**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility investigations and grievance logs, it was determined that the facility failed to report allegation for neglect and misappropriation for two of 18 residents reviewed (Resident R19 and R51).Finding include: Review of facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated September of 2024 revealed that Misappropriation of resident property is defined as means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Further review revealed that Neglect is defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is a policy of this facility that abuse allegations including abuse, neglect, exploitation, or mistreatment including injuries of an unknown source and misappropriation of resident property are reported per federal and state law, in addition local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. If an incident or allegation is considered reportable the administrator or designee will make an initial report to the state agency. Follow up investigation will be submitted to the state agency within five working days Review of facility grievances logs dated June 30, 2025, revealed that resident R 19 stated that money was taken from his nightstand, he noticed that cash was missing but didn't know exactly when the money was taken. Review of the facility documented valuable agreement dated May 23, 2025, revealed that the resident has $6.00 in a wallet and wished to keep the money with him. Review of facility interview with resident R 19 stated that he noticed that the money was missing on June 30, 2025. Resident R19 confirmed he was aware that the drawer has a lock, he was not sure if he locked it. Review of the facility investigation included a review of facility security recorded taped footage of resident R19's hallway at time of suspected theft, and interviews with all staff that had access to the resident's room and five residents residing on the same nursing unit. Interview with NHA employee E1 on July 16,2025 at 12:58 PM confirmed that the incident was thoroughly investigated and a perpetrator was identified and terminated. Employee E1 confirmed that the incident was not reported. 28 Pa. Code 201.14(a) responsibility of Licensee No Notes Review of facility grievance log revealed grievance report for Resident R51, dated June 12, 2025, reporting that “Resident reported to SSD that on June 12, 2025 during first shift 2 girls (Black girl with [NAME] Mouse shirt and Spanish girl) were changing her diaper. While changing her diaper the black girl said, “Don’t pull that.” Then the Spanish girl yanked out her biliary drain (a thin, flexible tube that is used to drain bile). Resident stated that she then had to go to the hospital and while at the hospital they had to recut her to put another biliary drain in.” Review of Resident R51's clinical record revealed that resident was admitted to facility on April 20, 2025, with diagnosis of, but not limited to, Acute Cholecystitis (inflammation of the gallbladder that occurs due to impaired emptying of the gallbladder). Review of Resident R51’s MDS (Minimum Data Set) dated May 21, 2025, revealed that resident has a BIMS (Brief Interview for Mental Status) of 15, indicating resident is cognitively intact. Review of Resident R51’s hospital records dated June 12, 2025, revealed resident had dislodged cholecystostomy tube (Biliary drain) and that resident was sent to IR (interventional radiology) to have drain replaced. Interview with Employee E2 on Director of Nursing on July 15, 2025, at 1:20pm confirmed that the facility failed to report the Resident R51’s allegation of neglect received for June 12, 2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to ensure the timely acquisition and administration of a prescribed pain medication to meet the needs of one of four residents reviewed for pain management (Resident R64). Findings include: Review of facility policy titled Pharmacy Services, revised 2019, revealed pharmacy services are available to residents 24 hours a day, seven days a week. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. Review of Resident 64's clinical record revealed Resident R64 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (loss of muscle mass and strength), chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems), and chronic pain syndrome (condition where pain persists for more than 3 months and significantly impacts a person's physical, mental, and emotional well-being). Review of facility documentation, dated June 17, 2025, revealed Resident R64 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on July 14, 2025 at 10:46 a.m. with Resident R64 revealed Resident R64 has not received his/her scheduled Xtampza ER (extended-release of oxycodone, indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate) since admission. Resident R64 stated he/her takes this scheduled medication at home. Further interview on July 14, 2025 at 10:50 a.m. revealed Resident R64 stated he/she had a pain level of 8.5 (pain level scale of 1-10 with 1 being the least pain and 10 being the most pain) in his/her lower back throughout leg and pain in head. Review of Resident R64's physicians orders, dated July 11, 2025, revealed the physician prescribed Xtampza ER oral capsule 9 mg- one capsule by mouth every 12 hours related to pain. The order had a start date for the medication to be given on July 11, 2025 at 9:00 p.m. Review of Resident R64's MAR (medication administration record) revealed physician order for Xtampza was not given at the scheduled administration times as ordered by physician:-July 11th at 9:00 p.m.-July 12, 2025 at 9:00 a.m. and 9:00 p.m.