revealed two missed doses on the following dates.
-12/1/24 Medications not here.
-12/5/24 'Remains on order from pharmacy.
During an interview on 12/19/24, at 9:57 a.m. Resident R17 stated he was not receiving his Doxepin for a while.
During an interview on 12/20/24, at 9:24 a.m. the Assistant Director of Nursing, Employee E14 confirmed Resident R17's Doxepin was not available or dispensed from the facility from 11/12/24, through 12/5/24. ADON, Employee E14 confirmed the facility failed to administer Resident R17's Doxepin as ordered.
Review of the clinical record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes, and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression, and decrease in functional abilities).
Review of Resident R45's care plan dated 10/16/24, indicated the resident has diabetes and to monitor/document/report to physician as needed signs and symptoms of hypo- and hyperglycemia.
Review of Resident R45's vitals record for November 2024, indicated the following blood glucose measurements:
11/12/24 at 8:09 a.m. 50 mg/dL
11/13/24 at 7:28 a.m. 64 mg/dL
11/13/24 at 4:55 p.m. 57 mg/dL
11/16/24 at 8:19 a.m. 59 mg/dL
11/16/24 at 12:07 p.m. 58 mg/dL
11/28/24 at 3:50 p.m. 431 mg/dL
11/28/24 at 8:54 p.m. 456 mg/dL
11/30/24 at 4:56 p.m. 66 mg/dL
Review of Resident R45's progress notes from 11/1/24, through 11/30/24, failed to include documentation that the physician was made aware of Resident R45's abnormal blood glucose readings on the dates listed above.
Review of a physician order dated 12/16/24, indicated to administer Lantus (a long-acting insulin) inject 40 units subcutaneously (under the skin into the fatty tissue layer) at bedtime for diabetes. Hold if less than 80 blood sugar.
Review of a Medication Administration Note dated 12/18/24, at 10:55 p.m. completed by Licensed Practical Nurse (LPN) Employee E19 stated, Lantus held, blood sugar 206. Resident did not eat.
Review of Resident R45's progress notes from 12/18/24, to 12/19/24, failed to include documentation that the physician was made aware of Resident R45 not eating. Review of the documentation also failed to include an order from the physician to hold Resident R45's scheduled Lantus dose.
During an interview on 12/19/24, at 10:55 a.m. the Director of Nursing (DON) confirmed that the facility failed to notify the physician of Resident R45's abnormal blood glucose readings and held a medication without a physician order. During this interview, the DON confirmed that the facility failed to make certain that Resident R45 was provided appropriate treatment and care.
Review of Resident R47's admission record indicated the resident was admitted to the facility 3/10/23.
Review of Resident R47's MDS dated [DATE], included diagnoses of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (a high level of fat particles in the blood).
Review of Resident R47's care plan dated 12/16/24, indicated the resident has diabetes and to monitor/document/report to physician as needed signs and symptoms hyperglycemia.
Review of Resident R47's vitals record for December 2024, indicated the following blood glucose measurements:
12/1/24 at 8:53 p.m. 422 mg/dL
12/3/24 at 8:00 p.m. 369 mg/dL
12/4/24 at 7:43 p.m. 360 mg/dL
12/7/24 at 7:13 p.m. 443 mg/dL
12/8/24 at 6:05 p.m. 438 mg/dL
12/8/24 at 8:10 p.m. 389 mg/dL
12/9/24 at 7:20 p.m. 365 mg/dL
12/10/24 at 5:09 p.m. 388 mg/dL
12/10/24 at 9:41 p.m. 378 mg/dL
12/11/24 at 4:37 p.m. 385 mg/dL
12/11/24 at 7:01 p.m. 371 mg/dL
12/14/24 at 7:43 p.m. 375 mg/dL
12/16/24 at 4:31 p.m. 406 mg/dL
Review of Resident R47's progress notes from 12/1/24, through 12/16/24, failed to include documentation that the physician was made aware of Resident R47's abnormal blood glucose readings on the dates listed above.
Review of a physician order dated 12/10/24, indicated to administer Humalog (a short acting insulin) three units. Hold is blood sugar is less than 100, wait until food in front of to make sure eating.
Review of a physician order dated 12/14/24, indicated Lantus (a long-acting insulin) ten units in the morning. No parameters are given as to when to notify physician.
During an interview on 12/19/24, at 11:05 a.m. the Director of Nursing confirmed above findings and that the facility did not notify physician of abnormal blood glucose readings for Resident R47.
Review of Resident R50's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R50's MDS dated [DATE], indicated diagnoses of high blood pressure, seizure disorder (a disorder in which nerve cell activity in the brain is disturbed), and depression.
Review of Resident R50's physician orders dated 4/3/24, indicated to schedule resident a neurology appointment due to possible seizures.
Review of Resident R50's clinical record on 12/18/24, at 11:33 a.m. failed to have neurology appointment records to review.
During an interview on 12/18/24, at 2:15 p.m. [NAME] Clerk Employee E5 stated, I tried making an appointment and the physician office declined taking the resident due to past noncompliance with medical appointments prior to admission and referred me to another office. I did not call and set up that appointment.
During an interview on 12/18/24, at 2:32 p.m. [NAME] Clerk Employee E5 confirmed that the facility failed to make an appointment per physician order for Resident R50.
Review of Resident R53's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R53's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).
Review of Resident R53's physician orders dated 2/11/24, indicated to schedule resident a screening colonoscopy.
Review of Resident R53's clinical record on 12/18/24, at 10:33 a.m. failed to have colonoscopy records to review.
During an interview on 12/20/24, at 11:43 a.m. [NAME] Clerk Employee E5 stated, He hasn't gotten a colonoscopy yet. I haven't scheduled it.
During an interview on 12/20/24, at 11:50 a.m. [NAME] Clerk Employee E5 confirmed that the facility failed to make an appointment per physician order for Resident R53.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(a) Resident Rights
28 Pa. Code 211.10 (c)(d) Resident Care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, resident, and staff interviews, it was determined that the facility failed to complete quarterly wander guard (a device that triggers alarms when close to an exit) assessments for two of two residents (Resident R8, and Resident R53).
Findings include:
Review of facility Elopements and Wandering Residents policy dated 12/3/24, indicated that the facility ensures that residents who exhibit wandering behavior and at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay.
Review of Resident R8's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 10/2/24, indicated diagnoses of high blood pressure, arthritis, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Restraint and Alarm Section P0200 wander-elopement alarm is coded.
Review of Resident R8's plan of care, as of 1/4/24, indicated Resident R8 will wear a wander guard. Check placement every shift. Check function daily on night shift.
Review of Resident R8's clinical record on 12/19/24, at 10:55 a.m. revealed that Resident R8's last elopement assessment was completed on 7/1/24.
Review of Resident R53's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R53's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Restraint and Alarm Section P0200 wander-elopement alarm is coded.
Review of Resident R53's plan of care, as of 1/2/24, indicated Resident R53 will wear a wander guard. Check placement every shift. Check function daily on night shift.
Review of Resident R53's clinical record on 12/19/24, at 10:58 a.m. revealed that Resident R53's last elopement assessment was completed on 5/3/24.
During an interview on 12/19/24, at 1:33 p.m. Registered Nurse Employee E14 confirmed that the facility failed to complete quarterly wander guard (a device that triggers alarms when close to an exit) assessments for two of two residents (Resident R8, and Resident R53).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one two residents (Resident R36).
Findings include:
Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR (Medication Administration Record) to identify medication to be administered.
Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE].
Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/24, indicated diagnoses of high blood pressure, muscle wasting, and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).
Review of a physician order dated 10/25/24, indicated to administer Milk of Magnesia 30 mL (milliliters) by mouth as needed for constipation, give if no bowel movement in 48 hours.
Review of a physician order dated 10/25/24, indicated to administer a Dulcolax suppository 10 mg (milligrams) rectally as needed for constipation if Milk of Magnesia is ineffective.
Review of a physician order dated 11/14/24, indicated to administer Miralax 17 gm give one packet by mouth every 24 hours as needed for constipation.
Review of Resident R36's care plan on 12/20/24, failed to indicate goals and interventions related to constipation management.
Review of Resident R36's bowel record for December 2024 revealed:
- No bowel movement from 12/6/24, day shift until 12/10/24, evening shift; four days, 13 shifts with no bowel movement.
Review of Resident R36's December 2024 MAR indicated the following:
- Dulcolax suppository was not administered.
- Milk of Magnesia administered 12/10/24, at 5:37 a.m.
- Miralax not was administered.
Review of progress note dated 12/10/24, at 3:51 p.m. indicated that Resident R36 was given 30 mL of Milk of Magnesia. The note further indicated that the Milk of Magnesia was effective and Resident R36 had a large bowel movement.
During an interview on 12/20/24, at 12:50 p.m. the Director of Nursing (DON) stated that the facility does not have a bowel protocol and that the facility failed to follow physician orders and administer medications as ordered.
During an interview on 12/20/24, at 12:50 p.m. the DON confirmed that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function for one two residents as required.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights.
28 Pa code: 211.10 (c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R39).
Findings include:
Review of facility policy Ostomy Care-Colostomy, Urostomy, and Ileostomy dated 12/3/24, indicated it is the facility policy to ensure that residents who require colostomy (a stoma that has been constructed by connecting a part of the colon onto the anterior abdominal wall) services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Ostomy care will be provided by licensed nurses under the orders of the attending physician.
Review of the clinical record indicated that Resident R39 was admitted to the facility on [DATE], with diagnoses of overactive bladder and kidney disease.
Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/28/24, indicated the diagnoses were current.
Review of Resident R39's care plan dated 1/25/24, failed indicated to change the resident's ostomy (any type of surgically created opening of the gastrointestinal tract for discharge of body waste) appliance every seven days and as needed.
