Health inspection·March 21, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that services were provided with reasonable accommodation of resident need for one of 17 residents reviewed (Resident 6). Residents Affected - Some Findings include: Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease). Review of Resident 6's care plan revealed a focus area of [Resident 6] has impaired visual function related to legal Blindness ., created on February 23, 2023, with interventions for Place foods in individual bowl except sandwiches, arrange all items on tray, by placing same arrangement on tray each time to enhance ability to feed self created on February 23, 2023, and The resident prefers to have their room and things arranged to promote independence. Resident prefers to have cell phone within reach while awake, staff to place on charger at bedside every evening and remove from charger and keep within reach while awake, created on April 12, 2023. Observations of Resident 6 on March 18, 2024, at 12:09 PM; March 18, 2024, at 12:50 PM; March 19, 2024, at 9:13 AM; March 19, 2024, at 12:29 PM; and March 20, 2024, at 9:37 AM, revealed Resident 6 was awake, sitting in her recliner, and her cell phone was across the room charging on a table. Observation of Resident 6 during her lunch meal on March 18, 2024, at 12:50 PM, revealed her food was in three separate bowls and they were all set-up on her tray in a straight line. Observation of Resident 6 during her lunch meal on March 19, 2024, at 12:29 PM, revealed her food was in three separate bowls, her ice cream and carrots were in the front of her tray side-by-side, and her entrée was at the back of her tray. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:37 AM, the surveyor revealed the observations of Resident 6's phone not being in reach while awake and the inconsistencies of her tray set-up during lunch. During a follow-up interview with the NHA on March 20, 2024, at 2:56 PM, she revealed Resident 6's meal tray should be set-up with the bowls arranged in a clockwise manner, and she would expect her phone to be within reach when she's awake. Page 1 of 35 395784 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0558 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395784 Page 2 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **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 six of 19 residents reviewed (Residents 6, 7, 8, 22, 33, and 41). Residents Affected - Some Findings Include: Review of Resident 6's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), legal blindness (a term to describe severe visual impairment that cannot be corrected with glasses or contact lenses), and generalized anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease). Review of Resident 6's Quarterly 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 February 23, 2024, revealed under Section O. Special Treatments, Procedures and Programs, subsection K1. Hospice Care, Resident 6 was marked yes, indicating she was receiving hospices services during the ARD (assessment reference date of previous 7 days). Review of Resident 6's clinical record revealed a social services progress note on November 28, 2023, that stated Resident 6's last covered day for hospice services was December 1, 2023, and that they are not able to recertify her on hospice services. Review of Resident 6's clinical record revealed she had a Significant Change MDS Assessment completed on December 1, 2023, due to the discontinuation of hospice services. During an interview with Employee 1 on March 20, 2024, at 2:41 PM, the surveyor inquired about hospice being coded on Resident 6's MDS with ARD of February 23, 2024. Employee 1 (Registered Nurse Assessment Coordinator) replied Yes, that was a mistake. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:42 PM, she revealed she would expect Resident 6's aforementioned Quarterly MDS assessment to be coded accurately. Review of Resident 7's clinical record revealed diagnoses that included Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident 7's current physician orders revealed orders, both dated February 26, 2023, for Olanzapine (antipsychotic medication), 2.5 mg daily, and Xarelto (anticoagulant medication), 15 mg at bedtime. Review of Resident 7's quarterly MDS assessment dated [DATE], revealed that in Section N, it was marked No, that Resident 7 was taking an antipsychotic medication or an anticoagulant medication. Further review of Resident 7's MDS revealed that Section N0450 A, was coded No, antipsychotics were 395784 Page 3 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0641 not received. Level of Harm - Minimal harm or potential for actual harm Review of Resident 7's Medication Administration Record (MAR) dated February 2024, revealed that Resident 7 received Olanzapine and Xarelto every day in February 2024. Residents Affected - Some During an interview with the NHA on March 21, 2024, at 10:20 AM, she stated that Resident 7's MDS was marked in error. Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia. Review of Resident 8's quarterly MDS assessment dated [DATE], revealed that Section P0100 Physical Restraints, D. Other, was marked Used daily. Review of Resident 8's clinical record revealed no indication of Resident 8 having a physical restraint. Observation of Resident 8 on March 18, 2024, at 10:09 AM, revealed no observation of Resident 8 having a physical restraint. During an interview with the NHA on March 20, 2024, at 2:21 PM, she revealed that Resident 8 does not have a physical restraint. During an interview with the NHA on March 21, 2024, at 10:37 AM, she revealed that Resident 8's quarterly MDS dated [DATE], Section P0100 D was coded incorrectly and should not have indicated Resident 8 had a physical restraint. Review of Resident 22's clinical record revealed diagnoses that included dementia, history of falling, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 22's clinical record revealed she had an unwitnessed fall on December 24, 20213, that resulted in a fracture to her left forearm. Review of Resident 22's care plan revealed a focus area of, [Resident 22] has an alteration in musculoskeletal status related to fracture of the left forearm, initiated on December 29, 2023, upon her return from the hospital. Review of Resident 22's Discharge Return Anticipated MDS dated [DATE], revealed that in section J under subsection J1900, resident 22 was marked one for Number of falls since admission or Prior assessment Injury (except major) and one for Number of falls since admission or Prior assessment - Major injury. During an interview with Employee 1 (RNAC - Registered Nurse Assessment Coordinator) on March 20, 2024, at 2:32 PM, she revealed Resident 22 had a fall with major injury prior to the assessment, and did not have a fall with injury (except major) that should be coded on that assessment. She revealed Resident 22 was coded incorrectly for Number of falls since admission or Prior assessment - Injury (except major) and should have been coded no under that section. 395784 Page 4 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a follow-up interview with the NHA on March 20, 2024, at 2:32 PM, she revealed she would expect Resident 22's MDS assessment to be coded accurately. Review of Resident 33's clinical record revealed diagnoses that included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 33's current physician orders revealed an order dated March 5, 2023, for CPAP (continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while you sleep) for sleep. Review of Resident 33's quarterly MDS assessment dated [DATE], revealed that in Section O, Non-Invasive Mechanical Ventilator (provides respiratory support without the use of invasive ventilation, such as CPAP) was coded as No. During an interview with the NHA and Employee 1 on March 20, 2024, at 2:42 PM, Employee 1 stated that the CPAP was missed being coded on Resident 33's MDS. Review of Resident 41's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), unspecified heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and depression. Review of Resident 41's physician orders revealed an order for CPAP, continue with current settings at 8.0, dated March 9, 2023. Review of Resident 41's Annual MDS with the assessment reference date of January 17, 2024, and Quarterly MDS with the assessment reference date of February 28, 2024, revealed in Section O. Special Procedures, Treatments, and Programs that at question G1. Non-invasive Mechanical Ventilator Resident 41 was coded as No, therefore, disabling question G3. CPAP from being answered. During an interview with the NHA and Employee 1 on March 20, 2024, at 2:21 PM, Employee 1 confirmed that Resident 41's MDS was coded inaccurately for their CPAP. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395784 Page 5 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident's comprehensive plan of care was updated upon changes in the resident's condition for three of 17 residents reviewed (Residents 29, 53, and 60). Findings Include: Review of facility policy, titled Care Plan Revisions Upon Status Change, with a last revised date of April 18, 2023, revealed 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current care plan revealed an active care plan for a pressure ulcer, dated December 10, 2023. Review of Resident 29's wound assessment dated [DATE], revealed that Resident 29's pressure ulcer resolved as of this date. During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 10:19 AM, she stated that Resident 29's care plan should have been updated when the pressure ulcer resolved. Review of Resident 53's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and atrial fibrillation. Review of Resident 53's care plan revealed a focus area for risk of falls related to deconditioning, with an initiated and revised date of March 21, 2023. Interventions included, but were not limited to, ensuring that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, with a last revision date of March 10, 2024. Observations of Resident 53 on March 19, 2024, at 8:28 AM; March 19, 2024, at 12:43 PM; and March 20, 2024, at 8:33 AM, all revealed that the resident was barefoot and sitting on the side of the bed. During an interview with the NHA on March 20, 2024, at 10:35 AM, the aforementioned observations of Resident 53 were shared. She indicated that she would look into the concern. Email communication received from the NHA on March 20, 2024, at 1:47 PM, indicated she had spoken to the staff on the unit where Resident 53 resides and that they said that Resident 53 often removes their socks. She further indicated that she asked them to care plan that. During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator-RNAC) on March 20, 2024, at 2:21 PM, the NHA confirmed that Resident 53's care plan prior to today should have 395784 Page 6 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0657 included that they often remove their socks. Level of Harm - Minimal harm or potential for actual harm Review of Resident 60's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Residents Affected - Some Review of Resident 60's care plan on March 18, 2024, revealed she had an active care plan with a focus area The resident has oxygen therapy r/t Ineffective gas exchange, with a start date of June 22, 2023, with an intervention for Oxygen settings: O2 via nasal cannula, with a start date of June 22, 2023. Observation in Resident 60's room on March 18, 2024, at 1:04 PM, failed to reveal oxygen equipment. Review of Resident 60's active physician orders on March 21, 2024, failed to reveal an order for oxygen. Review of select facility order sheet provided for Resident 60 revealed an order for Oxygen: Obtain SPO2 as needed, with discontinued date of October 26, 2023, and a reason of Resident is no longer in need of oxygen. An interview with the NHA on March 21, 2024, at 1:25 PM, revealed she would expect Resident 60's oxygen care plan to be resolved. 28 Pa. Code 211.12(d)(5) Nursing services 395784 Page 7 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary that anticipated resident needs and included all required information for one of two discharged residents reviewed (Resident 69). Findings Include: Review of Resident 69's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 69's clinical record revealed she was discharged to her home on December 23, 2023. Continued review of Resident 69's clinical record revealed no documentation of a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of the resident's pre-discharge and post-discharge medications, or a post-discharge plan of care, developed with resident participation, to assist Resident 69 to adjust to her living environment. An interview with the Nursing Home Administrator on March 20, 2024, at 1:30 PM, revealed a recapitulation of Resident 69's stay, a final summary of the resident's status, and reconciliation of the resident's medications were not completed, and she would have expected them to have been completed. 28 Pa. Code 211.5(d)(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395784 Page 8 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide assistance with activities of daily living (ADL) for dependent residents for one of 19 residents reviewed (Resident 29). Residents Affected - Few Findings Include: Review of facility policy, titled Activities of Daily Living, dated November 26, 2016, revealed The facility will provide care and services for the following activities of daily living: (1) Hygiene- bathing, dressing, grooming and oral care. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current ADL care plan, dated December 10, 2023, revealed that Resident 29 is a moderate 1-2 assist for dressing. Further review of Resident 29's care plan revealed no evidence that Resident 29 prefers to stay in bed or prefers to be in a gown. Observation of Resident 29 on March 18, 2024, at 12:13 PM and 1:00 PM, revealed Resident 29 in bed, wearing a nightgown. During an interview with Resident 29 on March 18, 2024, at 12:13 PM, Resident 29 stated she has not yet received her morning care and the gown she is wearing is what she slept in the night prior. During an interview with the Nursing Home Administrator on March 21, 2024, at 1:23 PM, she stated that she has not had a chance to speak to the Nurse Aide who cared for Resident 29 on March 18, 2024, to determine why the resident remained in bed and a gown at that time, but stated that she would expect that residents would be dressed prior to that time, unless it would be noted as a preference on their care plan to remain in bed and/or in a gown. 28 Pa. code 211.10(d) Resident care policies 28 Pa. code 211.12(d)(1)(5) Nursing services 395784 Page 9 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for four of 19 residents reviewed (Residents 7, 22, 45, and 67). Residents Affected - Some Findings Include: Review of facility policy, titled Dressing Change Policy, dated January 15, 2017, revealed Remove soiled dressing and discard in a trash bag; .Don non-sterile/sterile gloves (when appropriate) prior to cleansing wound site; Cleanse wound site per physician's order; Wash hands; [NAME] non-sterile/sterile gloves (when appropriate) and apply topical treatment as ordered . Review of facility policy, titled Pressure Injury Prevention and Management, dated October 23, 2022, revealed Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Review of Resident 7's clinical record revealed diagnoses that included Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Reivew of Resident 7's current physician orders revealed a treatment order for Resident 7's MASD (moisture associated skin damage), dated February 23, 2024, to cleanse sacrum with normal saline solution (NSS), pat dry, apply medical grade honey and cover with a foam border, daily, and PRN (as needed) when soiled/dislodged. Observation of Resident 7's treatment on March 20, 2024, at 11:23 AM, revealed Employee 7 (Licensed Practical Nurse [LPN]) washed her hands and applied gloves. Resident 7 was positioned onto his side and his brief was removed. At that time, Resident 7 was observed to not have a dressing in place to remove from his sacrum. Employee 7 was asked why Resident 7 did not have a dressing in place, as ordered. Employee 7 stated that the nurse aide had just been in the room prior to the dressing change, and Resident 7 was incontinent; the dressing was soiled and removed. Further observation of Resident 7's treatment revealed Employee 7 cleansed Resident 7's wound with NSS, patted the wound dry, and applied the medical grade honey and then the foam border. Employee 7 then removed her gloves and washed her hands. Employee 7 did not change gloves or perform hand hygiene after cleansing the wound and prior to applying the medical grade honey. During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 9:45 AM, she stated that Employee 7 should have followed the facility policy regarding hand hygiene and changing gloves. Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). 