-July 13, 2025 at 9:00 a.m. and 9:00 p.m.-July 14, 2025 9:00 a.m. Interview on July 15, 2025 at 12:08 p.m. with Employee E2, Director of Nursing, confirmed Resident R64 did not receive his/her scheduled pain medication due to delay in delivery from pharmacy. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services28 Pa. Code 211.9 (f)(2) Pharmacy services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident timely received the necessary behavioral health care to attain or maintain the highest practicable mental and psychosocial well-being for one of 13 residents sampled (Resident 38). Findings include: Review of admission record indicated Resident R38 admitted to the facility on [DATE].with diagnoses including anxiety. The Social Service assessment dated [DATE], revealed that Resident R28 had been experiencing feelings of being down, depressed, or hopeless for 7 to 11 days, which accounts for half or more of the days during that period. Resident 38's clinical record indicated a progress noted documented by the physician on August 22, 2024, that resident R38 has a diagnosis of anxiety. A further progress note, documented by Psychologist Employee E4 on August 27, 2024, revealed that Resident R38 exhibited anxiety about the future of her marriage. On September 10, 2024, at 12:18 p.m., an interview was conducted with Resident R38, who was observed crying. The resident shared, I have really bad anxiety, and changing roommates has made it worse. My first roommate was coughing and had COVID, so I was exposed and had to change rooms. My second roommate didn't like that I needed my TV and light on because that's the only way I can fall asleep. Now my current roommate is moving out today, and I don't want to deal with another roommate. On September 12, 2024, at 10:17 a.m. a telephone interview was held with nurse practitioner, Employee E11 who prescribed Mirtazapine 7.5 mg give one table by mouth at bedtime for insomnia on September 4, 2024. It was confirmed that there was no treatment provided to address anxiety during the day. On September 12, 2024, at 10:32 p.m., Resident R38 was interviewed regarding her new roommate. During the interview, Resident R38 shared that when she experiences anxiety, she becomes aware of it through symptoms of trichotillomania, a mental health condition characterized by the recurrent, irresistible urge to pull out hair from the scalp, eyebrows, eyelashes, or other parts of the body. R38 pointed to her head, where a large portion of hair was missing from the top. She further reported that coloring helps her calm down. Further record review did not indicate any intervention that were develop to help the resident to cope with anxiety. During an interview with the Director of Nursing and the Nursing Home Administrator on September 12, 2024, at approximately 4:15 p.m., they were unable to provide evidence that Resident R38 had received any interventions to address her anxiety needs. Additionally, no documentation was available regarding services provided to manage the resident's behaviors or to promote her highest practicable physical, mental, and psychosocial well-being. 28 Pa. Code: 201.29 (a)(b)(c) Resident Rights

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food stored in the refrigerator, freezer and resident's room was stored by professional standards for food service safety. Findings include: Review of facility policy Labeling and Dating System Protocol undated, revealed that All fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has Purveyor shipping label ot it. Make sure to not date over or cover up the manufacture's expiration date on the product. It further, specifies Refrigerated items opened: mayo, garlic, dressings, salsa 30 days; cheese sliced or shredded opened 1 week from open date; Deli Meat opened unsliced 7 days; Deli meat opened sliced 3 days; Beef , Pork Poultry raw 3 days. An initial tour of the Food Service Department conducted on September 9, 2024, at 10:35 a.m. with Food Service Director, Employee E6, revealed the following: Observation in the main walking refrigerator had open catchup expired 5/27/24, 2 cheeses without labels one was shredded bag of open cheese and the second was block of open cheese, pastrami, opened beef bologna labeled, opened Italian sausages labeled as received date of 8/26/24 no expiration date. Opened raw pork lion with expiration date of 9/5/24, with no label. In the main freezer opened home fries not labeled, veggies burgers opened not labeled. At the serving table of the prep line the spices such as soy sauce-received date 3/18/24, syrup received date 7/1/24, teriyaki sauce received date 8/24/24 and no expiration dates. Vegetable oil opened not labeled, yellow food coloring received date 5/27/24, spices paprika, garlic received date 8/19/24, rosemary expired 7/19/24, paper, sesame, oregano only received date of 7/1/24. An interview on September 9, 2024, at 10:35 a.m., with Food Service Director, Employee E21, confirmed the above findings. On September 10, 2024, at 2:28, 2024 an interview was held with Resident R22 who had opened salsa, nacho cheese, ranch, two opened pickled pickles jar without labeling nor refrigeration. Nursing aid, Employee E12 confirmed the observations. 