Review of Resident R39's physician orders dated 1/26/24, indicated to change ostomy appliance every 3 days and as needed with a 2.75-inch wafer and bag.
During an interview on 12/16/24, at 10:48 a.m. Resident R39 indicated her ostomy appliance was changed last Wednesday, 5 days ago.
Review of Resident R39's clinical record on 12/16/24, at 11:53 a.m. failed to indicate the resident's care plan was updated to reflect the current physician order to change the ostomy device every three days and as needed.
Review of Resident R39's December 2024 Treatment Administration Record (TAR) failed to indicate Resident R39's ostomy appliance was changed as ordered on 12/15/24.
During an interview on 12/17/24, at 9:17 a.m. Licensed Practical Nurse, Employee E15 confirmed Resident R39's ostomy appliance was not changed as ordered. LPN, Employee E15 indicated if a treatment is completed then it is signed off in the electronic record on the TAR.
Interview on 12/17/24, at 9:44 a.m. the Nursing Home Administrator confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for one of three residents reviewed (Resident R39).
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, clinical record review, and staff, resident, and family interviews, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Residents R17).
Findings include:
Review of the facility policy Noninvasive Ventilation dated 12/3/24, indicated it is the policy of the facility to provide non-invasive ventilation as per physician orders and current standards of practice. The facility will obtain an order for the use of a BIPAP (a mechanical breathing device that uses positive pressure ventilation to treat sleep apnea and other health conditions that affect your breathing) device and settings from the practitioner. If a resident's personal BIPAP device is brought into the facility, the nurse/respiratory therapist will verify settings on the machine prior to use. The facility will follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine. The use of machine, resident's tolerance, any skin, respiratory or other changes and responses will be documented. Equipment will be replaced immediately when it is broken or malfunctions, or if visible soiling remains after cleaning. Equipment is replaced routinely in accordance with manufacturer recommendations. General guidelines include face mask and tubing once every three months. Head gear, non-disposable filters, and humidifier chamber, once every six months, and disposable filters, twice monthly.
Review of the facility policy Provision of Physician Ordered Services dated 12/3/24, indicated the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of practice. Documentation of consultations, and date/time of physician notification will be maintained in the resident's clinical record. In instances where diagnostic testing or consultations are not available to be performed on-site or the physician has requested that the services be performed at an off-site facility, the facility will work with the resident and their family to secure appropriate transportation arrangements for such appointments.
Review of the facility policy Comprehensive Care Plans dated 12/3/24, indicated it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completion of the MDS (periodic assessment of care needs). The comprehensive care plan will include measurable objectives and timeframes to meet the resident needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure.
Review of Resident R17's clinical record indicated referral paperwork from the hospital effective 7/25/24, uploaded 12/17/24, indicated the resident wears a BIPAP machine at night but states his broke and he hasn't worn it in about 3 nights.
Review of Resident R17's Hospital Discharge summary dated [DATE], indicated the resident has COPD and uses 4L (liters) oxygen via nasal canula (medical device that delivers oxygen to your nose through a flexible tube with two prongs) continuously, and has obstructive sleep apnea and uses BIPAP.
Review of Resident R17's physician orders dated 7/25/24, indicated to follow up with pulmonary within seven days.
Review of Resident R17's clinical record from 7/25/24, through 8/1/24, failed to indicate the resident followed up with pulmonary.
Review of Resident R17's progress note dated 7/26/24, entered by, Registered Nurse, Employee E9 stated the resident is on oxygen or BIPAP at all times. No physician order was entered for the resident oxygen or BIPAP use.
Review of Resident R17's progress note dated 7/28/24, entered by Licensed Practical Nurse, Employee E10 stated Resident said to writer that he can't breathe. The resident's Spo2 (blood oxygen level that measures how much oxygen is circulating in your bloodstream) was 88% via 2 L nasal cannula. Care is ongoing.
Review of Resident R17's active physician order dated 7/28/24, indicated to administer 2L oxygen continuously, every shift for oxygen therapy.
Review of Resident R17's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R17's History and Physical note dated 8/7/24, entered by Medical Doctor, Employee E11 indicated the resident had a history of COPD with respiratory failure and obstructive sleep apnea. It was indicated the resident was on BIPAP with settings of 12/8. The plan was to continue to use his BIPAP. No physician order was entered for the resident's BIPAP settings.
Review of Resident R17's clinical record indicated he was transferred out to the hospital on the following dates for respiratory distress.
-9/9/24
-9/15/24
-9/18/24
-9/28/24
-10/30/24
Review of Resident R17's Readmission note dated 9/23/24, entered by Nurse Practitioner, Employee E7 indicated the resident was readmitted from the hospital. It was indicated per ER documentation they suspect that him being off the BIPAP at night while in the facility for two nights may have caused him to retain carbon dioxide (a colorless, odorless gas formed by the chemical reaction of carbon and oxygen, and it plays a critical role in various biological and physical processes). The BIPAP settings were adjusted while he was in the hospital. It was indicated he is to use a BIPAP at bedtime. A physician order for BIPAP settings was not entered.
Review of Resident R17's physician order dated 10/7/24, entered by Nurse Practitioner, Employee E7 indicated the resident is to wear BIPAP at night and any time during the day when sleeping. The settings were 12/8 with 4L oxygen.
Review of Resident R17's hospital Discharge summary dated [DATE], indicated to follow-up with pulmonary within 4-6 weeks.
During an interview on 12/16/24, 10:38 a.m. Resident R17's was observed wearing 5 L of oxygen via nasal cannula. Resident R17's BIPAP mask was observed on a dresser next to his bed not in a bag. The mask was unclean and visibly dirty. Resident R17 stated he was unsure the last time it was cleaned.
During an interview on 12/16/24, at 10:47 a.m. LPN, Employee E15 confirmed Resident R17 was not receiving his oxygen as ordered, the humidification bottle was undated, and the BIPAP face mask was visibly dirty and not stored properly.
During an interview on 12/17/24, at 11:13 a.m. Nurse Partitioner, Employee E7 confirmed Resident R17 did not have an order for BIPAP entered prior to 10/7/24. NP, Employee E7 stated there were orders in the hospital discharge paperwork that did not get put in.
During an interview on 12/17/24, at 11:36 a.m. [NAME], Employee E5 confirmed she is responsible for scheduling appointments. [NAME], Employee E5 confirmed Resident R17 has not been scheduled a pulmonary appointment as ordered.
During an interview on 12/17/24, at 1:24 p.m. Resident R17's family member expressed concerns regarding Resident R17 hospitalizations and care.
During a phone interview on 12/19/24, at 9:06 a.m. Resident R17's Case Manager stated Resident R17's had his BIPAP since he has been at the facility. It was indicated the facility can't take care of him, that's why he keeps going back to the hospital.
During an observation and interview on 12/19/24, at 9:57 a.m. Resident R17's BiPAP mask was observed not in a bag again. Resident R17 stated I told them to put it in the bag. Resident R17's BIPAP filter was observed filthy with lint. Resident R17 stated he has never refused his BIPAP, and stated I know I need it. I don't mind it.
During an interview on 12/19/24, at 10:10 a.m. RN, Employee E16 confirmed Resident R17's BIPAP mask was not stored properly and the BIPAP filter was unclean.
During an interview on 12/19/24, at 1:30 p.m. the Nursing Home Administrator confirmed Resident R17 had a BIPAP since he was admitted on [DATE], with no orders for settings or to clean the machine. It was indicated on 9/16/24, the facility rented a new BIPAP machine because Resident R17's was not working. The NHA confirmed the facility failed to provide appropriate respiratory care for one of three residents (Residents R17).
28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical documentation. observation and staff interview it was determined the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R55).
Findings:
Review of facility policy Discontinued Medications, dated 12/3/24, indicated when medications are discontinued by prescriber order, a resident is transferred or discharged and does not take medications with him or her, or in the event of resident ' s death, the medications are marked as discontinued and destroyed or returned to the issuing pharmacy. Medications are stored in a locked secure area designated for that purpose until destroyed.
Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE].
Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/16/24, indicated diagnoses of depression, muscle weakness, and hypothyroidism (a condition in which they thyroid gland doesn't produce enough thyroid hormone.
Review of Resident R55's physician orders dated 12/17/24, indicated that Buspirone (a medication used to treat anxiety) 7.5 mg was ordered with a discontinued date of 12/17/24.
During an observation on 12/20/24, at 12:07 p.m. the facility had a blister pack of Buspirone 7.5 mg laying on a shelf beside the refrigerator in the medication room. The blister pack of Buspirone contained 28 pills.
During an interview on 12/20/24 at 12:15 p.m. Registered Nurse Employee E14 stated, The facility should have destroyed them when the order was discontinued.
During an interview on 12/20/24, at 2:23 p.m. the Director of Nursing confirmed that the facility failed to dispose and reconcile discontinued medication in a timely manner for one of two residents (Resident R55).
28 Pa. Code211.12(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for one of one dialysis resident (Resident R64).
Findings include:
Review of the admission record indicated Resident R64 was admitted to the facility on [DATE].
Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/29/24, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, and high blood pressure.
Review of current physician orders on 1/30/24, indicated Resident R64 attends dialysis on Monday, Wednesday, and Friday each week.
A review of the clinical record did not include complete communication forms for the month of December 2024. There were seven incomplete communication sheets (Portion Completed by Nursing Home was incomplete) for the following dates: 12/6/24, 12/9/24, 12/11/24, 12/13/24, 12/16/24 and two without a date.
Interview on 12/17/24, at 10:59 a.m. Licensed Practical Nurse confirmed the above dates did not include complete communication forms as required for Resident R64.
Interview on 12/17/24, at 2:55 p.m. the Nursing Home Administrator confirmed the facility failed to make certain consistent dialysis communication was maintained for one of one dialysis resident (Resident R39).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36 and R85).
