Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of 19 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included gastrostomy status (a surgical procedure that involves creating an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube) and cerebral palsy (a neurological disorder that affects body movement and muscle coordination, typically caused by abnormal brain development or damage to the brain). Review of Resident 1's physician orders revealed an order for Bilateral hand rolls worn when OOB (out of bed). Don/Doff by (Nurse Aide), with a start date of April 24, 2024.Review of Resident 1's comprehensive care plan revealed a focus area of Impaired Mobility with potential for contractures (structural changes to your soft and connective tissues that cause them to stiffen, tighten and contract) related to diagnosis cerebral palsy with an intervention for Bilateral hand rolls when out of bed, with a start date of April 22, 2024. Observations of Resident 1 on September 2, 2025, between 9:40 AM and 12:26 PM, revealed he was sitting in his wheelchair and did not have bilateral hand rolls in his hands. Observations of Resident 1 on September 3, 2025, between 9:30 AM and 11:52 AM, revealed he was sitting in his wheelchair and did not have bilateral hand rolls in his hands. Review of Resident 1's clinical record revealed a nurse aide task Apply or remove- Bilateral hand rolls worn when OOB. Further review of the aforementioned nurse aide task revealed documentation to indicate Employee 4 (Nurse Aide) donned the bilateral hand rolls on Resident 1 on September 3, 2025, at 8:48 AM.Interview with Employee 5 (Licensed Practical Nurse) on September 3, 2025, at 12:00 PM, revealed she was unsure as to why Resident 1 did not have his bilateral hand rolls in place, and she was unable to find them in his room. Interview with the Director of Nursing (DON) on September 4, 2025, at 10:06 AM, she revealed Employee 4 stated she put the hand rolls on that morning but then took them off for care and forgot to put them back on, and that an employee from the therapy department went back to the room later that day and found the hand rolls in Resident 1's top drawer in his room. During an email correspondence with the Nursing Home Administrator on September 4, 2025, at 10:53 AM, he revealed his expectation that the bilateral hand rolls would be applied following the physician orders. 28 Pa. Code 211.10 (a) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) appropriately, in advance of changes for Medicare covered services, to three of three residents reviewed whose Medicare coverage was discontinued (Residents 6, 9, and 66).Findings include: Review of Resident 6 clinical record documented last covered day for Medicare A services was April 10, 2025. Review of progress note dated April 8th, 2025, read, in part, a message was left for Resident 6's parents stating the Medicare services will end on April 10th, 2025, and on April 11th, 2025, she will evert back to Medicaid. Notice of Medicare Non-Coverage (NOMNC) was mailed to Resident 6's parents. The facility provided a copy of the signed NOMNC, which was dated April 11th, 2025. Review of Resident 9's clinical record documented last covered day for Medicare A services was May 6, 2025. Review of progress note, dated May 2nd, read, in part, Resident 9 was notified that his Medicare services will end on May 6th, 2025, and on May 7th, 2025, he will evert back to Medicaid. The Resident had no further questions. The facility provided a copy of the signed NOMNC, which was dated May 2nd, 2025. Review of Resident 66's clinical record documented last covered day for Medicare A services was May 26, 2025. Review of progress noted dated May 23rd, 2025, read, in part, Resident 66 was notified that his Medicare services will end on May 26th, 2025, and on May 27th, 2025, he will evert back to Medicaid. The Resident had no further questions. The facility provided a copy of the signed NOMNC, which was dated May 23rd, 2025. Interview with Employees 1 and 2 on September 4th, 2025, at 11:48 AM, revealed the facility wasn't utilizing the Center for Medicaid/Medicare Services SNF ABN form as of January 2025. It was revealed that they were informed regarding an update to the NOMNC form January 2025 and assumed the SNF ABN form was no longer required. Interview with the Nursing Home Administrator on September 4, 2025, at 12:16 PM, revealed the SNF ABN form should've been completed. 28 Pa. Code 201.29(c.3)(1) Resident rights

