Every finding on record at Accela Rehab and Care Center at Somerton

Based on review of clinical record, review of facility documentation, and interview with resident and staff it was determined that the facility failed to administer medications in accordance with professional standards of practice and physician recommendations for one of eight residents reviewed (Resident R1).Findings include: Review of the facility Administering Medications revised April 2019, revealed medications should be administered in a safe and timely manner and as prescribed. The policy further states that medications are administered in accordance with the prescribed order, including any required time frames. Review of Resident R1 clinical record revealed an admission date of June 30, 2026, with diagnoses of surgical aftercare following surgery on the digestive system, migraine, acquired absence of other specified parts of digestive tract, and chronic pain. Review of Resident R1's clinical record revealed a physician order dated June 30, 2026, and discontinued July 3, 2026, for Oxycodone 10 milligrams (mg) one tablet by mouth every four hours as needed for severe pain (7-10/10). Resident R1's clinical record revealed a resident went to the hospital on July 1, 2026, with an admitting diagnosis of intrabdominal abscess. Resident R1 was discharged from the hospital, and readmitted back to the facility, on July 3, 2026. Review of Resident R1's hospital discharge paperwork revealed discharge orders for Oxycodone Immediate Release Tablet 5 milligrams (mg) oral every 4 hours as needed (PRN), last dose given on July 3, 2026, at 9:56 a.m. Review of Resident R1's facility medication administration record (MAR) revealed the resident was given 10 mg of oxycodone on July 3, 2026, at 4:23 p.m. by licensed nurse, Employee E10. Interview on August 5, 2026, at 11:11 a.m. with the Director of Nursing, Employee E2, confirmed Resident R1 was given 10mg oxycodone on July 3, 2026 after readmission from the hospital. The Director of Nursing, Employee E2, revealed that the oxycodone 10 mg order should have been discontinued at the time of the hospital admission on [DATE]; however, it remained active until July 3, 2026, at 5:39 p.m. According to Resident R1's hospital discharge medication orders, the facility should have entered new order for oxycodone immediate release, 5 mg, oral, every four hours as needed (Q4 PRN). Per a review of Resident R1's clinical record, this new order was not entered and was not reflected on the MAR. Instead, a 10 mg dose of oxycodone was administered on July 3, 2026, at 4:23 p.m. by licensed nurse Employee E10. The original 10 mg order was then discontinued at 5:39 p.m. that same day (July 3, 2026). The DON confirmed that the wrong dose of oxycodone was administered to Resident R1, who should have received 5 mg in accordance with the hospital discharge recommendations. The Director of Nursing, Employee E2, further confirmed an order for oxycodone 5mg was not entered into the physician orders or clinical record. A telephone interview was conducted on August 6, 2026, at 9:15 a.m., with the facility's physician, Employee E11. The physician reported that he/she approved of Resident R1's hospital's discharge order for oxycodone 5 mg and did not increase the dosage to 10 mg upon readmission on [DATE]. The physician further stated that Resident R1 does not require a higher dose of 10 mg oxycodone and that Resident R1 has pain medication seeking behaviors. The physician confirmed, I did not increase his/her dose and agreed with the hospital's dosage of 5 mg. Further review of Resident R1's clinical record revealed progress note dated July 4, 2026, at 12:17 a.m. that stated: Resident R1 frequently requested oxycodone PRN every four hours and expressed dissatisfaction regarding the timing of administration. Education was provided regarding the risks of leaving AMA (Against Medical Advice) and the importance of remaining for continuity of care. Resident AAOx3 (Awake, Alert, and Oriented to Person, Place, and Time) and signed AMA documentation. Physician, Employee E11, was notified. It was further confirmed in the same interview on August 4, 2026, at 11:11 a.m. with the Director of Nursing that, based on Resident R1's MAR, the last dose of oxycodone was administered on July 3, 2026, at 4:23 p.m., and the next dose was due at 8:23 p.m. In the progress note dated July 4, 2026, at 12:17 a.m., it was documented that Resident R1 frequently requested oxycodone PRN every four hours and expressed dissatisfaction regarding the timing of administration. Review of Resident R1's clinical record revealed no documented evidence the resident received oxycodone prescription as requested. There was no explanation for why there was no physician order or administration for oxycodone 5 mg for Resident R1 when it was requested after 8:23 p.m. that night. 