Findings include:
Review of facility policy Trauma Informed Care dated 12/3/24, indicated the facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health professionals to develop and implement individualized care plan interventions. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which may re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan.
Review of the clinical record indicated Resident R36 was admitted to the facility on [DATE].
Review of Resident R36's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/1/24, indicated diagnoses of high blood pressure, muscle wasting, and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).
Review of Resident R36's care plan on 12/16/24, did not include a plan of care developed with goals and interventions related to post-traumatic stress disorder.
During an interview on 12/17/24, at 10:04 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E2 confirmed that the facility failed to develop a care plan related to post-traumatic stress disorder for Resident R36.
Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE].
Review of Resident R85's MDS dated [DATE], indicated diagnoses of anxiety, depression, and PTSD.
Review of Resident R85's care plan on 12/16/24, did not include a plan of care developed with goals and interventions related to post-traumatic stress disorder.
During an interview on 12/17/24, at 11:03 a.m. Resident R85 stated no one from the facility has asked her about her trauma or triggers.
During an interview on 12/17/24, at 1:00 p.m. Social Services Director Employee E4 confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R36 and R85).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R56).
Findings include:
Review of facility policy Proper Use of Bed Rails dated 12/3/24, indicated a nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail.
Review of the clinical record indicated Resident R56 was admitted to the facility on [DATE].
Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/2/24, indicated diagnoses of high blood pressure, muscle weakness, and anemia (too little iron in the blood).
Review of a physician order dated 7/26/22, indicated bilateral (both sides) bed enablers (enabler bars) to promote bed mobility independence.
Review of Resident R56's care plan dated 3/19/21, indicated I require the use of bilateral enablers when in bed to assist with bed mobility, positioning, transfers in and out of bed and to increase functional independence. A nursing assessment will be completed quarterly, annually and with significant change in my status for the need of enablers.
Review of Resident R56's clinical record revealed the last Side Rail/Grab Bar Review was completed on 5/2/24.
During an observation on 12/16/24, at 11:24 a.m. two top enabler bars were present on Resident R56's bed.
During an interview on 12/20/24, at 12:49 p.m. the Director of Nursing (DON) confirmed that the Side Rail/Grab Bar Review was last completed for Resident R56 on 5/2/24.
During an interview on 12/20/24, at 12:49 p.m. the DON confirmed that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for one of two residents (Resident R56).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.12 (d) (1)(3)(5) Nursing services.
28 Pa. Code 211.10(c)(d) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, hospital records review, facility policy review, and staff interview, it was determined that the facility failed to ensure that the resident's total program of care, including medications and treatments, were reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 1).
Findings include:
Review of the facility policy Provision of Physician Ordered Services dated 12/3/24, indicated the purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of practice.
Review of the clinical record indicated that Resident R17 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), Obstructive Sleep Apnea (a sleep disorder in which the throat muscles relax and block the airway, causing breathing to become restricted and briefly stop), and respiratory failure.
Review of Resident R17's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R17's History and Physical note dated 8/7/24, entered by Doctor of Medicine, Employee E11 indicated the resident had a history of COPD with respiratory failure and obstructive sleep apnea. It was indicated the resident was on BIPAP with settings of 12/8. The plan was to continue to use his BIPAP. No physician order was entered for the resident's BIPAP settings.
Review of Resident R17's Readmission note dated 9/23/24, entered by Nurse Practitioner, Employee E7 indicated the resident was readmitted from the hospital. It was indicated per ER documentation they suspect that him being off the BIPAP at night while in the facility for two nights may have caused him to retain CO2. The BIPAP settings were adjusted while he was in the hospital. It was indicated he is to use a BIPAP at bedtime. A physician order for BIPAP settings was not entered.
Review of Resident R17's physician order dated 10/7/24, entered by Nurse Practitioner, Employee E7 indicated the resident is to wear BIPAP at night and any time during the day when sleeping. The settings were 12/8 with 4L oxygen.
During an interview on 12/17/24, at 11:13 a.m. Nurse Partitioner, Employee E7 confirmed Resident R17 did not have an order for BIPAP entered prior to 10/7/24. Nurse Practitioner, Employee E7 stated there were orders in the hospital discharge paperwork that did not get put in.
During an interview on 12/19/24, at 10:25 a.m. Doctor of Medicine, Employee E11 confirmed the facility failed to ensure that the resident's total program of care, including medications and treatments, were reviewed with accuracy at each physician visit for one of three residents reviewed (Resident 17).
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.5(ii)(iv)(vii) Medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete annual performance evaluations for one of three nurse aide personnel records (Nurse Aide Employee E26).
Findings include:
The facility Certified Nursing Assistant position description last reviewed 12/3/24, indicated that compliance is a factor in evaluating job performance. It was indicated individual performance will be evaluated using a scale ranging from unsatisfactory to exceeds standards.
Review of Nurse aide (NA) Employee E26's personnel record indicated she was hired to the facility on [DATE]. The record indicated that the position description and the employee handbook were both signed on 11/30/23.
Review of Nurse aide (NA) Employee E26's performance evaluation on 12/20/24, at 9:30 a.m. for the evaluation period of 11/30/23 to 1/30/24, failed to reveal an annual performance evaluation was performed.
During an interview on 12/20/24, at 9:38 p.m. the Director of Human Resources Employee E22 confirmed that the facility failed to complete an annual performance evaluation for NA Employee E26 as required.
28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two of two residents (Resident R48, and Resident R53).
Findings include:
The facility policy Medication Regimen Review and Reporting reviewed 12/3/24, indicated a MRR is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated.
Review of Resident R48's admission record indicated she was admitted to the facility on [DATE].
Review of Resident R48's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/26/24, indicated the diagnoses high blood pressure, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).
Review of Resident R48's clinical pharmacy review notes on 12/20/24, at 10:00 a.m. indicated the following:
January 2024 - no recommendations in clinical record
March 2024- no recommendations in clinical record
May 2024- no recommendations in clinical record
July 2024- no recommendations in clinical record
September 2024- no recommendations in clinical record
December 2024 - no recommendations in clinical record
Review of Resident R53's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R53's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).
Review of Resident R53's clinical pharmacy review notes on 12/20/24, at 10:00 a.m. indicated the following:
January 2024 - no recommendations in clinical record
March 2024 - no recommendations in clinical record
April 2024 - no recommendations in clinical record
July 2024 - no recommendations in clinical record
September 2024 - no recommendations in clinical record
December 2024 - no recommendations in clinical record
During an interview on 12/20/24, at 11:30 a.m. the Director of Nursing (DON) stated, I know the pharmacy does monthly reviews, but I can't find them in the residents record.
During an interview on 12/20/24, at 12:52 p.m. the DON confirmed that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist recommendations were made for two out of two residents (Resident R48, and Resident R53).
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.9 (k) Pharmacy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of three medication carts (3A medication cart), and in one of three medication rooms (Medication room [ROOM NUMBER]BC) and failed to properly secure a medication cart for one of three medication carts (3A medication cart).
Findings include:
Review of facility Medication Storage policy dated 12/3/24, indicated the facility will ensure all medication housed on our premises will be stored in the medication rooms according to manufacturer's guideline. All drugs and biologicals will be stored in locked compartments. During a medication pass, medication must be under the direct observation of the person administering medications or locked in the medication storage area or cart.
During a tour of the facility on 12/17/24, at 10:53 a.m. revealed a medication cart that was unattended, and unlocked on 3A.
During an interview on 12/17/24, at 11:00 a.m. Licensed Practical Nurse (LPN) Employee E23 confirmed that 3A medication cart was unlocked.
During an observation on a medication pass on 12/18/24, at 9:50 a.m. revealed a liquid medication in a cup poured sitting on top of the medication cart 3A.
During an interview on 12/18/24, at 9:53 LPN Employee E24 stated I'm waiting for a resident to finish eating then I am going to give it to her.
During an interview on 12/18/24, at 9:55 a.m. LPN Employee E24 confirmed that a pre-poured medication was sitting on top of the medication cart and was not given to the resident.
During a medication room storage review on 12/20/24, at 11:50 a.m. revealed that the secured narcotic lock box inside the refrigerator was unlocked with two oral concentrated Ativan (narcotic controlled medication used to treat anxiety) in it.
During an interview on 12/20/24, at 12:05 p.m. LPN Employee E25 confirmed that the narcotic lock box was unlocked in medication room [ROOM NUMBER]BC.
28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to ensure that a resident's physician was promptly notified about abnormal laboratory test results for one of two residents (Resident R34)
Findings include:
The facility policy Notification of Changes: dated 12/3/24, and previously dated 9/12/24, indicated that the facility will promptly inform the physician when there is a change requiring notification.
Review of the clinical record revealed that Resident R34 was admitted to the facility on [DATE] from a hospital.
Review of Resident 34's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), and pain.
Review of medical records revealed that Resident R34 had a physician's order dated 9/20/24, indicated to complete a CBC (Complete Blood Count- a group of blood tests that measure the number and size of the different cells in your body), and BMP (Basal Metabolic Panel- a blood test that measures the body's metabolism).
Review of Resident R34's lab results dated 9/20/24, indicated the following out of range results:
BUN 28
RBC 3.28
HGB 9.0
HCT 29.7
MCHC 30.3
Review of Resident R34's clinical record did not include a call to the physician to review the abnormal results and/or obtain new orders related to the results from 9/20/24.
Review of medical records revealed that Resident R34 had a physician's order dated 12/4/24, indicated to complete a CBC, and BMP.
Review of Resident R34's lab results dated 12/4/24, indicated the following out of range results:
Glucose 111
BUN 40
Creatinine 1.5
Anion Gap 2
Review of Resident R34's clinical record did not include a call to the physician to review the abnormal results and/or obtain new orders related to the results from 12/4/24.