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Review of facility policy, titled Labeling and Dating last reviewed September 2, 2025, read, in part, All food items must be labeled and dated. All food items must be labeled with either a manufacturer label or handwritten label.Review of facility policy titled Purchasing Policy- Storage last reviewed September 2, 2025, read, in part, all items in refrigerators and freezers must be properly wrapped, labeled, and dated.Observation in the dry storage area on September 2, 2025, at 9:57 AM, revealed one open bag of macaroni pasta without an open date; one open bag of penne pasta without an open date; two bags of angel hair pasta not dated; one bag of open powdered sugar not labeled or dated; and one bag of candy topping not labeled or dated.Observation in the walk-in refrigerator on September 2, 2025, at 9:59 AM, revealed one package of vegan cheese left open to air not properly sealed; one container of mozzarella cheese left open to air not properly sealed; two packages of meat revealed to be turkey breast not labeled or dated; one bag of spinach not dated; one bag of parsley not dated; two bags of broccoli not dated; one open container of sour cream open without an open date; and one bag of whipped cream open and not dated.Observation in walk-in freezer unit on September 2, 2025, at 10:04 AM, revealed two packages of zucchini fries not dated; two bags of waffles not dated with one left open to air not properly sealed; and two packages of hot dogs not dated. Observation in the main kitchen on September 2, 2025, at 10:08 AM, revealed a blank temperature log from July 2025 on the wall overtop of the three-compartment sink. Observation in the three-compartment sink on September 2, 2025, at 10:09 AM, revealed dirty pans in the wash section, and the sanitizer sink filled with water and sanitizing solution. Employee 3 (FSD- Food Service Director) tested the sanitizer concentration with testing strips. The surveyor checked the expiration date on the strip container used to test the concentration of the sanitizer, and it revealed an expiration date of May 1, 2024.Interview with Employee 3 on September 2, 2025, at 10:14 AM, revealed he would expect labeling and dating per facility policy, and he would be reaching out to their supplier for new test strips. Return visit to the main kitchen on September 3, 2025, at 11:37 AM, revealed the blank temperature log from July 2025 remained on the wall overtop of the three-compartment sinkInterview with Employee 3 on September 3, 2025, at 11:38 AM, revealed the concentration of the sanitizer solution did not get logged from the morning of September 2, 2025, and that there are no logged sanitizer solution concentration measures since July 2025. Interview with the Nursing Home Administrator on September 3, 2025, at 1:20 PM, revealed it is his expectation that food items are labeled and dated per facility policy, and kitchen equipment is utilized in accordance with professional standards.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on an observations, facility policy review, record review, and staff interviews, the facility failed to implement infection control policies regarding Enhanced Barrier Precautions for eight of 19 Residents reviewed (Residents 1, 2, 6, 7, 10, 11, 12, and 13). Findings include: Review of facility policy, Enhanced Barrier Precautions, dated July 22, 2025, read, in part, indications for use include chronic wounds and/or indwelling medical devices such as central lines regardless of MDRO (multidrug-resistant organism) status.Review of Resident 1's clinical record revealed diagnoses that included gastrostomy status (a surgical procedure that involves creating an opening in the stomach through the abdominal wall, with the placement of a feeding tube) and cerebral palsy (a neurological disorder that affects body movement and muscle coordination, typically caused by abnormal brain development or damage to the brain). Observations outside of Resident 1's room on September 2, 2025, between 9:40 AM and 12:26 PM, failed to reveal any signage indicating that Resident 1 was on enhanced barrier precautions (EBP).Observations outside of Resident 1's room on September 3, 2025, between 9:30 AM and 11:52 AM, failed to reveal any signage indicating that Resident 1 was on EBP.Review of Resident 1's physician orders failed to reveal an order to follow EBP when caring for Resident 1.Review of Resident 1's comprehensive care plan failed to reveal any mention of the need to follow EBP when caring for Resident 1.Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and type II diabetes mellitus (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).Review of Resident 2's clinical record revealed that Resident 2 had a Percutaneous Endoscopic Gastrostomy tube (PEG tube - feeding tube surgically inserted into the stomach that extends through the abdomen for long term nutrition and hydration needs) and a foley catheter (tube inserted into the bladder through the urethra to facilitate the removal of urine from the bladder).During multiple observations of Resident 2's room on September 2, 2025 through September 4, 2025, failed to reveal any signage indicating that Resident 2 was on EBP.Review of Resident 2's physician orders revealed no order for EBP for Resident 2. Review of Resident 2's comprehensive plan of care revealed that EBP was not included in Resident 2's comprehensive plan of care.During observation on September 4, 2025, at approximately 9:28 AM, two Nurse Aides (Employee 4 and Employee 6) were observed in Resident 2's room. Resident 2 was observed in a wheelchair. Employee 6 was observed holding a bag of what appeared to be soiled linens. It was also observed that there was a lift in the room. When Employee 4 and Employee 6 exited Resident 2's room, Employee 4 and Employee 6 confirmed they were providing incontinence care and transferred resident to the wheelchair. Employee 4 and Employee 6 confirmed that they did not wear gowns during the care provided.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 2 on EBP.Review of Resident 6's clinical record revealed diagnoses that included dysphagia (difficulty swallowing). Observation of Resident 6's room on September 2nd, 2025, at 12:20 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident 6's care plan revealed a focus area for PEG (percutaneous endoscopic gastrostomy - a thin, flexible tube inserted through the skin of the abdomen and into the stomach) tube placement related to dysphagia. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 6. Review of Resident 6's physician orders included Glucerna 1.5 via J tube (jejunostomy tube- a surgically place tube that delivers nutrients and medication directly into the jejunum, the second part of the small intestine) 65 ml/hr until 780 ml has been infused every day via a pump, started June 9, 2023; cleanse PEG tube with normal saline solution and apply drain sponge as needed every day and evening shift, started March 4, 2025; and J/G tube medically necessary due to dysphagia, ordered February 19, 2021. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 6. Review of Resident 7's clinical record revealed diagnoses that included neurogenic bladder (a condition that occurs when the relationship between the nervous system and the bladder function is disrupted) and urinary tract infection (an infection of the urinary tract). Observation of Resident 7 on September 2, 2025, at 10:35 AM, revealed that Resident 7 had a suprapubic catheter (a flexible tube inserted into the bladder through the abdomen to drain urine). Further observation outside of Resident 7's room failed to reveal any signage indicating that Resident 7 was on EBP. Review of Resident 7's care plan revealed a care plan with a focus area of, Presence of Suprapubic Catheter. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 7. Review of Resident 7's physician orders failed to reveal an order to follow for a need to follow EBP when caring for Resident 7. Review of Resident 10's clinical record revealed diagnoses that included dysphagia. Observation of Resident 10's room on September 2nd, 2025, at 11:56 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident10's care plan revealed a focus area for PEG (percutaneous endoscopic gastrostomy - a thin, flexible tube inserted through the skin of the abdomen and into the stomach) tube placement related to dysphagia. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 10. Review of Resident 10's physician orders included Jevity1.2 (an enteral tube feeding) 95 ml/hr via gastrostomy tube until 1000 ml has been infused, started September 13, 2023; and cleanse PEG site with normal saline solution and apply drain sponge as needed every day and evening shift, started March 14, 2025. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 10. Review of Resident 11's clinical record revealed diagnoses that included neuromuscular dysfunction of bladder, history of urinary tract infections, and dysphagia. Observation of Resident 11's room on September 2nd, 2025, at 11:03 AM, and September 4th, 2025, at 10:00 AM, revealed there was no identification for the need for EBP. Review of Resident 11's care plan revealed a focus area for need for PEG placement related to dysphagia, and need for urinary straight catheterization multiple times a day related to neurogenic bladder with urinary retention. Further review of the care plan failed to reveal any mention of the need to follow EBP when caring for Resident 11. Review of Resident 11's physician orders included Jevity 1.5 via G tube (a tube inserted into the abdominal wall directly into the stomach to provide nutrition, fluids and medications when someone can't eat or swallow safely) 120 ml by gravity at hour of sleep, 237 ml in the morning, and 237 ml if less than 75% of lunch and dinner was consumed, started