Based on review of facility policy and procedure, clinical record, facility documentation, and staff interviews, it was determined the facility failed to ensure that one of three residents reviewed were free from neglect during care resulting in actual harm causing a subcapital humeral fracture for Resident 1. Findings include: Review of facility policy titled Freedom from Abuse, Neglect, and Exploitation, last revised October 2024, revealed neglect is the failure of the facility, its Team Members or service providers to provide care, goods, or services to a Resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident 1's diagnosis sheet revealed diagnoses of Hemiplegia and Hemiparesis (weakness and paralysis) following Cerebral Infarction (stroke) affecting dominate side, severe protein-calorie malnutrition, history of falling, and contractures of the right elbow and hand. Review of Resident 1's care plan revealed a care plan for limited physical mobility related to Cerebrovascular Accident (stroke) with right sided weakness, including an intervention for Extensive two (person) assist for transfers, initiated January 25, 2025. Review of Resident 1's Care Kardex under Bed Mobility revealed Resident 1 was to have 2 person assist for transfers. Review of Resident 1's Quarterly Minimum Data Set (MDS-periodic assessment of resident needs), dated July 1, 2025, revealed Resident 1 required assistance from staff while transferring and had weakness on one side of their body. Review of Resident 1's progress notes revealed a Nursing Note on July 30, 2025, at 5:16 p.m. indicating Resident reported to a CNA (certified nurse aide) on 3-11 shift that [he/she] felt a pop in [his/her] right shoulder after being helped by one CNA today. Resident is a 2A (two person assist). [Resident] complained of pain in [his/her] right shoulder and tenderness as noted when moving RUE (right upper extremity) . Order obtained from provider for STAT (immediate) Xray of the right shoulder and Humerus (long bone of the upper arm) to r/o (rule out) and fracture or dislocation. Review of information submitted by the facility on July 30, 2025, to the Department of Health revealed, RN Supervisor immediately went to assess resident. Scheduled Tylenol administered by charge nurse and effective. Interview completed by nursing staff and social worker. Order obtained from provider for STAT Xray of the right shoulder and humerus Investigation is completed. (AP-alleged perpetrator) was an agency CNA who confessed to giving the resident a bear hug. Agency aware and CNA DNR'd (Do Not Return). Review of Resident 1's x-ray report, dated July 30, 2025, revealed a subcapital (part of the bone closest to the shoulder) humeral fracture. Review of facility investigation into the injury revealed a witness statement from licensed nursing employee E3 interviewing Resident 1 on July 30, 2025, indicating Resident 1 said, when she (staff member) went to lift me over she was standing next to the wheelchair and I was by the recliner and she said ‘oh', and all of a sudden I heard a pop. You couldn't miss it. It was loud. She said, ‘I'm sorry' and kept asking ‘Do you feel better? Is it ok now?' And I said, ‘not right now I don't.' then she was ready to leave and gathered her things. Further review of facility investigation into incident revealed an interview of nursing employee E4 by licensed nursing employee E5 on August 1, 2025, at 11:20 a.m. indicated, I asked her exactly what happened. She stated, ‘I bear hugged [resident] and transferred [resident] alone.' ‘I am so sorry [resident] got hurt.' ‘She didn't tell me she hurt [resident]. Further review of the facility investigation of the injury revealed the facility substantiated the allegation of neglect for not following the care plan for the resident to have the assistance of two staff members while transferring the resident. Interview with the Nursing Home Administrator and the Director of Nursing on August 26, 2025, at 1:30 p.m. confirmed Resident 1 was not transferred according to resident's individual care plan causing actual harm to Resident 1 when Resident 1 sustained a fractured humerus as a result of the improper transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, hospital records, and staff interviews, it was determined the facility failed to provide necessary services of consistent wound treatment and ensure correct wound medication was applied to an unstageable wound (obscured full-thickness skin and tissue loss). The failure caused actual harm to Resident CL1 when the wound deteriorated and become infected resulting in hospitalization and unnecessary pain for one of three residents reviewed. (Resident CL1) Findings include: Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation last revised in [DATE], revealed, facility is committed to interacting with and treating its Residents with dignity and respect. While a resident at or in the care of the facility, each resident is to be free from Abuse, exploitation, fraud, misappropriation of property, harassment, neglect, and mistreatment. Neglect is defined as the failure of the facility, its Team Members, or service providers to provide care, goods, or services to a Resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident CL1's diagnosis list includes