Review of medical records revealed that Resident R34 had a physician's order dated 12/9/24, indicated to complete a BMP, and an H and H level (a blood test that provides information about the oxygen-carrying capacity of the blood).
Review of Resident R34's lab results dated 12/4/24, indicated the following out of range results:
BUN 37
Anion Gap 1
HGB 8.5
HCT 26.6
Review of Resident R34's clinical record revealed a signature from a nurse practitioner that labs from 12/9/24, were reviewed, however it failed to indicate a date that this was reviewed to ensure a prompt notification.
During an interview on 12/20/24, at 12:18 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that a resident's physician was notified promptly about abnormal laboratory test results for Resident R34.
28 Pa. Code 211.12(d)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of five residents (Resident R1).
Findings include:
Review of facility policy Care Plan Revision Upon Status Change dated 9/12/24, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of depression (a constant feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease), and constipation (a problem with passing stool).
Review of a Nursing Progress Note dated 11/6/24, at 10:45 a.m. completed by the Director of Nursing (DON) stated, Resident demanding to be sent to ER (emergency room) stating that he needed to have a bowel movement. He had however moved his bowels. Sent as per residents request. Physician aware. Nursing to be educated on the protocol.
Review of a Nursing Progress Note dated 11/6/24, at 10:45 a.m. completed by Licensed Practical Nurse (LPN) Employee E3 stated, Resident OTH (out to hospital) per his request, stating to writer that he is constipated despite going yesterday and today, telling different stories to different staff. Took morning medications by mouth without issue and ate breakfast before departure.
Review of a Nursing Progress Note dated 11/6/24, at 7:17 p.m. completed by Registered Nurse (RN) Employee E1 stated, Resident returned from hospital around 4:00 p.m. No new orders, continue regular constipation medications.
Review of a Nursing Progress Note dated 11/13/24, at 9:26 a.m. completed by LPN Employee E4 revealed Resident R1 refused his scheduled Senna (medication used to treat constipation) 17.2 milligrams, stating, the doctor wants him to have a suppository daily.
Review of a Nursing Progress Note dated 11/13/24, at 11:58 a.m. completed by the DON stated, Spoke with resident today about bowel movements and his refusal of Senna. States that the doctors here don't know anything and that the ER doctor stated on his last admission that he should have regular enemas. Resident educated on facility bowel regimen and that he must follow the protocol. Educated that we do not send him out without following the guidelines and having an abdominal assessment, flat plate (an x-ray of the abdomen), acceptance of medications. States he removes his bowel movements by hand. Physician aware.
Review of a Nursing Progress Note dated 11/16/24, at 8:52 a.m. completed by LPN Employee E5 stated, Resident called 911 by himself in room due to being constipated. Resident sent to hospital. Supervisor notified.
Review of a Clinical Nurses Note dated 11/16/24, at 10:01 a.m. completed by RN Employee E6 stated, Resident stating that he needs to go to the hospital due to constipation. Resident stated that his last bowel movement was 3 days ago. LPN and RN tried to encourage resident to remain in house and utilize bowel movement protocol. Notified physician.
Review of Resident R1's care plan on 11/19/24, failed to reveal goals and interventions related to Resident R1's constipation concerns and refusal of physician ordered bowel regimen.
During an interview on 11/19/24, at 1:39 p.m. the DON confirmed that the facility failed to ensure a resident's care plan was updated and revised to reflect the resident's specific care needs for one of five residents as required.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.11(a) Resident care plan.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of two nursing units (Second Floor).
Findings include:
Review of facility policy Safe and Homelike Environment dated 9/12/24, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.
During an observation on 11/19/24, at 10:50 a.m. the Resident's Day Room (activity/dining area) in the 200 hallway indicated two wheelchairs and a stretcher were being stored in the room.
During an interview on 11/19/24, at 11:08 a.m. Registered Nurse (RN) Employee E1 confirmed the above observation. RN Employee E1 stated, Resident wheelchairs are stored in the hallway during the morning while staff are getting residents out of bed. In the evenings, equipment is stored in the Day Rooms. The stretcher was left by transport.
During an interview on 11/19/24, at 1:39 p.m. the Director of Nursing confirmed that the facility failed to maintain a clean homelike environment in one of two nursing units as required.
28 Pa. Code 201.29(j) Resident rights.
29 Pa. Code 207.2(2) Administrator's Responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of four medication carts (Medication Cart 3C).
Findings include:
Review of facility policy Medication Storage dated 9/12/24, indicated all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
During an observation on 11/19/24, at 11:24 a.m. the 3C Medication Cart was observed outside of resident room [ROOM NUMBER] with the cart unlocked and unattended.
During an interview on 11/19/24, at 11:25 a.m. Licensed Practical Nurse Employee E2 confirmed the 3C Medication Cart was unlocked and unattended.
During an interview on 11/19/24, at 1:39 p.m. the Director of Nursing confirmed that the facility failed to properly secure a medication cart while not in use for one of four medication carts as required.
28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services.
28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to follow physician orders for surgical wound care for one out of three residents (Resident R1).
Findings include:
Review of facility policy Wound Treatment Management, dated 9/12/24, revealed that wound treatments will be provided in accordance with physician order. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.
Review of hospital documentation revealed that Resident R1 was discharged from the hospital on 9/9/24, after receiving surgery to the spine.
Review of hospital discharge documents included a physician's orders to provide wound care to Resident R1's surgical incision on her back with a dry dressing, daily.
Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/16/24, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and pain.
Review of clinical record did not reflect the physician's orders from the hospital to provide wound care to Resident R1's surgical incision on her back with a dry dressing, daily.
Review of the clinical record revealed that Resident R1 did not receive any dressing changes to her surgical incision on her back from 9-9-24 through 9/18/24.
During an interview on 10/18/24, at 2:56 p.m., the Nursing Home Administrator confirmed that the facility failed to follow physician orders for surgical wound care for one of three residents (Resident R1).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Residents R1, R2, R3, R4).
Findings Include:
Review of the facility policy Accidents and Supervision dated 5/24/23, last reviewed 9/12/24, indicated each resident will receive adequate supervision and assistive devices to prevent accidents.
Review of the facility policy Nursing Services and Sufficient Staff dated 5/24/23, last reviewed 9/12/24, indicated it is the facility policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Review of the facility policy Fall Prevention Program dated 5/24/23, last reviewed 9/12/24, indicated each resident will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
Review of Resident R1's clinical record indicated she was admitted to the facility on [DATE], with diagnoses of encephalopathy (damage or disease that affects the brain), alerted mental status, and delirium (a serious change in mental abilities).
Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/6/24, indicated the diagnoses were current.
Review of Resident R1's care plan dated 8/7/24, indicated to provide me with 1:1 monitoring when I am in danger of hurting myself with my behaviors.
Review of Resident R1's progress note dated 8/17/24, at 3:29 a.m. indicated the resident has been redirected several times to no avail. It was indicated the resident was going in into other resident rooms taking their items. Resident went into areas that are not safe for residents to be. Resident is going through items at nursing station while staff is assisting other residents. Resident trying to open doors that lead to stair cases. Staff had to lock med cart in treatment room due to resident taking items off the cart. Redirection is unsuccessful. Resident starting to get physically aggressive when redirected.
Review of Resident R1's progress note dated 8/17/24, at 9:51 a.m. indicated the resident was wake with gross confusion. Does not redirect even briefly. It was indicated the resident wanders constantly, goes into other resident's belongings constantly, very disruptive, and requires 1:1 often.
Review of Resident R1's progress note dated 8/18/24, at 10:01 a.m. indicated the resident began wandering as soon as she woke up. Gross confusion and does not redirect. Removed from 2 residents rooms within minutes of waking up. Removed all garbage can lines from 3A bathroom and does not want to give them back.
During an interview on 9/24/24, at 9:55 a.m. the Interim Director of Nursing (DON) stated I did 16 hours on Saturday. When asked what does the facility do when there is not a licensed nurse available in a 24 hour period, the DON indicated she comes in, I actually did 40 hours because a Registered Nurse (RN) quit.
During an interview on 9/24/24, at 10:20 AM Resident R2 stated call bells are not answered quickly, and stated she has waited up to an hour and a half.
During an interview on 9/24/24, at 10:27 a.m. Resident R3 indicated it can take staff a while to answer her light because they are busy. Resident R2 stated she has waited up to a half hour.
During an interview on 9/24/24, at 10:33 a.m. Nurse Aide, Employee E1 stated staff are not reliable, it's the same shift, same people calling off. NA, Employee E1 stated she sometimes comes in at 3 a.m. because they are short. NA, Employee E1 stated I don't think they have enough staff in general, they are working them like dogs.
During an interview on 9/24/24, at 10:37 a.m. Nurse Aide, Employee E2 stated there is a staffing concern for the overnight shift. NA, Employee E2 stated there are a lot of residents with behaviors on the third floor, and there are some residents that should be 1:1 supervision depending on the day, and it can be overwhelming.
During an interview on 9/24/24, at 10:44 a.m. Licensed Practical Nurse, Employee E3 stated it is sometime overwhelming when we don't have enough staff, during the week we are very busy. LPN, Employee E3 stated she has to stay every day after her shift to document. LPN, Employee E3 stated she knows there are two residents that sit around the nursing station, so they always have eyes on them. It was indicated there was one point we had 4 to 6 residents who needed to be fed for meals, when there were only two aides or a nurse. There were not enough staff to feed residents, and she would call downstairs asking for help, and it was indicated they were not qualified and could not help to feed.
During an interview on 9/24/24, at 11:06 a.m. Resident R4 stated they need to hire more people. It was indicated she can wait up to 45 minutes for help.
During an interview on 9/24/24, at 11:11 a.m. NA, Employee E4 stated Resident R1 often sits at the nurses station because she needs supervision. We don't have staff for 1:1, that the reason she is at the nursing station. Somedays she gets a little antsy.
