**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident or resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the person's mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for two of 39 residents reviewed (Residents 3 and 36).Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was admitted to the facility on [DATE], was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards others, took antipsychotic medications (medications used to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications (psychotic medications), and had diagnoses that included Alzheimer's dementia, depression, and anxiety.Physician's orders for Resident 3, dated May 13, 2025, May 30, 2025, and August 1, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan (a psychotropic medication) gel twice daily as needed for agitation. A psychiatry note for Resident 3, dated May 23, 2025, revealed that as needed Ativan gel was recently added May 15, 2025, by the resident's primary care physician.Review of Resident 3's Medication Administration Record (MAR) for May 2025 through August 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., June 24 at 3:54 p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., July 7 at 3:35 a.m., August 16 at 8:00 p.m. and August 25 at 3:26 a.m.Review of Resident 3's clinical record revealed no documented evidence that an informed consent was obtained from the resident representative prior to initiating the administration of the as needed transdermal Ativan.An admission MDS assessment for Resident 36, dated August 25, 2025, revealed that the resident was cognitively impaired, was rarely/never, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer's dementia and anxiety.Physician's orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive 0.25 mg of Ativan three times daily as needed for anxiety and agitation.Review of Resident 36's MAR for August 2025, revealed that the resident received 0.25 mg of Ativan on August 23 at 1:17 p.m., August 25 at 3:32 p.m., and August 27 at 8:39 p.m.Physician's orders for Resident 36, dated August 25, 2025, revealed that the resident was to receive 0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for anxiety/agitation.Review of Resident 36's MAR for August 2025, revealed that the resident received 0.25 mg of transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29 at 12:30 p.m.Review of Resident 36's clinical record revealed no documented evidence that an informed consent was obtained from the resident representative prior to initiating the administration of the as needed Ativan.Interview with the Director of Nursing on August 29, 2025, at 2:02 p.m., revealed that the facility was completing informed consents for use of antipsychotic medications, but not for any other psychotropic medications.28 Pa. Code 201.29(a)(j) Resident Rights.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete nurse aide registry verification for one of three new nurse aides reviewed (Nurse Aide XX) and failed to ensure that the status of nursing licenses were checked with the State Board of Nursing for one of one newly hired nurses reviewed (Registered Nurse XX).Findings include:The facility's policy regarding abuse prohibition, dated March 31, 2025, indicated that the prior to the first day of employment, the facility would verify with the Pennsylvania Department of Health Nurse Aid Registry the standing/certification of all applicants offered employment as a nurse aide. The facility would not employ individuals who had a finding entered in the nurse aide registry or who had a disciplinary action in effect against their professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of their property or mistreatment of residentsThe personnel file for Nurse Aide E3 revealed that she was hired as a nurse aide on May 11, 2025, and there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to hire. The personnel file for Registered Nurse E4 revealed she was hired as a registered nurse on June 1, 2025. There was no documented evidence that her licensure status was checked with the State Board (Texas).Interview with the Director of Human Resources on August 27, 2025, at 1:19 p.m. and 2:09 p.m. confirmed that Nurse Aide E3's standing on the Pennsylvania Nurse Aide Registry was not verified prior to her hire and Registered Nurse E4's licensure status was not checked prior to hire.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 39 residents reviewed (Residents 101). Findings include: An admission note for Resident 101, dated August 21, 2025, at 12:16 p.m., revealed that the resident arrived at the facility and had sinusitis (an inflammation of the sinuses) and was going to receive medication for three more days. A current care plan for the resident, dated August 21, 2025, indicated that the resident had an infection diagnosed as sinusitis. A progress note for Resident 101, dated August 22, 2025, at 3:01 p.m. revealed that the resident was positive for COVID and was in respiratory isolation. Observations during the facility tour on August 27, 2025, at 11:34 a.m. revealed a stop sign on Resident 101's door. Interview with staff during the tour indicated that the resident was placed on droplet precautions due to testing positive for covid on admission. There was no documented evidence in the resident's clinical record that a baseline care plan was implemented related to the resident's positive COVID diagnosis and his need for droplet precautions. Interview with the Assistant Director of Nursing on August 30, 2025, at 1:08 p.m. confirmed that a baseline care plan was not implemented for Resident 101 related to his positive COVID diagnosis after admission. She indicated that he had a diagnosis of sinusitis on admission, and the care plan was not revised to reflect that he had COVID and was on droplet precautions. 