Based on clinical record review and staff interviews, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 13 residents reviewed (Resident 23).Findings include: Review of Resident 23's clinical record revealed diagnoses that included cerebrovascular disease (disease affecting blood flow to the brain), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). Further review of Resident 23's clinical record revealed that he was admitted to hospice services on July 7, 2025. Review of Resident 23's Minimum Data Set's (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 21, 2025, revealed that the assessment was still in progress with three sections lacking completion. During a staff interview with Employee 5 (the Registered Nurse Assessment Coordinator) on August 27, 2025, at 2:12 PM, Employee 5 confirmed that the significant change MDS had not been completed timely. She indicated that she had just completed and submitted it that day. During a staff interview with the Director of Nursing on August 27, 2025, at 2:25 PM, she confirmed that the MDS should have been completed timely. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 49).Findings include: Review of facility policy, titled Negative Pressure Wound Therapy [wound vac], last reviewed on September 10, 2024, revealed, in part, Change dressings per physician orders and manufacturer guidelines. 13. Turn pump on: a. initiate negative pressure setting on the pump as ordered (-125 mm/HG [milliliters of mercury] is a typical default setting;]. b. Establish negative pressure setting (as ordered). Document the following in the resident's medical record: 1. The wound status at time of application of negative pressure. 2. The number of sponge pieces used in the wound dressing. 3. The negative pressure and time settings on the pump. 4. The resident's tolerance of the procedure. 5. The date and time of the dressing application/change. 6. The date and time negative pressure therapy was started and stopped. 7. The name and initials of the person performing the procedure. Review of facility policy, titled Changing the Needless Connection Device and Extension Tubing, last reviewed on September 10, 2024, revealed, in part, 4. Change needless connection device with each dressing change and after blood draws as needed. 5. For multi-lumen catheters, change needleless connection device every 7 days for lumens not in use. Documentation 1. Document on treatment kardex when procedure was done. Review of Resident 49's clinical record revealed diagnoses that included acute and subacute endocarditis (a life-threatening inflammation of the inner lining of the heart's chambers and valves usually caused by an infection) and cellulitis (skin infection) of the chest wall. Review of Resident 49's physician orders revealed the following order: Wound vac therapy to left upper chest surgical wound continuous at 75mm/HG every shift document amount of drainage, dated August 17, 2025; and IV [intravenous]site - Change dressing once weekly and PRN [as needed]. Measure extending line and check for displacement. If more than 1 cm, notify physician for further orders dated August 25, 2025. Further review of Resident 49's physician orders failed to reveal an order for the frequency of his wound vac dressing changes or needleless connection device changes. Review of Resident 49's progress notes revealed a note dated August 18, 2025, at 8:24 PM, which indicated NPWT (Negative Pressure Wound Therapy] placed at 125, no leaks, currently charging, explained to patient about charging overnight, patient acknowledged that he understood the wound vac. The note failed to include the wound status at time of application of negative pressure, the number of sponge pieces used in the wound dressing, the time setting on the pump, or the resident's tolerance of the procedure. Review of Resident 49's progress notes revealed a note dated August 22, 2025, at 9:38 AM, which indicated Wound vac was changed per orders. Area is 5.0cm L by 2.5cm W. Wound bed is 90% granulation. There is a very light layer of about 10% slough at the very top of the wound. Resident denies pain to the area. Wound vac is currently plugged in, and he was encouraged to take the charger to dialysis with him. Vitals are stable this morning. The note failed to include the number of sponge pieces used in the wound dressing or the negative pressure and time settings on the pump. During an observation of Resident 49 on August 28, 2025, at 10:50 AM, with the Director of Nursing (DON), the DON indicated that the facility practice was to change wound vac dressings on Mondays, Wednesdays, and Fridays. Observation of Resident 49's dressing revealed that the dressing was not dated. During an immediate interview with Resident 49, he indicated that they did not change it last evening. He said, they changed it on Friday and Monday, but not yesterday. He further indicated that he was aware that the dressing was to be changed on Mondays, Wednesdays, and Fridays. Observation of Resident 49's wound vac pump on August 28, 2025, at 1:03 PM, with Employee 6 (Registered Nurse/Assistant Director of Nursing) revealed that Resident 49's wound vac pump was set on 125mm/HG, not the ordered 75 mm/HG. Review of Resident 49's progress notes failed to reveal any other documentation of his wound vac dressing changes or any documentation of the needleless connection device changes or baseline measurement of the extending line of the central IV line. Review of Resident 49's August 2025 Medication and Treatment Administration Records failed to reveal any documentation of wound vac dressing changes on August 20, 25, or 27, 2025; any needleless connection device changes; or any measurements of the extending line of the central IV line. During a staff interview with Employee 6 on August 28, 2025, at 2:05 PM, Employee 6 indicated that when she researched the setting on Resident 49's wound vac pump, she saw that the DON had addressed the wound vac pump setting that morning with Resident 49's physician because staff cannot change the pump settings as the pumps are pre-programmed. Employee 6 also indicated that the facility practice is to change the needleless connection devices with the weekly dressing changes. Employee 6 confirmed that the changing the needleless connection devices was not part of the order because it was a preset order in the facility's database, but that they could have entered a separate order. During a staff interview with Employee 3 (Executive Director), the DON, and Employee 6 (Registered Nurse/Assistant Director of Nursing) on August 28, 2025, at 2:22 PM, the DON indicated that nurses cannot edit batch orders in the facility database. The DON confirmed that Resident 49's wound vac setting was 125 mm/HG since it was placed on August 18, 2025. The DON indicated that she would expect staff to have followed physician orders for wound vac settings or to have addressed the issue with the pre-programmed pump setting when the order could not be followed at time of placement. The DON also confirmed that the wound vac dressing was missed on August 27, 2025. Employee 6 indicated that she had changed the dressing on August 25, 2025, before Resident 49 went to dialysis, but did not date the dressing or complete any documentation of the dressing change. The DON confirmed that there was no documentation of measurements of the extending line of the central IV line. The DON confirmed that there was no documentation of the needleless connection device changes being changed and that they should have been changed weekly. 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)(5) Nursing services.

