Number of residents sampled: Number of residents cited: Based on observations and interview with staff, it was determined that the facility failed to treat each resident with respect and dignity during meal service in one of two dining rooms (Herrnhut).Findings include:Observation on August 26, 2025, at 11:47 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 9.Observations on August 27, 2025, at 11:54 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 19 and Employee E5 wearing disposable gloves while feeding Resident 14.Observations on August 28, 2025, at 11:54 a.m. revealed Employee E6 wearing disposable gloves while feeding Resident 14. Employee E6 was also standing while feeding Resident 14. Employee E3 was standing and wearing disposable gloves while assisting Resident 19. Employee E8 was wearing disposable gloves while feeding Resident 9. An additional observation revealed licensed staff E7 wearing disposable gloves while feeding Resident 37. Interview with the Nursing Home Administrator on August 28, 2025, at 12:55 p.m. revealed that wearing gloves while feeding is not the facility's protocol. Staff should be using good hand hygiene. Additionally, staff should not be standing while feeding residents.

Based on a review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of the 18 residents reviewed (Resident 53). Findings include: Review of the facility's policy titled Abuse Investigation, with a review date of May 17, 2023, revealed that all reports of resident abuse, neglect, and injuries of unknown origin are promptly investigated by facility management. The investigation includes interviewing staff members (on all shifts) who had contact with the resident during the alleged incident. Review of Resident 53's diagnosis list includes Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Vascular Dementia with behavioral disturbances. Review of Resident 53's clinical record including the nursing progress notes dated June 20, 2024, at 10:17 p.m., revealed that during the weekly skin assessment, a 20.0 x 9.0 cm (centimeter). yellow bruise area was observed on the resident's right upper arm. The same note also revealed that the resident was combative and resistant to care as observed by the writer on the night the bruise was observed, the physician and the responsible party were notified. Interview with the Director of Nursing on July 31, 2024, at 11:30 a.m., revealed an investigation for an injury of unknown origin is to inlcude statements from staff that had contact with the resident 24 hours before discovering the bruise. Review of the facility's documentation/investigation revealed the facility did not perform a thorough investigation as evidenced by missing statements from several of the staff that cared for Resident 53, 24 hours before discovering the bruise on Resident 53's right upper arm. Interview with the Director of Nursing on July 31, 2024, confirmed the facility did not obtain statements from several staff that cared for the resident within the 24 hours prior to discovering the bruise. The facility failed to ensure Resident 53's bruise of unknown origin was thoroughly investigated. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 9/15/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 9/15/23 28 Pa. Code 201.29(a)(d) Resident Rights Previously cited 9/15/23 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/15/23