28 Pa. Code 201.14 (a) Responsibility of Licensee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview with staff, it was determined that the facility did not ensure that physician orders were recorded completely and accurately for two of 16 records reviewed (Residents R96 and R145). Findings include: Review of clinical documentation for resident 96 revealed that he was admitted to the facility on [DATE]th, 2024 with diagnoses including, but not limited to, anemia, malnutrition, and dependence on renal dialysis. Continued review revealed an order for ProSource Nocarb 30mL two times a day for hemodialysis. No route of administration was recorded. Interview with employee E2, the director of nursing, on September 11, 2024, at 1:30 p.m. revealed that a complete physician order was to include the appropriate route of administration and confirmed the absence of such for this order. Review of clinical documentation for resident R145 revealed that he was admitted to the facility on [DATE], with diagnoses including, but not limited to, methicillin resistant staphylococcus aureus (MRSA, a bacteria which is resistant to treatment by penicillin and its derivatives), and long term use of antibiotics. Continued review revealed an order for Vancoycin HCL Intravenous Solution Reconstituted 1 GM .Use 1 gram intravenously two times a day for IV ABT (antibiotic), ordered on September 7, 2024. Interview with employee E2, the director of nursing, on September 10, 2024, at 11:20 a.m. revealed that a complete physician order was to include an appropriate diagnosis for the medication, and confirmed that IV ABT was the class of drug, not the reason for its use. 28 Pa. Code 211.12(c) Nursing service 28 Pa. Code 211.12(d)(1) Nursing service 28 Pa. Code 211.12(d)(2) Nursing service 28 Pa. Code 211.12 (d)(5) Nursing service

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to provide necessary services to maintain adequate grooming for dependent residents for three of 13 residents reviewed (Resident R11, R22 and R95). Findings include: A review of the Bath(Bed/Shower) policy last updated November 30, 2018, indicated A bath is given to cleanse the skin and refresh the patient. Use whatever bath method is suitable to each patient, however, a bed bath is to be used only if it is impossible to bathe the patient in the tub or shower. Review of admission record indicated Resident R11 was admitted to the facility on [DATE], with a diagnosis of fracture of lower end of right femur, fracture of upper end of right tibia, aftercare following joint surgery, difficulty in walking , presence of right artificial knee joints. Review of Resident R11's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated September 5, 2024, revealed the resident required assistance with personal hygiene with substantial/maximal assistance. A review of Resident R11s care plan dated August 30, 2024, revealed the resident requires the assistance with activity of daily living (ADL), functions-partial/moderate assist with UB self-care, maximal to total assist with LB self-care and toileting of one staff with bathing/showering and dressing. Observations on September 10 , 2024, at 2:48 p.m., revealed Resident R11 had long facial hair on her chin, cheeks, and long nails. When asked if Resident R11 desires to be shaved the reply indicated I feel like people think I'm a man and I would love to get a shave and cut my nails. This observation was confirmed by the Director of Nursing, Employee E2. Review of admission record indicated Resident R95 was admitted to the facility on [DATE], with a diagnosis of difficulty in walking, reduced mobility, chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breath). A review of Resident R95s care plan dated September 4, 2024, revealed the resident requires the limited assistance with activity of daily living (ADL), set up/supervision with UB self-care. Observations on September 10, 2024, at 11:59 a.m., revealed that Resident R95 had long nails, facial hair, and had not received a shower since his admission. The resident expressed a desire to be shaved, and it was noted that his scheduled shower days were Tuesday and Friday. Resident R95 should have received a shower on Friday, September 6, 2024. A review of the shower task records showed no indication of whether the shower was provided or if Resident R95 had refused it. Director of Nursing, Employee E3 confirmed the observations. Review of admission record indicated Resident R22 was admitted to the facility on [DATE], with a diagnosis of sequelae of cerebral infarction (long term effects after a stroke), muscle weakness, difficulty in walking, need for assistance with personal care, muscle wasting and atrophy. A review of Resident R22s care plan dated July 19, 2024, revealed the resident requires the assistance with activity of daily living (ADL). Review of Resident 22's admission Minimum Data Set (MDS) - a periodic assessment of care needs) dated August 5, 2024, revealed the resident is dependent for with personal hygiene, showers, toileting with substantial/maximal assistance. Observations on September 10, 2024, at 02:28 p.m., revealed that Resident R22 had long nails, facial hair and wanted to them to be cut and be shaved. Nursing aid, Employee E12 confirmed the observations. 28 Pa. Code 211.12 (d)(1) (5) Nursing Services