395784 Page 10 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 22's care plan revealed a focus area of, [Resident 22] has an alteration in musculoskeletal status related to fracture of the left forearm, last revised March 21, 2024, with an intervention to encourage the resident with use of supportive devices (splints, braces, canes, crutches etc.) as recommended, last revised March 21, 2024. Observations of Resident 22 on March 18, 2024, at 9:13 AM and at 12:49 AM; and March 19, 2024, at 12:33 PM failed to reveal Resident 22 wearing a splint device to her left forearm. Email correspondence with the NHA on March 20, 2024, at 7:22 PM, revealed Resident 22 came back from the hospital with orders for a splint and it is care planned, and when therapy had her on their caseload from January 1, 2024, to January 11, 2024, she was still ordered the splint. Her family declined her appointment for her orthopedic follow-up and they had decided on comfort care. According to staff interviews, she continued to refuse the sling, but it is in her room and available and, due to lack of orthopedic follow-up, the care plan remained for her to wear when she is agreeable. Review of Resident 22's hospital Discharge summary dated [DATE], revealed Open fracture of the distal end of left radius (arm) .Post reduction placed in sugar tong splint. Review of Resident 22's physician orders failed to reveal an order for a splint/brace. Email correspondence with the NHA on March 21, 2024, at 12:59 PM, revealed Resident 22 had no order for her splint in her electronic health record. The usage of the splint was from her discharge order from the hospital and a clarification order will be obtained and the care plan updated accordingly. During a follow-up interview with the NHA on March 21, 2024, at 1:26 PM, the NHA explained she will follow-up with the physician to clarify if Resident 22 should be ordered the splint, because the family cancelled her orthopedic follow-up and she refuses the splint. She revealed the facility never ordered the splint per the directions of her hospital discharge summary, and they should have ordered it when she returned from the hospital. Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer. Observations of Resident 45 on March 19, 2024, at 12:42 PM, and on March 20, 2024, at 1:34 PM, revealed Resident 45's bilateral feet/toes were resting against the footboard of their bed. Review of Resident 45's clinical record progress notes revealed a nurse's progress note dated November 7, 2023, at 9:55 PM, that indicated that Resident 45 was found to have a dark, purple red coloration with generalized dependent edema noted at right lower shin, ankle, and foot. Noted area that presents as venous stasis issue at tip of right great toe and same at left great toe. Bilateral lower extremities are cool to touch with dependent, generalized edema noted. Review of Resident 45's clinical record progress notes also revealed a nurse's note dated November 7, 2023, at 10:05 PM, that indicated that a consult had been faxed to Wound Healing Solutions (wound mangement consultation service) to determine etiology and treatment of areas at the tip of right great toe and tip of left great toe. Review of Resident 45's clinical record progress notes revealed a note dated November 17, 2023, at 395784 Page 11 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2:41 PM, that indicated that the resident had been seen by the wound specialist from Healing Partners (wound mangement consultation service) earlier that day at 7:41 AM, and Resident 45 had a pressure injury to their left great toe that measured 0.4 centimeters (cm) by 0.6 cm, and was classified as a deep tissue injury. A diagnosis of Pressure-induced deep tissue damage of the other site was added, treatment orders were given, and a recommendation was made for staff to ensure the resident had proper fitting footwear to prevent/minimize unwanted pressure and friction. Review of Resident 45's clinical record progress notes revealed a note dated November 20, 2023, at 1:39 PM, that indicated their toe was assessed that morning and, at that time, Resident's toes were noted to be hitting against footboard of bed causing possible trauma to site. Resident was repositioned to prevent sliding in bed. Review of Resident 45's clinical record progress notes revealed a note dated November 24, 2023, that indicated the area to their left toe now measured 0.5 cm by 0.5 cm, and was documented as a trauma area to left great toe. Review of Resident 45's clinical record progress notes revealed a note dated December 1, 2023, at 3:07 PM, that indicated that the resident was seen by the wound specialist from Healing Partners earlier that day at 8:07 AM, and that Resident 45 had an injury to their left great toe. Per nursing staff this is due to trauma from the patient hitting her toes on the end of the bed. The note went on to state that the primary etiology was trauma, that the wound was still classified as a deep tissue injury, and measured 0.4 cm by 0.6 cm. Review of Resident 45's clinical record progress notes revealed a note dated December 7, 2023, that indicated the resident was seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was arterial and measured 0.4 cm by 0.5 cm. This note also included the results of their November 8, 2023, arterial studies that showed No significant PAD [Peripheral Artery Disease - condition in which narrowed arteries reduce blood flow to the arms and legs] of arteries of bilateral LE [lower extremities]. ABI [Ankle Brachial Index - test for peripheral artery disease]: normal range and satisfactory perfusion [how much pressure it takes to push blood through all the blood vessels in a specific area]. Review of Resident 45's clinical record progress notes revealed a note dated December 15, 2023, that indicated they were seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was arterial and measured 0.4 cm by 0.5 cm. This note also included the aforementioned results of their November 8, 2023, arterial studies that showed No significant PAD of arteries of bilateral LE. ABI: normal range and satisfactory perfusion. Review of Resident 45's clinical record progress notes revealed a note dated December 21, 2023, at 1:01 PM, that indicated L[eft]Toe is NOT a Pressure Injury - We need to d/c [discontinue] documenting this as a Pressure injury, per DON [Director of Nursing]/WCC [wound care certified]. Review of Resident 45's clinical record progress notes revealed a note dated December 22, 2023, that indicated the resident was seen by the wound specialist from Healing Partners earlier that day, and that the etiology of Resident 45's wound to their left great toe was arterial and measured 0.4 cm by 0.5 cm. This note also included the aforementioned results of their November 8, 2023, arterial studies that showed No significant PAD of arteries of bilateral LE. ABI: normal range and satisfactory perfusion. 395784 Page 12 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 45's clinical record progress notes revealed a note dated December 29, 2023, that indicated they were seen by the wound specialist from Healing Partners earlier that day, the the etiology of Resident 45's wound to their left great toe was arterial and measured 0.0 centimeters by 0.0 centimeters and was resolved. Further review of Resident 45's clinical record progress notes revealed that facility nurses continued to document on the area to the left great toe on a weekly basis. During an interview with the NHA on March 20, 2024, at 10:37 AM, concerns were presented regarding wound documentation and classification of Resident 45's wound in the clinical record. Discussion specifically included that there were notes by the wound specialist consultant that had identified the area as pressure initially, then the wound specialist consultant documented that the wound was trauma related, and then the wound specialist consultant documented that the wound was an arterial ulcer. It was also shared that in the same note by the wound specialist consultant that indicated the wound was an arterial ulcer, it was noted that the arterial test results revealed that Resident 45 did not have any arterial blood flow blockages. Surveyor also shared that there were notes that indicated the wound was resolved and notes that indicated that the wound remained. During an interview with the NHA and Employee 1 (RNAC - Registered Nurse Assessment Coordinator) on March 20, 2024, at 2:26 PM, Employee 1 indicated that they were reviewing everything to determine what type of wound Resident 45 had. The NHA also indicated that the Registered Nurse Supervisor was going to assess Resident 45 to determine if the wound was still present. She also indicated that she had reached out to the wound specialist consultant for additional information. The NHA indicated that she seemed to recall that there was some discussion with the former Director of Nursing (DON) and the wound specialty consultant having conflicting information regarding Resident 45's wound. Email communication received from the NHA on March 20, 2024, at 7:30 PM, indicated that Resident 45 had a wound to their left great toe that was documented as resolved on December 29, 2023. She also indicated that, according to an interview with the Nurse Supervisor that date, staff continued to document on the resolved area because there is still a scab. Email communication received from the NHA on March 21, 2024, at 9:00 AM, included an email from Wound Healing Partners's wound nurse who saw Resident 45 for her left great toe wound, and indicated that the DON did not think this