Based on observations, staff interview, and facility policy review, it was determined that the facility failed to store drugs and biologicals in accordance with accepted professional standards for one of one medication carts observed (300/400 hall medication cart).Findings include:Review of facility policy, titled Medication Storage; Storage of Medication, last reviewed September 10, 2024, revealed subsection 12 stated, Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.During observation of the 300/400 medication cart on August 27, 2025, at approximately 10:00 AM, revealed that an insulin pen for Resident 19 had been opened and previously used with no open date written on the pen. During the observation, it was revealed that the medication cart contained a manufacturer's box of single-use polyvinyl alcohol 1.4% eye drop applicators. Review of the single-use eye drop applicators and the box that they were contained in revealed that the lot number (number assigned to a manufactured good to allow for tracking and identification of a specific manufactured good in the case of a recall) on the box did not match the lot number printed on the individual single-use eye drop applicators. The observations above were confirmed in the presence of the Director of Nursing (DON) on August 28, 2025, at approximately 9:30 AM.During a staff interview on August 27, 2025, at approximately 1:20 PM, the DON confirmed that insulin pens should be labeled with a date when they are opened. Further, medications should be stored in their original manufacturer's container and should not be placed in separate containers which have different lot numbers.211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was revealed that the facility failed to ensure that five of 20 residents reviewed during meal service received a therapeutic diet per physician order (Residents 17, 19, 22, 40, and 59) .Findings include: Clinical record reviews for Residents 17, 19, 22, 40, and 59 revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and physician orders for a no concentrated sweets diet. During an interview with Resident 40 on August 26, 2025, at 9:50 AM it as revealed she is diabetic and feels the meals are carbohydrate heavy. A review of the diet spreadsheet for August 27, 2025, (day 23 of the Spring/Summer menu 2025) lunch meal revealed the no concentrated sweet diet (liberal diabetic diet) were to be served fruit cup in place of the pudding for dessert. Observation of tray line on August 27, 2025, at 12:05 PM, revealed Residents 17, 19, 22, 40, and 59 were ordered a no concentrated sweets diet and were served pudding vice fruit cup. The surveyor confirmed with Employee 2 (Food Service Director) on August 27, 2025, at 12:15 PM, that the Residents that ordered a no concentrated sweets diet were to be served fruit cup in place of the pudding. At that time, the pudding was removed from the aforementioned Resident's trays and a fruit cup was provided. Interview with the Employee 3 (Executive Director) on August 28, 2025, at 2:30 PM, revealed residents should be served the physician ordered diet. Pa code 211.6(a) - Dietary Services

Based on review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for one of five employee records reviewed (Employee 7); and failed to provide annual training that included dementia management for one of five employee records reviewed (Employee 8).Findings include: Review of personnel information revealed Employee 7's hire date was March 5, 2024. Review of her training record from August 29, 2024, through August 28, 2025, revealed that she had only completed 9.5 hours of annual training. Review of personnel information revealed Employee 8's hire date was May 21, 2024. Review of her training record from August 29, 2024, through August 28, 2025, revealed that she had not completed any dementia management training. During a staff interview with Employee 4 (Human Resources Director) on August 27, 2025, at 10:59 AM, she confirmed that Employee 7 did not complete the required training hours and that Employee 8 did not complete dementia training. During a staff interview with the Employee 3 (Executive Director), the Director of Nursing (DON), and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:18 PM, the DON confirmed that she would expect nurse aides to complete required training topics and to obtain a minimum of 12 hours of training per year. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.19(7) Personnel policies and procedures.28 Pa. Code 201.20(a)(d) Staff development.

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to determine residency status in order to perform the accurate criminal history background checks prior to hire for five of five personnel files reviewed (Employees 9, 10, 12, 13, and 14); and failed to validate and verify licensure status for one of two nurse personnel files reviewed (Employee 10).Findings include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated November 1, 2017, with a last review date of September 10, 2024, revealed Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment by the Facility in accordance with applicable state and federal regulations. Review of Employee 9's personnel file revealed her hire date was June 3, 2025, and that a Pennsylvania State Criminal Background check was completed on May 29, 2025. Employee 9's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 10's personnel file revealed her hire date was July 29, 2025, and that a Pennsylvania State Criminal Background check was completed on July 11, 2025. Employee 9's personnel file review failed to reveal that her Pennsylvania state residency status was verified in order to determine which criminal background check needed completed. Further review of Employee 10's file revealed that a copy of her Florida compact nursing license was present but failed to include that a license verification was completed to determine that the license was active and in good standing with no allegations of abuse, neglect, and exploitation of residents and misappropriation of resident property against it. Review of Employee 12's personnel file revealed her hire date was August 12, 2025, and that a Pennsylvania State Criminal Background check was completed on August 8, 2025. Employee 12's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 13's personnel file revealed her hire date was May 2, 2025, and that a Pennsylvania State Criminal Background check was completed on April 28, 2025. Employee 13's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 14's personnel file revealed her hire date was June 10, 2025, and that a Pennsylvania State Criminal Background check was completed on June 9, 2025. Employee 13's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. During a staff interview with Employee 4 (Human Resources Director) on August 27, 2025, at 11:10 AM, Employee 4 revealed that an applicant enters their information, which includes their addresses for the past 7 years into the database that the facility uses for hiring purposes. Employee 4 confirmed that no one at the facility has knowledge of the addresses that an applicant enters in order to determine whether a state or federal background check should be completed. Employee 4 indicated that she completes a state background check on all new hires. Employee 4 confirmed that she had no additional information to offer for Employees 9, 10, 12, 13, and 14. Employee 4 indicated that the corporate recruiter generally handles the licensure verification process. Employee 4 confirmed that she had no documentation to provide to show that Employee 10's nursing license had been validated or the status verified. During a staff interview with Employee 3 (Executive Director) and the Director of Nursing on August 27, 2025, at 1:37 PM, Employee 3 confirmed that the facility had no other information to offer for Employees 9, 10, 12, 13, and 14. Employee 3 indicated that the facility would review their processes. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

