Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to provide residents access to grievance forms on one of three units observed (Third Floor); and failed to provide residents access to the right to file written grievances anonymously on three of three units observed (First, Second, and Third Floor). Findings include: Review of facility policy, titled Resident Grievances, last reviewed January 2025, read, in part, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Grievances may be voiced in the following forums. Verbal complaint to a staff member or Grievance Official. Written complaint to a staff member or Grievance Official. Written complaint to an outside party. Verbal complaint during resident or family council meetings. Via the company toll free Customer Service Line (if applicable). A grievance may be filed anonymously.During a group interview with Residents 2, 6, 37, and 73 on July 23, 2025, at 9:59 AM, all four residents revealed they were not sure how to file a grievance, including how to file one anonymously.Observation on the Second-Floor unit on July 23, 2025, at 10:18 AM, revealed some grievance forms attached to a bulletin board. There was no designated box or folder, etc. to put the grievances in if residents would prefer to file a grievance anonymously. Another posting detailed the information for the Grievance Official and stated, If you have any concerns, please forward them to our social workers or contact the grievance official as listed above, thank you.Interview with Employee 1 (Nurse Aide) on July 23, 2025, at 10:18 AM, revealed she is not aware of where residents would put a grievance if they wanted to file anonymously but that they could bring it to Human Resources. Observation in the First-Floor unit on July 23, 2025, at 10:27 AM, revealed some grievance forms in a folder attached to a bulletin board. The folder had instructions on it that stated, If you have a concern, please complete the top section of the form and return it to social services, the Registered Nurse supervisor, or at any nurses station, thank you!During an interview with the Nursing Home Administrator (NHA) on July 23, 2025, at 10:37 AM, she revealed that the process for residents to file a grievance anonymously would be to contact herself or a social worker privately. Observation in the Third-Floor unit on July 23, 2025, at 10:39 AM, revealed a bulletin board that did not contain grievance forms. Employee 2 (Social Worker) then went to get blank grievance forms in a drawer in the locked nurse's station. Further observation on the unit failed to reveal a designated box or folder, etc. to put the grievances in if residents would prefer to file a grievance anonymously. Interview with the NHA on July 23, 2025, at 10:39 AM, revealed the forms are usually kept on the bulletin board and she is unsure as to why they were not there. During an interview with Employee 2 on July 23, 2025, at 10:41 AM, she revealed the process for residents to file a grievance anonymously would be to contact herself or the grievance official, and if they wanted it to be anonymous, they would not share who the grievance came from with other staff members; or residents can put their grievance in an envelope and hand it a staff member to give to the grievance official or herself. During a follow up interview with the NHA on July 23, 2025, at 10:54 AM, she revealed the facility was going to purchase drop boxes for the units so that residents can file written grievances anonymously, and she would expect residents to have the opportunity to file grievances anonymously. 28 Pa code 201.18(b)(2)(3) Management28 Pa code 201.29(a) Resident rights

Based on clinical record review, facility policy, and staff interview, it was determined that the facility failed to ensure that residents were offered the pneumococcal vaccine as required for one of five residents reviewed (Resident 56). Findings include: A review of the facility's policy, titled Pneumococcal Conjugate Vaccine, recently revised June 12, 2024, read, in part, All residents should be offered the pneumococcal conjugate vaccine to aid in preventing pneumococcal infections (i.e. pneumonia). The policy continued, Prior to or upon admission, residents should be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, should be offered the vaccination within thirty (30) days of admission to the community unless medically contraindicated or the resident has already been vaccinated. Also, Before receiving the pneumococcal vaccine, the resident or resident representative should receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education should be documented in the resident's medical record. A review of Resident 56's clinical record revealed an admission date of April 8, 2024. According to Resident 56's immunization documentation, the facility received historical data reflecting Resident 56 received the vaccine on April 10, 2024. Further review of Resident 56's clinical record revealed no documentation the facility provided education on the risks and benefits of the vaccine entered into the Resident's clinical record. An interview with the Director of Nursing on August 1, 2024, at 9:56 AM, confirmed the facility could not locate any documentation of the Resident or Resident Representative being provided education regarding the risks/benefits of receiving or refusing the vaccine in the clinical record. 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure that residents were offered any current COVID-19 vaccinations as required for two of five residents reviewed (Residents 16 and 56). Findings include: A review of the facility's policy, titled Covid-19 Vaccine for Residents, effective June 1, 2021, read, in part, All residents should be offered the COVID-19 vaccine to aid in prevention and transmission of COVID-19 infections. The policy continued, Before receiving the COVID-19 vaccine, the resident or resident representative should receive information and education regarding the benefits and potential side effects of the covid vaccine. Provision of such education should be documented in the resident's medical record. Also, In situations where COVID-19 vaccination requires multiple doses, the resident, the resident representative is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses. A review of Resident 16's clinical record revealed an admission date to the facility on February 8, 2024. Further review of the clinical record revealed Resident 16's Power of Attorney (POA) refused the administration of the COVID-19 vaccine to Resident 16. Further review of Resident 16's clinical record revealed no documentation of the Resident or POA provided education regarding the risks/benefits of the vaccine. A review of Resident 56's clinical record revealed an admission date to the facility on April 8, 2024. Further review of the clinical record revealed Resident 56's POA refused the administration of the COVID-19 vaccine to Resident 56, Further review of Resident 56's clinical record revealed no documentation of the Resident or POA provided education regarding the risks/benefits of the vaccine. An interview with the Director of Nursing on August 1, 2024, at 9:56 AM, confirmed the facility could not locate any documentation of the Resident or Resident Representative being provided education regarding the risks/benefits of receiving or refusing the Covid-19 vaccine in those Resident records. 28 Pa. Code 201.18(b)(1) Management