28 Pa. Code 201.18 (b)(3) Management. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility documentation, observations, and interview with staff it was determined that the facility failed to establish and implement systems to accurately reconcile controlled medications using acceptable standards of practice for one of one medication cart reviewed (B-Unit, Front Hall). Findings include: Review facility policy, undated, Discarding and Destroying Medications last revised April 2019 revealed completed medication disposition records shall be kept on file in the facility for at least two years, or as mandated by the state law governing the retention and storage of such records. Review of Resident R1 clinical record revealed an admission date of June 30, 2026, with diagnoses of encounter for surgical aftercare following surgery on the digestive system, migraine, acquired absence of other specified parts of digestive tract, chronic pain. Resident R1's clinical record revealed a resident was admitted to the hospital on [DATE], with an admitting diagnosis of intrabdominal abscess. Resident R1 was discharged from the hospital, and readmitted back to the facility, on July 3, 2026. Review of Resident R1's clinical record revealed a progress note dated July 4, 2026, at 12:17 a.m. that revealed Resident R1 frequently requested his/her as needed (PRN) oxycodone prescription every four hours and expressed dissatisfaction regarding the timing of administration. Resident R1 was dissatisfied with his/her medication management and, despite education by nursing staff, signed Against Medical Advice (AMA) paperwork and discharged from the facility. The physician, Employee E11, was notified. Interview on August 5, 2026, at 11:11 a.m., with the Director of Nursing (DON), Employee E2, revealed that Resident R1 had a prescription filled by a local pharmacy for oxycodone 10 milligrams (mg), 60 tablets, ordered by the physician, Employee E11. The medication was delivered to the facility on July 2, 2026, at 3:07 a.m. and was acknowledged by licensed nurse, Employee E12. Based on a review of Resident R1's July Medication Administration Record (MAR), the prescription was signed out as administered once, meaning there should have been 59 tablets remaining. The DON confirmed that the facility did not have a narcotic accountability sheet available to verify that the remaining 59 tablets were destroyed after Resident R1 was discharged . The DON also confirmed that Resident R1 left the facility Against Medical Advice (AMA) on July 4, 2026, and that there was no evidence available to validate that the destruction of the remaining oxycodone tablets. Observations were conducted on August 5, 2026, at 11:46 a.m., with the Director of Nursing (DON), EmployeeE2, of the B-Unit Medication Cart, Front Hall. The medication cart was assigned to licensed nurse, Employee E3. A review of Resident R9's narcotic sheet, stored on the medication cart, showed that on August 2, 2026, and August 3, 2026, two nurses signed out oxycodone 5 mg capsules and labeled the entries as wasted. The Director of Nursing, Employee E2, explained that when the facility does not have enough oxycodone in its emergency supply and another resident is in need, the nurses borrow the medication from another resident, have two nurses sign it out, and record it as wasted. The DON further explained that the facility does not have a tracking mechanism to identify which resident actually received the borrowed medication, other than interviewing the nurses afterward. The Director of Nursing, Employee E2, acknowledged that this is not a professional practice, but it is a practice the facility currently uses. In addition, the current shift count sheet used to communicate the overall narcotic count from shift to shift was missing required documentation. For August 3, 2026, there was no shift count recorded for the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift, and for August 4, 2026, the 11 p.m.-7 a.m. shift count was also missing. These findings were confirmed by the Director of Nursing. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.9(j.1)(1-3) Pharmacy services.