Based upon review of clinical records, it was determined the facility failed to ensure resident's code status coincided with resident's wishes and failed to ensure those wishes were identified in resident's medical record for two of 24 residents reviewed (Residents 20 and 49). Findings include: Review of Resident 20's Progress Notes revealed a nursing entry dated June 28, 2023 stating Resident was sent to the hospital on June 26, 2023 at 10:30 p.m. due to a decline in the residents status, residents eyes where rolling in back of head and was very hard to get a response out of, resident heart rate was high as well as blood pressure and the residents hands where blue and arms clenched tight against chest. Resident was belly breathing. Review of Resident 20's POLST (Pennsylvania Orders for Life Sustaining Treatment) signed by the resident and dated March 16, 2018 revealed the resident was a DO Not Resuscitate and wanted comfort measure only including not to send to the hospital for life sustaining treatment only if comfort needs cannot be met. Review of Resident 20's care plan revealed a care plan initiated on January 28, 2020 for receiving only comfort measures and not to be hospitalized . Interview with the Nursing Home Administrator and the Director of Nursing on September 14, 2023 at 1:00 p.m. confirmed Resident 20 was sent to the hospital on June 26, 2023 against the wishes of her POLST. Review of Resident 49's clinical record revealed Resident 49's Living Will indicating Resident 49 was not interested in life sustaining measures in the event of illness. Further review of Resident 49's clinical record revealed a physician's order for Full Code status. Further review of Resident 49's clinical record revealed resident had a Full Code status. Review of Resident 49's Quarterly Minimum Data Set (periodic assessment of resident needs) dated July 20, 2023, revealed a Brief Interview for Mental Status score of 15 indicating Resident 49 was cognitively intact. Further review of Resident 49's clinical record revealed a Physician's Order for Life Sustaining Treatment (POLST) dated February 21, 2020, indicating a Do Not Resuscitate (DNR) status and further indicating full treatment requested. Further review of this POLST revealed it had been voided. Interview with the Director of Nursing and Nursing Home Administrator on September 14, 2023, revealed Resident 49's spouse had a blank POLST in his possession and was in the process of completing the document after speaking with Resident 49. Resident 49 is cognitively intact and able to complete POLST and indicate code status wishes. Interview with the Director of Nursing on September 15, 2023, at 10:00 a.m. revealed Resident 49's spouse had not signed and/or returned the POLST. This interview further failed to reveal the origin of Resident 49's physician order for Full Code status and failed to reveal evidence that Resident 49 was consulted regarding life sustaining treatments. The facility failed to consult Resident 49 regarding code status and life sustaining treatments and failed to ensure Resident 49's clinical record accurately reflected Resident 49's wishes regarding code status and life sustaining treatments. 28 Pa. Code: 201.29 (i) Resident rights. 28 Pa. Code: 211.5 (f) Clinical records. 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 procedure, clinical record review and staff interview it was determined that the facility failed to notify resident's representative of medication changes and failed to notify a physician of a resident's weight gain for two out of 24 residents reviewed. (Resident 23 and Resident 225) Findings include: Review of facility policy and procedure titled Protocol for residents with diagnosis of CHF revealed Resident with a diagnosis of CHF will automatically be put on daily weights. Further review of facility policy and procedure revealed the MD [physician] will be notified if there is a three or more pound weight gain in one day or if there is a five or more pound weight gain in one week. Review of Resident 23's diagnosis list revealed diagnoses including Congestive Heart Failure (CHF - excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 23's physician orders dated April 12, 2023, revealed an order for daily weights: notify doctor if there is a 3 pound or more weight gain in 1 day or if there is a 5 pound or more weight gain in 7 days. Review of Resident 23's Weight Summary for August 11, 2023, revealed a weight of 221.2 pounds. Review of Resident 23's Weight Summary for August 12, 2023, revealed a weight of 227.0 pounds indicating a 5.8-pound weight gain in one day. Review of Resident 23's Weight Summary for August 14, 2023, revealed a weight of 220.0 pounds. Review of Resident 23's Weight Summary for August 15, 2023, revealed a weight of 223.6 pounds indicating a 3.6-pound weight gain in one day and a 9.4-pound weight gain in four days. Review of Resident 23's clinical record for August 2023 failed to reveal evidence Resident 23's physician was notified of Resident 23's weight gain on August 12, 2023, or August 15, 2023. Interview with the Director of Nursing on September 15, 2023, confirmed that Resident 23's physician was not notified of Resident 23's significant weight gain. The facility failed to ensure physician was notified of Resident 23's significant weight gain. Review of the clinical record revealed that Resident 224 was admitted to the facility on [DATE], with a diagnosis of Lewy Bodies Dementia (a type of dementia characterized by changes in sleep, behavior, cognition, movement and regulation of bodily fluids). Review of the Physician orders revealed Quetiapine (Seroquel - a medication used to treat certain mental/mood conditions) for hallucinations 50 mg at HS (bedtime) beginning June 29, 2023. Review of the clinical record revealed a nursing note dated August 12, 2023, to monitor resident for sleepiness in dayshift and evening shift before bedtime due to Seroquel changed. Further review revealed a nursing note on August 16, 223, stating that on August 11, 2023, Seroquel was changed from 50mg at bedtime to 25mg twice a day (morning and night), because of behaviors of combativeness and yelling. This was done in a meeting in August that consisted of the medical director, Pharmacist, DON and Social Services, that giving her the Seroquel 50mg at night was not benefiting during the day. There is no mention that the family was notified of the change. Interview with the Director of Nursing (DON) on September 15, 2023, at 8:30 a.m. confirmed the facility had no further documentation that the family was notified of the change. 28 Pa. Code 211.12(b)(c)(d)(3) Nursing Services Previously cited 9/29/2022

