Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately working for one of four nursing units (West Hall Nursing Unit). Findings include: Review of the facility policy entitled, Call Light Response with a revision date of 11/1/24 , revealed that a call bell or alternative device will be placed within the reach of each resident while in their room, toilet or bathing area. The resident will be instructed in the use of the call bell or alternative device. Staff will respond to the call bell in a timely manner. Staff will be alert to signals that the call bell is on by the following: Flashing light on intercom Beeping of intercom Lighted call signal over the resident's door Sounding of tap bell Observation of the [NAME] Hall Nursing Unit, revealed the call bell system in the corridors did not illuminate when resident call bells in their rooms had been activated. Upon review of maintenance records, it was confirmed that the call bell system on the [NAME] Hall Nursing Unit had not been functioning since 4/22/25, and a temporary call bell system was installed on 4/29/25. A price quote for a new call bell system was obtained but was not completed. Upon observation of the temporary call bell system on the [NAME] Hall Nursing Unit, it was confirmed that residents can call, but no visible overhead light system illuminates. Requests by residents go to a screen located in center hall at the time of call. It was observed that if another resident uses their call bell before staff becomes aware, the previous resident's call is not visible and there is no way to review previous calls and those calls get missed. During interviews with residents at the time and date of the investigation revealed the following: Resident R1 stated that there are long wait times always, on all shifts; you will wait hours to get assistance sometimes; the system does not have a light system over the door and employees don't know you call; wait times have been worse since the original system stopped working. Resident R2 stated that there are consistent wait times of one to two hours for assistance after you call for help on all shifts; it is concerning. Resident R3 stated that assistance is always slow after you call for help on all shifts; you will wait over one hour sometimes. Resident R4 stated that there are always long wait times after you call on the call bell for help or needs; thirty to sixty minute wait times are not uncommon and it upsets him/her. Resident R5 stated that there are always 30 minute wait times or longer and sometimes employees don't know there was a call; Resident R5 also stated I wait too long to go to the bathroom when I call, so I just get up by myself if I cannot wait. Resident R6 stated that there are constantly long wait times when he/she calls for help of over 30 minutes and staff doen't know the call system was used. During an interview on 6/10/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the central call bell system on the [NAME] Hall Nursing Unit was not fully functioning to provide visual communication of which room the call bell activation was coming from. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1) Management

Based on review of facility policy and manufacturer's instructions, observations and staff interview, it was determined that the facility failed to label one multi-dose vial of Aplisol-tuberculin purified protein derivative (PPD-testing solution for tuberculosis) injection with the date it was opened and date it should be used by in one of three medication storage rooms observed (North Two Nurse Station medication room). Findings include: Review of manufacturer's instructions for Aplisol- tuberculin PPD Vials revealed Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of facility policy entitled Storage of Medications, with a policy review date of 3/26/24, revealed that Medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated, or deteriorated medications are available for use in the facility. All such medications are destroyed. Observations of the North Two Nurse Station medication room on 3/12/25, at approximately 1:15 p.m. revealed that one multi-dose vial of Aplisol-Tuberculin PPD was opened and was currently in use, but not labeled with the opened date or the use by date. At the time of the observation, the Assistant Director of Nursing confirmed that the one undated multi-dose vial of Aplisol was opened, in use daily, and should have been labeled with the date opened and use by date. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to monitor a resident's personal refrigerator for temperatures for one of one residents reviewed with personal refrigerators (Resident R8). Findings include: Review of facility policy entitled, Personal Refrigerators with a policy review date of 3/27/23, revealed Personal refrigerators will be subject to the same monitoring as other facility refrigerators. The food stored in the personal refrigerator must meet the same standards as food stored elsewhere in the facility. The policy also revealed Inform resident that refrigerator must include a thermometer and will be monitored regularly for temperature compliance. Establish a temperature and contents monitoring process. Initiate temperature monitoring and content inspection for food labeling and dating. Observation on 5/16/23, at 1:30 p.m. revealed that Resident R8 had a personal refrigerator in the room that contained food and beverage items. The observation also revealed that there was no thermometer in the refrigerator and no temperature log sheets in order to monitor the resident's personal refrigerator and food/beverage items for proper storage. During an additional observation of Resident R8's personal refrigerator on 5/16/23, at 4:25 p.m. with the Director of Nursing it was confirmed that there was no thermometer in the refrigerator and no temperatures recorded to ensure the safe storage of resident food/beverage items. 