Based on review of personnel files, facility documentation, policy review and interviews with staff, it was determined that the facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs for three of three personnel files reviewed related to skills competencies evaluations (Employees E8, E9, E10). Findings include: The facility policy titled Staff Training Policy last updated January 2024, revealed The facility is committed to providing high-quality care and services to its residents. To achieve this goal, the facility recognizes the importance of ongoing staff training and development. It further stated Competency Validation: Employees will be assessed for competency in their specific job duties and responsibilities. Review of Employee E8's personnel file revealed that the employee was agency employee worked on June 28, 2024, hired, as a registered licensed nurse. Review of Employee E9's personnel file revealed that the employee was agency employee worked on August 26, 2024, hired, as a nursing aid licensed nurse. Review of Employee E10's personnel file revealed that the employee was agency employee worked on September 9, 2024, hired, as a licensed nurse. On September 12, 2024, at 10:41 a.m. an interview with Human Resource Director, Employee E4 and Director of Nursing, Employee E2 confirmed that agency staff including registered nurse, Employee E8, nursing aid licensed nurse, Employee E9, and license nurse, Employee E10 are not being evaluated on their competency to ensure nursing employees possess the required skills to properly care for resident's needs and are oriented to the facility practices. 28 Pa. Code 201.19(7) Personnel records 28 Pa. Code 201.20(b) Staff development

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents and resident clinical records and interviews with staff and residents, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for two of two residents reviewed (Resident R11, and Resident R38). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated September 5, 2024, indicated the diagnoses of fracture and orthopedic aftercare and a BIMS score of 15 - cognition intact. Review of Resident R11's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that she signed the document on admission on [DATE]. Review of admission record indicated Resident R38 admitted to the facility on [DATE]. Review of Resident R38's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated August 26, 2024, indicated a BIMS score of 15 - cognition intact. Review of Resident R38's Binding Arbitration Agreement indicated she signed it on admission on [DATE]. Interview on September 12, 2024, at 9:15 a.m. with the Nursing Home Administrator confirmed that that The Arbitration Agreement was found to limit all residents to a 10-day period to revoke the agreement, instead of the standard 30 days. During an interview on September 12, 2024, at 12:49 p.m., Resident R11 revealed that they were unaware of the arbitration agreement. When asked if they understood the procedures, Resident R11 responded, I have never heard anything about it; I don't know what it is. During an interview on September 12, 2024, at 12:55 p.m., Resident R38 stated that they were not aware of the arbitration agreement. When asked if they understood the procedures, Resident R38 responded, Upon admission, I remember someone came and had me sign something, but I don't know what the arbitration procedure is. During an interview with the Admissions Director, Employee E5, on September 12, 2024, at 1:10 p.m., it was revealed that she is responsible for educating all residents about the arbitration agreement. However, she was unaware of the 30-day revocation rights, stating that this aspect had never been addressed in any of her educational sessions with residents. Employee E5 remarked, I don't educate them about the 30-day revocation right. I've been here for a year, and I haven't learned everything yet. 28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policy and procedure, review of facility documentation and interviews with staff, it was determined that the facility failed to conduct a complete and thorough injury of unknown origin investigation regarding a hip fracture for one of 3 residents reviewed. (Resident CL1). Findings include: Review of facility policy, Abuse Prevention, date last revised February 25, 2022, revealed that It is the policy of Pines of Philadelphia does not tolerate any form of resident abuse, neglect , or exploitation by staff members, volunteers, visitors or family members, or by another resident. The facility will have an abuse prevention program that protects residents from physical and mental abuse, neglect, exploitation, misappropriation of property, and injuries of unknown origin in compliance with State and Federal regulations and the mission and philosophy of this facility. Review of facility policy, Incident and accident , dated last approved March 2019, revealed under Protocol .2. A thorough investigation and follow-up will be completed within five working days. A summary of the accident/incident will be documented. 3.The event may be an accident or a situation that could result in an accident. Accidents/incident may include, but are not limited to, the following: fall/suspected falls, explained or unexplained bruises/skin tears, medication errors, elopement, resident/patient to resident/patient abuse, self-inflicted injury, injuries of unknown origin, injury to resident/patient during handling. 4.All accidents/incidents, where there is suspected mistreatment, neglect, abuse, or injuries of unknown origin will be reported to the Administrator and Director of Nursing immediately. Reports to other officials will be made in accordance with the Elder Justice Act and applicable state law. Follow Abuse Policy and Procedure. A review of clinical record of Resident CL1 revealed admission on [DATE] with the following diagnosis: rhabdomyolysis (a rare muscle injury where muscles break down and release toxic components into your blood and kidneys), dementia, hyperlipidemia, disorder of the skin and subcutaneous tissue, difficulty in walking, muscle wasting and atrophy, muscle weakness, lack of coordination, history of falling. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the Resident CL1's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated November 9, 2023, indicated a BIMS (Brief Interview of Mental Status) severe impaired. Review of clinical record indicated Resident CL1 had an unwitnessed fall on November 4, 2023 with nursing assessment dated , November 4, 2023 indicating complain of pain level 2 progress note on November 4, 2023 at 11:41 p.m. revealed pt complaint of pain from lower left portion of back, 4x4 bruise noted .MD contacted and acknowledged. Neuro checks were initiated and completed and Resident CL1 had no further pain documented. Further review of the record indicated CL1 started complaining of pain on: November 12, 2023, at 8:53 PM for pain level of 5 Acetaminophen administered with being ineffective November 13, 2023 at 1:42 AM for pain level of 7 Acetaminophen administered with being ineffective November 13, 2023 at 8:37 AM for pain level of 10 Acetaminophen administered with being effective November 13, 2023 at 4:14 PM for pain level 8 Acetaminophen administered with being effective November 13, 2023 at 8:49 PM for pain level 6 Acetaminophen administered with being effective November 14, 2023 at 9:00 a.m. pain level 5 MeloxiCNA 7.5 mg table was administered November 14, 2023 at 8:53 p.m. for pain level 4 Acetaminophen administered with being unknown result of effectiveness Based on the CL1 interview which occurred on November 14, 2023, at 11:59 a.m. CL1 had a pain level 10. There was no documented evidence that CL1 was assessed and treated for pain management on November 14, 2023, from 9:00 a.m. to 8:53 p.m. Based on the nursing progress notes dated November 14, 2023, at approximately 16:30 p.m. it noted patient presented in bed on left side at start of shift x-tray tech arrived approx. 16:30 to obtain Xray of back but patient refused. Another nurse from C- unit arrived to help with interpretation, patient was agreeable but then patient refused while yelling no while guarding left side. Patient yelled each time attempt was made to reposition him off his left side. An interview with the Director of Nursing on December 12, 2023, at approximately 10:00 a.m. confirmed that CL1 was without pain medication for a period of approximately 12 hours before being transfer to the local hospital for evaluation and was diagnosed with a hip fracture. On December 12, 2023, at 10:30 a.m. an interview with the Director of Nursing, Employee E2 revealed that facility did not interview the following Certified Nurse Assistant, (CNA), and License Practice Nurse (LPN)s for the days when CL1 started experiencing pain based on the assignment sheets: 11/12/23 shift 7-3 CNA, Employee E5 was not interviewed. 11/12/23 shift 3-11 CNA, Employee E6 was not interviewed. 11/12/23 shift 11-7 CNA Employee E6 was not interviewed 11/12/23 shift 11-7 LPN Employee E4 was not interviewed. 11/13/23 shift 7-3 CNA Employee E3 was not interviewed. 11/13/23 shift 3-11 CNA Employee E6 , CNA and LPN, Employee E8 were not interviewed. 11/13/23 shift 11-7 CNA, Employee E9 and LPN, Employee E4 were not interviewed. 11/14/23 shift 7-3 CNA Employee E9 was not interviewed. 11/14/23 shift 3-11 CNA Employee E10 was not interviewed. 11/14/23 shift 11-7 CNA Employee E10 and LPN Employee E11 were not interviewed. It was further revealed that facility did not conclude the investigation with the decision which was documented as they were waiting for the resident to return to the facility. Facility did not review the cameras to determine if CL1 could have experience any unwitnessed fall between November 12, 2023 and November 14, 2023 when he was transferred to the hospital. On December 12, 2023, at 2:30 p.m. an interview was held with Administrator, Employee E1 and the Director of Nursing, Employee E2 confirming that facility did not conduct complete and thorough injury of unknown origin investigation for CL1 which resulted in hip fracture. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a Resident Council meeting, resident interviews, review of facility policy and procedures, it was determined that the facility failed to ensure that grievance forms were available and accessible to residents' on the nursing units for five of 14 sample residents reviewed (Residents R201, R197, R2, R23, R4). Findings include: A review of facility policy Resident Grievance , revised November 2023 revealed: A resident may file an anonymous grievance by filling out a grievance form and placing it in the secured anonymous grievance box located near the social services office. On November 15, 2023, at 10:03 a.m. a tour of the facility was conducted with the Nursing Home Administrator, Employee E1 and Social Worker, Employee E10 revealed that grievance forms were not available to residents to make anonymous grievances. During the Resident Council meeting on November 15, 2023, at 1:15 p.m. Residents R201, R197, R2, R23, R4, who were alert and oriented reported that they did not know how to report grievances nor had seen the grievance forms. 