Based on observation, resident interview, and staff interview it was determined that the facility failed to serve food prepared by methods that conserve flavor and appearance, and failed to serve food at palatable, attractive, and appetizing temperatures during meal service on one of three nursing units (A Unit).Findings include: A review of the facility policy titled Food Preparation and Service, last revised April 2019, revealed under the procedure for food preparation, cooking, and holding temperatures that The danger zone for food temperatures is between 41 F (Fahrenheit) and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Bullet #3 states, The longer food remains in the danger zone, the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 F or above 135 F. On August 5, 2026, at 12:54 p.m., an interview with Resident R4 revealed that food is too bland. On August 5, 2026, at 12:58 p.m., an interview with Resident R5 revealed that food is not appetizing, and it's hard to answer why it's not appetizing. On August 5, 2026, at 1:01 p.m., an interview with Resident R10 revealed that he/she doesn't eat raviolis; ordered an alternative but received raviolis. On August 5, 2026, at 1:05 p.m., an interview with Resident R8 revealed that food is not good. Resident R8 stated he/she receives red sauce, which he/she does not like. Resident R8 ordered the alternative meal of chicken wings, not raviolis, and received only one chicken wing. On August 5, 2026, at 12:45 p.m., the test tray left the kitchen and traveled to the A Wing for distribution of lunch trays. The Dietary Director, Employee E4, followed the food cart. All lunch trays were delivered to the residents by 1:16 p.m., which was an extensive amount of time, totaling 31 minutes to deliver the trays for A Wing. At 1:16 p.m., the temperatures on the test tray were recorded as follows:Ravioli: 108 FChicken wing: 108.7 FZucchini: 113.2 FCoffee: 107.2 F Interview at the time of the test tray with Dietary Director, Employee E4, confirmed that the food temperatures did not meet the facility's standards. In addition, the test tray revealed: the chicken wing was served with bone in and was too dry, making it difficult to remove the meat from the bone. The zucchini was overcooked, contained excess moisture, and had no flavor. The pale green color was not visually appealing. The ravioli was sticking together and lacked flavor. The overall tray did not look appetizing. The garlic bread was simply a piece of white toast, which did not resemble garlic bread and appeared more like sandwich bread. 28 Pa. Code 201.18 (b)(3) Management

Based on review of facility documentation and staff interview it was determined that the facility failed to conduct a complete and thorough investigation regarding an allegation of fraud for one of one investigation reviewed. Findings include: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a revision date of April 2021 indicated that the facility would investigate and report any allegations within timeframes required by federal requirements. Review of allegations submitted to the State Survey Agency on June 5, 2026, revealed allegations that Nurse Aide, Employee E3, was allegedly utilizing another nurse aide's identity when entering the facility. Review of the facility documentation dated June 8, 2026, revealed the facility received notification via electronic mail on June 8, 2026, at 12:42 p.m. alleging that Nurse Aide, Employee E3, was working at the facility by clocking in/and working under a different nurse aide's name. The writer of the email was unaware of the name of the individual that Nurse Aide, Employee E3, was allegedly working under. The writer of the email provided the name of Nurse Aide, Employee E3, along with an alleged picture of Nurse Aide, Employee E3, that was reportedly taken on a day Nurse Aide, Employee E3, worked at the facility. Interview on July 8, 2026, at 10:50 a.m. with the Nursing Home Administrator and Director of Nursing revealed Nurse Aide, Employee E3, works for a staffing agency contracted with the facility. During an interview with the Nursing Home Administration (NHA), Director of Nursing (DON), and Human Resource Director (HR) on July 8, 2026, at 10:50 a.m., HR confirmed receiving the above noted email on June 8, 2026, regarding Nurse Aide, Employee E3, who was allegedly utilizing another nurse aides identity when clocking in at the facility. HR stated after receiving the email, he/she made rounds throughout the building on June 8, 2026, and did not find any staff that looked like the person in the picture attached to the email. Continued interview on July 8, 2026, at 10:50 a.m. the Director of Nursing revealed that he/she was notified on June 9, 2026, at around 8:30-9:00 a.m. by the HR director of the above referenced email received June 8, 2026. The Director of Nursing subsequently began looking around the facility with the picture provided in the email to see if the employee could be identified. Further interview on July 8, 2026, at 10:50 a.m., the DON reported that during a tour of the facility on June 9, 2026, he/she found that Nurse Aide, Employee E4, matched the picture provided via email that was allegedly Nurse Aide, Employee E3. The Director of Nursing approached Nurse Aide, Employee E4, and asked if he/she was really Nurse Aide, Employee E3. Nurse aide, Employee E4, denied the allegations. The Director of Nursing reported that the facility did not have a picture on file of Nurse Aide, Employee E4, and subsequently asked