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 in the kitchen, in one of two nourishment centers (300/400 pantry), and in the creamery (an accessible lounge area).Findings include: Review of facility policy, Food Safety Requirements, not dated, read, in part, keep foods covered or in a tight container; and label, date and monitor foods to ensure they are utilized by the use-by date or frozen or discarded. Review of facility policy, Use and Storage of Food Brought in by Family or Visitors, not dated, read in part, all food items brought into the facility must be labeled with content and dated. Review of facility policy, Ice machines and Portable Ice Carts, revised and implemented August 27, 2025, read, in part, it is the policy of the facility to ensure that ice machines are clean and maintained. Ice machines will be cleaned at a frequency specified by the manufacturer. Review of manufacturer use and care guide, page 10, read, in part, maintenance should be completed on a semi-annual basis or more based on usage and location. Observation in walk-in freezer on August 25, 2025, at 6:17 PM, revealed a tray of muffins and 1/3 tray of marble cake open covered in plastic wrap with no date. Observation in walk-in refrigerator on August 25, 2025, at 6:15 PM, revealed feta cheese and mozzarella cheese open and not dated. Observation in dry storage on August 25, 2025, at 6:18 PM, revealed 1 bag ziti, 1 bag golden raisin, and 1 bag granola open, covered in plastic wrap, not dated; and 1 box chocolate chip gluten free cookies open and not securely closed in a box with other gluten free items dated 6/23. Observation in the main kitchen on August 25, 2025, at 6:23 PM, revealed one bulk bin of onions, not dated. Observation on the shelf above the 3-compartment sink on August 25, 2025, at 6:25 PM, revealed four individually wrapped sugar cookies, not dated. Observation in the creamery on August 25, 2025, at 6:28 PM, revealed a damp white towel with brown liquid marks was visible under the sink. The drip shield inside the ice machine contained a black moist substance along the bottom edge that was able to be wiped away with a paper towel. Observation in the 300 /400 nourishment center refrigerator on August 25, 2025, at 6:30 PM, revealed one vanilla might shake, thawed and not dated, with a thaw or use by date (product is to be utilized within 14 days once thawed); clear liquid on the bottom of the inside of the refrigerator; and 1 Styrofoam container of buffalo wings and celery without a resident identifier and not dated. Interview with Employee 11 (Food service Supervisor) on August 25, 2025, at 6:18 PM, revealed the aforementioned items should be securely closed and date marked when opened. Interview with Employee 2 (Food Service Director) on August 27, 2025, at 11:34 AM, it was revealed the aforementioned items should be securely closed and date marked once opened. Review of the most recent facility provided ice machine service contract documentation dated October 31, 2024, revealed preventive maintenance was completed on the kitchen ice machine. There was no documentation for preventive maintenance on the ice machine in the creamery. Observation and interview with Employee 3 (Executive Director) on August 28, 2025, at 9:36 AM, it was revealed that the ice machine in the creamery is utilized by staff to obtain ice for the residents. The drip shield on the inside of the ice machine contained a moist black substance that was able to be wiped away with a paper towel. Employee 3 confirmed that the ice machine needed to be cleaned. It was also revealed that the contracted service on the ice machine was last completed October 31, 2024, and service should've been performed in April 2025. The contract company was contacted and service was scheduled for September 2, 2025. Employee 3 moved the towel from underneath the sink, a water mark stained the flooring, and stated he would contact maintenance regarding the sink. Observation in the creamery on August 28, 2025, at 10:30 AM, revealed the towel remained under the sink and the ice machine drip shield remained soiled. Interview with the Employee 3 on August 28, 2025, at 2:30 PM, revealed food items should be date marked once opened or pulled from the freezer, resident items should be labeled with a resident identifier and date marked, and ice machines should be cleaned bi-annually or as needed. 28 Pa code 211.6(f) - Dietary Services

Based on facility documentation review and staff interview, it was determined that the facility failed to ensure that the governing body was responsible and accountable for the facility Quality Assurance Performance Improvement (QAPI) program.Findings include: Review of the facility Quality Assurance Performance Improvement (QAPI) Plan undated indicated the following, in part, VibraLife's governing body is ultimately responsible for overseeing the QAPI committee. The owner/president has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of QAPI attendance sign-in sheets for January-March 2025, failed to reveal that the facility Medical Director (MD) or the Nursing Home Administrator (NHA) attended any of the monthly meetings in the quarter. Review of QAPI attendance sign-in sheets for April-June 2025, failed to reveal that the facility MD or NHA attended any of monthly meetings in the quarter. Review of a Memorandum with the Subject of Administrator Coverage dated August 12, 2024, provided by Employee 3, revealed that the designated Administrator of Record (NHA) had appointed Employee 3 as the full-time, permanent administrator on-site. The memorandum further indicated, in part, that the Administrator of Record remains actively engaged with facility operation; his office is located just three miles from the facility, enabling him to be on-site daily as needed; and that the NHA and Employee 3 communicate regularly, ensuring that all operational aspects are aligned with both state regulations and corporate objectives. This memorandum was signed by both the Administrator of Record and Employee 3 on October 17, 2024. During a staff interview with Employee 3 (Executive Director), the Director of Nursing, and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:49 PM, Employee 3 confirmed that although he is not the NHA, he has attended the QAPI meetings. Employee 3 further indicated that the NHA is also the Vice-President of Operations for the company that owns the facility and, in that capacity, also serves as part of the governing body. Employee 3 confirmed that the facility's NHA nor the MD have attended the QAPI meetings January through June 2025. Employee 3 indicated that he communicates via phone with the NHA at least twice a week, and often daily, but confirmed that he does not necessarily discuss or send QAPI minutes to him to review nor does he remind him to read meeting minutes in the facility electronic database even though the NHA also serves as a member of the governing body. Employee 3 was unable to provide any written documentation between him and the NHA/governing body in correlation to QAPI or ensuring that the MD attends the QAPI meetings. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.

Based on review of the facility provided attendance sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that two of the required members failed to attend at least one meeting in two out of three quarters.Findings include: Review of QAPI attendance sign-in sheets for January-March 2025, failed to reveal that the facility Medical Director or the Nursing Home Administrator (NHA) attended any of the monthly meetings in the quarter. Employee 3 (Executive Director) had signed as the NHA. Review of QAPI attendance sign-in sheets for April-June 2025, failed to reveal that the facility Medical Director or the NHA attended any of monthly meetings in the quarter. Employee 3 had signed as the NHA. During a staff interview with Employee 3, the Director of Nursing, and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:49 PM, Employee 3 confirmed that he is not the NHA, and that the facility's NHA nor the Medical Director had attended the QAPI meetings. He further indicated that he communicates via phone with the NHA at least twice a week and most of the time daily, but confirmed that he does not necessarily send QAPI minutes to him to review. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.