Review of the facility's list of incidents on 9/24/24, at 11:22 a.m. Resident R1 had a total of 16 incidents since she was admitted .
During an observation on 9/24/24, at 11:48 a.m. Resident R1 was observed sitting at the nursing station trying to get out of her chair.
During an interview on 9/24/24, at 11:49 a.m. LPN, Employee E5 stated if it was possible, a 1:1 would be beneficial for Resident R1.
During an interview on 9/24/24, at 12:52 a.m. Registered Nurse, Employee E6 stated Resident R1 is very confused, hard to redirect, she can't help it. It's difficult to implement 1:1. LPN, Employee E6 stated she could benefit from 1:1, however I don ' t know we can always supply that, that's a question better directed towards the Nursing Home Administrator. LPN, Employee E6 indicated a concern for staffing.
During an interview on 9/24/24, at 2:01 p.m. the Nursing Home Administrator and the interim Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of four of eight residents (Resident R1, R2, R3, and R4).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code: 201.20(a) Staff development.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that the status of nursing licenses were checked with the State Board of Nursing and failed to ensure that references were checked from previous employers and/or current employers for one of one newly hired nurses reviewed (Registered Nurse 1). This deficiency was cited as past non-compliance.
Findings include:
The facility's policy regarding abuse, neglect, and exploitation, dated July 6, 2022, indicated that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility will maintain documentation of proof that the screening occurred.
The personnel file for Registered Nurse 1 revealed a start date of November 30, 2022. However, there was no documented evidence that her license was checked with the State Board or that her references were checked from previous employers and/or current employers prior to her working.
Interview with the Director of Nursing on December 20, 2023, at 1:50 p.m. revealed that she cannot speak for that period of time because she was not at the facility. She indicated that the person in the corporate office that would have completed the checks no longer works there, so they were unable to provide any documented evidence that Registered Nurse 1's license and reference checks were completed prior to her working.
The facility's corrective action included these Quality Assurance and Performance Improvement (QAPI) initiatives:
Medication administration and errors. All licensed staff were educated on the facility's medication administration policy, and in May 2023 the facility initiated daily routine audits of missing medication administrations and treatments by their Regional Quality Registered Nurse (RN) with associated follow ups. All licensed staff completed in-servicing on medication errors in July 2023.
Resident abuse and neglect education was whole house completed during the first quarter of 2023.
Accountability has been ongoing throughout the facility's Quality Assurance (QA) process. The facility has also instituted increased displays for their Med-Net corporate compliance, which is a third-party reporting hotline throughout the building. As of May 2023, the Regional Quality RN reviews all incidents, accidents, and documentation of transfers to ensure such receive appropriate follow-up.
The facility completed a comprehensive review of Registered Nurse 1's file to confirm appropriate hiring practices were followed. Although there was no evidence of wrongdoing, and her license was in good standing during her employment with the facility, the facility amended the hiring process as they have gone from a contract Human Resources (HR) to an in-house HR Department. The facility has instituted processes including checklists to ensure that new hires have all required references and background checks completed. Effective November the Nursing Home Administrator and the HR department received in-depth training on completing background checks.
The facility's hypoglycemia/hyperglycemia policy, assessing for change in condition, and physician notification policies were reviewed and in-serviced to all licensed staff in July 2023.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy and clinical record review, and staff interview, it was determined the facility failed to notify a resident of a room change and the physician for a change in condition for three of five residents (Resident R12, R34, and R85).
Findings include:
Review of the facility policy Notification of Changes last reviewed 2/21/23, indicated the facility will promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification. It was indicated if a change in the resident's room occurs, the facility must inform the resident.
Review of the facility policy Change of Room or Roommate dated 2/21/23, stated it is the policy of the facility to notify a resident in writing prior to changing a resident's room, and it must include the reason for the room change.
Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/11/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and depression.
Review of Resident R12's progress note dated 12/30/23, stated the resident was upset with room move.
During an interview on 1/2/24, at 9:54 a.m. Resident R12 indicated he was unhappy with his current room and he was moved to a different room without being notified of the room change.
Review of Resident R12's Census List last revised 1/1/23, indicated Resident R12 had a room change on 12/29/23, then again on 12/30/23.
Review of Resident R12's clinical record on 1/2/23, failed to include documentation for the reason of the room change and that the resident was notified of the room change.
During an interview on 1/3/23, at 1:16 p.m. the Director of Nursing (DON) confirmed the facility failed to document the reason for Resident R12's room change and provide evidence the resident was informed of the room change in writing.
Review of the face sheet indicated Resident R34 was admitted to the facility on [DATE].
Review of Resident R34's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and an overactive bladder.
Review of Resident R34's progress note dated 8/21/23, stated the resident rang tonight several times with complaints of urinary urgency as well as a burning sensation in her vaginal area. It was documented that the Registered Nurse (RN) was notified.
During an interview on 1/4/23, at 10:49 a.m. LPN, Employee E8 indicated if a resident has a change in condition or has signs and symptoms of a urinary tract infection, the RN must be notified and the RN contacts the physician. It was indicated a doctor should be notified by then end of the shift and it must be documented in the clinical record. LPN, Employee E8 confirmed the facility failed to notify a physician for Resident R34's change in condition on 8/21/23.
Review of the Clinical Record indicated Resident R85 was admitted to the facility on [DATE].
Review of Resident R85's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids).
Review of Resident R85's progress notes indicated the following:
-10/29/23, at 2:37 p.m. indicated Nurse Aide (NA) alerted floor nurse that resident was shivering and talking out of the normal. Resident having emesis (vomiting), and given medication. Registered Nurse (RN) Supervisor notified.
-10/29/23, at 3:11 p.m. this nurse spoke with supervisor. Resident put on doctor book.
-10/29/23, at 9:36 p.m. NA alerted nurse to resident shaking and vomiting again. Temperature elevated at 101.2 degrees. Resident denied pain but stated his stomach doesn't feel right. Resident cleaned up and given medications.
-10/30/23, at 8:25 p.m. resident with emesis and not feeling well. Oxygen saturation 72-84 % (low), heart rate 138 beats per minute (high), and blood pressure 174/95 (high). Send to emergency room for eval and treatment of decreased oxygen saturation and emesis.
Review of Residents R85's progress notes indicated the facility failed to notify the physician of a change in condition from 10/29/23, at 2:37 p.m. until 10/20/23, at 8:25 p.m. despite ongoing symptoms.
Interview with Director of Nursing on 1/5/23, at 1:00 p.m. confirmed the facility failed to notify a resident of a room change and the physician for a change in condition for three of five residents (Resident R12, R34, and R85).
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(d) Resident Rights
28 Pa. Code 211.10 (c)(d) Resident Care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of six residents reviewed (Resident R31).
Findings include:
The facility's policy Abuse Neglect, and Exploitation Policy dated 2/21/23, indicated it is the facility's policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Review of admission record indicated Resident R31 was admitted to the facility on [DATE].
Review of Resident R31's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/4/23, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), high blood pressure, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids). Section GG indicated substantial/maximum assistance for toileting and hygiene needs.
Review of a facility submitted report dated 10/7/23, indicated Resident R31 was not changed the entire shift (left saturated in urine without receiving hygiene).
Review of Nurse Aide (NA) Employee E7's witness statement dated 10/7/23, indicated the linen cart was left for the other NA to use on B hallway. At 2:30 a.m. the cart was in the same spot. The other NA was on break at that time. NA Employee E7 and Licensed Practical Nurse (LPN) Employee E8 went to check residents and found quite a few full bed changes and soaked briefs.
Review of LPN Employee E8's witness statement dated 10/7/23, indicated they had the impression that B hall nurse aide did not check residents for incontinence care (clean of urine and feces) and proceeded to check on residents. Resident R31 was found to be a complete bed change (urine saturated through all linens on bed and resident's brief). When Resident R31 was interviewed by LPN Employee E8 he indicated no one had checked on him.
Review of facility investigation dated 10/11/23, at 1:15 p.m. indicated the facility's conclusion that Nurse Aide was found to be negligent in care practices and was terminated.
Interview on 1/5/23, at 1:00 p.m. the Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse and neglect for one of six residents reviewed (Resident R31).
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(d) Resident Rights
28 Pa. Code 211.10 (c)(d) Resident Care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations of resident areas and nursing units, and staff interview it was determined that the facility failed failed to post all required information to submit a grievance on two of three resident areas (Second floor and Third floor).
Findings include:
The facility Resident and family grievances policy dated 2/21/23, indicated that it is the poicy of the facility to support each resident's right to voice grievances.
During a tour on 1/2/24, the following was observed:
At 11:41 a.m. observations of the postings on the Third floor common areas and hallways found no grievance procedure or grievance policy posted.
At 11:52 a.m. observations of the postings on the Second floor common areas and hallways found no grievance procedure or grievance policy posted.
During a tour on 1/3/24 with the Director of Social Services Employee E1, the following was observed:
At 9:38 a.m. the Second Floor day room by room [ROOM NUMBER] was observed with no grievance policy posted (name of grievance official, address, phone number or e-mail).
At 9:40 AM the Second Floor day room by room [ROOM NUMBER] was observed with no grievance policy posted (name of grievance official, address, phone number or e-mail).
At 9:42 a.m. the Third floor day room by room [ROOM NUMBER] was observed with no grievance policy posted (name of grievance official, address, phone number or e-mail).
At 9:43 a.m. the Third floor day room by room [ROOM NUMBER] was observed with no grievance policy posted (name of grievance official, address, phone number or e-mail).
During an interview on 1/3/24, at 9:45 a.m. the Director of Social Services Employee E1 confirmed that the facility failed failed to post all required information to submit a grievance on two of three resident areas.
28 Pa Code: 201.18 (e )(4) Management
28 Pa Code: 201.29(l) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in one of two nursing units (second floor), and two of two facility elevators (Elevator A and Elevator C).
