Health inspection·June 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **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 notify the resident/resident representative of the resident transfer, in writing, to include the following: the reason for the transfer or discharge, date of transfers, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman; and failed to provide the resident/resident representative written notice of the bed hold policy at time of transfer for four of four residents reviewed for hospitalizations (Residents 10, 23, 32, and 43). Findings include: Review of facility policy, Transfer or Discharge Documentation, revised December 2016, read, in part, an appropriate transfer notice will be provided to the resident and/or legal representative. Review of facility policy Bed-Hold and Return to Facility Policy and Procedure, initiated 2015, read, in part, before the resident is transferred to a hospital, the Facility must provide written information to the resident or resident representative, which specified the duration of the bed-hold and the reserve bed payment Review of facility Bed Hold Agreement, revised December 2008, read in part, the resident/resident representative was informed of the bed-holding policy and the basic per-diem rate and are to elect whether they wish to hold the bed or not. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall and unsteadiness on feet. Review of Resident 10's clinical record revealed he was transferred out of the facility and admitted to the hospital on [DATE]. Further review of Resident 10's clinical record failed to reveal notation that a bed hold notice or transfer notice were provided to the Resident or the Resident Representative at the time of the hospitalization. Interview with the Director of Nursing (DON) on June 18, 2025, at 9:50 AM, revealed that it was the responsibility of nursing staff to be completing and sending the notices, but they were not competing them, and she would expect for them to be completed and sent upon hospital transfers. Page 1 of 18 395844 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0628 Level of Harm - Minimal harm or potential for actual harm Review of Resident 23's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and anxiety disorder (mental health disorder characterized by excessive worry or fear). Review of Resident 23's clinical record revealed that on May 8 and 30, 2025, Resident 23 was transferred to a hospital emergency department after a medical change in condition. Residents Affected - Some Review of available documentation revealed the facility did not provide Resident 23, nor Resident 23's Representative, with notices nor the facility's bed hold policy upon transfer to the hospital for the aforementioned dates. Review of Resident 32's clinical record revealed diagnoses that included acute on chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats) and acute respiratory failure with hypoxia (the inability of the respiratory system to meet the oxygenation requirements of the body). Review of Resident 32's clinical record revealed that he was transferred and admitted to the hospital on [DATE], secondary to complaints of chest pain and shortness of breath. Review of Resident 32's clinical record revealed a progress note dated May 16, 2025, at 9:48 AM, that indicated the facility's bed hold policy was reviewed with Resident 32's Representative and that she agreed to hold the bed, but review of the clinical record failed to reveal a copy of the bed hold notice was reviewed with Resident 32's Representative. Further review of the clinical record also failed to reveal the presence of a notice of transfer for his May 16, 2025, hospital transfer or documentation that the transfer notice was provided to Resident 32 or his representative. During a staff interview with the DON on June 18, 2025, at 10:20 AM, she confirmed that hospital transfer notices to the responsible party and bed hold notices were not completed as nursing was not aware they needed to complete the notices. Review of Resident 43's clinical record revealed transfers to the hospital on March 6, 2025, and April 11, 2025; Resident payor source was Medicare A. Review of Resident 43's clinical record failed to include a notice of transfer to the Resident Representative, and bed hold notice for the aforementioned dates. Interview with the DON on June 18, 2025, at 10:20 AM, revealed hospital transfer notices to the responsible party and bed hold notices were not completed, nursing wasn't aware they needed to complete the notices. 28 Pa. Code 201.14(a) Responsibility of Licensee 395844 Page 2 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on Resident Assessment Instrument (RAI - a standardized approach for applying a problem identification process in nursing homes, adopted to examine nursing home quality and to improve nursing home regulation), 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 three of 13 residents reviewed (Residents 2, 26, and 27). Residents Affected - Few Findings included: Review of RAI Version 3.0 dated October 2024, pages N1 - 11, read, in part, N0415 high risk drug classes: is taking - check if the resident is taking any medication by pharmacological classification during the last 7 days or since admission. Indication noted 1 is checked if there is an indication noted for all medications in the drug class. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (PTSD - a mental disorder that develops from experiencing a traumatic event), cerebral palsy (a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's physician orders included apixaban 5 milligrams by mouth two times a day for deep vein thrombosis (DVT - a serious condition that occurs when a blood clot forms in a deep vein), start February 4, 2025, and discontinued May 27, 2025. Review of Resident 2's significant change 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 June 7, 2025, documented yes for taking AC and indication noted. Interview with the Director of Nursing (DON) on June 18, 2025, at 12:23 PM, it was revealed that the significant change MDS was incorrect, and the care plan should've been updated to reflect the anticoagulant was discontinued. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 26's clinical record revealed she had a significant weight loss of 11% from April 8, 2025, to May 2, 2025. Review of Resident 26's Medicare 5 Day MDS with ARD (assessment reference date - last day of the assessment period) of May 7, 2025, revealed under Section K0300. Weight Loss: Loss of 5% or more in the last month or loss of 10% or more in last 6 months, Resident 26 was marked No or unknown. Interview with the DON on June 18, 2025, at 10:13 AM, revealed the aforementioned MDS was coded in error and she would expect MDS assessments to be coded accurately. 395844 Page 3 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of Resident 27'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), 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 delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Residents Affected - Few Review of Resident 27's Quarterly MDS with ARD of September 26, 2024, indicated in Section N. Medications that she had received an antipsychotic medication on a routine basis and that she had not had a gradual dose reduction. Review of Resident 27's clinical record revealed that her antipsychotic medication dose had been reduced by her physician on September 11, 2024. Review of Resident 27's Annual MDS with the assessment reference date of May 2, 2025, indicated in Section N. Medications that she was coded as receiving antianxiety and anticonvulsant medications. Review of Resident 27's clinical record revealed that she had not received any antianxiety or anticonvulsant medications. During a staff interview with the DON on June 18, 2025, at 12:29 PM, she confirmed that the MDS's were coded in error and that modifications were completed. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395844 Page 4 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on clinical record review, observation, staff and resident interviews, and facility policy review, it was determined that the facility failed to develop a baseline plan of care for one of two residents reviewed for new admission (Resident 95). Findings include: Review of facility policy, titled Care Plans - Baseline, last reviewed January 15, 2025, revealed it stated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs . Review of Resident 95's clinical record revealed diagnoses that included history of venous thrombosis (blood clot formation) and embolism (blood clot that travels through the circulatory system and blocks blood flow through a vessel) and hypertension (elevated/high blood pressure). Review of Resident 95's clinical record revealed that Resident 95 was admitted to the facility on June, 8, 2025. During an interview with Resident 95, Resident 95 was observed wearing a lidocaine patch to her right knee. When asked about her right knee, Resident 95 stated she had chronic pain in her right knee. Review of Resident 95's physician orders revealed the Resident was receiving meloxicam (prescription non-steroidal anti-inflammatory medication), and the lidocaine 4% (topical pain medication) for right knee pain. Review of Resident 95's baseline plan of care revealed no care plan for pain. Review of Resident 95's physician orders revealed Resident 95 also received an anticoagulant medication (medication that decreases the clotting ability of the blood). Review of Resident 95's baseline care plan revealed no care plan was initiated for the use of an anticoagulant medication. During a staff interview on June 17, 2025, at approximately 10:30 AM, Director of Nursing revealed that Resident 95's baseline care plan should have included a care plan for pain and anticoagulant use. 28 Pa code 211.12(d)(1)(3)(5) Nursing services 395844 Page 5 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

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. Based on policy review, observations, clinical record review, and resident and staff interviews, the facility failed to review and revise the resident plan of care for five of 13 residents reviewed (Residents 2, 19, 26, 27, and 30). Findings include: Review of facility policy, Comprehensive Person-Centered Care Plans, revised December 2016, read, in part, the care plan will include services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate risk factors associated with identified problems. Assessments of residents are ongoing, and care plans are revised as information about residents and the resident's condition changes. The interdisciplinary team must review and update the care plan. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety disorder (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's physician orders included apixaban 5 milligrams by mouth two times a day for deep vein thrombosis (a serious condition that occurs when a blood clot forms in a deep vein), start February 4, 2025, and discontinued May 27, 2025; and admission to Serenity Hospice on May 27, 2025, due to sarcopenia (muscle disease that involves a progressive loss of muscle mass, strength, and function). Review of Resident 2's care plan documented anticoagulant therapy to treat: At risk for adverse effects, date Initiated February 25, 2025, and revised on April 10, 2025. Further review of the care plan failed to document a plan of care for hospice. During an interview with the Director of Nursing (DON) on June 17, 2025, at 10:36 AM, it was revealed that the care plan should have been updated prior to June 16, 2025, to include hospice services. Interview with the DON on June 18, 2025, at 10:13 AM, it was revealed that the care plan should be updated quarterly and as needed. Review of Resident 19's clinical record revealed diagnoses that included 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 need for assistance with personal care. Review of Resident 19's care plan revealed an active focus area of At risk for loss of range of motion related to physical limitations with an intervention for Restorative Splint/Brace: Sling to right upper extremity to be worn at all times. May remove for care and skin checks, last revised May 14, 2025. 395844 Page 6 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0657 Level of Harm - Minimal harm or potential for actual harm Further review of Resident 19's care plan revealed an active focus area of Self-care deficit related to physical limitations, with in intervention for transfers: extensive assistance of 1, last revised April 25, 2025. Observation of Resident 19 on June 16, 2025, at 10:19 AM, revealed he was walking without assistance and did not have a sling on his right arm. Residents Affected - Some Observations of Resident 19 on June 16, 2025, at 11:04 AM, and June 17, 2025, at 9:53 AM, failed to reveal he was wearing a sling on his right arm. Interview with Resident 19 on June 17, 2025, at 9:54 AM, revealed he no longer needs to wear a sling on his arm. Review of Resident 19's physician orders revealed he had an order for resident may perform pulleys with range of motion of right shoulder, advance to weight bearing as tolerated in 2 weeks on June 2, 2025, with a start date of May 19, 2025. Interview with the DON on June 18, 2025, at 10:12 AM, revealed that Resident 19 has not needed the sling since he went to weight bearing as tolerated, he no longer requires extensive assistance with transfers, and she would expect his care plan to be updated. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia (difficulty swallowing), and muscle weakness. Review of Resident 26's care plan revealed an active focus area for infection of urinary tract, with a start date of April 8, 2025. Interview with the DON on June 18, 2025, at 10:12 AM, revealed Resident 26 does not have an active urinary tract infection, and she would expect care plans to be reviewed and revised as needed. Review of Resident 27'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), anxiety disorder, and delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue). Review of Resident 27's care plan revealed a care plan focus that indicated she was at risk for adverse effects related to use of antianxiety (anxiolytic) medication, dated March 31, 2024. Review of Resident 27's clinical record revealed that she was not receiving an antianxiety medication. During a staff interview with the DON on June 18, 2025, at 10:40 AM, she confirmed that Resident 27's care plan should have been revised when the antianxiety medication was discontinued. She indicated that the care plan was most likely not revised because the wrong indication for use was utilized for Resident 27's antidepressant medication. Review of Resident 30's clinical record documented diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract 395844 Page 7 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0657 Level of Harm - Minimal harm or potential for actual harm thinking), dysphagia (difficulty swallowing), transient ischemic attack (a temporary interruption of blood flow to the brain), and left wrist fracture with routine healing. Observation in Resident 30's room revealed she was dressed, in bed with a perimeter mattress, and no cervical collar observed. Residents Affected - Some Review of Resident 30's physician orders included: cervical collar except during meals: skin and circulation check every shift, start date November 20, 2024, and discontinued December 16, 2024; and cervical collar at all times except meals, start weaning collar over a 2-week period if no neck pain, every shift, start date December 16, 2024, discontinued December 30, 2024. Review of Resident 30's care plan included activities of daily living self-care deficit related to fractures and history of TIA, initiated October 15, 2024, with interventions that included cervical collar on at all times (patient has a C1/neck fracture) initiated October 15, 2024, and revised on November 21, 2024. Review of Resident 30's progress notes included on January 13, 2025, out to Neuroscience surgery, new order to discontinue neck collar, follow up as needed. During an interview with the DON on June 17, 2025, at 10:36 AM, it was revealed that the care plan should have been updated to remove the cervical collar prior to June 16, 2025. 42 CFR 483.21(b)(2) Comprehensive Care Plans 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services 395844 Page 8 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on facility policy review, review of select facility fall reports, clinical record review, and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents and failed to conduct thorough fall investigations for one of two residents reviewed for falls (Resident 10). Findings include: Review of facility policy, titled Falls and Fall Risk, Managing last reviewed on January 25, 2025, read, in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include lower extremity weakness. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall and unsteadiness on feet. Review of facility fall report dated February 21, 2025, revealed Nursing Description: Registered Nurse (RN) was called to resident's bathroom by licensed practical nurse, per nurse aide (NA), NA was transferring resident from wheelchair to toilet, resident was unable to turn right lower extremity and requires to be lowered to the floor by nurse aide. Was witnessed and resident did not hit his head. Review of facility fall report dated March 18, 2025, revealed Nursing Description: During transfer with staff [Resident 10] was lowered to the floor. Review of Resident 10's comprehensive care plan revealed staff was to use a sit to stand (sts) lift for transfers at the time of Resident 10's fall on February 21, 2025, and March 18, 2025. Interview with the Director of Nursing (DON) on June 18, 2025, at 9:22 AM, revealed the NA in the fall report from February 21, 2025, was not utilizing the sts lift at the time of Resident 10's fall, and that in response she did a verbal education with that nurse aide, and the following month she did an education with all nursing staff. She further revealed staff was not utilizing the sts lift at the time of Resident 10's fall on March 18, 2025, and that Employee 14 (Registered Nurse) did not notify the DON of the fall that morning per facility protocol, so a proper investigation was not conducted, including gathering witness statements. During a follow-up interview with the DON on June 18, 2025, at 12:21 PM, revealed she was unable to find any witness statements associated with the fall on February 21, 2025, and she would expect witness statements to be available for review. Review of facility fall report dated April 21, 2025, detailed a fall sustained by Resident 10 that evening. The intervention noted in response to the fall read, Staff to offer to get resident out of bed for supper at the start of shift. Review of Resident 10's comprehensive care plan failed to reveal the fall intervention had been 395844 Page 9 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0689 added to Resident 10's care plan. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on June 18, 2025, at 12:56 PM, revealed she was adding the fall intervention to Resident 10's care plan, and she would expect his care plan to be updated. Residents Affected - Few 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services 395844 Page 10 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide a physician ordered nutritional supplement, per physician's order, for two of four residents reviewed for nutritional status (Residents 2 and 26), and failed to notify the physician of significant weight changes for two of four residents reviewed for nutritional status (Residents 10, and 26). Residents Affected - Few Findings include: Review of facility policy, titled Weight Policy last reviewed January 25, 2025, read, in part, The Registered Dietitian will review the medical record of residents with significant weight changes. Dietary interventions will be recommended as needed. All significant weight changes will be reported to the physician. Review of facility policy, titled Medication Administration last reviewed January 25, 2025, read, in part, Medications are administered in accordance with prescriber orders. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for the drug and dose. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), post-traumatic stress disorder (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Weight history for Resident 2 revealed a 10-pound weight loss from May to June of 2025; May 6th 95 pounds, and June 6th 84 pounds. Review of Resident 2's physician orders included house supplement after meals 90 milliliters three times a day, starting March 6, 2025, and Remeron 7.5 milligrams at bedtime for poor appetite starting May 20, 2025, and discontinued June 6, 2025. Review of Resident 2's April 2025 Medication Administration Record (MAR- documentation of medication administered per physician orders) for house supplement documented X or 0 on the 14th and 26th at 1:00 PM, and 27th at 9:00 AM, 1:00 PM, and 6:00 PM. Review of progress notes revealed the house supplement was not available on April 14th, 26th, and 27th, 2025. Progress notes failed to document the physician was notified that the supplement was not available. May 2025 MAR for house supplement documented an X, NA, or 0 on the 17th at 1:00 PM and 6:00 PM; 22nd and 23rd at 9:00 AM, 1:00 PM, and 6:00 PM; 24th at 1:00 PM; and 25th, 29th, 30th and 31st at 6:00 PM. Review of progress notes revealed the house supplement was not available on May 17th, and 18th, 395844 Page 11 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0692 2025. Progress notes failed to document the physician was notified that the supplement was not available. Level of Harm - Minimal harm or potential for actual harm June 2025 MAR for house supplement documented an X, or 0 on the 1st at 1:00 PM; 4th at 1:00 PM and 6:00 PM; 10th at 1:00 PM; and 13th at 6:00 PM. Residents Affected - Few Interview with Employee 6 (Registered Nurse) on June 17, 2025, at 12:10 PM, revealed that the house supplement is Med Pass 2.0 or 2 Cal HN. Observation with Employee 6 on June 17, 2025, at 12:11 PM, in the medication room and nourishment pantry (in the cabinet and refrigerator) there was no Med pass 2.0 or 2 Cal HN. Observation in central supply and interview with Employee 6 and Employee 7 (Director of Dietary/Housekeeping) revealed there was no house supplement. Per Employee 7, the house