Based on surveyor observation, facility policy, and staff interview, it was determined that the facility failed to store schedule IV-controlled medication in a separately locked, permanently affixed compartment for one of three (500 west medication storage room refrigerator) areas observed. Findings Include: Review of facility provided policy, Controlled Medications Orders, revised September 17, 2013, revealed, Medications included in the DEA classifications as scheduled II thru V and are considered controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in the facility. The facility failed to provide any more specific information regarding how the medication would be stored. Observation of the 500 west medication storage room refrigerator on July 31, 2024, at 10:00 AM, revealed two 30 ml bottles of 2 mg/ml Lorazepam (sedative medication and schedule IV-controlled substance). The two bottles of Lorazepam were in the main part of the refrigerator and not secured in a separately locked, permanently affixed compartment in any way. Interview with Director of Nursing on August 1, 2024, at 11:35 AM, revealed that the Lorazepam should have been kept in a separate locked container inside of the refrigerator. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety on the spice rack in the main kitchen, in three of three nourishment pantry refrigerators, and in one kitchenette refrigerator. Findings include: Review of facility policy, Food Storage Chart, no date, read, in part, butter should be stored in the refrigerator and is good for four days once removed from the master case, and commercially prepared nutritional supplements should be used within seven days once thawed. Observation on the spice rack in the main kitchen on July 29, 2024, at 9:32 AM, revealed the following items were not labeled to identify contents or date marked: one metal pan containing a red colored spice blend with a black plastic spoon inside; one plastic container with a red colored spice blend inside; and one metal pan containing roux (a cooked flour and butter mixture use for thickening liquid). During an interview with Employee 2 (Assistant Manager of Dining Services) on July 31, 2024, at 9:32 AM, it was revealed that the pan of roux didn't require refrigeration, the red spices were made in-house, and all the aforementioned items should've been labeled and date marked. Observation on July 29, 2024, at 9:52 AM, on the 500 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: nine chocolate nutritional drinks and 14 vanilla nutritional drinks. Observation in the kitchenette refrigerator on July 29, 2024, at 9:53 AM, revealed one unopened plastic bag of thawed non-dairy topping was not date marked with a thawed or use by date. During an interview with Employee 2 on July 29, 2024, at 9:55 AM, it was revealed that each carton of nutritional drink and the non-dairy topping should be date marked when remove from the freezer. Observations on July 29, 2024, at 10:02 AM, on the 400 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: 18 vanilla nutritional drinks and 12 chocolate nutritional drinks. Observation on July 29, 2024, at 10:12 AM, on the 300 neighborhood in the nourishment refrigerator revealed the following items were thawed and not date marked with a thaw or use by date: three chocolate nutritional drinks and nine vanilla nutritional drinks. During an interview with the Nursing Home Administrator on August 1, 2024, at 10:30 AM, the surveyor reviewed concerns with labeling and dating of items on the spice rack and in the refrigerators in the kitchenettes on all three neighborhoods. No further information was provided. 28 Pa code 211.6(f) - Dietary Services

Based on staff interview and facility policy review, it was determined the facility failed to maintain a data collection system of surveillance designed to identify possible communicable disease or infection for three of 10 months reviewed (October 2023, November 2023, and December 2023). Findings include: A review of the facility policy, titled Infection Preventionist, last reviewed May 21, 2024, read, in part, the Infection Preventionist will Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff and visitors. The facility's monthly infection control logs for October 2023 through December 2023 were unable to be provided by the facility. An interview with the Director of Nursing (DON) and Nursing Home Administrator on August 1, 2024, at 9:46 AM, revealed the facility's former DON did not complete the line listing during October 2023, November 2023, and December 2023 to track resident disease or infection. 28 Pa Code 201.14(a)(c) Responsibility of licensee 28 Pa Code 211.1(a)(c) Reportable diseases