the employee to leave the building. Interview on July 8, 2026, at 10:50 a.m., with the NHA, DON, and HR revealed Nurse Aide, Employee E4, also worked for the same contracted staffing agency as Nurse Aide, Employee E3. The facility notified the contracted staffing agency to request that Nurse Aide, Employee E3, and Nurse Aide Employee E4, do not return to the facility to work. During an interview with the contracted staffing agency owner on July 9, 2026, at 11:34 a.m. the staffing agency owner reported he/she was made aware of the allegation that Nurse aide, Employee E3, was allegedly utilizing another nurse aide's identity when entering the facility. Continued interview with the staffing agency owner indicated that Nurse Aide, Employee E3, was hired by the staffing agency on February 21, 2024, and was logged in as working 17 shifts at the facility. The staffing agency owner reported that Nurse Aide, Employee E3, was terminated on April 29, 2026, for not showing up for shifts at various facilities. The staffing agency owner reported that nurse aide, Employee E4, was hired by the staffing agency on May 18, 2026, and was logged in as working 25 shifts at the facility. The staffing agency owner reported that both nurse aide, Employee E3, and nurse aide, Employee E4, were both deactivated on June 9, 2026, when they were notified of the above-referenced allegation by the facility. Review of the facility's investigation did not show evidence of any interviews with staff on any shifts that either nurse aides may have worked to inquire if any of the staff may have witnessed something, observed something, overheard something, or know of something that would have provided any additional insight/information. Review of the investigation did not include any interview with any residents that the two nurse aides may have been assigned to see if any additional individuals were aware of the above-referenced allegations. Continued review of the investigation did not show evidence that the facility made any attempts to obtain witness statements from Nurse aide, Employee E3, or Nurse aide, Employee E4. During an interview with the Nursing Home Administration, on July 10, 2026, at 12:45 p.m. the above-referenced concerns regarding the investigation were discussed. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.29 (c) Resident rights28 Pa. Code 211.10 (d) Resident care policies

Based on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to report a resident's self-injurious behavior resulting in injury requiring hospital transfer and sutures to the Department of Health for one of three residents reviewed (Resident R1).Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with diagnoses including dementia (condition that causes a decline in memory, thinking, reasoning, and the ability to do everyday activities), schizoaffective disorder (mental health condition that includes symptoms of both schizophrenia and a mood disorder), and generalized anxiety disorder. Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of Resident R1's clinical record revealed the resident was sent out and admitted to a psychiatric facility on [DATE] related to inappropriate behaviors and re-admitted to the facility on [DATE]. Documentation revealed the resident was subsequently sent back to the hospital due to increased behavioral disturbances and unsafe behaviors and returned to the facility on [DATE]. Review of Resident R1's nursing progress note, dated [DATE] at 1:10 p.m., revealed Resident observed with increase psych behaviors. Resident observed placing himself on the floor multiple times. Charge nurse walked into room and witnessed resident banging his head against the floor. (Assistant Director of Nursing and Physician) made aware and order received to send to the ER for evaluation and treatment r/t self-harm. Wound nurse in room to clean open area to right forehead and observed resident then banging his head against his siderail. Resident stated to UM, Charge nurse and wound nurse that his deceased dad and the vampires told him to do it. Resident then started howling like a wolf and was repeating I'll be good I'll be good. Review of Resident R1's nursing progress note, dated [DATE] at 6:30 p.m., revealed Resident R1 returned to the facility status post head injury and laceration, repaired with sutures, resident to follow up with PCP to remove the stitches in 3-5 days. Review of Department of Health Reporting System revealed no evidence the incident was reported to the appropriate agency. Interview on [DATE] at 10:00 a.m., with Employee E1, Administrator, confirmed the incident was not reported to the Department of Health. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29 (a) Resident rights