thoracic spinal cord injury, and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident CL1's admission Braden Scale (scale used for predicting pressure sore risk) completed on [DATE], revealed resident was At Risk for developing pressure ulcers. Review of Resident CL1's admission skin assessment revealed Resident CL1 was admitted to the facility on [DATE], with an improving Stage 3 Pressure Ulcer (full thickness skin loss) to the coccyx (commonly known as the tail bone is a small triangular bone located at the bottom of the spine) with a measurement of 1.2 x 1.0 x 0 cm (centimeter). Review of Resident CL1's physician order dated [DATE], revealed a new wound treatment to cleanse the coccyx/sacrum with normal saline and apply Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and Calcium Alginate (wound dressing used to absorb wound exudate) then cover with dressing daily in the evening and as needed. Review of Resident CL1's [DATE], Treatment Administration Record (TAR) and progress notes failed to reveal documented evidence of Resident CL1's unstageable coccyx wound was treated on [DATE], [DATE], and [DATE]. Interview conducted with Licensed Nursing Employee E4 on February 5, 2025, at 1:30 p.m., revealed the daily Medihoney wound treatment order expired on [DATE], and was not renewed by nursing. The as needed treatment order remained and was administered on [DATE]. Further interview with licensed nursing Employee E4 confirmed the daily wound treatment order should have been renewed on [DATE]. Review of Resident CL1's clinical record failed to reveal documentation of the attending physician being notified of the missed wound care treatments on [DATE], [DATE], and [DATE]. Review of Resident CL1's Wound and Skin Evaluation dated [DATE], at 7:22 a.m., revealed Resident CL1's coccyx wound was deeper with new slough (layer of dead, yellow or white tissue that covers the wound bed) areas distal to the opening. The wound was identified as unstageable pressure ulcer with measurement of 1.0 x 4.3 x 2.5 cm. with 100% slough. A new treatment of Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) was recommended. Review of Resident CL1 physician's order dated [DATE], revealed a wound care order to cleanse the coccyx/sacral wound with normal saline, apply a Santyl pack with Calcium Alginate then cover it with a foam dressing daily. Interview with the Nursing Home Administrator (NHA) on February 5, 2025, at 1:00 p.m. revealed when the wound nurse assessed the resident's coccyx wound on [DATE], he/she discovered that the Santyl medication was not available but the Treatment Administration Record was documented as treatment was administered. Facility investigation revealed the Santyl medication was incorrectly entered in the computer which resulted in the medication not being delivered. The Santyl medication was re-ordered. Interview with licensed nurse Employee E3 on February 5, 2025, at 2:00 p.m. revealed on [DATE], Resident CL1's Santyl medication was not available in the facility, the nurse stated the wound was instead cleansed with normal saline and was lightly packed with Calcium Alginate then covered with a foam dressing. Employee E3 reported the same treatment without the santyl was done on [DATE], and [DATE]; since the Santyl medication was still not available. Employee E3 reported she/he assumed the medication would be delivered soon and did not call the pharmacy to follow up on the medication, did not inform the supervisor that medication was not available, and did not inform the physician that the medication was not available and therefore treatment order was not done as ordered on [DATE], [DATE], and [DATE]. Review of Resident R1's nursing progress notes dated [DATE], at 2:00 p.m., revealed the wound dressing was replaced due to soilage, awaiting delivery of Santyl from the pharmacy, the order was re-entered in the computer. Review of the pharmacy delivery records revealed Resident CL1's Santyl medication wasn't delivered to the facility until [DATE], four days after it was ordered by the physician. Review of Resident CL1's Wound and Skin Evaluation, dated [DATE] 8:18 a.m., revealed Resident CL1's coccyx wound was determined unstageable with a measurement of 4.9 x 4.4 x 2.5 cm. with 4.0 cm tunneling (wound that progressed to form passageways underneath the surface of the skin) at 6 o'clock, 100% slough with increased moderate purulent (product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris), and moderate odor. Further review of same document revealed a wound culture was ordered and collected due to purulent discharge and odor in the area and resident's body temperature of 102 F (farenheit) recorded the previous evening. Resident CL1's current temperature was 99.9 F (normal body temperature range for adults is 97.0 - 99.0 F). Review of the wound culture report dated February 1, 2025, revealed Resident CL1's coccyx wound was positive for the following organisms: Staphylococcus Aureus, Enterococcus Avium, Enterococcus Faecalis, and Morganella Morganii. Review of CL1's clinical records revealed Resident CL1's wound treatment was changed, antibiotic treatment was started, and Resident CL1 was scheduled to be seen by a wound specialist. Review of the wound consult dated February 3, 2025, revealed the