28 Pa. Code 211.12(d)(1) Nursing Services

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for two of 39 residents reviewed (Residents 10 and 88). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that it is the facility’s policy that each resident receives individualized, comprehensive, and coordinated care through the development, implementation and ongoing evaluation of an interdisciplinary care plan. The development of a comprehensive care plan should occur by the interdisciplinary team following the initial Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated July 17, 2025, revealed that the resident was cognitively impaired, was usually understood and was able to sometimes understand others, required assistance with care needs, took an anticoagulant medication (used to prevent or treat blood clots). Physician’s orders for Resident 10, dated August 25, 2025, included an order for the resident to receive 2 milligrams (mg) of warfarin (an anticoagulant) every other day for atrial fibrillation (irregular heart rhythm). There was no documented evidence that the facility implemented a care plan related to the resident’s need for anticoagulant therapy. An interview with the Director of Nursing on August 30, 2025, at 2:37 p.m. confirmed that there was no documented evidence that the facility implemented a care plan related to Resident 10’s need for anticoagulant therapy. A quarterly MDS) assessment for Resident 88, dated July 11, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included heart failure and was receiving anticoagulant medication (used to prevent or treat blood clots). Physician’s orders for Resident 88 dated August 27, 2025, included for the resident to receive 3 milligrams (mg) of warfarin (an anticoagulant) daily. An interview with the Assistant Director of Nursing on August 30, 2025, at 1:11 p.m. confirmed that Resident 88's care plan did not include care and treatment needs related to the resident’s anticoagulant medication use. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 39 residents reviewed (Residents 7 and 9). Findings include: A facility policy for Comprehensive Care Plans dated March 31, 2025, indicated that the resident’s plan of care should be updated as necessary on an on-going basis. Changes will be communicated to team members as needed or indicated. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 7 dated August 4, 2025, indicated that the resident was cognitively intact, was understood, could understand, required assistance with daily care needs, and had diagnoses that included a stroke. Interview with Resident 7 on August 28, 2025, at 1:43 p.m. indicated that he currently had an indwelling catheter, and no other to have straight catheterization (single-use tube inserted into the bladder to drain urine). Physician’s order for Resident 7 dated August 11, 2025, indicated he had a indwelling foley catheter (a thin, flexible tube inserted into the urethra that carries urine from the bladder to the outside of the body to drain urine) size 16 French (Fr) with a 15 cubic centimeter (cc) balloon for urinary retention. The care plan for Resident 7 dated July 28, 2025, indicated that the resident was continent and incontinent of bladder. He has urinary retention with the need for intermittent catheterization. Resident 7 has a intervention that he requires straight catheterization. An interview with the Assistant Director of Nursing on August 28, 2025, confirmed that Resident 7 care plan was not revised to reflect that he has an indwelling catheter and should have been. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 9 dated June 25, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included a hip fracture. The Care plan for Resident 9 dated June 24, 2025, indicated that the resident had anticoagulant (used to prevent and treat blood clots) medication ordered that included Lovenox (an anticoagulant), and that the resident had diabetes and staff were to administer insulin as ordered. Review of the Medication Administration Record (MAR) for Resident 9 dated August 2025 and September 2025, revealed no documented evidence that the resident received Lovenox or insulin. An interview with the Director of Nursing on August 30, 2025, confirmed that Resident 9 was no longer receiving Lovenox or insulin and her care plan should have been revised to indicate that. 28 Pa. Code 211.12(d)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 39 residents reviewed who used a electric lifting recliner chair (Resident 6) and failed to ensure that assistance devices to prevent accidents or injury were in place for one of 39 residents reviewed (Resident 15).Findings Include: A facility policy for wheelchair leg rests dated March 31, 2025, indicated that the facility would ensure and promoted safe and appropriate use of wheelchairs leg rests when transporting residents short or long distances. Wheelchair leg rests should be used when transporting residents over klong distances or when a resident is unable to lift their leg rests while the chair is in motion. Wheelchair leg rests should also be used when resident cannot or will not [NAME] their legs for short transports. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 10, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included chronic kidney disease (condition where the kidneys gradually lose their ability to function properly over time). A nurse’s note for Resident 6 dated August 7, 2025, at 4:41 a.m. revealed that the resident was observed on his knees facing his recliner with his upper body resting on the recliner. The resident reported at the time that he was getting up to ring his call bell. An occupational therapy note for Resident 6 dated August 13, 2025, indicated that the resident was able to operate his recliner to sit upright and elevated with supervision. Observation in Resident 6’s room on August 27, 2025, revealed the resident sitting in his wheelchair with a electric lifting recliner chair in his room in the up position. Review of a fall investigation provided by the facility dated August 7, 2025, indicated that the Resident 6 was in his recliner because he was vomiting earlier in the night and that he has poor safety awareness with impulsive actions and behaviors. An interview with the Director of Nursing on August 29, 2025, at 2:02 p.m. revealed that the facility did not have an electric lifting recliner chair safety assessment completed on Residents 6 who used electric lifting recliner chair at the time of the survey. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 15 dated July 31, 2025, indicated that the resident was severely cognitively impaired, was usually understood, could usually understand, required assistance with daily care needs, used a wheelchair for mobility, and had diagnoses that included a rheumatoid (Joint pain, stiffness and swelling) and osteoarthritis Joint pain, stiffness, creaking or grinding sounds in the joints, and limited range of motion) Observations on August 27, 2025 at 11:46 a.m. revealed that Hospitality Aide E5 pushed Resident 15 from the her room to in the dining room through the hall past both nursing stations while her feet, which had shoes were crossed at the ankles, with one foot dragging on the floor. Interview with Hospitality Aide E5 on August 27, 2025 at 11:31 a.m. revealed that she pushed the resident to the dining room for lunch. She stated that Resident 15 was able to self-propel and that is why she did not have leg rests on her chair. She further stated that she didn't think that she had foot petals for her wheelchair. Interview with Director of Nursing on August 28, 2025, at 9:44 a.m. confirmed that Resident 15 should have had leg rests on her wheelchair while being transported if she was unable to lift her feet off the floor. She said that they will use them for long distances when outside of the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that a toileting program was followed to maintain a resident's continence for one of 39 residents reviewed (Resident 24). Findings include: A facility policy related to restorative nursing programs, dated March 31, 2025, indicated that facility provides individualized restorative nursing interventions in accordance with resident needs, care plans, and regulatory requirements to promote and maintain the highest level of physical, mental and psychosocial functioning for residents. Restorative interventions may include bowel and bladder programs that consist of training and toileting schedules. Restorative programs will be carried out by trained restorative nursing assistants, nurse aides, or licensed staff as delegated. Restorative interventions, frequency, and outcomes will be documented in the medical record per facility policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated August 12, 2025, revealed that the resident was mildly cognitively impaired, was clearly understood and able to clearly understand others, was dependent on staff for toileting transfers and hygiene, was on a toileting program, was frequently incontinent of urine, and had a diagnosis of Parkinsonism (a neurological disorder causing slowed movements, stiffness and tremors) and dementia. A care plan for the resident, dated September 6, 2024, indicated that the resident was on a scheduled toilet plan for bladder. Interventions included to offer assistance/encourage toileting at least every two hours during awake time and at bed checks. Offer toileting upon rising, within one hour before meals, within one hour after meals, at bedtime and whenever the resident requests. In addition to routine toileting, toilet at scheduled times as follows: have the resident sit on the toilet to void at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. if still awake. An interview with Resident 24 on August 27, 2025, at 10:47 a.m. revealed that she cannot use bathroom any sooner than every two hours and if she says she has to go, they don't always take her indicating that it is not her scheduled time to go. Interview with the resident's husband at the time of the resident interview indicated that they do not toilet her when needed. Review of Resident 24's clinical documentation from April 18, 2025, through August 22, 2025, including review of progress notes and review of the toileting program documentation, revealed that there was no documented evidence that the resident's toileting program was completed as scheduled and as per the resident's care plan. Interview with the Director of Nursing on August 30, 2025, at 12:50 p.m. confirmed that there was no documented evidence that Resident 24's toileting program was completed as scheduled and as per the resident's care plan. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of Resident Council meeting minutes and information provided to residents, as well as resident and staff interviews, it was determined that the facility failed to act promptly upon the grievances of the Resident Council. Findings Include: Resident Council meeting minutes for June 30, July 28 and August 25, 2025, revealed that residents brought up repeat concerns regarding food temperatures and flies in the dining room. During each meeting the residents were reminded that any dining concerns with food temperatures were to be brought to their attention immediately so they could make necessary adjustments at the time of the complaint. The residents were also reminded that there was regularly scheduled pest control visits and multiple remedies in place to control the flies as best as possible. At June's meeting they were to notify the pest control company. An interview with a group of residents on August 28, 2025, at 11:30 a.m. revealed that the food was not hot and they brought flies up three times and the facility didn't do anything about it. Pest control records for June 20, July 18, and August 15, 2025 revealed there was no treatment for flies There was no documented evidence provided to show that prompt efforts were made to resolve the Resident Council's concerns, regarding food temperatures and flies, when they were expressed during the meetings on June 30, July 28 and August 25, 2025. Interview with the Assistant Nursing Home Administrator on August 29, 2025 at 3:02 p.m. revealed that a fly catcher was purchased in June; however there were no new interventions put into place in July and August. Interview with the Nursing Home Administrator on August 30, 2025, at 11:08 a.m. revealed that tray audits were done on June 15 and July 16, 2025 and that the President of Resident Council complains at every meeting. 28 Pa. Code 201.29(i) Resident rights.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for four of 39 residents reviewed (Residents 3, 28, 36 and 78).Findings Include: A facility policy for psychotropic medication management dated March 31, 2025, indicated that the facility will minimize the use of psychotropic medications, avoid unnecessary drug use, and promote the use of non-pharmacological interventions whenever possible. Psychotropic medications include antipsychotics (class of drugs used to treat mental health conditions), antianxiety medications, antidepressants, and hypnotics (induce sleep and sedation). Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed for agitation. Review of Resident 3’s Medication Administration Record (MAR) for May 2025 through July 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., June 24 at 3:54 p.m., June 29 at 5:29 p.m., June 30 at 4:45 a.m., and July 7 at 3:35 a.m. Resident 3’s Ativan was ordered on May 30, 2025, and extended through August 1, 2025. There was no documented evidence that a physician provided a rationale to extend the medication past 14 days. An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed to ensure that Resident 3’s as needed psychotropic medication was limited to 14 days or had a clinical rationale for continuing beyond 14 days. Physician’s orders for Resident 3, dated May 30, 2025, revealed that the resident was to receive 1 milligram (mg) of transdermal (application of a medicine through the skin) Ativan gel twice daily as needed for agitation. A care plan for the resident, dated March 24, 2025, revealed that the resident was taking psychotropic medications and staff were to offer non-pharmacological interventions prior to medication administration. Review of Resident 3’s MAR for May 2025 through August 2025, revealed that the resident received 1 mg of transdermal Ativan on June 2 at 5:04 p.m., July 7 at 3:35 a.m., and August 16 at 8:00 p.m. Review of Resident 3’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 3 on the above-mentioned dates/times. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 28 dated June 6, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included dementia. Physician’s orders for Resident 28 dated August 4, 2025, included for the resident to receive 0.25 milligrams (mg) of Ativan (an antianxiety medication) every six hours as needed for anxiety. There was no documented evidence that a physician provided a rationale to extend the medication past 14 days. Review of the Medication Administration Record (MAR) for Resident 28 dated August 2025, revealed that the resident was administered 0.25 mg of Ativan on August 24, 2025, at 3:58 p.m. An Interview with the Director of Nursing on August 28, 2025, at 3:18 p.m. confirmed that the facility failed to ensure that Resident 28’s as needed psychotropic medication was limited to 14 days or had a clinical rationale for continuing beyond 14 days. An admission MDS assessment for Resident 36, dated August 25, 2025, revealed that the resident was cognitively impaired, was rarely/never, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer’s dementia and anxiety. A care plan for the resident, dated August 18, 2025, revealed that the resident was taking psychotropic medications and staff were to offer non-pharmacological interventions prior to medication administration. Physician’s orders for Resident 36, dated August 23, 2025, revealed that the resident was to receive 0.25 mg of Ativan three times daily as needed for anxiety and agitation. Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of Ativan on August 23 at 1:17 p.m., August 25 at 3:32 p.m., and August 27 at 8:39 p.m. Review of Resident 36’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Physician’s orders for Resident 36, dated August 25, 2025, revealed that the resident was to receive 0.25 mg of transdermal Lorazepam (Ativan) gel twice daily as needed for anxiety/agitation. Review of Resident 36’s MAR for August 2025, revealed that the resident received 0.25 mg of transdermal Lorazepam (Ativan) on August 26 at 4:16 p.m., August 27 at 10:39 a.m., and August 29 at 12:30 p.m. Review of Resident 36’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 4:02 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 36 on the above-mentioned dates/times. An annual MDS assessment for Resident 78, dated June 25, 2025, revealed that the resident was cognitively impaired, was sometime understood, could sometimes understand, took antipsychotic and antianxiety medications, and had diagnoses that included Alzheimer’s dementia, depression, and anxiety A psychiatry consult dated March 14, 2025, for Resident 78 indicated that the facility and their staff were to utilize non pharmacological interventions, supportive care, and redirection. Physician’s orders for Resident 78, dated May 12, 2025 and August 18, 2025, revealed that the resident was to receive 0.5 mg of Ativan every eight hours as needed for anxiety. Review of Resident 78’s MAR for July and August 2025, revealed that the resident received 0.25 mg of Ativan on July 26 at 9:32 p.m., August 21 at 9:53 p.m., and August 21at 11:29 p.m. Review of Resident 78’s clinical record, including documentation on the MAR and in the progress notes, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Ativan on the above-mentioned dated and times. Interview with the Director of Nursing on August 29, 2025, at 2:48 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Ativan to Resident 78 on the above-mentioned dates/times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 26, 2025, indicated that the resident was cognitively impaired, was rarely or never understood, had physical, verbal and other behaviors not directed towards others, took antipsychotic (medications used to treat psychosis and other mental and emotional conditions), antianxiety and antidepressant medications, and had diagnoses that included Alzheimer’s dementia, depression, and anxiety. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (main kitchen). Findings include: The facility's policy for ice machines, dated March 31, 2025, revealed that every month the ice machines were to have the ice removed, the inside of the machine washed with sanitizing solution and a clean cloth, allowed to dry, and then refilled with ice. A third party vendor would come in quarterly and as needed to service the ice machine. A Service log, dated March 3, 2025, revealed that preventative maintenance was performed by a contracted service. There was no documented evidence that the ice machine was cleaned on a monthly basis. Observations on August 27, 2025, at 9:02 a.m. revealed that inside the ice machine there was a build up of a pink substance on the right hand corner of the white plastic piece and a build up of a black substance on the entire length of the strip at the top of the ice machine. The chest was full of ice. Interview with Dietary Manager at that time confirmed that the ice machine needed cleaned. 28 Pa. Code 211.6(f) Dietary services.

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 83). Findings include: Review of Resident 83's clinical record revealed that the resident was discharged from the facility on July 2, 2024. Further review of Resident 83's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge. Interview with the Nursing Home Administrator on July 10, 2024 at 10:00 a.m. confirmed that the discharge summary was not completed. 28 Pa Code 211.5(d) Clinical record

Based on observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for one of four residents reviewed (Residents 2). Findings include: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated March 2024, revealed EBP will be used in the care of any residents who are at higher risk of colonization or infection with multi-drug resistant organisms (MDROs). Use of Enhanced Barrier Precautions is a strategy for improved success for infection control and to expand on standard precautions. Enhanced Barrier Precautions are designed to reduce the risk of transmission and/or colonization of MDROs from both recognized and unrecognized sources. Enhanced Barrier Precautions require gowns and gloves to be worn during any high-contact resident care based on the location of the organism (i.e., urine, nares, wounds, etc ). EBP are to be used for residents who are at an increased risk of infection, including those with a known infection or colonization of a resistant organism who do not require contact precautions, and residents with chronic wounds or indwelling medical devices. It is meant to remain in place for these residents during the duration of their stay at the facility. Isolation is not required for those who have EBP in place. Clinical records review revealed Resident 2 had a Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss) to the coccyx. Observation conducted of Resident 2's room failed to reveal evidence of EBP signage/communication. Interview with the Director of Nursing, Nursing Home Administrator, and Wound Nurse was conducted on July 10, 2024, at 2:10 p.m., where it was confirmed that the EBP process was not followed for Resident 2. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services