supplement should be with the delivery that was due that. Surveyor stated that there was no house supplement available on the nursing unit and that residents scheduled to receive after lunch or this afternoon may not receive it; Employee 7 stated that he would call a sister facility to obtain the supplement. Observation with the Director of Nursing (DON) on June 17, 2025, at 12:57 PM, there was one 8-ounce container of med pass 2.0 in the one medication cart; the other medication cart didn't have a supply. Observation with the DON on June 17, 2025, at 1:04 PM, in the medication room after the supply order arrived, there were 2 cases (12- 32 ounce) med pass 2.0. It was also revealed that the supply company will deliver what they have whether it is med pass 2.0 or 2 Cal HN and in whatever packaging, 32 oz containers or 8 oz containers. Supplies are delivered every two weeks on Tuesday, however if the facility requires additional supplies, an additional delivery will be made. Interview with DON June 17, 2025, at 2:32 PM, it was revealed the physician should be notified if the supplement wasn't available or administered. Review of Resident 10's clinical record revealed diagnoses that included wedge compression fracture (a type of compression fracture that occurs when vertebrae collapses and creates a wedge shape) unspecified fall, and unsteadiness on feet. Review of Resident 10's weight measures revealed he had a significant weight loss of 10.1% in one month from February 5, 2025, to February 26, 2025. Review of Resident 10's clinical record failed to reveal physician notification of the significant weight loss. Interview with the DON on June 18, 2025, at 10:15 AM, revealed the dietitian emails weight loss notifications to the DON and nurse unit manager to notify the physician, but they thought she was notifying him separately, so they did not send the weight loss notifications to the doctor. She further revealed moving forward the doctor will be copied on the email sent to the DON and unit manager for review. Review of Resident 26's clinical record revealed diagnoses that included at risk for malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), dysphagia 395844 Page 12 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0692 (difficulty swallowing), and muscle weakness. Level of Harm - Minimal harm or potential for actual harm Review of Resident 26's clinical record revealed she had a significant weight loss of 11% from April 8, 2025, to May 2, 2025. Residents Affected - Few Review of Resident 26's clinical record failed to reveal physician notification of the significant weight loss. Review of Resident 26's physician orders revealed an order for House Supplement every evening shift 120mL daily, with a start date of May 2, 2025. Review of Resident 26's May 2025 MAR for house supplement documented NA (not available) on May 6, 14, 15, 19, 20, 27, and 30, 2025. Review of Resident 26's June 2025 MAR for house supplement documented NA (not available) on June 5 and 9-11, 2025. On June 16, 2025, it was marked 9 for other/see progress notes. Review of Resident 26's nursing progress notes failed to reveal documentation the physician was notified that the supplement was not available on the aforementioned dates, and the progress note linked to the MAR on June 16, 2025, read not available. Interview with DON on June 17, 2025, at 2:32 PM, revealed the physician should be notified of significant weight losses and if the supplement wasn't available to administer. Further revealed is that they did had the supplement in one of the medication carts on the evening of June 16, 2025, so staff should have communicated supplies between medication carts and administer the supplement if it was available. 28 Pa. Code 211.12(d)(3) Nursing services 395844 Page 13 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to complete a timely assessment for trauma, and then develop and implement an individualized person-centered care plan to render trauma-informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one of one resident reviewed with PTSD (Resident 2). Residents Affected - Few Findings include: Review of facility policy, Trauma Informed Care, revised March 2019, read, in part, nursing staff are trained on screening tools, trauma assessment, and how to identify triggers associated with re-traumatization. Implement universal screening of residents for trauma. Review of Resident 2's clinical record diagnoses that included depression (feelings of severe despondency and dejection), anxiety (a feeling of worry nervousness or unease), intellectual disabilities (a condition characterized by significant limitations in both intellectual function and adaptive behavior), PTSD (a mental disorder that develops from experiencing a traumatic event), cerebral palsy ( a group of neurological disorders that affect movement and posture causing activity limitations), and encephalopathy (brain disease, damage or disorder that impacts brain structure or function). Review of Resident 2's hospital Discharge summary dated [DATE], documented PTSD. Review of the Centers for Medicare and /Medicaid Services form 802 (matrix- a list of all current residents and to note pertinent care categories) Resident 2 was documented for PTSD. Further review of the clinical record failed to reveal a screening for a history of trauma, documentation, or care planning per facility policy related to trauma-informed care. Review of Resident 2's care plan failed to reveal Resident 2's diagnosis, symptoms, or triggers related to the diagnosis of PTSD. Interview with the Director of Nursing on June 18, 2025, at 10:30 AM, it was revealed the facility doesn't complete a trauma assessment due to it not being available in the electronic record, and the facility does have a form to complete the assessment. It was also revealed the Social Worker will be tasked with completing the trauma informed care assessment. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 395844 Page 14 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