January 10, 2025; cleanse PEG site with normal saline solution and apply drain sponge as needed every day and evening shift, started March 14, 2025; and intermittent catheterization 5 times a day with 12 French catheter started September 3, 2024. Further review of the physician orders failed to reveal an order for the need to follow EBP when caring for Resident 11. Review of Resident 12's clinical record revealed diagnoses that included hypertension and stage two chronic kidney disease (mild decrease in the kidney's ability to filter toxins from the blood).Review of Resident 12's clinical record revealed that Resident 12 had a suprapubic catheter inserted (tube surgically implanted into the bladder that extends through the abdominal wall that facilitates the drainage of urine from the bladder).During multiple observations of Resident 2's room on September 2, 2025 through September 4, 2025, failed to reveal any signage indicating that Resident 2 was on EBP.Review of Resident 12's physician orders revealed that Resident 12 did not have an order for EBP.Review of Resident 12's comprehensive plan of care revealed no care plan that included the use of EBP for Resident 12 high-contact care.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 12 on EBP. Review of Resident 13's clinical record revealed diagnoses that included osteoporosis (loss in bone density) and hypertension.Review of Resident 13's clinical record revealed that Resident 13 had a PEG tube placed.Review of Resident 13's physician orders revealed that Resident 13 did not have an order for EBP.Review of Resident 13's comprehensive plan of care revealed no care plan included the use of EBP for Resident 13 during high-contact care.Review of a resident list identifying residents on EBP, provided by the facility's infection preventionist on September 4, 2025, at approximately 10:00 AM, revealed the facility had not placed Resident 13 on EBP.Interview with the DON on September 3, 2025, at 1:30 PM, and September 4th, 2025, at 10:15 AM, it was revealed that EBP are only in place for residents with wounds, gastrostomy tubes, or catheters who have an active infection. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 49 and 74). Findings include: Review of Resident 49's clinical record revealed diagnoses that included severe intellectual disabilities (major delays in development, and individuals often have the ability to understand speech but otherwise have limited communication skills) and spastic quadriplegia cerebral palsy (cerebral palsy refers to a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination. Spastic quadriplegia cerebral palsy is a form of cerebral palsy that affects both arms and legs and often the torso and face). Review of Resident 49's quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated July 29, 2024, revealed that in Section K, it was marked no or unknown for a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Review of Resident 49's clinical record revealed a weight of 83 pounds on July 29, 2024, and a weight of 98.4 pounds on January 17, 2024, which is a 15.65% weight loss in 6 months. Review of Resident 49's nutrition progress note dated August 1, 2024, revealed that Resident 49's weight was down 10% in 180 days. During an interview with the Nursing Home Administrator (NHA) on August 28, 2024, at 11:49 AM, he confirmed that Resident 49's quarterly MDS was a coding error and that her weight loss should have been coded on the MDS. A review of the clinical record for Resident 74 on revealed diagnoses that include spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder that affects all four limbs, the trunk, and the face) and Unspecified Psychosis (condition that affects the mind and makes it hard to tell what is real and what is not. It can cause delusions, hallucinations, and disorganized speech or behavior). A review of Resident 74's Quarterly MDS dated [DATE], revealed that Section H. Bladder and Bladder, Subsection H0100. Appliances. A. was marked yes for an indwelling catheter. Observation of Resident 74 while in bed on August 25, 2024, at 10:00 AM, failed to reveal any catheter bag or tubing hanging on the side of his bed. During an interview with Employee 6 (Licensed Practical Nurse) on August 26, 2024, at 10:15 AM, Employee 6 informed the surveyor that Resident 74 never had an indwelling catheter. Employee 6 informed the surveyor that Resident 74 wears a condom catheter (a non-invasive device that can be used to collect urine and is considered an alternative to incontinence pads) that is connected to a urine drainage bag when the Resident is out of bed. During an interview with the NHA on August 27, 2024, at 2:00 PM, the NHA confirmed that Resident 74's June 14, 2024, MDS was marked in error for an indwelling catheter. 