Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for three of 24 residents reviewed. (Resident 18, Resident 31, and Resident 52). Findings include: Review of Resident 18's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 17, 2024, revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 18 physician's orders revealed that the resident was not ordered insulin. Review of the Medication Administration Record (MAR) revealed that the resident did not receive insulin. Interview with the licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the resident's MDS assessment was marked incorrectly. Review of Resident 31's quarterly MDS of December 6, 2024, section N0350-Insulin, indicated that the resident received an injection of insulin once in the last seven days. Review of physician's orders and MAR revealed no evidence that the resident received insulin. Interview with licensed staff, Employee E3, on January 15, 2025, at 1:08 p.m. confirmed that the MDS was marked incorrectly. Review of Resident 52's wound and skin documentation dated October 10, 2024, revealed resident had an unstageable pressure ulcer (full thickness tissue loss where the depth cannot be assessed due to the presence of necrotic tissue [dead or dying cells] to the right heel. Review of quarterly MDS of October 11, 2024, section M0210-Unhealed Pressure Ulcers indicated Resident 52 did not have any unhealed pressure ulcers. Interview with licensed staff, Employee E3, on January 16, 2025, at 11:14 a.m. confirmed that the MDS was marked incorrectly. 483.20 Resident Assessments Previously cited 2/15/24 28 Pa. Code 211.5(f) Clinical records Previously cited 2/15/24 28 Pa. Code 211.12(c) Nursing services Previously cited 2/15/24 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/15/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the four units observed (Dementia Unit). Findings include: Observation conducted during the environmental tour of the rooms in the Dementia Unit on February 11, 2024, at 10:22 a.m. The observation revealed room [room number] was occupied by two residents. A white paper with a typewritten note indicating Please use XL (extra-large) pull up with underwear over top and remind resident it's ok to urinate in underwear if can't make it to the bathroom was posted above Resident 43's bed (A) which was visible to the people walking in the hallway. Observation conducted on February 15, 2024, at 10:00 a.m., revealed the same message noted above continued to be posted on Resident 43's wall above the bed. Interview conducted with unlicensed staff, Employee E5, on February 15, 2024, at 10:15 a.m., revealed that the note had been posted on the resident's wall for a couple of weeks now but was not sure who did it. Interview conducted with the Nursing Home Administrator (NHA) on February 15, 2024, at 1:00 p.m., The NHA confirmed that the note was not posted by the resident's family. The NHA was unable to determine who posted the note mentioned above. The NHA confirmed that resident personal information should have not been posted visible to the public. The facility failed to ensure the dignity of Resident 43 was maintained by posting private information visible to the public. 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to report to the State agency an allegation of abuse for one of 24 residents reviewed (Resident 28). Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed For Skilled Facilities covered under the Elder Justice Act an individual must report any alleged violations of abuse OR if there was serious bodily injury the facility MUST report the allegation to the DOH IMMEDIATELY BUT NO LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE. For those allegations that are neglect, exploitation, misappropriation of resident property, or mistreatment that do NOT result in serious bodily injury, the facility must report the allegation no later than 24 hours. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was reported to the State agency. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not reported to the State Agency. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management

Based upon review of facility policy and procedure and clinical record review, it was determined the facility failed to thoroughly investigate an allegation of abuse for one of 24 residents reviewed (Resident 28). Findings include: Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed Events involving evidence or reports of physical, sexual, mental or verbal abuse, involuntary seclusion, neglect and misappropriation of resident's property shall be thoroughly investigated including obtaining statements from all potential persons who might have had contact with the resident in the previous 24 ours or within the timeframe that has been identified. Review of Resident 28's clinical progress notes dated December 2, 2023, revealed CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied yes Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied no, I'm okay. Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied yes. Supervisor updated. Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was thoroughly investigated by the facility. Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not thoroughly investigated by the facility. 28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 24 residents reviewed (Residents 82 and 84). Findings include: Review of Resident 82's MDS Assessment (periodic assessment of resident needs) dated January 2, 2024, revealed a discharge status of home/community. Review of Resident 82's nursing progress notes dated January 2, 2024, at 12:55 p.m., revealed Nurse Practitioner ordered to transfer the resident to the ER (Emergency Room) due to acute left-sided abdominal pain. Review of the nursing progress notes dated January 2, 2024, at 6:48 p.m., revealed that after the evaluation from [name of hospital] ER, Resident 82 was transferred to another hospital where she/he had previous surgery. The family will be coming to gather personal items. Interview conducted with the RNAC (Registered Nurse Assessment Coordinator) Employee E3, on February 15, 2024, at 11:00 a.m., confirmed that the Resident was sent to the hospital and was not discharged to home/community on January 2, 2024. Review of Resident 84's discharge MDS assessment dated [DATE], Section A2105 Discharge Status, indicated that the resident was discharged to an acute hospital. Review of Resident 84's clinical record including nursing progress note dated November 15, 2023, revealed that the resident was discharged home on November 14, 2023. During an interview with the RNAC , Employee E3, on February 15, 2024, at 10:08 a.m. confirmed that the resident was discharged home and that the MDS assessment was marked incorrectly. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 18 residents reviewed (Resident 141). Findings include: Review of Resident 141's admission MDS (Minimum Data Set - periodic assessment of resident needs) of February 5, 2024, revealed that the resident had an indwelling catheter (flexible tube placed in the bladder to drain urine). Review of the current physician's orders also indicated that the resident had a catheter. Further review of the clinical record failed to reveal a care plan related to the indwelling catheter. Interview with Employee E4, corporate representative, on February 15, 2024, at 9:13 a.m. confirmed that a care plan for the catheter was not developed until February 14, 2024. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/20/23

Based on review of clinical records and staff interviews, it was determined that the facility failed to follow a physician's order regarding diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) treatment for two of 18 residents reviewed (Residents 2 and 85). Findings include: Review of Resident 2's Physician's Order Sheet (POS) dated January 12, 2023, revealed the following orders: Check blood sugar three times a day with a scheduled time at 7:30 a.m., 11:30 a.m., and 4:30 p.m. An order on the same day was also made to inform the physician if the blood glucose level results are greater than 450 mg/dl (blood glucose level). Review of Resident 2's March 2023 Medication Administration Records (MAR) revealed a blood sugar of 475 mg/dl on March 2, 2023, at 4:30 p.m. Further review of Resident 2's clinical record failed to reveal the physician was notified of the blood sugar result of 475 mg/dl on March 2, 2023. Review of Resident 2's April 2023 MAR revealed an order initiated on December 30, 2020, to administer Novolog (fast-acting insulin) 10 units subcutaneously (Insertion of medications beneath the skin either by injection or infusion) at 11:30 a.m. The MAR further revealed on April 11, 2023, the ordered blood sugar check and Novolog 10 units ordered at 11:30 a.m., were not done, with documentation that the resident was out of the facility. At 4:30 p.m., on the same day, Resident 2's blood sugar was 469 mg/dl. Review of the progress notes dated April 11, 2023, at 3:02, revealed resident attended a Walmart outing. The clinical records review failed to reveal that the physician was notified of the missed blood sugar check and ordered Novolog 10 units at 11:30 a.m. There was no evidence that the physician was also notified of the blood sugar of 469mg/dl at 4:30 p.m. Review of Resident 85's POS dated March 8, 2023, revealed an order for Insulin Aspart (A fast-acting insulin) sliding scale coverage before meals and at bedtime: 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; >400- 12 units and notify provider. Nursing notes dated March 8, 2023, at 1:51 p.m., revealed that the above order was made by the NP (Nurse Practitioner) after being informed of a blood sugar of 568 at 8:00 a.m., and a blood sugar of 507 at noon. Review of the March 2023 MAR revealed a blood sugar of 427 mg/dl on March 8, 2023, at 4:30 p.m., the resident was administered a sliding scale order of 12 units of insulin. The clinical records review failed to reveal that the physician was notified of Resident 85's blood sugar of 427 mg/dl at 4:30 p.m. Interview with licensed nurse Employee E3 was conducted on April 19, 2023, at 10:00 a.m. Employee E3 confirmed that the physician should be notified immediately of a blood sugar result above the ordered parameter for possible additional orders. Employee E3 reported that documentation of the blood sugar result, conversation with the physician, and possible new orders are documented in the resident's clinical record. Interview with the Director of Nursing was conducted on April 20, 2023, at 11:30 a.m. The DON confirmed that there was no documented evidence that the physician was notified of the following: Resident 2's elevated blood sugar result on March 2, 2023, and April 11, 2023, at 4:30 p.m.; Resident 2's missed blood sugar check and ordered Novolog insulin on April 11, 2023, at 11:30 a.m.; and Resident 95 's blood sugar of 427 on March 8, 2023, at 4:30 p.m. The facility failed to ensure Resident 2's and Resident 85's physician's order for their diabetic treatment was followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of personnel records, and interviews with staff, it was determined that the facility failed to ensure newly hired employees received the abuse training outlined in their policy for two of 5 personnel records reviewed (Employees E4 and E5). Findings include: Review of facility policy Abuse Neglect or Exploitation last revised October 24. 2022 revealed that all employees would be trained on abuse, neglect, mistreatment of residents, and misappropriation of resident's property prior to being assigned to resident care areas. Training would include education on facility policy, interventions on dealing with aggressive residents, reporting abuse without fear of reprisal, recognizing burnout, what constitutes abuse, what constitutes reasonable suspicion of crime, definition of serious bodily harm, responsibility for reporting abuse, consequences of not reporting abuse and resident's right to privacy. Review of Dietary Aide, Employee E4's personnel record revealed a hire date of January 28, 2023. Further review of Employee E4's personnel record failed to reveal any completed abuse training. Review of CNA, Employee E5's personnel record revealed a hire date of February 3, 2023. Further review of Employee E5's personnel record failed to reveal any completed abuse training. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 1:30 p.m. confirmed that there was no completed abuse training in the personnel file for CNA, Employee E5 and Dietary Aide E4. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 (b) Management