Based on review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to establish Enhanced Barrier Precautions (EBP) and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on two of two nursing units; and failed to maintain an effective infection control program related to the administration of medications for one resident observed during medication administration observation (Resident 63). Findings include: Review of facility policy, Enhanced Barrier Precautions (EBP), effective 2024 and revised 2024, read, in part, EBP are indicated for residents with any of the following: infection or colonization with a CDC [Center for Disease Control] targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Chronic wounds include unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A short-term peripheral intravenous line (PIV) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, device care or use: central line, urinary catheter, feeding tube, trach/ventilator, wound care: any skin opening requiring a dressing. Review of Resident 40's clinical record review documented diagnoses that included urinary tract infection. Interview with Resident 40 on August 26, 2025, at 9:50 AM revealed she received an intravenous antibiotic for a urinary tract infection, and it finished on August 25th, 2025. Surveyor observed empty medication bags hanging from the intravenous (IV) pole. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible near Resident 40's room. Further clinical record review documented physician orders that included: place midline (peripheral catheter longer than a standard IV positioned in the vein of the upper arm near the armpit) for IV antibiotic one time, started August 15, 2025; normal saline 10 ml intravenously every shift for midline maintenance, started August 15, 2025, and discontinued August 27th, 2025; Zosyn intravenous 100 ml every 6 hours for 10 days, started August 15, 2025, and discontinued August 25th, 2025, at 2:00 PM. Review of Resident 40's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 46's clinical record documented diagnoses that included lumbar spine incision wound care, osteomyelitis (bone infection) of vertebra. Further clinical record review documented physician orders that included: Cefepime 2 gram intravenously every 8 hours, started August 19, 2025, discontinue September 26, 2025; heparin injection 5000 units subcutaneously two times a day for clot prevention, started August 25, 2025; IV Site - Change dressing once weekly and as needed every Tuesday on day shift and measure extending line and check for displacement - if more than 1 cm notify physician for further orders, started August 26, 2025; lumbar spine incision - keep dressing in place and monitor for increase redness, swelling, drainage daily on day shift - notify provider, started August 20, 2025. Progress note dated August 19, 2025, at 5:33 PM, read, in part, PICC line right upper extremity. Further review of progress notes documented the weekly sterile PICC dressing change was completed on August 26th, 2025, at 6:35 PM. Review of Resident 46's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Review of Resident 47's clinical record documented diagnoses that included fracture right ulna (thin bone in the forearm) and retention of urine. Further clinical record review documented physician orders that included: Foley Catheter 16 FR 10 ml balloon for (urine retention), revised August 20, 2025; foley catheter care every shift and as needed- soap and water cleanse at meatus and down catheter tubing every shift, started August 24, 2025; foley catheter and drainage bag change as needed for infection, obstruction, or when the closed system is compromised as needed, started August 24, 2025. Review of Resident 47's August 2025 medication and treatment administration record documented catheter care was documented as completed August 20th through 27th, and the catheter was changed on August 24th. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 49's clinical record revealed diagnoses that included acute and subacute endocarditis (a life-threatening inflammation of the inner lining of the heart's chambers and valves usually caused by an infection) and cellulitis (skin infection) of the chest wall. Review of Resident 49's physician orders revealed the following orders: Wound vac therapy to left upper chest surgical wound continuous at 75 mm HG (millimeters of mercury) dated August 17, 2025; and IV [intravenous]site - Change dressing once weekly and PRN [as needed]. Measure extending line and check for displacement. If more than 1 cm, notify physician for further orders, dated August 25, 2025. Observation of Resident 49 on August 26, 2025, at 10:14 AM, revealed that his IV site was a double lumen central line located on his right chest. His wound vac was in place to his left upper chest. Observation failed to reveal any notation thatResident 49 was on EBP. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 53's clinical record documented diagnoses that included a urinary tract infection. Further clinical record review documented physician orders that included: foley catheter 16 FR 10 ml balloon for (retention - failed voiding trial), started August 25, 2025; foley catheter care every shift and as needed, started August 25, 2025; foley catheter and drainage bag change as needed for infection, obstruction, or when the closed system is compromised, started August 25, 2025; irrigate foley catheter with 60 ml normal saline every shift until hematuria (blood in urine) clears, started August 26, 2025. Review of Resident 53's August 2025 medication and treatment administration record documented catheter care was documented as completed August 25th through 27th. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Interview with Resident 59 on August 26,2025, at 9:24 AM, reveled he's receiving an intravenous antibiotic for sepsis. Observation revealed empty medication bags hanging from intravenous pole. No EBP signage or Personal Protective Equipment readily visible near Resident 59's room. Review of Resident 59's clinical record review documented diagnoses that included sepsis (blood infection), acute cholecystitis (inflammation of the gallbladder), and bacteremia (bacterial infection in the blood). Further clinical record review documented physician orders that included: change IV site dressing weekly and as needed every Monday dayshift, start September 1, 2025; IV Tubing changes, started August 25, 2025; empty chole/biliary drain and record output evening shift every 3 days, started August 25, 2025; Wound care - chole drain right upper quadrant of abdomen - cleanse with soap and water - pat dry, apply split gauze around drain - cover with foam dressing every evening shift, started August 25, 2025; Ampicillin 2 grams intravenously every 4 hours for sepsis, started August 25, 2025, until September 24,2025; Vancomycin 1 gram intravenously two times a day for cellulitis bilateral lower extremities, started August 27,2025; ceftriaxone 2 gram intravenously two times a day for sepsis, started August 25, 2025 until September 24,2025; normal saline flush 10 ml intravenously every shift for PICC (peripherally inserted central catheter- thin tube inserted into a vein in the arm guided to a large vein near the heart) patency started August 25, 2025. Review of Resident 59's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. Review of Resident 60's clinical record documented diagnoses that included pneumonia and bacteremia (bacterial infection in the blood). Further clinical record revealed physician orders that included: Cefepime Intravenous Solution 1 GM/50ML every 8 hours for 6 weeks, started August 24, 2025, and discontinue September 26, 2025; Normal Saline Flush 10 ml intravenously every shift for PICC maintenance Flush both ports every shift started August 25, 2025; IV site dressing change once weekly and as needed, and measure extending line and check for displacement. If more than 1 cm, notify physician for further orders day shift every Monday started August 31, 2025. Review of Resident 60's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Interview with the Director of Nursing (DON) on August 27, 2025, at 1:40 PM, it was revealed that EBP haven't been implemented per facility policy. Review of facility policy titled, Medication Administration; Eye Drops, last reviewed September 10, 2024, revealed that subsection 16 (procedure after eye drop administration) stated, Remove and dispose of gloves. Discard any barrier used forcarrying or storing the medication and supplies. Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer. During observation of medication administration on August 26, 2025, at approximately 8:32 AM, Employee 1 (Licensed Practical Nurse) was observed using his gloved hands to apply eye drops in both of Resident 63's eyes. Employee 1 then left the Resident's room with Resident 63's water cup. Employee 1 was then observed to utilize the common room's ice scoop to scoop ice from the container with the gloved hands. Employee 1 was then observed dispensing water from a water dispenserlocated in the common area using gloved hands. Employee 1 returned to Resident 63's room, provided Resident 63 with the ice water, then removed his gloves and performed hand hygiene. During a staff interview on August 27, 2025, at approximately 1:20 PM, DON confirmed that Employee 1 should have removed gloves and performed hand hygiene after applying eye drops to Resident 63 and prior to accessing the icecontainer and water dispenser in the unit common area. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa code 211.10(d) Resident care policies28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure residents the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors for one of one facility survey results book reviewed (facility lobby area). Findings Include: An observation of the facility's designated survey results book revealed the most recent Federal and State survey information dated November 2023. A review of the facility's history revealed the most recent survey dated February 16, 2024. An interview with the Nursing Home Administrator on September 17, 2024, at 1:21 PM, confirmed the facility's survey book did not contain the most recent survey for resident review. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to perform criminal history background checks prior to hire for one of five personnel files reviewed (Employee 4); failing to verify the nurse aide registry prior to hire for one of five personnel files reviewed (Employee 4); and failing to perform reference checks prior to hire for two of five personnel files reviewed (Employees 4 and 5). Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated November 1, 2017, revealed Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment by the Facility in accordance with applicable state and federal regulations. Review of Employee 4's (Nurse Aide) personnel file revealed a hire date of June 18, 2024. In an email correspondence with the Director of Nursing (DON) on September 18, 2024, at 10:16 AM, she stated that Employee 4's first day working in the facility was on July 3, 2024. Further review of Employee 4's personnel file revealed a Pennsylvania State Police background check wasn't conducted until July 22, 2024, there was no evidence that the nurse aide registry was verified until September 17, 2024, and there was no evidence that any reference checks were completed or attempted. Review of Employee 5's personnel file revealed a hire date of July 30, 2024. Further review of Employee 5's personnel file revealed no evidence that any reference checks were completed or attempted. During an interview with Employee 2 (Human Resources Coordinator) on September 17, 2024, at 11:52 AM, she stated that she verified the nurse aide registry for Employee 4 prior to September 17, 2024, but didn't print out the form at that time to verify the date that it was done. In a follow-up interview with Employee 2 on September 18, 2024, at 11:42 AM, she confirmed that Employees 4 and 5 did not have reference checks attempted or completed prior to their employment with the facility. During an interview with the Nursing Home Administrator (NHA) on September 19, 2024, at 11:49 AM, he confirmed that Employee 4's background check wasn't completed until after she started working at the facility and stated that the nurse aide registry was checked prior to hire, but confirmed there is no evidence of that. During this time, the NHA also confirmed that reference checks were not done for Employees 4 or 5. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.19(3) Personnel policies and procedures

Based on document review, clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure allegations of neglect are thoroughly investigated for one concern form reviewed (Resident 153). Findings Include: A review of the facility's policy, titled Abuse, Neglect, and Exploitation, effective November 1, 2017, read, in part, When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation will be initiated immediately. The policy defined neglect as 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. The policy continued, Components of an investigation may include: 3. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. 4. Document the entire investigation chronologically. A review of Resident 153's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and Diabetes Mellitus Type II (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of the facility's grievance log, revealed Resident 153 reported to the Director of Social Services (Employee 3) on September 12, 2024, that the Nurse Aide, Employee 8 is rude and did not want to help her [Resident 153] transfer from bed to w/c [wheelchair] so she [Resident 153] could use the bathroom. A review of the facility's form titled Employee Warning Notice, dated September 17, 2024, revealed Employee 8 was given a verbal warning. The notice described the type of offense as substandard work and rude to customers/coworkers. The warning notice continued under the description of violation Resident complaint- you [Employee 8] refused to put her shoes on prior to transfer, she almost fell-then you refused to help her up in bed and made her use the headboard to pull herself up. An interview with the Assistant Director of Nursing (Employee 1) on September 19, 2024, at 12:25 PM, revealed the facility had no witness statements or documentation by the alleged perpetrator, Employee 8, and interviewed Resident 153 on September 19, 2024, at 12:04 PM, regarding any concerns of safety or additional concerns regarding the incident and allegation made on September 12, 2024. The interview also revealed the facility did not believe the allegation to be abuse or neglect, however, admitted to having no additional investigative information for the final determination. A final interview with the Nursing Home Administrator on September 19, 2024, at approximately 12:30 PM, revealed an acknowledgement of the concern. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to ensure the required in-service training for nurse aides include dementia management training and resident abuse prevention training for one of five nurse aide training documents reviewed (Employee 7). Findings Include: A review of the facility's annual training documentation for Employee 7 revealed none regarding resident abuse and none regarding dementia care. An interview with the Nursing Home Administrator on September 19, 2024, at 11:17 AM, revealed the required training for Employee 7 could not be located at the time of the survey. 28 Pa. Code 201.19 (7) Personnel policies and procedures