28 Pa. Code 201.14(a)Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility policy and interviews with staff, it was determined that the facility failed to ensure a resident received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure ulcers and continue treatments to prevent new from forming for one of 14 resident records reviewed. (Resident R20). Finding include: Review of the facility's policy titled Skin-Pressure Ulcers updated on January 15, 2023, states the facility has a systemic approach to a zero tolerance of pressure ulcers. The degree of risk is high for all patients, as determined by this patient population. Individual risk factors will be noted on the Nursing admission Assessment to direct specific preventative treatments. Individual modalities will be incorporated in the care plan but will always include basic skin care, nurses will perform a thorough skin assessment on admission and once a week and will report any new or acquired stage of ulcer formation or impaired skin integrity. Review of Resident R20's admission nursing evaluation dated October 13, 2023, indicated the resident's admitting diagnosis was idiopathic peripheral autonomic neuropathy (damaged peripheral nerves) and type two diabetes (increased levels of blood sugar), and the general condition of the skin was documented intact without presence of wounds, ulcers, or skin discoloration. On admission, Resident R20 was at risk for skin breakdown related to his decrease mobility, chronic pain and deconditioning. The goal was the resident not to develop any skin impairments. Interventions included to keep the skin clean and dry and provide a well-balanced diet dated, October 13, 2023. Review of the nursing skin assessment dated , October 16, 2023, documented Resident R20 with discoloration to the left heal and complained of pain. Two weeks later, the next nursing skin assessment dated [DATE], documented Resident R20 continuing pain and discoloration to the left heel and indicated the area needed Attention. No further documented evidence was found regarding the left heel until the pintail wound care consult dated November 8, 2023. Review of the initial wound care consult dated November 8, 2023, diagnosed Resident R20's with pressure ulcers on now both of his heels. The physician staged the pressure ulcers as a deep tissue injury (DTI- depth unknown), that measured, 2.5 cm. x 3. cm. x -on the right heel and 5. cm x 5. cm. x - on the left. The same day Resident R20 was diagnosed with his pressure ulcers, his care plan was updated on November 8, 2023 to included new intervention (skin prep to heels and heel boots in bed). Interview with Resident R20 on November 16, 2023, at 10:05 a.m. stated he complained to nursing his heels were hurting but they didn't do anything. I saw the wound doctor and now I use heel boots (protects and off loads the heels in bed). Interview with the Director of Nursing on November 16, 2023, at 12:00 p.m. stated when the third shift nurse completed the skin assessments (October 16 and 30, 2023) it was not communicated to the rest of the staff the resident had pain and discoloration to the heels. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12. (d)(1)(2)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record, and staff interview, it was determined that the facility failed to ensure that the resident received enteral feedings as prescribed and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of one resident sampled (Resident 17). Findings include: Review of Resident 17's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, of respiratory failure, dysphagia following cerebral infarction (stroke), oropharyngeal phase; hemiplegia (weakness of one entire side of the body) and hemiparesis (most severe form complete paralysis) following unspecified cerebrovascular disease affecting left dominant side, paroxysmal atrial fibrillation, neuromuscular dysfunction of bladder. Resident 17 required a percutaneous endoscopic gastrostomy (PEG tube) also known as G-tube (gastrostomy tube is a medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements). Review of Resident R17's November 8, 2023 physician orders revealed an order for every shift for GI rest related to dysphagia following cerebral infarction Jevity 1.5 via peg tube at 50 ml/hr x 20 hrs total feeding 1000 ml (up at 6pm, down 2pm). Auto flush 150ml q4 hrs (6x/day). Observations of the resident's tube feeding pump on November 14, 2023, at 9:58 a.m. revealed feed bag had no identifying details on the bag , to include the name of the enteral feeding formula and rate of delivery to ensure that the resident was receiving the enteral feeding as prescribed. License nurse, Unit Manager, Employee E3 confirmed the observation and reported that it should have been labeled with the name of its content, rate given and every shift a nurse should have monitored it. On November 14, 2023, at 10:02 a.m. an interview with License nurse, Employee E6 who was the nurse assigned to the resident reported that the feed was placed during the November 13, 2023, evening shift at 6 p.m. and Employee E6 didn't realized it was not labeled. 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide to ensure that one of 19 residents reviewed was properly access for pain and provided effective pain management. (Residents R190). Findings include: The facility policy entitled, Pain Management last reviewed February 2023, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. An interview was held with Resident R190 on November 14, 2023, at 11:59 a.m. with his grandson by resident's bedside. Resident R190 reported that he had severe pain level 10 on his left side of the back going into his left tight. Grandson asked the license nurse, Employee E4 who was assigned to care for the Resident R190 if resident received Celebrex (anti-inflammatory medication) which was ordered yesterday November 13, 2023. Employee E4 reported that the physician had order Melaxican and it was administered to the resident today between 9:00AM -10AM. Review of Resident's R190 November 2023 physician orders revealed an order dated November 3, 2023 for Acetaminophen Table 325 milligrams (mg) give 2 tablets by mouth every 4 hours as needed for pain. Review of Resident 190's November 2023 Medication Administration Record, revealed that the resident was administered Acetaminophen Table 325 mg 2 table every 4 hours on the following dates and times: November 12, 2023, at 8:53 PM for pain level of 5 Acetaminophen