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on document review and staff interview, it was determined that the facility failed to complete a performance review of every nurse aide once every 12 months for five of five nurse aide employee files reviewed (Employees 1-5). Findings Include: A performance evaluation or appraisal is defined as a tool to document an employee's performance over time. A review of Employee 1's information revealed a hire date of May 22, 2023. A review of Employee 1's training information revealed no annual performance evaluation. A review of Employee 2's information revealed a hire date of January 18, 2021. A review of Employee 2's training information revealed no annual performance evaluation. A review of Employee 3's information revealed a hire date of April 17, 2017. A review of Employee 3's training information revealed no annual performance evaluation. A review of Employee 4's information revealed a hire date of February 20, 2006. A review of Employee 4's training information revealed no annual performance evaluation. A review of Employee 5's information revealed a hire date of April 21, 2008. A review of Employee 5's training information revealed no annual performance evaluation. An interview with the Nursing Home Administrator on August 27, 2024, at 10:22 AM, confirmed the facility has not completed annual performance evaluations on those nurse aides. 28 Pa. Code 201.19 (2) Personnel policies and procedures

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 5 and 14). Findings Include: Review of Resident 5's clinical record revealed diagnosis that included cerebral palsy (weakness or problems with using the muscles) and hypertension (high blood pressure). Review of Resident 5's MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated July 21, 2023, revealed that section J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment, was marked 0, No. Review of a fall incident report dated June 24, 2023, at 11:45 AM, revealed Resident 5 had a fall in their room. Review of Resident 5's clinical nursing progress notes revealed a progress note dated June 24, 2023, at 1:09 PM, revealed that the Resident was found sitting on the floor with their back against the bed frame and feet extending in front of them. Review of Resident 5's MDS dated [DATE], revealed that section N0410. Medications Received (B. Medication received: Days: Antianxiety) was marked 0, indicating Resident 5 has not received any antianxiety medications in the last seven days of when the assessment was completed. Review of Resident 5's July 2023 Medication Administration Record revealed that Resident 5 received Lorazepam Tablet 0.5 Milligram two times a day for the entire month. Further review of Resident 5's current Medication Review Report revealed that the Resident is prescribed Lorazepam Tablet 0.5 milligram two times a day, with a start date of March 31, 2021. During an interview with the Nursing Home Administrator on October 25, 2023, at 1:53 PM, he confirmed that the fall that occurred on June 24, 2023, and the antianxiety medication not being captured on the MDS completed on July 21, 2023, were both errors and they have both been fixed. Review of Resident 14's clinical record revealed diagnoses that included thoracic spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly) with hydrocephalus (a build-up of fluid in the cavities deep within the brain), hypertension, and major depressive disorder. Review of Resident 14's quarterly MDS assessment dated [DATE], revealed that in section H, Resident 14 was coded as having an indwelling catheter (a catheter that is maintained within the bladder for the purpose of continuous drainage of urine). Further review of the MDS revealed that intermittent catheterization (insertion and removal of a catheter through the urethra for bladder drainage) is not marked, and urinary continence is coded as 9- not rated. Review of Resident 14's current physician orders revealed an order dated August 4, 2023, for intermittent straight catheterization twice a day. Further review of Resident 14's clinical record failed to reveal any evidence that Resident 14 had an indwelling catheter at any time in the seven days prior to, and including, September 29, 2023. During an interview with the Director of Nursing (DON) on October 26, 2023, at 10:52 AM, she stated that the Resident does receive intermittent catheterization twice daily, and that Resident 14 is also sometimes incontinent of urine. In a follow-up interview with the DON on October 26, 2023, at 11:18 AM, she stated that Resident 14 did not have an indwelling catheter at any time around September 29, 2023, and stated that the MDS assessment was incorrectly coded and a modification would be completed. 28 Pa Code 211.12 (d)(3)(5) Nursing Services