Findings Include:
Review of the facility policy Safe and Homelike Environment dated 2/21/23, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.
Observation on 1/2/23, at 9:20 a.m. Resident R21's resident room [ROOM NUMBER]A, indicated a ceiling tile above the head of the bed area that was stained brown.
Observation on 1/2/23, at 9:42 a.m. Resident R187's resident room [ROOM NUMBER], indicated peeling plaster down the wall by the window, with lifted and jagged edges protruding from wall.
Observation on 1/2/23, at 9:53 a.m. Residents' Day Room (activity/dining area) in the 200 hallway indicated 15 wheelchairs were stored to the right side of the room, occupying over a quarter of the room's space.
Observation on 1/2/23, at 10:05 a.m. Residents' Day Room in the opposite hallway indicated 9 wheelchairs, several walkers and two rollators (walkers with wheels and brakes).
Observation on 1/2/23, at 11:38 a.m. Elevator A indicated a cracked blue, plastic, covering to the lower perimeter of the elevator car with shards of broken plastic with sharp edges at the level of leg rests on residents' wheelchairs.
Observation on 1/2/23, at 11:40 a.m. Resident R31's resident room [ROOM NUMBER]-2, indicated a ceiling tile above the head of the bed area that was stained brown.
Observation on 1/2/23, at 11:58 a.m. Elevator C indicated a lifted piece of black vinyl square flooring that could cause a tripping hazard.
During a tour on 1/3/23, at 1:09 p.m. the Director of Nursing confirmed the observations as stated above.
Interview on 1/3/23, at 1:10 p.m. the Director of Nursing confirmed the facility failed to maintain a clean homelike environment in one of two nursing units (second floor), and two of two facility elevators (Elevator A and Elevator C).
29 Pa. Code 207.2(2) Administrator's Responsibility.
28 Pa. Code 201.29(j) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, notice of non-coverage documents, clinical record review and staff interview, it was determined that the facility failed to provide the Advanced Beneficiary Notice prior to discharge from Medicare Part A services for one of three sampled residents (Resident R83).
Findings include:
The facility Statement of resident rights policy indicated that the resident has the right to receive information about the services available in the facility and about the charges for those services, including any changes for services not covered under Medicare.
Review of Resident R83's admission record indicated he was admitted on [DATE], with diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), diabetes (a metabolic disorder impacting organ function related to glucose levels in the human body), and anxiety disorder.
Review of Resident R83's MDS assessment (Minimum Data Set Assessment-MDS: a periodic assessment of resident care needs) dated 10/20/23, indicated that the diagnoses were current upon review.
Review of Resident R83's Notice of Medicare Non-Coverage (NOMNC-form provided to residents that are being discharged from skilled therapy services typically covered by Medicare Part A or Part B) dated 11/24/23, indicated that Resident R83 last covered day of therapy was 11/28/23 and Resident R83 would be staying at the facility for long-term care services.
Review of Resident R83's clinical record did not include evidence that an advanced beneficiary notice (ABN-a document explaining potential liability for services usually covered by Medicare) was provided.
During an interview on 1/3/24, at 10:31 a.m. the Director of Therapy Services Employee E5 stated the following: assuming the resident meets all Medicare requirements, Resident R83 was discharged on day 47 out of 100 Medicare therapy days.
During an interview on 1/3/24, at 10:37 a.m. the Director of Social Services Employee E1 confirmed that the facility failed to provide the Advanced Beneficiary Notice prior to discharge from Medicare Part A services for Resident R83 as required.
28 Pa Code: 201.29(b)(n) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse for four of six residents reviewed (Resident R12, R43, R84, and R85).
Findings include:
The facility policy Abuse, Neglect, and Exploitation dated 2/21/23, indicated it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Neglect, exploitation, and misappropriation of resident property. The Administrator must follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation within final within five working days of the incident, as required by stated agencies.
Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/11/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and depression.
A review of Resident R12's progress note dated 12/25/23, stated resident states she won't take care of me and she threw my EpiPen at me and wanted me to give my own insulin. This RN clarified with resident that it was not EpiPen but insulin dial pen. He agrees it was his insulin pen. Resident states maybe I feel threatened.
During an interview on 1/2/23, at 9:04 a.m. Resident R12 indicated last weekend there was a nurse who refused to administer his insulin injection and she threw it at him. It was indicated the Director of Nursing was notified of the incident.
Review of the facility's Incident Report dated 1/2/23, failed to include the incident that involved Resident R12 that occurred on 12/25/23.
During an interview on 1/2/23, at 11:19 a.m. the Director of Nursing (DON) confirmed the facility failed to investigate the allegation of abuse for Resident R12 and stated It did not happen.
Review of the admission Record indicated Resident R43 was admitted to the facility on [DATE].
Review of Resident R43's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids).
Review of Resident R43's care plan dated 12/11/23, indicated activity of daily living deficit related to toilet use, total assist. Performed in bed.
Review of the admission Record indicated Resident R84 was admitted to the facility on [DATE].
Review of Resident R84's MDS dated [DATE], indicated the diagnoses of high blood pressure, anemia (the blood doesn ' t have enough healthy red blood cells), Coronary artery disease (narrow arteries decreasing blood flow to heart), and heart failure (the heart doesn't pump as well as it should).
Review of Resident R84's care plan dated 12/5/23, indicated resident requires assistance of one with toileting and to report incontinence to the nurse.
Review of the admission Record indicated Resident R85 was admitted to the facility on [DATE].
Review of Resident R85's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and renal insufficiency.
Review of Resident R85's care plan dated 11/5/23, indicated resident requires assistance of one with toileting and to report incontinence to the nurse.
Review of LPN Employee E8's witness statement dated 10/7/23, indicated they had the impression that B hall nurse aide did not check residents for incontinence care (clean of urine and feces) and proceeded to check on residents. Resident R43 was found to need a complete bed change due to urine saturation, Resident R84 was found to need a complete bed change due to urine saturation, and R85 was saturated in urine. LPN Employee E8's interview with Resident R43 indicated that nobody had been in to check on her.
Interview with the Director of Nursing (DON) on 1/5/23, at 9:15 a.m. to review the facility's investigation of the neglect allegations above for residents R43, R84, or R85 and DON could not produce and confirmed the facility failed to fully investigate allegations of abuse for four of six residents reviewed (Resident R12, R43, R84, and R85).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.14 (c)(e) Responsibility of licensee.
28 Pa. Code: 201.18 (e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for one of four residents receiving hospice services (Resident R21).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election.
Review of the admission record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/26/23, indicated the diagnoses of stroke, high blood pressure, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
A review of the clinical record revealed a physician's order, dated 9/28/23, indicating that hospice services were initiated for Resident R21.
Further review of the clinical record failed to indicate documented evidence that a significant change MDS with an ARD was completed within 14-days from when Resident R21 was admitted to hospice.
Interview on 1/4/23, at 9:13 a.m., Registered Nurse Assessment Coordinator (RNAC) Employee E3, confirmed that the facility failed to complete a comprehensive assessment after a significant change in condition for Resident R21 receiving hospice services.
During an interview on 1/5/23, at 2:00 p.m., Nursing Home Administrator (NHA) confirmed that the facility failed to complete a comprehensive assessment after a significant change in condition for one of four residents that received hospice services (Resident R21).
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.
28 Pa. Code: 201.29(j) Resident Rights
28 Pa Code: 211.10 (c ) Resident care policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) user's manual, facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one of two sampled residents (Resident R74).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual (the manual providing instructions for completing Minimum Data Set assessments) dated 10/2023 indicated that the intent of the active diagnoses section is to code diseases that have a direct relationship to the resident ' s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS
assessment is to generate an updated, accurate picture of the resident ' s current health status.
The facility Conducting an accurate resident assessment policy last reviewed 2/21/23, indicated that accuracy of assessment means that the appropriate health professional correctly document the resident's medical, functional and psychosocial problems.
Review of Resident R74's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE] with diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and change in urination), dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), hypertension (a condition impacting blood circulation through the heart related to poor pressure).
Review of Resident R74's admission record also indicated she had a diagnoses of Post-Traumatic Stress disorder (PTSD-a mental health condition following a traumatic event with characterized behaviors of recurrent anxiety and stress). The Post-Traumatic Stress disorder diagnoses was indicated with a line across it.
Review of Resident R74's MDS assessment (Minimum Data Set Assessment-MDS: a periodic assessment of resident care needs) dated 6/29/23, indicated that the diagnoses were current upon review.
Review of Resident R74's MDS assessment dated [DATE], Section I6100 -(Active Diagnoses Psychiatric Mood disorder) was indicated with an (x) for an active diagnosis of Post-Traumatic Stress disorder.
Review of Resident R74's MDS assessments dated 6/8/23, 6/29/23 and 9/29/23 found that Section I6100 -(Active Diagnoses Psychiatric Mood disorder) indicated PTSD was an active diagnoses.
Review of Resident R74's hospital records, physician notes, and psychiatric notes did not include an indication of an active diagnoses of Post-Traumatic stress disorder.
Review of Resident R74's care plan did not indicate a diagnoses of PTSD.
During an interview on 1/3/24, at 2:18 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E3 stated: we looked through everything, we cannot figure out or understand why diagnoses of PTSD was on record. when you put things in the electronic health record, it can pull over to the MDS. The diagnoses was not verified. no one in our building has it. The diagnoses was an error.
During an interview on 1/4/24, at 10:40 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that MDS assessments accurately reflected Resident R74's status.
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of six residents (Resident R14, R44, and R63).
Findings include:
Review of the facility Care Plan policy dated 2/21/23, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Review of the facility Catheter Care policy last reviewed 2/21/23, indicated it is the facility's policy to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.