Based on observations, review of facility polices and documents, clinical record review and interviews with staff, it was determined the facility failed to properly supervise a cognitively impaired resident who was able to exit the facility and board a train, for one of five residents reviewed for elopement risk (Resident R1). This failure placed the resident in an Immediate Jeopardy situation. Findings include:Review of facility policy, Wandering and Elopements dated March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of facility education module Front Door Monitoring and Access Control undated, revealed, Elopement prevention programs are required for cognitively impaired residents. Continued review revealed, Elopement is defined as a resident leaving the facility without staff knowledge or authorization. It is a serious event that can result in injury, death and regulatory citation. Continued review revealed, The front door entrance must be actively monitored at all times . Being alert to any resident who may be approaching the exit. Further review revealed that receptionist responsibilities include knowing which residents are on the unit-level elopement alert list. Review of Resident R1's admission MDS (Minimum Data Set - mandatory periodic resident assessment tool), dated March 17, 2026, revealed the resident was admitted to the facility on [DATE], and had diagnoses including Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Cerebrovascular accident (damage to the brain from interruption of its blood supply) and cognitive communication deficit (problems with communication due to difficulties with thinking processes). Continued review revealed that the resident had a BIMS (Brief interview for Mental Status) score of four, indicating the resident was severely cognitively impaired. Review of Resident R1's Elopement Risk Evaluation, dated March 12, 2026, revealed the resident was at risk for elopement due to history of attempting to leave the facility without informing staff; verbally expressing the desire to go home, packing belongings to go home or staying near a door; wandering with a goal directed pattern; wandering behavior that is likely to affect safety or well-being of self/others; and being recently admitted to the facility. Review of Resident R1's care plan, dated initiated March 12, 2026, revealed the resident was at risk for elopement due to history of attempts to leave the facility unattended; impaired safety awareness; removing name tag from door, and removing wander guard several times. Interventions included use of a wanderguard (device that is placed on resident's wrist or ankle which sound alarms or prevent doors from being opened for exit) and to distract the resident from wandering. Continued review of Resident R1's care plan, dated initiated March 16, 2026, revealed the resident had impaired cognitive function/dementia or impaired thought processes related to difficulty making decisions, impaired decision-making, long-term memory loss and short-term memory loss. Interventions included to cue, reorient and supervise the resident as needed. Review of Resident R1's admission note, dated March 11, 2026, at 10:11 p.m. revealed the resident had confusion upon admission to the facility with behaviors including refusals of care and wandering. Review of Resident R1's nursing note, dated March 12, 2026, at 6:44 a.m. revealed the resident was up at this time trying to go home. Resident redirected at this time. Continued review of Resident R1's clinical record revealed a BIMS (Brief Interview of Mental Status) evaluation completed by Employee E7, Speech Therapist, on March 12, 2026, at 9:52 a.m. Employee E7 noted that the resident had increased agitation, it is to be noted first answer 2038 for year, resident uncertain of year . resident additionally does not know where (he/she) is presently. The BIMS evaluation revealed a score of four, indicating severe cognitive impairment. Review of Resident R1's nursing note, dated March 14, 2026, at 2:50 p.m. revealed the resident had wander guard and that the resident required redirection during the shift. Review of Resident R1's eMAR note (electronic medication administration record), dated March 16, 2026, at 1:36 p.m. revealed the resident removed his/her wanderguard device. Review of Resident R1's nursing note, dated March 16, 2026, at 2:22 p.m. revealed the resident expresses comments about wanting to leave the facility, the resident often packing (his/her) things in a bag and walks to the front door, trying to reason with the staff about letting leaving, the resident has spoken to social worker, the resident was taken back to (his/her) room, wander guard is still off. Review of physician notes for Resident R1 on March 19, 20, and 21, 2026, revealed the resident was confused and requesting to discharge home. The physician assessment and plan for the resident's diagnosis of dementia included supportive care, reorientation and to monitor cognition and safety awareness. Review of Psychosocial Evaluations for Resident R1, dated March 23, 2026, revealed the mental health provider conducted a BIMS assessment and determined the resident's score was four (severe cognitive impairment). The mental health provider noted the resident has Dementia, and that cognitive impairment impacts the ability to retain information and therapeutic interventions. Review of Resident R1's Psychiatric (mental health) Evaluation and Consultation, dated March 24, 2026, revealed upon exam the resident had memory impairment, irritability, agitation, restlessness, confusion, weakness, and forgetfulness. Review of Resident R1's Social Services note, by Employee E5, Director of Social Services, on April 6, 2026, at 1:39 p.m. revealed Resident expressed desire to leave the facility and stated that if discharge does not occur today, (he/she) will attempt to leave on (his/her) own. Resident noted to have severe cognitive impairment and lacks capacity to make informed discharge decisions. Resident unable to verbalize understanding of risks associated with leaving independently. Resident redirected, however, continues to verbalize intent to leave. Physician notified. Resident will be closely monitored with implementation of least restrictive interventions due to elopement risk. Continue review revealed