Patient (Resident CL1) with a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) of sacrum, diffuse necrotic tissue (The death of the cells in the body tissue) in the base. Skin exam revealed Stage 4 sacral ulcer with necrotic tissue, foul odor, (+) rough exposed bone. The same report revealed that the physician attempted to do debridement (Removal of dead, infected, or damaged tissue from a wound), but the patient was sensate unable to accomplish much. The physician recommended operative debridement in the Operating Room and Intravenous (IV) (medication administered in vein) antibiotics. Review of Resident CL1's clinical record revealed Resident CL1 was sent to the hospital on February 4, 2025. Review of the hospital record document titled History and Physical, dated February 5, 2025, revealed patient (Resident CL1) was seen in the wound clinic by surgery [physician's name] and tried to debride the diffuse necrotic base, but the patient did not tolerate it due to pain. admission was requested for debridement under general anesthesia. The resident was placed on IV antibiotics and was referred to surgery for wound debridement. Review of information dated [DATE] submitted by the facility, on Janaury 29, 2025 revealed the faciltiy substantiated neglect for Employee E3 and Employee was reeducated. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on February 6, 2025, at 2:30 p.m. The facility failed to provide wound treatment to Resident CL1's unstageable coccyx consistently and failed to ensure the correct wound treatment was administered. This failure resulted in actual harm to Resident CL1 causing the wound to deteriorate, become infected, leading to hospitalization where added surgical procedures added unnecessary pain. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(3) Management Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based facility policy review, clinical record review, hospital record review, facility documentation review, and staff interviews, it was determined that the facility failed to provide consistent and appropriate treatment for an Unstageable Pressure Ulcer (obscured full-thickness skin and tissue loss), resulting in wound deterioration, infection, and hospitalization for one of three residents reviewed (Resident CL1). Findings include. Review of the facility's policy titled Skin Care/Integrity, last revised in February 2024, revealed that the facility's policy is to identify residents at risk for impairment in skin integrity, initiate appropriate preventative interventions, and provide treatment to promote healing, prevent infections, and prevent the development of pressure ulcers. Review of the facility's policy titled Pressure Wounds, last reviewed in May 2024, revealed wounds in the category of pressure will have an appropriate treatment to promote the healing process. Review of Resident CL1's diagnosis list includes thoracic spinal cord injury, neuromuscular dysfunction of bladder, and Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident CL1's admission skin assessment revealed Resident CL1 was admitted to the facility on [DATE], with an improving Stage 3 Pressure Ulcer (Full thickness skin loss) measuring 1.2 x 1.0 cm to the coccyx (commonly known as the tail bone, is a small triangular bone located at the bottom of the spine). A wound treatment order was in place. Review of Resident CL1's admission Braden Scale (scale used for predicting pressure sore risk) completed on December 28, 2024, revealed resident was At Risk for developing pressure ulcers. Review of Resident CL1's care plan revealed that the skin impairment care plan was developed on December 28, 2024, with interventions as follows: chair cushion; adequate nutrition; resident education; turning and positioning; incontinent care and to provide wound treatment as ordered. Review of the physician's order dated January 3, 2025, revealed a wound treatment to cleanse the coccyx/sacrum with normal saline and apply Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) and Calcium Alginate (wound dressing used to absorb wound exudate) then cover with dressing daily in the evening and as needed. Review of the Wound and Skin Evaluation dated January 16, 2025, at 7:39 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 2.0 x 1.2 x 1.5 cm. with 80% slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) with moderate serous drainage (watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage) with no signs of infection. Wound treatment remained Medihoney and Calcium Alginate. Review of Resident R1's January 2025, Treatment Administration Record (TAR) and progress notes failed to reveal documented evidence that Resident CL1's unstageable coccyx wound was treated on January 20, January 22, and January 23, 2025. Review of Resident R1's clinical records failed to reveal the attending physician was notified of the missed wound care treatments on January 20, January 22, and January 23, 2025. Interview conducted with Licensed Nursing Employee E4 on February 5, 2025, at 1:30 p.m., confirmed there were no documented evidence of the physcian being notified of the missed wound treatments. Review of the Wound and Skin Evaluation dated January 23, 2025, at 7:22 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 1.0 x 4.3 x 