was pressure and did not want it listed as such. The email further indicated that was why arterial studies were ordered. The NHA also indicated that facility staff are still treating the L[eft] great toe because there is still a scab on it. They continue to monitor and will make referral to WHP (Wound Healing Partners) if necessary. During a final interview with the NHA on March 21, 2024, at 10:30 AM, she confirmed that she would expect clear communication to have occurred to determine the exact wound type for adequate follow-up at the time that Resident 45 developed the wound. She also indicated that the DON who was employed at the facility at the time that Resident 45 developed their wound has since been terminated, and that part of the reason they were terminated was related to wound classifications. Review of Resident 67's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia. Review of Resident 67's current comprehensive person-centered care plan revealed a focus area of: The Resident has a Urinary Tract Infection (UTI), with an initiation date of February 19, 2024, and a 395784 Page 13 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0684 Level of Harm - Minimal harm or potential for actual harm revision date of March 16, 2024, with an intervention to include: monitor vital signs every shift until March 19, 2024, with an initiation date of March 16, 2024. Review of Resident 67's clinical record revealed vital signs were not being monitored every shift as care planned from March 12, 2024, to March 19, 2024. Residents Affected - Some During an interview with the NHA on March 21, 2024, at 1:28 PM, she revealed that Resident 67's vital signs were not consistently documented, and she would have expected them to have been if it was care planned. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services 395784 Page 14 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to implement a fall intervention for one of six residents reviewed for falls (Resident 29). Residents Affected - Few Findings Include: Review of facility policy, titled Fall Prevention and Management Interventions, dated May 11, 2018, revealed Bedside mat. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's progress notes revealed a note dated January 22, 2024, stating that Resident 29 had an unwitnessed fall and a new fall intervention would be a fall mat to the left side of Resident 29's bed. Review of Resident 29's current care plan revealed an intervention dated January 22, 2024, for a fall mat to the left side of the bed. Review of Resident 29's current physician orders revealed an order dated February 8, 2024, for a fall mat to the left side of the bed. Observations of Resident 29's room on March 19, 2024, at 1:21 PM, and on March 21, 2024, at 9:07 AM, revealed Resident 29 in bed, with a fall mat on the right side of the bed. Further observations revealed there was no fall mat on the left side of the bed during either observation. On March 21, 2024, at 10:16 AM, the Nursing Home Administrator (NHA) was made aware of the observations of the fall mat not being on the left side of the bed. In an email correspondence from the NHA on March 21, 2024, at 11:40 AM, she stated that, based on Resident 29's physician order and care plan, staff are not following the care plan by placing the fall mat to the right side of the bed. 28 Pa code 211.12(d)(1)(5) Nursing services 395784 Page 15 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring and timely implementation of interventions to maintain acceptable parameters of nutritional status for four of 17 residents reviewed (Residents 22, 23, 45, and 57), resulting in actual harm as evidenced by continued weight loss after a significant weight loss was documented for two of 17 residents reviewed (Residents 22 and 45). Residents Affected - Few Findings include: Review of facility policy, titled Weight Monitoring, dated October 2022, read, in part, The facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or residents preferences indicate otherwise .the facility will utilize a systematic approach to optimize a residents nutritional status. This process includes .Monitoring the effectiveness of interventions and revising them as necessary .Residents with weight loss-monitor weight weekly .the physician should be informed of a significant change in weight and may order nutritional interventions .The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .the interdisciplinary plan of care communicates care instructions to staff. Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). Review of Resident 22's weights revealed she weighed 127.5 pounds (lbs) on January 22, 2024; 109.8 lbs on February 2, 2024; 109.7 lbs on February 7, 2024; and 107.4 lbs on February 13, 2024. This equated to a weight loss of 17.7 pounds (-13.8%) from January 22, 2024, to February 2, 2024, and a continued weight loss of 2.4 pounds (-2%) from February 2, 2024, to February 13, 2024. Review of Resident 22's clinical record failed to reveal that a nutritional assessment was completed for Resident 22 between the dates of August 14, 2023, and March 20, 2024; and failed to reveal that any interventions were put into place for a significant weight loss between February 2, 2024 (the date a significant weight loss was noted), and February 16, 2024 (the date the physician was notified of Resident 22's weight loss). Review of Resident 22's progress notes revealed a note dated February 16, 2024, that stated, [Employee 11 (Physician)] notified of resident's 20 lb weight loss over past 3 weeks. Resident is consuming 0-25% of meals consistently, has Med Pass 2.0 ordered twice daily and receives snacks between meals three times daily. Antibiotic treatment for UTI (urinary tract infection) was completed on 2/10/24. New order received for Remeron 15 mg by mouth in the evenings. POA (power of attorney) notified of new order. Review of Resident 22's progress notes revealed a note dated February 19, 2024, that stated, Fax placed to MD in regards to obtaining weekly weights. Review of Resident 22's progress notes revealed a note dated February 20, 2024, that stated, New 395784 Page 16 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0692 order for weekly weights due to weight loss. POA aware. Level of Harm - Actual harm Review of Resident 22's physician orders revealed an order for Weekly weights x 4 every day shift every Mon for 4 Administrations, with a start date of February 26, 2024. Residents Affected - Few Review of Resident 22's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored) and her clinical record failed to reveal a weekly weight was obtained on March 11, 2024, as per physician order. Review of Resident 22's progress notes revealed a note dated February 22, 2024, that stated, Notified by Social worker that resident's family was updated at care plan meeting about resident's weight loss and declining condition. Family will discuss hospice. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:34 PM, the surveyor revealed the concern with Resident 22's weight loss not being assessed timely, interventions not being put into place timely and implemented per order, and continued weight loss without interventions. The NHA confirmed she would have expected nutrition assessments and interventions to be put into place timely and implemented following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, since the facility did not have dietitian coverage during the period of Resident 22's weight loss. She also revealed that there was a corporate Certified Dietary Manager that they should have consulted during that time, but that they failed to consult them. The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 17 following a significant weight loss of 17.7 lbs (13.8%) in less than 14 days, resulting in harm as evidenced by an additional weight loss of 2.3 lbs (2%) before interventions were put into place. Review of Resident 23's clinical record revealed diagnoses that included dementia, hypertensive heart disease (heart condition caused by high blood pressure), and depression. Review of Resident 23's weight records revealed that they weighed 194.8 lbs on July 18, 2023; 187 lbs on September 3, 2023; and 164.2 lbs on March 1, 2024 (a loss of 12.19%). Review of Resident 23's Physician Services notes revealed a note dated February 27, 2024, which indicated the following: Resident 23 was being seen for a routine visit and review of their weight loss; the Resident had an 11.98% weight loss over the past six months; their weight had consistently declined month-to-month in that time; their nutritional supplement was increased in January 2024; the resident was on a regular diet with double portions and increased dessert portions; and their cause of weight loss was unknown as their caloric intake and meal consumption was high, but was likely unavoidable secondary to advanced dementia. The note further indicated that the practitioner's plan was to increase the nutritional supplement again, to have Resident 23 weighed weekly, and follow further recommendations of the dietician. Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility dietician on July 25, 2023, at the time of their admission to the facility. Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed 395784 Page 17 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0692 Level of Harm - Actual harm Residents Affected - Few that the last documentation completed by a dietician was dated August 3, 2023, at which time the note indicated that they were questioning a weight that had been obtained and had requested that the resident be reweighed. During an interview with the NHA and Employee 1 (Registered Nurse Assessment Coordinator - RNAC) on March 20, 2024, at 2:24 PM, the aforementioned information from the practitioner's note was shared, as well as concern regarding the lack of nutritional assessments or any documented follow-up by a dietician. The NHA confirmed that there were no additional nutritional assessments completed on Resident 23 since they were admitted to the facility on [DATE]. She indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the Director of Nursing (DON) was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility, and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. A follow-up review of Resident 23's clinical record on March 21, 2024, at 8:59 AM, revealed a progress note by the dietician which indicated that there was an order clarification for the weekly weight monitoring due to significant weight loss over six months. At the time of this review, there was still no documented nutritional assessment by the facility dietician. During a final interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. Review of Resident 45's clinical record revealed diagnoses that included dementia, dysphagia, and breast cancer. Review of Resident 45's weight records revealed the following weights: December 1, 2023, 111 lbs; January 22, 2024, 101.5 lbs; January 30, 2024, 101.6 lbs; February 20, 2024, 97.5 lbs February 21, 2024, 95.4 lbs February 22, 2024, 96.2 lbs February 26, 2024, 85.6 lbs February 27, 2024, 88.7 lbs March 1, 2024, 93.6 lbs March 5, 2024, 93.5 lbs 395784 Page 18 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0692 Level of Harm - Actual harm Residents Affected - Few This equated to a significant weight loss of 13.5 lbs (12.2%) between December 1, 2023, and February 20, 2024; an additional 11.9 lb weight loss between and February 20, 2024 and February 26, 2024; and a total weight loss of 17.5 lbs (15.7%) between December 1, 2023 and March 5, 2024. Review of Resident 45's clinical record revealed that their last nutritional assessment was completed by a dietician on September 20, 2023, at the time of their admission to the facility. Review of Resident 45's clinical record progress notes revealed a note by the facility dietician dated March 6, 2024, at 1:09 PM, which indicated that their weekly weights were reviewed and that their current weight on March 5, 2024, triggers as a significant loss of 6.9% x 30 days. Resident continues to tolerate a Regular diet, regular texture, thin liqs [liquids] PO [oral] intake is not adequate to meet estimated needs at ~ [approximately] 30 % ave[rage] w[ith]/ 9 meal refusals. Resident continues to receive and accept Medpass [a nutritional supplement] 240 mL [milliliters] BID [twice a day], ~[approximately] 100% ave[rage]. Recommending to increase Medpass to 240 mL TID [three times a day] to provide additional calories and protein. Order added on (2/17) to encourage fluids. Weekly wt [weight] monitoring to continue. Care plan updated. In addition, there was a progress note dated March 6, 2024, at 1:37 PM, which indicated that Resident 45's responsible party was notified of their weight change and new recommendations. The documentation did not indicate if Resident 45's physician was made aware of the weight loss. Further review of Resident 45's clinical record progress notes failed to reveal any documentation regarding Resident 45's weight loss, including physician notification and responsible party notification between February 20, 2024, when the resident started triggering for weight loss, and March 6, 2024. The last documentation of Resident 45's physician being made aware of any weight loss was on December 19, 2023, during which time the resident was experiencing a COVID-19 infection and additional orders were given for nutritional supplementation. During an interview with the NHA on March 20, 2024, at 10:24 AM, the aforementioned concerns were shared regarding Resident 45's weight loss identification, lack of dietician involvement, and lack of documentation that the physician or responsible party were notified of the weight loss that triggered on February 20, 2024, and of ongoing weight loss triggered with each weight obtained thereafter. The NHA confirmed that there were no other nutritional assessments completed for Resident 45 since they were admitted to the facility on [DATE]. She indicated that the facility did not have a dietician during this timeframe, and that nursing was attempting to identify and address weight concerns. During another interview with the NHA and Employee 1 on March 20, 2024, at 2:24 PM, the aforementioned concerns were all shared again. The NHA indicated that the facility was without a dietician from September 15, 2023, until March 5, 2024. She indicated that during the time the facility was without a dietician, the DON was to be reviewing resident weights and addressing weight concerns in the interim, and that there was a corporate Certified Dietary Manager that the facility could have reached out to when needed. The NHA shared that this DON was no longer an employee at the facility and that the facility had failed to contact the corporate Certified Dietary Manager for assistance. During an interview with the NHA on March 21, 2024, at 10:29 AM, she confirmed that she would expect a resident to have a nutritional assessment completed quarterly by a dietician, at minimum, and with any nutritional change, such as weight loss. During a final interview with the NHA on March 21, 2024, at 1:24 PM, the NHA confirmed that 395784 Page 19 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0692 Resident 45's physician and responsible party should have been notified when they began triggering for weight loss at the end of February 2024. Level of Harm - Actual harm Residents Affected - Few The facility failed to ensure timely evaluation and implementation of new interventions to prevent further weight loss for Resident 45 following a significant weight loss of 13.5 lbs. (12.2%), resulting in harm as evidenced by an additional weight loss which totaled 17.5 net pounds (15.7%) before interventions were put into place. Review of Resident 57's clinical record revealed diagnoses that included dementia, major depressive disorder, and vitamin D deficiency. Review of Resident 57's weight measures revealed she had a significant weight gain of 9.4 lbs. (+10.6%) from October 17, 2023, to November 3, 2023. Review of Resident 57's clinical record on March 20, 2024, failed to reveal that a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, and present. During an interview with the NHA on March 20, 2024, at 2:34 PM, the surveyor revealed the concern that Resident 57 did not have a nutritional assessment completed following a significant weight change. The NHA confirmed she would expect nutrition assessments to be conducted timely following a significant weight change. The NHA further revealed nursing was responsible for notifying the physician of significant weight changes at that time, as the facility did not have dietitian coverage during the period of Resident 57's weight gain. She also revealed there was a corporate Certified Dietary Manager that they should have consulted during that time, but failed to do. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(6) Management. 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services. 395784 Page 20 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for two of two residents reviewed for respiratory care (Residents 33 and 41). Residents Affected - Few Findings Include: Review of facility policy, titled Noninvasive Ventilation (CPAP [in part]), with an implemented date of April 17, 2023, revealed Definitions: CPAP, or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea [intermittent airflow blockage during sleep]. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth and 13. Follow manufacturer instructions for the frequency of cleaning/replacing filters [in part]. Review of Resident 33's clinical record revealed diagnoses that included sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and atrial fibrillation (A-fib - an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 33's current physician orders revealed an order dated March 5, 2023, for CPAP for sleep, and an order dated April 4, 2023 for CPAP mask to be placed in appropriate storage bag when not in use. Observations of Resident 33's room on March 18, 2024, at 10:44 AM; March 19, 2024, at 1:08 PM; and March 20, 2024, at 9:38 AM, revealed Resident 33's CPAP mask was not in a storage bag and was laying on top of the CPAP machine, which was located on Resident 33's bedside dresser. Additional observations on those dates and times also revealed a clear, gallon container of distilled water sitting near the CPAP machine. The distilled water container was not full and had no date indicating when the container was opened. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 11:08 AM, she stated that Resident 33's CPAP mask should be stored in a bag when not in use and the distilled water should be dated when opened. Review of Resident 41's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), unspecified heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and depression. Review of Resident 41's physician orders revealed the following orders: CPAP,continue with current settings at 8.0, dated March 9, 2023; Change CPAP mask and fine filter (light blue) every 14 days, dated February 28, 2023; and Resident requesting water level of CPAP to be checked at night and be refilled if needed every night shift, dated February 28, 2023. Observations of Resident 41's room on March 19, 2024, at 8:38 AM, and March 20, 2024, at 9:41 AM, revealed their CPAP machine to be sitting on their nightstand with a clear plastic gallon container of distilled water, approximately 25 percent full, with no date indicating when the container was opened. Observation of the CPAP filter at the same times revealed a slight gray, dusty appearance along 395784 Page 21 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0695 the blue plastic rim of the filter. Level of Harm - Minimal harm or potential for actual harm Review of Resident 41's March Treatment Administration Record (TAR) revealed that on March 13, 2024, their filter and tubing were scheduled to be changed, but that it was coded as 9. Other/See progress note. Residents Affected - Few Further review of the TAR revealed no other entries that the filter or tubing were changed. Review of Resident 41's clinical record progress notes for March 13, 2024, revealed a note that indicated the order was not completed because supplies were not available and that the Registered Nurse would notify Social Services. Further review of Resident 41's clinical record progress notes revealed no other documentation regarding obtaining the supplies and/or the filter and tubing being changed as ordered. During an interview with the NHA on March 20, 2024, at 10:54 AM, the aforementioned observations were shared as well as the concern that the documentation indicated that Resident 41's filter and tubing were not changed as ordered because of lack of supplies. The NHA indicated that the distilled water should have been dated when opened. She further indicated that she would look into the supply concern and the changing of the filter and tubing. In email communication received from the NHA on March 21, 2024, at 9:22 AM, she indicated: We do not have documentation to prove that the C-PAP tubing was changed. I do know we had a supply concern that weekend but it was communicated that when the supplies arrived Monday the tubing would be changed. However, we do not have documentation that it was done. During a follow-up interview with the NHA on March 21, 2024, at 10:27 AM, she confirmed that she would expect staff to communicate supply concerns and complete all necessary follow-up documentation of actions/communications. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services. 395784 Page 22 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure there was sufficient staff to ensure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being for one of 19 residents reviewed (Resident 29). Findings Include: Review of facility policy, titled Call Lights: Accessibility and Timely Response, dated October 23, 2022, revealed All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Review of Resident 29's clinical record revealed diagnoses that included atrial fibrillation (A-fib- an irregular, often rapid heart rate that commonly causes poor blood flow) and hypertension (elevated blood pressure). Review of Resident 29's current care plan revealed an intervention, dated December 10, 2023, for moderate assistance with toilet use, and a care plan intervention, dated February 6, 2024, to transfer and ambulate with assist of one with rolling walker and gait belt. During an interview with Resident 29 on March 18, 2024, at 12:13 PM, she stated that staff do not always answer her call bell timely and, if they do, they often tell her they are busy. At that time, Resident 29 was noted to be in her gown, which she stated she slept in the night prior and had not yet received morning care. On March 18, 2024, at 12:51 PM, staff were observed passing out lunch trays. The surveyor was in the lounge right outside of Resident 29's room and, at that time, the surveyor overheard an unidentified staff member say to Resident 29 that they were busy passing trays right now. The surveyor immediately entered Resident 29's room, but the unidentified staff member had already exited. The surveyor asked Resident 29 what she asked the staff member for and if Resident 29 knew the staff member's name. Resident 29 stated she asked to use the bathroom and she thought it was Employee 12 who told her they were passing out trays right now. Continuous observations from 12:51 PM through 1:22 PM revealed no staff member assisting Resident 29 to the bathroom. At 1:23 PM, Resident 29 told the surveyor she still needed to use the bathroom and put her call light on at that time. Resident 29's call light was immediately responded to and she was assisted to the bathroom, 32 minutes after she initially asked to use the bathroom. On March 19, 2024, at 1:10 PM, the surveyor observed Resident 29's call light to be on. The call light was already on prior to the surveyor arriving to the nursing unit. At 1:18 PM, the surveyor spoke to Resident 29 who stated she was ringing for a drink, but that her family member just went and got it for her so she didn't have to wait anymore. 395784 Page 23 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 1:27 PM, Resident 29's call light was responded to by staff, 17 minutes after the surveyor noted the call light to be on. On March 20, 2024, at 2:45 PM, the Nursing Home Administrator (NHA) was made aware of the aforementioned observations. She stated that she would have to look at the facility policy, but it is her expectation that a call light be responded to within 15 minutes. On March 20, 2024, at 5:15 PM, the NHA provided the call bell policy and stated Our policy does not address timely response or how long is expected to answer a call bell. In a follow-up interview with the NHA on March 21, 2024, at 10:18 AM, it was revealed that Employee 12 was not assigned to Resident 29's unit on March 18, 2024, so it was unable to be confirmed if that was the staff member who stated they were passing trays when Resident 29 requested to use the bathroom. At that time, the NHA again stated that it is her expectation for call bells to be responded to within 15 minutes. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 211.12 (d)(1)(4)(5) Nursing services 395784 Page 24 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on facility document review and staff interview, it was determined that the facility failed to complete a performance review for nurse aide staff at least once every 12 months for one of five employees reviewed (Employee 6). Residents Affected - Few Findings Include: Review of Employee 6's personnel record revealed a hire date of September 18, 2017, and no evidence of a recent annual performance review. On March 20, 2024, at 8:22 AM, the Nursing Home Administrator confirmed that Employee 6 did not have a recent annual performance review completed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(2) Personnel policies and procedures. 395784 Page 25 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 an accurate accounting of the disposition of uncontrolled medications during the discharge process for one of two discharged residents reviewed (Resident 68). Findings include: Review of Resident 68's closed clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats causing the heart to be unable to pump an adequate amount of blood to the body). The review of the closed clinical record for Resident 68 on March 21, 2024, revealed that Resident 68 was admitted to the facility on [DATE], and that they passed away at the facility on January 9, 2024. Review of Resident 68's physician orders revealed that the resident had a total of 24 uncontrolled medications orders at the time of their death. Further review of Resident 68's closed record revealed a form, titled Medication Disposition, with an effective date of January 11, 2024, which listed three medications with doses remaining that were being returned to the pharmacy. The form was not signed/dated as being completed. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 2:20 PM, the aforementioned concern was shared and additional information was requested. Email communication received from the NHA on March 21, 2024, at 10:23 AM, confirmed that Resident 68's medication disposition was started and not completed. During a final interview with the NHA on March 23, 2023, at 10:46 AM, the NHA confirmed that she would expect all uncontrolled medications to be accounted for on the medication disposition form at the time of a resident's discharge and that the form would be completed in it's entirety. 28 Pa. Code 211.9(j.1)(3) Pharmacy services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395784 Page 26 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations in a timely manner for one of five residents reviewed for unnecessary medications (Resident 7). Findings include: Review of facility policy, titled Medication Regimen Review, undated, revealed At least monthly, the consultant pharmacist reports any irregularities to the attending physician, Medical Director and Director of Nursing .The findings are faxed or e-mailed within (72 hours) to the director of nursing or designee and are documented in the resident's active record. The prescriber and/or medical director is notified if needed .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident 7's clinical record revealed diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident 7's monthly pharmacy reviews revealed that on December 27, 2023, a recommendation was made by the pharmacist. Review of Resident 7's clinical record revealed no evidence of what the recommendation was or if the physician responded to it. During an interview with the Nursing Home Administrator on March 20, 2024, at 11:04 AM, she stated that the pharmacist sent the recommendation to the person who was the Director of Nursing (DON) at that time, and that the DON did not forward the recommendation to the provider for a response. She further stated that she would expect the pharmacy recommendations to be forwarded to the physician and responded to timely. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395784 Page 27 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on clinical record review and staff interviews, it was determined that the facility failed to consult qualified dietary staff to assess the nutritional needs of residents in the absence of a qualified dietitian for four of 17 residents reviewed (Residents 22, 23, 45, 57). Findings include: During the initial tour of the kitchen and pantries with Employee 9 (Cook) on Monday March 18, 2024, at 9:25 AM, he revealed the Dietary Manager was off that day, the Dietitian was new, and he wasn't sure about her schedule. During an interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:50 AM, she revealed they now have a Dietitian that recently started a little over a week ago. During an interview with Employee 8 (Dietary Manager) on March 20, 2024, at 11:25 AM, he revealed he has been employed as the Dietary Manager at the facility since October 2023 and they have been without a Dietitian since then. He revealed nursing communicates residents' diet orders to the kitchen, and Employee 9, himself, or a dining clerk see residents upon admission, and as needed, to obtain their personal food and beverage preferences and allergies; this information is then sent to headquarters and a nutritional ticket is generated for that resident. He further revealed neither he nor Employee 9 would be able to assess residents' nutritional needs or nutritional status. During an interview with Employee 10 (Registered Dietitian) on March 20, 2024, at 12:08 PM, she revealed she started employment with the facility on March 5, 2024. She further revealed she usually comes to the facility on Wednesdays, but she has remote access to the facility's electronic health record and checks in daily and as needed. Review of Resident 22's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and dysphagia (difficulty swallowing). Review of Resident 22's clinical record failed to reveal a nutritional assessment was completed for Resident 22 between the dates of September 15, 2023, and March 20, 2024. Review of Resident 23's clinical record revealed diagnoses that included dementia and anemia (deficiency of healthy red blood cells). Review of Resident 23's clinical record on March 19, 2023, at 10:31 AM, revealed that they had one nutritional assessment completed by the facility Dietician on July 25, 2023, at the time of their admission to the facility. Review of Resident 23's clinical record progress notes on March 19, 2023, at 10:31 AM, revealed that the last documentation completed by a Dietician was on August 3, 2023, at which time the note indicated that they were questioning a weight that was obtained and had requested that the resident be reweighed. Review of Resident 45's clinical record revealed diagnoses that included dementia and dysphagia. 395784 Page 28 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0801 Level of Harm - Minimal harm or potential for actual harm Review of Resident 45's clinical record failed to reveal any nutritional assessments between the dates of September 20, 2023, and March 6, 2024. Review of Resident 57's clinical record revealed diagnoses that included dementia and vitamin D deficiency. Residents Affected - Some Review of Resident 57's clinical record on March 20, 2024, failed to reveal a nutritional assessment was completed for Resident 57 between the dates of September 15, 2023, to present. During an interview with the NHA on March 20, 2024, at 2:29 PM, the surveyor revealed the concern with absence of qualified dietary staff to conduct nutrition assessments during the period when the facility was without Dietitian coverage, which was between September 15, 2023, and March 5, 2024. The NHA revealed they could have been consulting the corporate Certified Dietary Manager at the time, and should have, but they failed to consult them. 28 Pa. Code 201.18(b)(1)(3)(e)(6) Management. 395784 Page 29 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, review of select facility documentation, observation, completion of a test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that were palatable and at appetizing temperatures for one of one meals tested. Residents Affected - Few Findings include: Review of facility policy, titled Resident Services- Taste and Temperature Control, last revised November 2002, read, in part, Cold foods such as milk, butter, ice cream and juices are refrigerated during service or properly iced. Review of document, titled Senior Living Meal Assessment, revealed hot food should be served at 130 degrees or greater, and cold beverages should be served at or below 45 degrees. An interview with Resident 270 on March 18, 2024, at 10:54 AM, revealed the food could be better and is always served cold. Review of facility grievance log for November 2023 revealed a grievance filed on November 15, 2023, with complaints of cold food. Observation during the tray line meal service on March 20, 2024, at 11:50 AM, revealed the cold beverages served on the trays were stored at room temperature during service. A test tray was completed on March 20, 2024, at 12:42 PM, utilizing a lunch tray served from tray line in the main kitchen. A test tray was served and placed in a closed food cart for approximately two minutes prior to being delivered to the Love Unit (other trays for room service were being delivered here also at this time). The test tray included: country fried steak with gravy, baked potato, green beans, strawberry cake, apple juice, and coffee. Temperatures taken by Employee 8 (Dietary Manager) revealed the country fried steak with gravy was 121 degrees, the green beans were 119 degrees (the green beans were not seasoned), and the apple juice was 60 degrees. Consequently, all items were not palatable. During an interview with Employee 8 on March 20, 2024, at 12:50 PM, he revealed that he would expect hot food and cold beverages to be served at palatable temperatures. He further revealed that he put a new pan of green beans directly on the tray line without seasoning them first with margarine, salt, and pepper, that he should have seasoned them, and that the cold beverages served from the tray line should be kept chilled during service. During an interview with the Nursing Home Administrator on March 20, 2024, at 2:31 PM, the surveyor revealed the concerns with the test tray. The NHA revealed