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 employee handbook review, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for five of five nurse aides reviewed (Employees 1, 2, 3, 4, and 5). Residents Affected - Some Findings include: Based on facility document, titled Employee Handbook effective June 6, 2023, read, in part, All employees will be subject to a written annual rating and evaluation by the department supervisor based on his/her anniversary date. This evaluation will be reviewed with the employee by the supervisor at the time of presentation for the employee's signature. Review of select facility documentation revealed a list of nurse aide's that had worked at the facility for greater than a year, which included: Employee 1 had a hire date of December 26, 2023; Employee 2 had a hire date of April 1, 2020; Employee 3 had a hire date of May 21, 2018; Employee 4 had a hire date of May 6, 2024; and Employee 5 had a hire date of April 15, 2002. Interview with the Director of Nursing on June 17, 2025, at 1:31 PM, revealed she routinely speaks with staff members about their performance, however, the formal process for annual performance evaluations was not in place at that time. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 395844 Page 15 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, facility policy review, and staff interviews, it was determined that the facility failed to ensure opened vials were labeled in accordance with currently accepted professional principles for one of one medication rooms reviewed. Findings include: Review of facility policy, titled Medication Labeling and Storage, last reviewed January 15, 2025, revealed subsection five of Medication Labeling, stated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. During observation of the facility medication storage room on June 17, 2025, revealed two of two vials of tuberculosis purified protein derivative solution (PPD - used to determine resident or staff exposure or infection with tuberculosis) were opened with no opened date written on the vial or the box that contained the vial. During a staff interview directly after the observation, Employee 9 (Licensed Practical Nurse) confirmed that the two vials appeared accessed and that there were no open dates on the two vials of the PPD solution. During a staff interview on June 18, 2025, at approximately 10:30 AM, Director of Nursing confirmed that the open dates should have been documented on the PPD solution. 29 Pa code 211.12(d)(1)(5) Nursing services 395844 Page 16 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure clinical records were complete and accurately documented for one of 13 residents (Resident 8). Findings include: Review of facility policy, titled Attending Physician Responsibilities; with a last review date of January 15, 2025, revealed, in part, Each attending physician will be responsible for providing appropriate, timely, and pertinent documentation; At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. The note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the facility for placement on the chart within a week. Review of Resident 8's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure) and fractures of the bilateral fibula (the smaller bone located in the lower leg). Review of Resident 8's clinical record on June 17, 2025, failed to reveal any physician progress notes since her admission to the facility. During a staff interview with the Director of Nursing (DON) on June 17, 2025, at approximately 1:45 PM, she indicated that she would look for the physician progress notes. On June 18, 2025, at approximately 10:00 AM, the DON provided physician progress notes dated March 18, 21, and 25, 2025. She said that she had texted Resident 8's physician requesting progress notes be sent to the facility. She indicated that these were the only three progress notes she had received and that she was still awaiting the others to be sent. During a staff interview with the Nursing Home Administrator (NHA) and the DON on June 18, 2025, at 12:11 PM, the DON indicated that Resident 8's physician dictates his notes, then his office types them up, and then the notes are faxed via email to a general email account at the facility for staff to print. She said that there was no clear process as to who would be responsible to print the notes and place on resident charts. She also indicated that Resident 8's physician is not timely with providing his notes for the Resident records. She further confirmed that she was yet to receive any additional progress notes for Resident 8 from her physician and could not state when Resident 8 was seen by her physician. During a final interview with the NHA and DON on June 18, 2025, at 12:28 PM, both confirmed that they had no additional documentation to provide and that they would expect physician progress notes to be on a resident's chart within 7 days as the facility policy states. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 395844 Page 17 of 18 395844 06/18/2025 Elizabethtown Nursing and Rehabilitation 141 Heisey Avenue Elizabethtown, PA 17022

F 0842 28 Pa. Code 211.5(f)(iv) Medical records Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Few 395844 Page 18 of 18