2.5 with 100% slough and moderate serous drainage with no evidence of infection. The same note revealed deteriorating, the area was deeper with new slough areas distal to the opening. A new treatment of Santyl (topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) was recommended. Review of Resident R1's physician's order dated January 23, 2025, revealed a wound care order to cleanse the Coccyx/sacral wound with normal saline apply a Santyl pack with Calcium Alginate then cover it with a foam dressing daily. Review of the pharmacy delivery records revealed that Resident CL1's Santyl medication was not delivered to the facility until January 27, 2025, four days after it was ordered by the physician. Interview with licensed nurse Employee E3 was conducted on February 5, 2025, at 2:00 p.m. Employee E3 reported that on January 24, 2025, Resident CL1's Santyl medication was not available, the nurse stated the wound was instead cleansed with normal saline and was lightly packed with a Calcium Alginate then covered with foam dressing. Employee E3 reported the same treatment was done on January 25, and January 26, 2025, since Santyl medication was still not available. Employee E3 reported that she/he assumed the medication would be delivered soon. Employee E3 reported she/he did not call the pharmacy to follow up on the medication, did not inform the supervisor the medication was not available, and did not inform the physician the treatment order was not appropriately done. Review of the Wound and Skin Evaluation, dated January 28, 2025, at 8:18 a.m., revealed Resident CL1's coccyx wound was unstageable with a measurement of 4.9 x 4.4 x 2.5 cm. with 4.0 cm tunneling (wound that progressed to form passageways underneath the surface of the skin) at 6 o'clock, 100% slough with increased moderate purulent (Is any product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris), and moderate odor. Additional review of the same note revealed, a wound culture was ordered and collected due to purulent discharge and odor in the area and a temperature of 102 F the night before. The current temperature was 99.9 F (normal body temperature range for adults is 97.0 - 99.0 F). Review of the wound culture report dated February 1, 2025, revealed Resident CL1's coccyx wound was positive for the following organisms: Staphylococcus Aureus, Enterococcus Avium, Enterococcus Faecalis, and Morganella Morganii. Review of Resident CL1's clinical records revealed wound treatment was changed to continuous negative pressure wound vacuum at 125 mm Hg on January 29, 2025. The resident was placed on antibiotics and was scheduled for a wound clinic consult. Review of the wound consult dated February 3, 2025, revealed the patient had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) of sacrum, diffuse necrotic tissue (death of the cells in the body tissue) in the base. Skin exam revealed Stage 4 sacral ulcer with necrotic tissue, foul odor, (+) rough exposed bone. The same report revealed that the physician attempted to do debridement (Removal of dead, infected, or damaged tissue from a wound), but the patient was sensate unable to accomplish much. Pre procedure wound area was 48.24 cm2 (square centimeter), post debridement measurements were 6.7 x 7.2 x 5.6 cm with 76-100% slough and 1-25% eschar. The physician recommended operative debridement in the Operating Room and Intravenous (IV) (medication administered in vein) antibiotics. Review of Resident CL1's clinical records revealed Resident was sent to the hospital on February 4, 2025. Review of the hospital record History and Physical, dated February 5, 2025, revealed patient was seen in the wound clinic by surgery [physician's name] and tried to debride the diffuse necrotic base, but the patient did not tolerate it due to pain. admission (hospital) was requested for debridement under general anesthesia. The same note revealed that the diagnosis of admission was Pressure Injury of the sacral region, stage 4. The patient was placed on IV antibiotics and was referred to surgery for debridement. The above information was discussed with the Nursing Home Administrator and the Director of Nursing on February 5, 2025, at 2:30 p.m. The facility failed to ensure Resident CL1 was provided with consistent and appropriate wound treatment on her/his sacral wound which resulted in actual harm when the wound deteriorated and became infected causing hospitalization and a surgical procedure that led to unnecessary pain. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 4/6/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 4/6/23 28 Pa. Code 201.18(e)(3) Management Previously cited 4/6/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 4/6/23