Review of the facility Hemodialysis policy dated 2/21/23, indicated the facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goal and preferences, to meet the special medical, nursing, mental, and psychosocial needs of resident's receiving hemodialysis.
Review of Resident R14's face sheet indicated he was admitted to the facility on [DATE].
Review of Resident R14's Minimum Data Set (MDS-periodic assessment of care needs) dated 12/4/23, indicated Resident R14 was admitted with diagnoses of high blood pressure, muscle weakness, and depression. Section H. Bladder and Bowel H0100. Appliances indicated the resident has a indwelling catheter.
Review of Resident R14's physician order dated 12/1/23, indicated to provide foley catheter care every shift and as needed.
Review of Resident R14's physician order dated 12/1/23, indicated the resident had a 16 Fr. 10 ml foley catheter inserted due to urinary retention (inability to voluntarily empty the bladder completely or partially.)
During an observation on 1/4/24, at 9:25 a.m. Resident R14 was observed lying in bed with a foley catheter intact and draining yellow urine.
Review of Resident R14's clinical record on 1/4/24, failed to reveal a resident-centered plan of care with goals and interventions related to the resident's foley catheter.
During an interview on 1/4/24, at 9:30 a.m., Licensed Practical Nurse (LPN), Employee E6 confirmed the facility failed to develop a care plan to include a focus and interventions for Resident R14's catheter.
Review of Resident R44's face sheet indicated he was admitted to the facility on [DATE].
Review of Resident R44's MDS dated [DATE], indicated Resident R44 was admitted with diagnoses of high blood pressure, heart failure, and renal insufficiency. Section O. Special Treatments, Procedures, and Programs indicated the resident receives hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately.)
Review of Resident R44's physician order dated 11/30/23, indicated the resident receives dialysis on Monday, Wednesday, and Fridays.
Review of Resident R44 care plan dated 1/2/24, failed to include a focus or interventions for Resident R44's dialysis.
During an interview on 1/5/24, at 9:40 a.m. Registered Nurse Assessment Coordinator (RNAC), Employee E3 confirmed the facility failed to update Resident R44's care plan to include a focus and interventions for dialysis.
Review of Resident R63's face sheet indicated she was admitted to the facility on [DATE].
Review of Resident R63's MDS dated [DATE], indicated the diagnoses of high blood pressure, heart failure, and renal insufficiency.
Review of Resident R63's physician order dated 12/12/23, indicated start every seven days to bladder scan (ultrasound of bladder to see how much urine is retained), for 30 days.
Review of Resident R63's care plan dated 12/11/23, failed to include a focus or interventions for urinary retention.
Interview with the Director of Nursing on 1/5/23, at 9:15 a.m. indicated the facility did not have a plan of care to address Resident R63's urinary retention concerns and that the facility failed to develop a plan of care to include a focus and interventions to maintain a resident's highest practicable physical well-being as required for three of six residents (Resident R14, R44, and R63).
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: §211.10(c) Resident care policies.
28 Pa Code: 211.11(a)(d)Resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to implement the bowel regimen protocol and provide treatment as required for four of six residents (Resident R1, R34, R63, and R237).
Findings include:
Review of facility policy Provision of Quality Care dated 2/21/23, indicated the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice.
A review of the Bowel Routine Policy dated 2/21/23, indicated if a resident has not had a bowel movement in three days (six shifts), 30 ml of Milk of Magnesia (a stimulant laxative used to treat constipation) must be administered. If Milk of Magnesia is ineffective, then a Dulcolax Suppository (a laxative that stimulates bowel movement designed to be inserted into the rectum to dissolve) must be administered on Day 4. If still no bowel movement then a fleet enema (liquid medicine used to help you have a bowel movement that is inserted into the rectum) should be administered on Day 5. It stated if the Fleet enema is ineffective, the physician must be notified.
A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included constipation, retention of urine, and anoxic brain injury (brain injury caused by lack of oxygen). A review of Resident R1's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R1's physician order dated 2/28/23, indicated to administer 30 ml of Milk of Magnesia every 24 hours as needed for constipation.
Review of Resident R1's physician order dated 3/26/23, indicated to administer 10mg Dulcolax suppository every 24 hours as needed for constipation if Milk of Magnesia is infective.
Review of Resident R1's physician order dated 3/26/23, indicated to administer 7-19 gm/118 ml Fleet Enema as needed for constipation, if no bowel movement after Dulcolax suppository.
A review of Resident R1's care plan dated 12/11/23, failed to include a focus and interventions for constipation.
A review of Resident R1's Documentation Survey Report v2 December 2023, indicated the resident did not have a bowel movement from 12/6/23, through 12/11/23.
A review of Resident R1's Medication Administration Record (MAR) for December 2023 indicated the facility failed to implement the bowel regimen protocol from 12/6/23, through 12/12/23. Resident R1 did not receive Milk of Magnesia, Dulcolax Suppository, or a fleet enema from 12/6/23, through 12/11/23.
During an interview on 1/4/24, at 10:14 a.m. LPN, Employee E9 stated nurse aides document resident's bowel movements in the clinical record. LPN, Employee E9 stated if a resident does not have a bowel movement in three days, the bowel protocol must be implemented. It was stated the orders for the bowel regimen protocol are entered upon admission for all residents.
During an interview on 1/4/24, at 10:19 a.m. Registered Nurse, Employee E4 stated if a resident has not had a bowel movement in six shifts, then the bowel protocol must be implemented. RN, Employee E4 confirmed the facility failed to implement the bowel regimen protocol for Resident R1 from 12/6/23, through 12/11/23.
A review of the clinical record indicated that Resident R34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included overactive bladder, high blood pressure, and renal failure.
A review of Resident R34's MDS dated [DATE], indicated the diagnoses were current.
Review of Resident R34's progress note dated 8/21/23, stated the resident rang tonight several times with complaints of urinary urgency as well as a burning sensation in her vaginal area. It was documented that the Registered Nurse (RN) was notified.
Review of Resident R34's clinical record from 8/21/23, through 8/22/23, failed to include documentation that a physician was notified of the resident's change in condition.
Review of Resident R34's progress note dated 8/23/23, stated She also endorsed to nursing staff after I left the unit that she had urinary frequency, urgency, and burning.
Review of Resident R34's physician order dated 8/24/23, indicated to obtain a urinalysis culture and sensitivity (a diagnostic test used to screen for diseases or medical conditions related to urinary tract infection for persons experiencing symptoms such as frequent and painful urination) via a straight catheter (a hollow tube that is inserted into the urethra or a in order to drain the bladder one time only for dysuria (pain or discomfort when urinating).
Review of Resident R34's progress note dated 8/24/23, entered at 9:30 a.m. indicated the urinalysis was not obtained that morning and stated night shift is to obtain for tomorrow during morning lab rounds.
Review of Resident R34's progress note dated 8/24/23, entered at 8:37 p.m. indicated at approximately at 7:45 p.m. the resident returned from bingo and was at baseline orientation. It was indicated the resident had a change in condition and was very weak, unable to answer questions, and unable to follow commands. It was indicated the resident became nauseated and shaking all over. The resident's physician was notified and the resident was transferred to the hospital.
Review of Resident R34's Transfer Form (Premier) dated 8/24/23, indicated the resident was transferred to the hospital for altered mental status.
Review of Resident R34's progress note dated 8/25/23, indicated the resident was admitted to the hospital due to urosepsis (a life-threatening condition that occurs when a urinary tract infection (UTI) spreads to the bloodstream and causes sepsis, a severe inflammatory response).
During an interview on 1/4/23, at 10:49 a.m. LPN, Employee E8 indicated if a resident has a change in condition or has signs and symptoms of a urinary tract infection, the RN must be notified and the RN contacts the physician. It was indicated a doctor should be notified by then end of the shift and it must be documented in the clinical record. LPN, Employee E8 confirmed the facility failed to provide care timely for Resident R34's change in condition that occurred on 8/21/23.
Review of the admission record indicated Resident R63 was admitted to the facility on [DATE].
Review of Resident R63's Minimum Data Set (MDS - a periodic assessment of care needs dated 11/10/23, indicated the diagnoses of high blood pressure, heart failure, and renal insufficiency.
Review of Resident R63's physician order dated 12/12/23, indicated start every seven days to bladder scan (ultrasound of bladder to see how much urine is retained), for 30 days.
Review of Resident R63's treatment administration record for December 2023 and January 2024, indicated a bladder scan was not conducted on 12/19/23, or 12/26/23.
Review of Resident R63's progress notes failed to include any details regarding lack of bladder scan results on 12/19/23, or 12/26/23, and failed to include a notification to the physician of the bladder scans not being completed as ordered.
A review of the clinical record indicated Resident R237 was admitted to the facility on [DATE], with diagnoses that included bronchitis (inflammation of the mucous membrane in the bronchial tubes), obesity and hypertension (a condition in which the force of the blood against the artery walls is too high).
A review of Resident R237's physician orders dated 12/22/23 indicated to empty foley drainage bag every shift and record output.
A review of resident R237's input and output record revealed no recording of output 12/24/23, 12/25/23, 12/26/23 and 12/27/23.
Interview on 1/5/23, at 1:00 p.m. the Director of Nursing confirmed the bladder scans, catheter output were not conducted at ordered and the physician was not notified that they were not completed as ordered.
Interview on 1/5/23, at 2:00 p.m. the Director of Nursing confirmed the facility failed to provide quality of care for four of six residents (Resident R1, R34, R63, and R237)
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 201.29(d) Resident Rights
28 Pa. Code 211.10 (c)(d) Resident Care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, resident, and staff interviews, it was determined that the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R40).