Based on document review and staff interview, it was determined that the facility failed to ensure information regarding its transferred residents is forwarded to a representative of the Office of the State Long-Term Care Ombudsman for 32 of 37 residents transferred to the hospital for 8 of 9 months reviewed (January 2024-August 2024). Findings Include: A review of the facility's hospital transfer information beginning January 2024 revealed information regarding 32 of the 37 residents transferred was not shared with the State Long-Term Care Ombudsman. An interview with the Director of Social Services (Employee 3) on September 17, 2024, at 10:03 AM, revealed an awareness of the information not being sent and the expression that the transferred resident information would be forwarded beginning September 2024. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on document review and staff interviews, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months for one of five nurse aide files reviewed (Employee 6). Findings Include: A performance appraisal, also referred to as a performance review, performance evaluation, development discussion, or employee appraisal, sometimes shortened to 'PA', is a periodic and systematic process whereby the job performance of an employee is documented and evaluated. A review of the facility's nurse aide information revealed a hire date for Employee 6 of August 10, 2021. A review of Employee 6's performance appraisal form revealed the most recent dated December 28, 2022. An interview with the Director of Nursing on September 18, 2024, at approximately 1:00 PM, revealed employees are to be evaluated on an annual basis. An interview with the Nursing Home Administrator on September 19, 2024, at 11:17 AM, confirmed the facility could not locate a more recent performance evaluation for Employee 6 after December 28, 2022. 28 Pa. Code 101.19 (2) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of three residents reviewed (Residents 3, 4, and 6). Findings Include: Review of Resident 3's clinical record revealed diagnoses that included fracture of medial condyle of left femur (lower extremity of the upper leg bone near the knee) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 3's December 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Lovenox (anticoagulant) injection each morning for deep vein thrombosis prevention (condition where blood clots form in veins located deep inside the body, usually in the thigh or lower legs causing pain and swelling ). Further review of the MAR revealed that Lovenox was not administered to Resident 3 on December 24-29, 2023. Review of nursing progress notes revealed that on the aforementioned dates, Resident 3's Lovenox was not administered because the medication was unavailable. Further review of available clinical documentation revealed that the physician was notified of the missed dose of Lovenox on December 27, 2023, but not of any other missed doses. Review of Resident 4's clinical record revealed diagnoses that included paroxysmal atrial fibrillation (irregular heart rhythm that can cause symptoms such as fatigue, lightheadedness, and stroke) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 4's December 2023 MAR revealed an order for Rivaroxaban (anticoagulant) daily for anticoagulation, and trazodone (used to treat depression) at bedtime for antidepressant. Further review of the MAR revealed that she did not receive Rivaroxaban on December 9-11, 2023; and did not receive trazodone December 9, 24, and 28-30, 2023. Review of Resident 4's nursing progress notes for the aforementioned dates revealed that Rivaroxaban and trazodone were not administered because the medications were unavailable at the time. Additionally, review of Resident 4's nursing progress notes indicated that she did not receive her scheduled doses of trazodone on January 1-4, 2024, due to the medication being unavailable. Further review of available clinical documentation failed to reveal any evidence that the physician was notified that Rivaroxaban and trazodone were not administered to Resident 4 as noted above. Review of Resident 6's clinical record revealed diagnoses that included paroxysmal atrial fibrillation and congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 6's December 2023 MAR revealed an order for Warfarin (anticoagulant) at bedtime daily Tuesday through Sunday for atrial fibrillation. Further review of the MAR revealed that this medication was not administered to Resident 6 on December 9-10, and 12-13, 2023. Review of Resident 6's nursing progress notes for the aforementioned dates revealed that Warfarin was not administered due to being unavailable. Further review of available clinical documentation failed to reveal any evidence that the physician was notified that Warfarin was not administered to Resident 6 as noted above. During an interview with the Nursing Home Administrator on January 4, 2024, at 2:26 PM, she did not provide any additional information regarding physician notification of missed medications for the aforementioned residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for three of three residents reviewed for medication administration (Residents 3, 4, and 6). Findings include: Review of Resident 3's clinical record revealed diagnoses that included fracture of medial condyle of left femur (lower extremity of the upper leg bone near the knee) and chronic obstructive pulmonary disease (COPD - chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident 3's December 2023 MAR (Medication Administration Record - form used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Lovenox (anticoagulant) injection each morning for deep vein thrombosis prevention (condition where blood clots form in veins located deep inside the body, usually in the thigh or lower legs causing pain and swelling ). Further review of the MAR revealed that Lovenox was not administered to Resident 3 on December 24-29, 2023. Review of nursing progress notes revealed the following regarding Resident 3's Lovenox: December 24, 2023 - waiting on pharmacy; December 25, 2023 - waiting on pharmacy; December 26, 2023 - out of stock waiting on pharmacy; December 27, 2023 - awaiting delivery from pharmacy, dr [doctor] aware; December 27, 2023 - pharmacy contacted, medications will be on next delivery. Lovenox not available in Omnicell [on-site pharmacy supply] or in med cart; December 28, 2023 - medication unavailable; December 29, 2023 - on order. Review of Resident 4's clinical record revealed diagnoses that included paroxysmal atrial fibrillation (irregular heart rhythm that can cause symptoms such as fatigue, lightheadedness and stroke) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 4's December 2023 MAR revealed an order for Rivaroxaban (anticoagulant) daily for anticoagulation, and trazodone (used to treat depression) at bedtime for antidepressant. Further review of the MAR revealed that she did not receive Rivaroxaban on December 9-11, 2023; and did not receive trazodone December 9, 24, and 28-30, 2023. Review of Resident 4's nursing progress notes revealed the following regarding Rivaroxaban: December 9, 2023 - awaiting delivery from pharmacy; December 10, 2023 - med not available; December 11, 2023 - awaiting delivery from pharmacy. Further review revealed the following regarding trazodone: December 9, 2023 - Medication not available; December 24, 2023 - Med not available; December 28, 2023 - Med not available; December 29, 2023 - not available; December 30, 2023 - Medication not available. Additional review of Resident 4's nursing progress notes indicated that she did not receive her scheduled doses of trazodone on January 1-4, 2024, due to the medication being unavailable. Review of Resident 6's clinical record revealed diagnoses that included paroxysmal atrial fibrillation and congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues). Review of Resident 6's December 2023 MAR revealed an order for Warfarin (anticoagulant) at bedtime daily Tuesday through Sunday for atrial fibrillation. Further review of the MAR revealed that this medication was not administered to Resident 6 on December 9-10, and 12-13, 2023. Review of Resident 6's nursing progress notes revealed the following regarding Warfarin: December 9, 2023 - med not available; December 10, 2023 - out of stock; December 12, 2023 - medication unavailable - awaiting for delivery from pharmacy; December 13, 2023 - medication unavailable - awaiting for delivery from pharmacy. During an interview with the Nursing Home Administrator on January 4, 2024, at 12:00 PM, she did not provide any additional information regarding the aforementioned residents at that time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on observation, clinical record review, policy review, and staff interview, it was determined that the facility failed to ensure residents are assessed for medication self-administration for one of three residents reviewed for medication administration (Resident 74). Findings include: Review of facility pharmacy policy titled, 2.1 Self Administering Medications, revealed in section, Procedure, stated, Facility should comply with Facility policy, Applicable Law and the State Operations Manual with respect to resident Self-Administration of Medications .Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and appropriate . Review of Resident 74's clinical record on October 4, 2023, at approximately 8:50 AM, revealed diagnoses that included hypertension (elevated/high blood pressure) and osteoarthritis (degenerative joint disease, which is characterized by the breakdown of soft tissue in the joints). During medication observations on October 3, 2023, at approximately 8:31 AM, Employee 1 was observed preparing medications for Resident 74. Employee 1 was observed preparing 10 separate medications for administration. Shortly after placing the medicines in a medicine cup, Employee 1 was observed leaving the medicine cup with medicines on the Resident's bedside table and exiting the room. Review of Resident 74's clinical record revealed no physician order for medication self-administration, no assessment for medication self-administration, and no care plan for medication self-administration. During a staff interview on October 5, 2023, at approximately 12:00 PM, Nursing Home Administrator (NHA) confirmed Resident 74 did not have an assessment for medication self-administration; adding that the NHA felt Resident 74 was functionally and cognitively safe to self-administer medications. 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 a review of facility documentation, clinical record review, and staff interview, it was determined the facility failed to timely issue the Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-10055), and a Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), for one of three residents reviewed (Resident 77). Findings include: Review of Resident 77's clinical record documented the Resident was admitted to the facility on [DATE]. Review of the Beneficiary Protection Notification Review Form revealed the facility failed to provide the Resident and/or Resident Representative the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) form that details the cost of care and services no longer covered under Medicare beginning June 21, 2023. Review of the Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), which provides residents/resident representatives an opportunity to appeal the decision of Medicare Part A non-coverage, indicated Resident 77's last date of coverage was June 20, 2023. Review of Resident 77's NOMNC CMS-10123 form indicated the Resident/Resident Representative was not notified of the last day of Medicare Part A coverage until June 19, 2023. During an interview on October 4, 2023, at 10:45 AM, the Nursing Home Administrator confirmed the facility failed to timely issue the Skilled Nursing Facility Advanced Beneficiary Notice form (SNF ABN CMS-20055) and a Notice of Medicare Non-Coverage form (NOMNC CMS-10123). 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to conduct a comprehensive assessment after a significant change in health status for one of nine residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record on October 2, 2023, at approximately 11:00 AM, revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 2's clinical record revealed Resident 2 had a Quarterly Minimum Data Set Assessment (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) with an assessment reference date of September 3, 2023. Review of the Quarterly MDS revealed section H. Bladder and Bowel was assessed as not having an indwelling catheter; section M. Skin Conditions was assessed as having one stage II pressure ulcer; section N. Medications was assessed as no antibiotic use; and section O. Special Treatments and Programs was assessed as no intravenous (IV) medication use. Review of Resident 2's clinical record revealed that, after the September 3, 2023, Quarterly MDS, Resident 2's pressure ulcer increased in severity to a stage IV pressure injury, as assessed by the consultant wound provided on September 12, 2023. Resident 2 also developed an infection of the bone, which resulted in an order for an IV antibiotic, ordered on September 20, 2023, and to last until October 26, 2023. Finally, Resident 2 had a foley catheter (internal urinary catheter used to facilitate bladder emptying) inserted on October 3, 2023. The aforementioned changes in Resident 2's health status represent significant changes in Resident 2's health status in four areas assessed in the MDS: section H. Bladder and Bowel, section M. Skin Conditions, section N. Medications, and section O. Special Treatments. Review of Resident 2's clinical record on October 3, 2023, at approximately 12:00 PM, revealed that no Significant Change MDS had been conducted nor started as of October 3, 2023. During a staff interview on October 5, 2023, at approximately 12:00 PM, Nursing Home Administrator confirm that Resident 2 had a significant change in health status and that a Significant Change MDS should have been started as a result. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the faciliy failed to ensure accuracy of the resident assessment for one of nine residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record on October 3, 2023, at approximately 10:00 AM, revealed diagnoses that included senile degeneration of the brain (a decrease in cognitive abilities or mental decline), unspecified fracture of left femur (a break in the bone connecting the hip and knee), and periprosthetic fracture around internal prosthetic left knee joint (a broken bone that occurs around the implant of a knee replacement). Review of Resident 1's admission Minimum Data Set (MDS - assessment tool utilized to identify a residents physical, mental, and psychosocial needs) with an Assessment Reference Date of March 7, 2023, revealed that Section J - Health Conditions, subsection J1700 - Fall History on Admission/Entry or Reentry, section A was coded No, for Did the resident have a fall any time in the last month prior to admission/entry or reentry?; section B was coded No, for Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?; section C was coded No, for Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?; and Subsection J2300 - Major Joint Replacement, was coded No, for Knee Replacement - partial or total. Review of Resident 1's clinical record revealed Resident 1's medical history included a fall in January 2023, which resulted in a fracture around the internal prosthetic left knee joint, and a fall in February 2023, which resulted in a left hip fracture with surgical repair on February 23, 2023. Review of Resident 1's Significant Change Minimum Data Set MDS with an Assessment Reference Date of April 3, 2023, revealed that Section I - Active Diagnoses, subsection I2300 - Urinary tract infection (UTI)(Last 30 Days), was coded No, and section I4800 - Non-Alzheimer's Dementia was coded No. Review of Resident 1's clinical record revealed Resident 1 was diagnosed with a urinary tract infection on March 3, 2023, and treated with antibiotics until March 14, 2023. Further review of Resident 1's record revealed she was admitted to Hospice services on March 22, 2023, with a diagnosis of Terminal Senile Degeneration of the Brain. An interview with the Nursing Home Administrator on October 4, 2023 at 2:00 PM, revealed it was the facility's expectation that the Resident's assessment would be coded correctly. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure a baseline care plan was developed and implemented for one of nine residents reviewed (Resident 121). Findings include: Review of Resident 121's clinical record on October 2, 2023, at approximately 11:50 AM, revealed diagnoses that included hypothyroidism (condition in which the body does not produce adequate hormones via the thyroid gland) and depression (prolonged feelings of sadness and depressed mood that is characterized by changes in appetite, decrease enjoyment of activities, and possible difficulties performing day to day tasks). Review of Resident 121's clinical record revealed that Resident 121 was admitted to the facility on [DATE]. Review of Resident 121's comprehensive plan of care revealed that areas designated for staff to specify individualized information for Resident 121 were not completed by staff. Areas left incomplete included Resident 121's assistance needs and number of staff required for assistance with Activities of Daily Living, ambulation status and assistive devices; Resident 121's risk level for falls; areas at risk for skin breakdown; psychotropic medication including anti-depressants, anti-psychotic, and anti-anxiety medications. During a staff interview on October 5, 2023, at approximately 12:15 PM, Nursing Home Administrator revealed the facility had no further information to provide regarding the completion of the comprehensive plan of care for Resident 121. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observation, staff interviews, and record review, it was determined that the facility failed to provide appropriate urinary catheter (tubing inserted into the bladder to drain urine into a bag) care for one of 11 residents reviewed (Resident 75). Findings include: Review of Resident 75's clinical record on October 3, 2023, revealed Resident 75 had diagnoses that included urinary retention (unable to empty bladder completely during urination) and benign prostate hyperplasia (BPH -age-associated prostate gland enlargement that can cause urinary difficulty). Review of physician orders dated October 2023, identified that Resident 75 had an indwelling urinary catheter in place per physician orders Observation of Resident 75 on October 2, 2023, at 12:23 PM, revealed Resident 75's catheter bag and tubing dragging on the floor as he was mobile in his wheelchair, both in his room and in the hall. During an interview with the Employee 2 (Assistant Director of Nursing) on October 2, 2023, at 12:25 PM, she observed Resident 75's foley catheter bag and tubing dragging on the floor, and agreed it should never touch the floor. During an interview with the Director of Nursing (DON) on October 4, 2023, at 10:45 AM, the DON confirmed the catheter bag and tubing should never be touching the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure pain management was provided per order for one of nine residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record on October 2, 2023, at approximately 11:00 AM, revealed diagnoses that included diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure). Review of Resident 2's physician's orders revealed an order for hydrocodone-acetaminophen (combination narcotic medication used to treat pain) 5-325 milligrams (mg - metric unit of measure) give one tablet by mouth every 24 hours as needed for pain, give one half hour prior to dressing change, which was dated September 29, 2023; and Hydrocodone-acetaminophen 5-325 mg give one tablet by mouth two times a day for severe pain, which was dated September 26, 2023. Review of Resident 2's hydrocodone-acetaminophen narcotic controlled substance count sheets (required documentation tool utilized to track the administration amount and time of controlled substances) revealed that on October 3, 2023, no evening dose was provided to Resident 2. Observation of Resident 2's wound dressing change on October 5, 2023, completed by Employee 2, at approximately 11:40 AM, revealed Resident 2 was experiencing signs of pain during the dressing change as evidenced by facial grimacing and moaning with movement and dressing removal and placement. Directly after the wound dressing change, a staff interview with Employee 2 revealed that Employee 2 assumed the medication nurse had provided the pain medication prior to the dressing change. Review of Resident 2's narcotic controlled substance count sheets and Resident 2's October Medication Administration Record on October 5, 2023, at approximately 11:50 AM, revealed staff did not document providing the as needed pain medication prior to the dressing change, nor was the medication provided prior to dressing changes on October 1 through 4, 2023. During a staff interview with the Nursing Home Administrator and Director of Nursing on October 5, 2023, at approximately 12:30 PM, it was revealed that Resident 2 was not provided pain medications as prescribed. 28 Pa code 211.12(d)(1)(5) Nursing Services

Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure infection prevention strategies were implemented for one of two medication carts observed (300 hall medication cart). Findings include: Review of facility policy, titled Glucometer Disinfection, last reviewed April 21, 2023, revealed the policy stated, VibraLife shall provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne disease to residents and employees .The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus .Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use . During general observations on October 3, 2023, at approximately 8:20 AM, Employee 11 was observed exiting a resident room with a glucometer (hand held device used to test a small amount of blood for the amount of glucose in the blood stream) in hand. Employee 11 was observed placing the glucometer on the 300 hall medication cart, at which time it was observed that a test strip (strip used to collect small amount of blood) was still inserted into the glucometer. At approximately 8:22 AM, Employee 11 was observed removing and discarding the test strip from the glucometer, and then placing the glucometer in the medication cart drawer directly on top of unused lancet devices (devices used to puncture the finger tip to produce blood for a glucose blood test). Employee 11 did not cleanse the glucometer prior to storage in the 300 hall medication cart. During a staff interview on October 5, 2023, at approximately 12:00 PM, Nursing Home Administrator revealed that the glucometer should be cleansed appropriate after use and prior to storage. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual training on dementia management, behavioral health, and abuse for one of five nurse aide personnel records reviewed (Employee 9), and the facility failed to complete annual training on abuse for one of five nurse aide personnel records reviewed (Employee 10). Findings include: Review of Employee 9's (Nurse Aide) personnel record indicated a date of hire on August 10, 2021, and that Employee 9 received the annual performance evaluation covering the period of July 31, 2022, through August 10, 2023. Review of the annual in-service documentation and personnel records did not include a training on dementia management, behavioral management, or abuse for Employee 9. Review of Employee 10's (Nurse Aide) personnel record indicated a date of hire on January 31, 2017, and that Employee 10 received the annual performance evaluation covering the period of March 1, 2022, through March 1, 2023. Review of the annual in-service documentation and personnel records did not include a training on abuse for Employee 10. During an interview on October 4, 2023, at 10:40 AM, the Nursing Home Administrator confirmed the facility failed to complete annual training on dementia management, behavioral health, and abuse for Employee 9, and failed to complete abuse training for Employee 10, as required. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(1) Management 28 Pa. Code 201.20(a)Staff development

Based on observation, staff interviews, and record review, the facility failed to develop a person-centered care plan for two of 14 residents reviewed (Residents 1 and 71). Findings include: Review of Resident 1's clinical record on October 3, 2023, at approximately 1:20 PM, revealed diagnoses that included senile degeneration of the brain (a decrease in cognitive abilities or mental decline) and chronic kidney disease (CKD - gradual loss of kidney function over time). Review of Resident 1's physician orders revealed an order for insertion of a foley catheter due to urine retention, written on May 8, 2023. Review of Resident 1's comprehensive plan of care revealed Resident 1 did not have a care plan developed or implemented that addressed the foley catheter. During an interview with the Director of Nursing (DON) and Nursing Home Administrator on October 4, 2023, at approximately 1:50 PM, it was revealed that it was the facility's expectation that Resident 1's comprehensive plan of care would include the foley catheter. A review of the clinical record on October 3, 2023, for Resident 71 revealed diagnoses that included right fractured ankle (broken ankle bone) and cerebral vascular accident (stroke). Observation of Resident 71 on October 2, 2023, revealed the Resident sitting in her wheelchair in her room. A review of Resident 71's physician orders dated September 16, 2023, revealed the Resident wa non-weight bearing right lower extremity ankle, meaning she may not stand on her right leg. A review of the Resident 71's care plan and interventions on October 3, 2023, failed to reveal a care plan for the non-weight bearing status of her right ankle. During an interview with the DON on October 4, 2023, at approximately 11:00 AM, the DON stated the Resident is care planned for mechanical lift transfers. On October 4, 2023, the facility revised Resident 71's care plan to include the non-weight bearing status of the right ankle, and agreed that it should have been on the care plan when the orders were written. 28 Pa. Code 211.12(5) Nursing services