she would expect food and beverages to be served at appetizing and palatable temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee. 395784 Page 30 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize and monitor equipment in accordance with professional standards for food service safety in the main kitchen and in two of two pantry areas. Findings include: Review of facility policy, titled Date Marking for Food Safety, last revised April 15, 2023, read, in part, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days .The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .the marking system shall consist of the day/date of opening and the day/date the item must be consumed or discarded .the department head, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard them accordingly. Review of facility policy, titled Unit Refrigeration, last revised August 2009, read, in part, Purpose: To assure that refrigeration units are properly monitored for temperatures and contents storage .Nursing team members to document on Refrigerator Temperature Log on all refrigerators on unit .Nursing team members will maintain daily temperature logs for each refrigerator. Observation in the dry storage area in the main kitchen on March 18, 2024, at 9:28 AM, revealed three gelatin mixes not dated; two stuffing mixes not dated; and one package of strawberry mousse mix not dated. Observation in the main walk-in refrigerator unit on March 18, 2024, at 9:34 AM, revealed a container of sweet and sour sauce with the lid partially open; one cut zucchini and tomato wrapped together, not dated; one bucket of pickles dated April 28, 2023 that had a black substance around the lid; and four individual yogurts with a use by date of February 2, 2024. Observation in the walk-in freezer unit on March 18, 2024, at 9:40 AM, revealed two bags of donut holes, not dated; two individual pie shells, not dated; six cupcakes in a bin labeled use by January 16, 2024; and four pumpkin pies labeled use by January 25, 2024. Observation in the main kitchen on March 18, 2024, at 9:43 AM, revealed four individually prepped cups of brown sugar, not dated. An interview with Employee 9 (Cook) on March 18, 2024, at 9:43 AM, revealed the brown sugar cups should have been labeled with a date. Observation in the main kitchen on March 18, 2024, at 9:49 AM, revealed one container of cinnamon sugar labeled use by March 6, 2024; one open container of donut glaze not dated with an open date; and one open container of margarine not labeled with an open date. An interview with Employee 9 on March 18, 2024, at 9:49 AM, revealed the open containers should have been labeled with an open date and a date when they should be discarded. 395784 Page 31 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the three-compartment sink in the main kitchen on March 18, 2024, at 9:53 AM, revealed the sanitizer sink was filled with sanitizing solution and water. The surveyor requested Employee 9 test the sanitizer water with a test strip. The test strip used to test the water revealed a concentration around 100 parts per million (ppm- concentration unit of measure). An interview with Employee 9 on March 18, 2024, at 9:54 AM, revealed he was not sure what concentration the sanitizer solution should be, and that they do not log the concentration of the sanitizer solution. Observation of the dishwasher temperature log in the main kitchen on March 18, 2024, at 9:56 AM, revealed the AM and PM temperatures were logged for March 1 and 2, 2024, but no other dates for March 2024 were logged. Observation during initial tour of the Faith pantry area on March 18, 2024, at 10:05 AM, revealed a bin of individual cookies, not dated. Observation of the Refrigerator/Freezer Temperature Log in Faith Pantry Area on March 18, 2024, at 10:07 AM, revealed there were holes in the PM area of the March 2024 temperature log on March 1-6, 9-10, and 13-16, 2024. Observation during initial tour of the Love pantry area on March 18, 2024, at 10:14 AM, revealed 12 individual cereal boxes in a bin, not dated; and nine individual cereal boxes in a cabinet, not dated. Observation of the Refrigerator/Freezer Temperature Log in Faith Pantry Area on March 18, 2024, at 10:17 AM, revealed it was a different log than the previous unit, as it only required staff to log the refrigerator and freezer temperatures once daily, and temperatures were not recorded on March 6, 2024. An interview with the Nursing Home Administrator (NHA) on March 20, 2024, at 10:14 AM, revealed it is the facility's expectation that food and beverages are labeled and dated, and food items and kitchen equipment are stored and utilized in accordance with professional standards. During an interview with Employee 8 (Dietary Manager) on March 20, 2024, at 11:31 AM, the surveyor revealed the concerns of the initial tour of the kitchen and pantries on March 18, 2024, including the lack of a log for the three-compartment sink sanitizer ppm. Employee 8 confirmed he would expect labeling and dating per facility policy, and staff should be logging the ppm of the three compartment sink sanitizer water. The surveyor requested information on the required ppm of the sanitizer solution used in order for it to be effective. Review of Safety Data Sheet (SDS) for the sanitizing solution provided by the NHA on March 20, 2024, at 12:28 PM, revealed the ppm of the sanitizing solution should be between 272 and 700 ppm to be effective. During a follow-up interview with the NHA on March 20, 2024, at 2:28 PM, she confirmed the SDS states the ppm should be between 272 and 700 ppm, dietary staff should be recording the concentration of the sanitizing sink, the facility should not be using conflicting temperature logs in the pantries, and she expects them to use the log that requires them to log temperatures daily. 395784 Page 32 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0812 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.6(f) Dietary services Residents Affected - Some 395784 Page 33 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review and staff interview, it was determined that the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Residents Affected - Many Findings Include: Review of facility policy, titled Water Management Program, dated October 23, 2022, revealed It is the policy of this facility to establish water management plans for reducing the risk of Legionellosis and other opportunistic pathogens . A water management team has been established to develop and implement the facility's water management program . The Maintenance Director maintains documentation that describes the facility's water system . A risk assessment will be conducted by the water management team annually . The facility was unable to provide an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and was unable to provide evidence of measures to prevent the growth of opportunistic waterborne pathogens and how to monitor them. During an interview with the Nursing Home Administrator on March 19, 2024, at 10:15 AM, she confirmed that the facility has not implemented a water management program. 28 Pa. Code 201.18(b)(1)(3) Management 395784 Page 34 of 35 395784 03/21/2024 Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on personnel file review and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided required in-service training consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention, for five of five nurse aide employee records reviewed (Employees 2, 3, 4, 5, and 6). Findings Include: Review of personnel information revealed Employee 2's hire date was February 14, 2022; Employee 3's hire date was May 2, 2016; Employee 4's hire date was June 21, 2022; Employee 5's hire date was September 4, 2012; and Employee 6's hire date was September 18, 2017. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that dementia management training was completed by Employees 2, 3, 4, 5, and 6 within the past 12 months, or that abuse prevention training was completed by Employee 3 within the past 12 months. During an interview with the Nursing Home Administrator (NHA) on March 19, 2024, at 2:55 PM, she stated that it had already been recognized that nurse aide education was a concern and that a performance improvement plan had been initiated. On March 20, 2024, at 8:22 AM, the NHA confirmed that Employees 2, 3, 4, 5, and 6 did not have any education for the year 2023. The NHA stated that Employees 2, 4, 5, and 6 completed an education fair in February 2024, which included Resident Rights, Abuse/Neglect and Exploitation, Emergency Preparedness, Lift Training (Nursing only), Behavioral Health, QAPI, Compliance & Ethics, Communication, but could provide no documented evidence that at least 12 hours of training had been completed in the past 12 months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(d) Staff development 395784 Page 35 of 35