28 Pa Code 201.14 (a) Responsibility of Licensee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update and/or individualize a care plan for one of 20 residents reviewed (Resident R42). Findings include: Review of facility policy entitled, Participation in Planning Care and Treatment dated 3/27/23, indicated that the resident care plan shall be reviewed, evaluated and updated, as necessary, by professionals involved in the care of the resident. Resident R42's clinical record revealed an admission date of 2/03/23, with diagnoses including heart disease, kidney disease, and gastrointestinal bleed. Documentation related to Resident R42's weekly weights revealed the following: admission weight documented - 2/03/23 - 227.9 pounds; next weight documented on 2/20/23 - 227.2 pounds 3/01/23 - 236.2 pounds 3/02/23 - 230.1 pounds 3/06/23 - 247.0 pounds - 20 pound weight gain in 14 days 3/20/23 - 247.0 pounds 3/27/23 - 161.4 pounds - 74.8 pound weight loss in 26 days, from 3/01/23 3/29/23- 161.6 pounds 4/02/23 -173.5 pounds 4/10/23- 178.2 pounds 5/15/23-183.2 pounds Review of Resident R42's Discharge Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated March 21, 2023, revealed that the resident had a weight gain of 5% or more in the last month. Review of Resident R42's Quarterly MDS assessment dated [DATE], revealed Resident R42 had a weight loss of 5% or more in the last month. The clinical record revealed a nutritional problem care plan related to dysphagia (difficulty swallowing) dated 2/13/23. As of 5/18/23, there was no evidence that Resident R42's care plan had been updated to reflect Resident R42's weight loss. During an interview on 5/18/23, at 2:18 p.m. the Director of Nursing confirmed that Resident R42's nutrition care plan was not updated to reflect weight loss and their current status. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and manufacturer's instructions, observation, and staff interviews it was determined that the facility failed to label pre-filled insulin pens with the date they were opened and discard multi-dose insulin bottle within the use by timeframe for one of two medication carts observed (South Hall) Findings include: Review of facility policy dated 3/27/23, entitled Labeling of Medications indicated that multi-dose medications must be dated when opened for determination of discard date based on manufacturer's instructions. Review of manufacturer's instructions for the Novolog (type of insulin) multi-dose vial directed that once open, they were to be used within 28-days, then discarded. Observation of South Hall medication cart on 5/16/23, at 4:33 p.m. revealed that Resident R15's Basaglar Kwik Pen (type of insulin), R41's Insulin Aspart Flex Pen, and Resident R28's Insulin Glargine and Insulin Lispro Pens were currently in use, but not labeled with an open date. Further observation revealed Resident R23's Novolog multi-dose bottle was open, dated for 4/15/2023, and was currently in use, or 31-days past the open date. During an interview at the time of observation, Licensed Practical Nurse Employee E1 confirmed that Resident R15, R41, and R28's insulin pens were in use and not labeled with an open date and that Resident R23's multi-dose insulin vial was being used past the 28-days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to appropriately monitor a resident identified with a significant weight loss for one of 20 residents reviewed (Resident R42). Findings include: Review of the facility policy related to weight monitoring and weight loss intervention dated 3/27/23, indicated that weight loss intervention will be implemented to prevent further weight loss and to maintain/improve the resident's nutritional status. It also indicated when there is a 5% weight loss in 30 days to follow up with Dietitian recommendations and to keep records of interventions implemented and the progress made. The Registered Dietitian (RD) job description indicated the purpose of the job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Resident R42's clinical record revealed an admission date of 2/03/23, with diagnoses including heart disease, kidney disease, and gastrointestinal bleed. Documentation related to Resident R42's weekly weights revealed the following: admission weight documented - 2/03/23 - 227.9 pounds; next weight documented on 2/20/23 - 227.2 pounds 3/01/23 - 236.2 pounds 3/02/23 - 230.1 pounds 3/06/23 - 247.0 pounds - 20 pound weight gain in 14 days 3/20/23 - 247.0 pounds 3/27/23 - 161.4 pounds - 74.8 pound weight loss in 26 days, from 3/01/23 3/29/23- 161.6 pounds 4/02/23 -173.5 pounds 4/10/23- 178.2 pounds 5/15/23-183.2 pounds Review of Resident R42's Discharge Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated March 21, 2023, revealed that the resident had a weight gain of 5% or more in the last month. Review of Resident R42's Quarterly MDS assessment dated [DATE], revealed Resident R42 had a weight loss of 5% or more in the last month. The clinical record revealed no evidence that Resident R42 was reassessed by the RD, since the initial admission Nutrition Data Collection dated 2/16/23, until 5/18/23, a period of three months. During an interview on 5/18/23, at 2:00 p.m. the Director of Nursing confirmed that Resident R42's clinical record lacked evidence of any dietitian notes or recommendations since the initial admission Nutrition Data Collection dated, 2/16/23, until 5/18/23, a period of three months. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services