Based on clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 37). Findings include: Review of the facility policy titled Injuries of Unknown Origin, dated January 2021, states, 2. Statements must be obtained from the person reporting the injury and from the caregivers during the past 24 hours and documented. Review of Resident 37's clinical record, reveals a nursing note dated July 20, 2023, an abrasion noted on the top of the right foot measures .5cm x 1 cm, Reddened areas on right great toe measures 0.3 cm and 0.2 cm and l foot 2nd toe 0.2 x0.2 cm. was reported. There was only one documentation from a caregiver in the past 24 hours. Further review of Resident 37's clinical record revealed a nursing note on August 18, 2023, the certified nursing assistant (CNA) alerted the nurse of a bruised area noted on the resident's left buttock, The area measures 3cmx1.7cm in size and is deep purple in color. There was only one documentation from a caregiver in the past 24 hours. Interview with the Director of Nursing on September 15, 2023, 10:35 a.m. confirmed that there was not an investigation with completed statements from the staff. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record review, it was determined the facility failed to notify the State Ombudsman's office of hospitalization of a resident for one of 24 residents reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed Resident 51 was hospitalized on [DATE] and August 5, 2023. Interview with the Director of Nursing on September 15, 2023 at 10:00 a.m. confirmed the State Ombudsman's office was not notified of Resident 51's hospitalization. This interview further confirmed the facility failed to notify the State Ombudsman's office of any hospitalizations or discharges of any resident from September 2022 through August, 2023. 28 Pa. Code 201.18(a)(b)(1)(3) Management

Based on clinical record review and interviews with staff it was determined that the facility failed to ensure assessments accurately reflect the resident's status for one of two closed records reviewed (Resident 73). Findings include: Review of Resident 73's clinical record revealed a nursing note dated June 30, 2023, indicating the resident was discharged to home with home health services. Further review of the clinical record revealed a discharge Minimum Data Set (MDS-periodic assessment of the residents care needs) was coded as acute hospitalization. Interview conducted with licensed Employee E3 on September 14, 2023 at 1:15 p.m. revealed the discharge MDS assessment was not completed correctly. The facility failed to ensure assessments accurately reflect the resident status for Resident 73. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to update and revise care plans to reflect resident's current status for one of 24 residents reviewed (Resident 52). Findings include: Review of Resident 52's diagnosis list revealed diagnoses including retention of urine. Review of Resident 52's clinical record revealed Resident 52 was admitted to the facility with a Foley catheter [catheter place to help remove urine]. Further review of Resident 52's clinical record revealed Resident 52's Foley catheter was removed on September 13, 2023. Review of Resident 52's physician orders dated September 13, 2023, revealed Bladder Scan TID [three times per day]; straight cath [catheter utilized for one time use; not to be permanently inserted] with 16F [catheter size] if > [greater than] 350 cc [cubic centimeters]. Review of Resident 52's active plan of care revealed a care plan for Resident 52's Foley catheter. Further review of Resident 52's care plan failed to reveal evidence the care plan was updated to reflect the removal of the Foley catheter and the physician's order for the bladder scan that was to be performed three times per day. Interview with the Director of Nursing on September 15, 2023, at 10:00 a.m. revealed Resident 52's care plan was not updated and/or revised to reflect the discontinuance of the Foley catheter and to reflect the physician's order for the bladder scan to be performed three times per day. The facility failed to update and/or revise Resident 52's care plan to reflect the removal of the Foley catheter and to include the performance of the bladder scan three times per day. Pa. 28 Code 211.11(a)(c)(d) Resident care plan Pa. 28 Code 211.12(b)(c)(d)(1)(3)(5) Nursing services Previously cited 9/29/2022

Based on clinical record review and staff interview it was determined the facility failed to follow recommendation by a would specialist consultant for one of four residents reviewed for pressure ulcers. (Resident 41) Review of Resident 41's progress notes revealed an entry dated July 18 2023 at 11:38 p.m. stating resident with SDTI (Suspected Deep Tissue Injury- brown or black tissues caused by damage due to pressure that is under the skin). Review of Resident 41's Wound care consultant report dated July 21, 2023 revealed the resident had a SDTI and recommended to have an Albumin level (blood test to determine protein in the blood needed for healing). Review of Resident 41's clinical record revealed there was no documented evidence resident 41 had the blood test drawn as recommended by the wound specialist. Interview with the Director of Nursing on September 15, 2023 at 10:35 a.m. confirmed The blood test was not completed as recommended by the wound specialist on July 21, 2023. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services