administered with being ineffective November 13, 2023 at 1:42 AM for pain level of 7 Acetaminophen administered with being ineffective November 13, 2023 at 8:37 AM for pain level of 10 Acetaminophen administered with being effective November 13, 2023 at 4:14 PM for pain level 8 Acetaminophen administered with being effective November 13, 2023 at 8:49 PM for pain level 6 Acetaminophen administered with being effective November 14, 2023 at 9:00 a.m. pain level 5 Meloxican 7.5 mg table was administered November 14, 2023 at 8:53 p.m. for pain level 4 Acetaminophen administered with being unknown result of effectiveness Based on the Resident 190 interview which occurred on November 14, 2023, at 11:59 a.m. Resident R190 had a pain level 10. There was no documented evidence that Resident R190 was assessed and treated for pain management on November 14, 2023 from 9:00 a.m. to 8:53 p.m. Based on the nursing progress notes dated November 14, 2023, at approximately 16:30 p.m. it noted patient presented in bed on left side at start of shift x-tray tech arrived approx. 16:30 to obtain Xray of back but patient refused. Another nurse from C- unit arrived to help with interpretation, patient was agreeable but then patient refused while yelling no while guarding left side. Patient yelled each time attempt was made to reposition him off his left side. An interview with the Director of Nursing on November 15, 2023, at approximately 10:00 a.m. confirmed that License nurse Employee E4 had no record that she provided pain medication after she administered Meloxican at 9:00 a.m. and the next pain medication was given at 8:53 p.m. on November 14, 2023. Resident was without pain medication for a period of approximately 12 hours before being transfer to the local hospital for evaluation and was diagnosed with a hip fracture. 28 Pa Code 211.10(c) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record and review of facility policy, it was determined that the facility failed to ensure residents who require dialysis treatments and prescribed medication received such services, consistent with professional standards of practice for one of 14 resident clinical records reviewed (Resident R11). Finding includes: Review of the facility's Hemodialysis policy updated on January 15, 2023, revealed the purpose of hemodialysis is to maintain venous access, hemodynamic, fluid volume, temperature, nutrition and prevent injury or infection. The policy further states, all patient observations, interventions, etc. will be recorded in the patient record. Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE], with physician orders for the resident be taken to the dialysis center for dialysis every Monday, Wednesday, and Friday starting at 6:00 a.m. Review of Resident R11's October 2023 and November 2023 electronic medication administration record (eMAR) revealed the resident's scheduled 9:00 a.m. medications on his dialysis days were coded as not given due to dialysis as follows: Amiodarone for atrial fibrillation (risk of stroke due to irregular heartbeat) 200 milligrams (mg) was not given on October 25, 27, 30, and November 1, 2023; Aspirin 81 mg was not given on October 25, 27, 30, and November 1, 2023; Bumetanide 2 mg was not given at 9:00 a.m. on October 25, 27, 30, and November 1, 2023. Keppra 500 mg of was not given at 9:00 a.m. on October 25, 30, and November 1, 2023; 45 ml Lactulose oral solution given for the resident's diagnosis of gastrointestinal hemorrhage was not given on October 25, 27, 30, 2023. and 8.6-50 mg. Senna-Docusate Sodium was not given at 9:00 a.m. on October 30, and November 1, 2023. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations and staff interview, it was determined that the facility failed to post daily nurse staffing data on each nursing unit on November 15, 20023, on both nursing floors of the facility. (First floor and Second Floor) Finding include: Observations on November 15, 20023, at 10:03 a.m. on the first-floor receptionist desk did not reveal that the staffing information was posted in a prominent place readily accessible to residents and visitors. An interview on November 15, 20023, at 10:03 a.m. with the Nursing Home Administrator, confirmed that the staffing information was not posted for the current date. 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale failed to provide the duration of a hypnotic medication for two of five residents reviewed (Resident R3 and Resident R87). Findings include: Review of Resident R3's October 2023 physician orders included an order dated October 30, 2023, for Zolpidem Tartrate Oral Table 10 milligrams (anti-psychotropic medication) 1 tablet by mouth every 24 hours as needed for sleep related to insomnia. Review of Resident R3's clinical record revealed a note to the attending physician/prescriber from the consultant pharmacist dated October 30 2023, with a recommendation to evaluate the use of prn (as needed) Zolpidem pm. The note indicated that per CMS regulation effective 11-28-2017 all PRN (as needed) psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior. To extend the PRN order past the 14 days, the prescriber must document the rationale in the medical record and indicate the duration of the PRN order. Review of the physician, not dated, indicated to disagree and insomnia chronic. Further review of the clinical record failed to indicate the duration or end date of the medication for the PRN use of Zolpidem. Review of Resident R87's physician's orders instructed to give one tablet of Zolpidem Tartrate 10 mg, every 24 hours as need for sleep related insomnia, dated November 1, 2023. Review of Resident 87's clinical record