Findings include:
Review of facility policy Ostomy Care- Colostomy, Urostomy, and Ileostomy dated 2/21/23, indicated the frequency of pouch changes and the products required for changing ostomy devices will be noted on the resident's plan of care for the ostomy. It was indicated the comprehensive care plan will reflect any special products or pouching techniques needed to prevent or manage any skin breakdown surrounding the ostomy. Interventions to prevent complications or promote dignity associated with the ostomy will be included in the person-centered care plan.
Review of the admission record indicated Resident R40 was admitted to the facility on [DATE], and readmitted [DATE]
Review of Resident R40's MDS dated [DATE], indicated the diagnoses of colostomy, constipation, and high blood pressure. Section H indicated a colostomy (a surgical process that diverts bowel through an artificial opening in the abdomen wall) was present.
Observation of Resident R40 on 1/4/24, at 1:16 a.m. revealed she had a colostomy.
Review of Resident R40's physician order dated 9/17/19, indicated to change colostomy as needed. The order failed to include the frequency of changes and the products required to change the ostomy device.
Review of Resident R40's care plan dated 10/24/23, failed to include the type of appliance, size of the appliance or wafer, and type of collection bag required for colostomy maintenance.
Interview on 1/4/24, at 1:18 p.m. the Licensed Practical Nurse (LPN), Employee E11 confirmed the facility failed to provide colostomy care and services consistent with professional standards of practice for one of two residents reviewed (Resident R40).
28 Pa. Code: 211.11 (a)(c)(d) Resident care plan
28 Pa. Code: 211.10(c) Resident care policies.
28 Pa. Code:211.12(d)(1) Nursing services.

Based on review of facility policies, observations and staff interview it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (second floor).
Findings include:
Review of the facility policy Storage of Medications dated 2/21/23, indicated medications are stored in locked compartments, only authorized personnel will have access to keys to locked compartments, and during a medication pass all medications must be in direct observation of the person administering the medications.
Observation on 1/2/24, at 10:47 a.m. revealed Resident R80 had a cup of medication and a cup of water with Miralax in it, and an inhaler left on the bedside table unattended.
During an interview on 1/2/24, at 10:49 a.m. Licensed Practical Nurse (LPN), Employee E12 confirmed one capsule of 0.5mg Dutasteride (used in men to treat the symptoms of an enlarged prostate), one tablet of 1mg Folic Acid (vitamin B-9 supplement), one scoop of 17 gm Miralax (used to treat constipation) mixed in 8 ounces of water, a 2.5-2.5 mcg/act Stiolto Respimat inhaler (used to control and prevent symptoms such as wheezing and shortness of breath, caused by ongoing lung disease), two capsules of 0.4mg Tamsulosin HCL (used to treat the symptoms of an enlarged prostate), and one tablet of 100mg Thiamine HCL (a vitamin B1 supplement) was left on Resident R80's bedside table unattended.
Observation on 1/2/24, at 11:38 a.m. medication cart 2B on the second floor was observed unlocked and unattended.
Interview on 1/2/24, at 11:40 a.m. with Registered Nurse (RN) Employee E10, upon her return to medication cart 2B, confirmed that the cart was unlocked and unattended, and apologized stating she knew it should have been locked.
Observation on 1/2/24, at 12:27 p.m. of the medication cart labeled 2B revealed two medication cups in the top drawer of the cart. One cup had the letters B1 on it and had 15 white pills inside it and the other cup had no lettering on it and had 30 plus green pills inside it.
Interview on 1/2/24, at 12:28 p.m. Registered Nurse (RN) Employee E10 confirmed the medications were not labeled in a manufacturers packaging and that the medications were in fact Vitamin B1 and Oscal (calcium supplement) and that they come in such a large bottles that the nurses pour them into smaller cups so the other carts can have some.
Interview with the Director of Nursing on 1/5/23, at 2:00 p.m. confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two nursing units (second floor).
28 Pa Code: 211.9 (a) Pharmacy services.
28 Pa code: 211.12 (d) (1) (5) Nursing services.

Based on facility policy, review of facility documents, and staff interviews, it was determined the facility failed to accurately track infections in the facility for one of six months (December 2023).
Findings include:
Review of the Infection Surveillance policy dated 2/21/23, indicated the purpose to track infections is to identify infections and to monitor adherence to recommend infection prevention and control practices in order to reduce infections and the prevent spread of infections. It was indicated all residents and infections will be tracked and monthly time periods will be used to capture and report data.
Review of the facility's Monthly Facility Infection Analysis dated December 2023 was left blank and not completed.
During an interview on 1/5/24, at 11:07 a.m. Infection Preventionist, Employee E13 confirmed the facility failed to actively track infections for December 2023.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observation and staff interviews it was determined that the facility failed to maintain resident dignity by not clothing a resident on the Third floor (Resident R74) and failing to cover a resident's catheter bag (Resident R14) for two of five residents.
Findings include:
The facility Promoting and maintaining dignity policy last reviewed 2/21/23, indicated that it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity.
Review of the facility Catheter Care policy last reviewed 2/21/23, indicated the catheter bag should have a privacy cover applied at all times.
During an observation on 1/4/24, at 9:25 a.m. Resident R14 was observed utilizing a foley catheter without a privacy cover on the urine collection bag.
During an observation on 1/4/24, at 9:30 a.m. Licensed Practical Nurse, Employee E6 confirmed Resident R14 did not have a dignity bag covering the urine collection bag and confirmed that the facility failed to uphold the privacy and dignity of one resident utilizing catheter care for Resident R14.
Review of Resident R74's admission record indicated she was originally admitted on [DATE], and readmitted on [DATE] with diagnoses that included chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and change in urination), dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), hypertension (a condition impacting blood circulation through the heart related to poor pressure).
Review of Resident R74's MDS assessment (Minimum Data Set Assessment-MDS: a periodic assessment of resident care needs) dated 6/29/23, indicated that the diagnoses were current upon review.
Review of Resident R74's care plan dated 6/1/23 did not indicate the disrobing behavior.
During observations on the Third floor on 1/2/24, at 11:38 a.m. the following was observed:
Resident R74 was observed in the Third floor day room observed sitting in love seat, with pink top and no pants. Her incontinence pull up was on and exposed.
During an interview on 1/2/24, at 11:39 a.m. interview with Licensed Practical Nurse (LPN) Employee E2 stated: she takes off her pants all the time; its a behavior.
During an interview on 1/4/24, at 1:40 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E3 stated that Resident R74 had behaviors of disrobing on 4/16/23.
During an interview on 1/4/24, at 1:42 p.m. Registered Nurse (RN) Employee E4 confirmed that the facility failed to maintain Resident R74 dignity.
28 Pa Code: 201.29 (i) Resident rights.
28 Pa Code 211.12 (d)(1) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, incident reports, facility supplied documentation, and staff interview it was determined that the facility failed to report allegations of abuse for four of six residents (Resident R12, R43, R84, and R85).
Findings include:
The facility policy Abuse, Neglect, and Exploitation dated 2/21/23, indicated the facility staff must immediately, no later than 24 hours after the allegation is made, report all alleged allegations of abuse to the Administrator, State agency, adult protective services, and to all other required agencies.
Review of the face sheet indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/11/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and depression.
A review of Resident R12's progress note dated 12/25/23, stated resident states she won't take care of me and she threw my EpiPen at me and wanted me to give my own insulin. This RN clarified with resident that it was not EpiPen but insulin dial pen. He agrees it was his insulin pen. Resident states maybe I feel threatened.
During an interview on 1/2/24, at 9:04 a.m. Resident R12 indicated last weekend there was a nurse who refused to administer his insulin injection and she threw it at him. It was indicated the Director of Nursing was notified of the incident.
During an interview on 1/2/24, at 11:19 a.m. the Director of Nursing (DON) confirmed the facility failed to report the allegation of abuse for Resident R12 to the local State field office and stated It did not happen.
Review of incidents of abuse reported to the local State field office from 12/25/23, through 1/2/24, did not include the incident involving Resident R12.
Review of the admission Record indicated Resident R43 was admitted to the facility on [DATE].
Review of Resident R43's Minimum Data Set (MDS- a periodic assessment of care needs) dated 11/20/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids).
Review of Resident R43's care plan dated 12/11/23, indicated activity of daily living deficit related to toilet use, total assist. Performed in bed.
Review of the admission Record indicated Resident R84 was admitted to the facility on [DATE].
Review of Resident R84's MDS dated [DATE], indicated the diagnoses of high blood pressure, anemia (the blood doesn ' t have enough healthy red blood cells), Coronary artery disease (narrow arteries decreasing blood flow to heart), and heart failure (the heart doesn't pump as well as it should).
Review of Resident R84's care plan dated 12/5/23, indicated resident requires assistance of one with toileting and to report incontinence to the nurse.
Review of the admission Record indicated Resident R85 was admitted to the facility on [DATE].
Review of Resident R85's MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and renal insufficiency.
Review of Resident R85's care plan dated 11/5/23, indicated resident requires assistance of one with toileting and to report incontinence to the nurse.
Review of LPN Employee E8's witness statement dated 10/7/23, indicated they had the impression that B hall nurse aide did not check residents for incontinence care (clean of urine and feces) and proceeded to check on residents. Resident R43 was found to need a complete bed change due to urine saturation, Resident R84 was found to need a complete bed change due to urine saturation, and R85 was saturated in urine. LPN Employee E8's interview with Resident R43 indicated that nobody had been in to check on her.
Review of the facility's reportable events as of 1/5/23, at 9:00 a.m. did not include the above allegations of abuse and neglect for Residents R43, R84, or R85.
Interview with the Director of Nursing on 1/5/23, at 9:15 a.m. indicated she had not reported Residents R43, R84, or R85 to the state agency as required.
Interview with the Director of Nursing on 1/5/23, at 2:00 p.m. confirmed the facility failed to report allegations of abuse for four out of six residents (Resident R12, R43, R84, and R85).
28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management
28 Pa Code: 201.18 (b)(1) (e)(1) Management.