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records, facility documentation review, and resident and staff interview, it was determined that the facility failed to ensure that the resident was free from neglect by not providing two-person assistance needed during transfers or providing the proper equipment during a transport for two of 32 residents reviewed (Residents 14 and 91) causing actual harm to Resident 14. Findings Include: Review of Resident 14's diagnosis list included a diagnosis of intracranial hemorrhage (stroke) and Hemiplegia non-dominate left side (inability to move one side of the body). Review of Resident 14's care [NAME] revealed as of January 30, 2023 Resident 14 was to have the foot pedals of the wheelchair removed while in the room as resident prefers to self-propel independently when in room. Utilize wheelchair foot pedals when assisting resident with mobility in the hallway. Review of Resident 14's care plan revealed interventions to prevent falls including an intervention initiated October 11, 2021, to encourage foot pedals when assisting resident with wheelchair mobility in the hallway. Review of Resident 14's progress notes revealed a nursing entry dated January 30, 2023, at 2:05 p.m. revealed CNA (Certified Nursing Assistant) pushing resident in WC (wheelchair) to dining room. Resident left foot caught on floor causing resident to fall forward, land on floor face down. Resident able to roll on left side to a seated position, resident assisted to WC by three employees, Pressure held to nose d/t (due to) bleed. Further review of Resident 14's progress notes revealed Resident 14 was having nose bleeds but not reporting any pain or discomfort in his/her face. Additional review of Resident 14's clinical record revealed a progress note dated February 6, 2023, at 4:26 p.m. indicating family is requesting [Resident 14] be sent to the ER (Emergency Room) for epistaxis (nosebleed). Review of documentation from the hospital stay of February 6-7, 2023, revealed the resident was admitted with diagnosis of epistaxis due to trauma, closed bilateral (both sides) nasal bone fractures, concussion, fall from wheelchair, acute blood loss anemia (low blood cell count) and coagulopathy (inability of blood to clot). Interview with Resident 14 on March 29, 2023, at 1:00 p.m. confirmed when she had the fall on January 30, 2023, she did not have the foot pedals on the wheelchair at the time of the fall. Resident 14 stated she was not asked if she wanted them or not and didn't want to say anything because she thought the CNA was busy at the time. Resident 14 confirmed that the foot pedals have been used every time when transferred outside of her room since her fall. Interview with the Director of Nursing on March 29, 2023, at 11:00 a.m. revealed Nursing Employee E4 resigned from her position and no longer worked at the facility after January 30, 2023. Interview with the Nursing Home Administrator on March 30, 2023, at 9:30 a.m. confirmed Resident 14's foot pedals were not placed on the wheelchair as both the care plan and care [NAME] instructed when transferring Resident 14 in the hallway. Review of documention provided by the facility revealed facility substantiated the allegation of neglect against the nurse aide who failed to follow care [NAME] and care plan by not providing foot pedals to wheelchair during transport. Resident 14 sustained a fall due to the facility staff not following Resident 14's care plan and care [NAME] interventions of placing foot pedals on the wheelchair while transporting the resident in the hallway causing actual harm when Resident 14 was transferred to the hospital and diagnosed with facial fractures. Review of facility audits of foot pedal placement and education provided to all nursing staff revealed the education provided was regarding wheelchair and use of foot pedals but did not address ensuring safety during transfers. Review of Resident 91's diagnosis list revealed Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), a history of falls, and a left femur (thigh bone) fracture. Review of Resident 91's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated January 7, 2023, revealed that the resident had severe cognitive impairment. The MDS also revealed that the resident requires extensive two-people assistance with transferring. Review of Resident 91's current care plan for safety revealed an intervention initiated on July 12, 2022, for two-person assistance with transferring with a rolling walker. Review of Resident 91's nursing progress notes dated February 26, 2023, at 2:09 a.m., revealed resident was lowered by an aide to the knees during the transfer from a recliner to a wheelchair. The resident became weak during the transfer and needed to be lowered to the ground, unable to complete the transfer. The resident had slight redness to the right knee but denied pain/discomfort. The resident was able to stand and was placed in a wheelchair with two staff assistants. Review of the facility documentation, and fall investigation, revealed that on February 26, 2023, at 1:43 p.m., the resident was lowered to their knees during a transfer from a recliner to the wheelchair. Records revealed non-licensed employee E3 transferred the resident by herself/himself. Review of non licensed Employee E3's statement dated March 8, 2023, revealed that she/he was aware of the resident's care plan to have two-person assistance with transferring, but the other aide was not on the unit and the nurse was occupied assisting another resident. Interview with the Director of Nursing on March 30, 2023, at 10:00 a.m., confirmed that the facility failed to ensure Resident 91 was free from neglect by not providing two-person assistance with transferring contributing to the resident's fall. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services