revealed on November 2, 2023 the consulting pharmacist recommended to the physcian evaluate the use of prn Zolpidem. The note indicated that per CMS regulation effective 11-28-2017 all PRN psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior. The same note indicated that in order to extend the PRN order past the 14 days, the prescriber must document the rationale in the medical record and indicate the duration of the PRN order. Further review of the same note, the physician response (not dated) disagree and insomnia chronic but failed to provide the duration of the medication. Interview with Director of Nursing on November 16, 2023, at 2:15 p.m. confirmed that the physician failed to provide to included the duration or end date of the medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast in three of three nursing units. (A, B, and C nursing units). Findings include: A review of facility policy titled Nutritional Services last revised March 2023 revealed The facility is committed to meeting the nutritional needs of and creating a memorable dining experience for its residents by providing a choice of snacks at bedtime (HS). A review of the established meal schedule for the residents revealed that the dinner meal was scheduled for 5 p.m., and that the breakfast meal the following morning was offered at 8:00 a.m. This was a 15-hour meal span of time until breakfast the following day. An interview was held on November 14, 2023, at 10:28 a.m. with Resident R27 who reported that he/she eats dinner at 5:00 PM and breakfast is being served at 8:30 AM and no one offers snacks. Resident R27 does go hungry and one time he requested night snack and was staff told kitchen closed. During the Resident Council meeting on November 15, 2023, at 1:15 p.m. Residents (R201, R197, R2, R23, R4), who were alert and oriented reported that they do not received night snack. An interview with Dietician, Employee E5 held on November 15, 2023, at 2:47 p.m. revealed that snacks are not being labeled for diabetic, variety stacks are stored in the refrigerator in the sunshine room for evening staff to offer it to resident. A observation of diabetic snacks such as salami, egg salad sandwiches, yogurt with low sugar, have been observed in the sunshine room refrigerator. On November 16, 2023, at 9:16 a.m. with a license nurse unit manager, Employee E3 a walk thru the B and C unit was conducted and diabetic Residents R1, R4, R20, R27, R29, R89 were interviewed in their room who reported that they did not receive a night snack during last night November 15, 2023. 28 Pa. Code: 201.14(a) Responsibility of license

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure the physician notes were was accessible in one of 14 resident clinical records reviewed (Resident R14). Findings include: Review of Resident R14's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of sepsis (acute infection) ischemic cardiomyopathy (the hearts decreased ability to pump blood), leading to heart failure (fluid builds in lungs causing excess fluid in the body and weight gain). The resident was documented with a weight of admission of 214.5 pounds and was ordered medications to rid the body of excess fluid. On November 15, 2023 the resident weighed 151.4 pounds a loss of 63.1 pounds in 41 days. Review of Resident R14's clinical records since admission revealed no documented evidence of physician notes recorded in the electronic clinical record and/or paper record for review. Interview with the Director of Nursing on November 16, 2023 at 2:30 p.m. stated the physician did not use the computer but the progress notes were handwritten. It wasn't until the surveyor requested these documents that the physician emailed the notes to the surveyor. 28 Pa Code 211.5(f)(ii) Medical records

Based on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of three nursing units (A nursing unit). Findings include: A review of the facility documentation dated November 14, 2023, revealed 9 residents were residing in the designated COVID-19 rooms on the A nursing Unit. Interview with the Nursing Home Administrator and Director of Nursing on November 14, 2023, at 7:45 a.m. revealed that the facility was having a COVID outbreak, 9 residents are located on Unit A. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy Personal Protective Equipment that includes disposable mask, gowns, gloves, goggles, used to break the chain of infection and prevent its spread. Every staff, and/or visitor going into COVID room must put on the all PPE when going into the resident's room who are diagnosed with COVID. Observation conducted on November 14, 2023, between 11:50 a.m. to 12:30 p.m. revealed lunch was being served by nursing aide, Employee 4 who was going in and out of the COVID rooms without appropriate PPE such as gown, and gloves. When nurse aide, Employee E4 was interviewed why she/he is not following PPE requirement when passing down lunch trays. E4 reported it's not necessary when going in and out of the room. License nurse, Employee E5 also was observed passing down lunch trays without PPE, gown and gloves. Observations made on November 15, 2023, at 12:14 p.m. during lunch meal of nurse aide, Employee E4 revealed that Employee E4 was going in and out of rooms without PPE. On November 16, 2023, at 3:09 p.m. interview with Licensed Nurse Infection Control Preventionist, Employee E7, confirmed that when she/he reviewed the camera in the hallway Employee E4 and Employee E5 were passing down tray on A unit without appropriate PPE when going in and out of the COVID rooms. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 PA. Code 211.12(d)(5) Nursing services