the resident's physician and representative were notified of resident's expressed desire to leave the facility and noted lack of decision-making capacity. Both made aware of potential elopement risk. Further review of progress notes for Resident R1 revealed a Social Services note, by Employee E5, Director of Social Services, on April 6, 2026, at 2:28 p.m., Resident left the facility without staff knowledge/authorization at approximately 2:00 p.m. Resident has a history of severe cognitive impairment and lack of capacity to make informed decisions regarding discharge. Resident had previously verbalized desire to leave the facility and intent to do so. Upon discovery of resident's absence, facility initiated immediate search of the building and surrounding area. Local police were notified via 911 (Emergency Medical Services) at 2:25 p.m. Description of resident, last known location and clothing provided to authorities. Physician and facility administration notified of incident. Attempts made to contact any known emergency contacts. Resident considered at risk due to impaired cognition and inability to ensure personal safety. Facility will continue to cooperate with authorities and monitor for resident's return. Review of information dated April 6, 2026, initially submitted by the facility on April 6, 2026, at 9:21 p.m. revealed on April 6, 2026, at approximately 2:00 p.m. nursing staff and the Director of Social Services noticed the resident was not in his/her room. Staff searched the building and surrounding area. The Maintenance Director stated that he saw the resident near the train station, but by the time he arrived, the resident was already on the train. The facility notified police and staff continued to search for the resident at train stations, shelters and hospitals. At 9:02 p.m. a local hospital was called; the hospital reported that the resident walked into their emergency department at 8:38 p.m. The resident returned to the facility on April 6, 2026, and was placed on one-to-one supervision and subsequently transferred to the Veterans hospital for placement on April 7, 2026, at 8:00 p.m. Review of facility documentation, dated April 6, 2026, revealed a statement from Employee E4, receptionist, I was sitting at desk giving the xray tech room numbers when resident left the building. I was unaware that I had even let (him/her) out. Continued review of facility documentation, dated April 6, 2026, revealed a statement from Employee E8, Maintenance Director, I took a late lunch around 1:30-1:40 p.m. on my way back from leaving [local restaurant] I 'thought' I may have seen [Resident R1] at the train station sitting there. When I returned to the facility I checked in at the front desk and overheard nursing and staff talking about (him/her) missing. Reason I did not immediately stop was because I thought (he/she) was being discharged when I realized (he/she) wasn't. I immediately told them (staff) what I may have seen and then ran to my truck and drove to [local] station within one minute of leaving and arriving at station there was a train leaving and did not locate [Resident R1] in the area after that. I then drove to . station without luck and went on to all stations from there to [adjacent state]. My search concluded at 10:30 p.m. without any luck. Review of facility documentation of the timeline of events, Resident R1 left the building via the front door on April 6, 2026, at 1:42 p.m. At 2:00 p.m. the facility initiated a search for the resident. Police were notified at 2:25 p.m. The facility called a local hospital at 9:03 p.m. was informed that the resident was in the emergency room. Review of nursing notes for Resident R1 revealed the resident was readmitted to the facility from the hospital on April 7, 2026, at 3:20 a.m. Review of hospital discharge records, dated April 7, 2026, revealed the resident was assessed upon (his/her) arrival to the emergency department and was noted to be disoriented to time and place. The resident was assessed at the hospital and found to have no injuries. Observation on April 14, 2026, at 8:50 a.m. revealed Employee E4, receptionist, seated at the reception desk in the lobby. Interview, at the time of the observation, Employee E4 stated she was the one who opened the door and let the resident out. Employee E4 stated she was reviewing room numbers with an x-ray technician and wasn't looking at the door when she opened it. Employee E4 stated the elopement binder was at the desk at the time, however, she could not recall if Resident R1 was listed as an elopement risk in the binder at the time of the incident. Interview on April 14, 2026, at 1:22 p.m. Employee E5, Director of Social Services, confirmed Resident R1 had cognitive impairment and was not safe to discharge independently from the facility. Resident R1 was unable to verbalize understanding of risks associated with leaving independently and would not provide sufficient information for discharge, including discharge address. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. Resident R1 left the facility and boarded a train on April 6, 2026, at 1:42 p.m. and was located at a local hospital on April 6, 2026, at 9:03 p.m., a period of over seven hours. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on April 14, 2026, at 2:37 p.m. On April 6, 2026, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following:- A thorough investigation and incident report were completed.- All staff were re-educated on elopement awareness, monitoring responsibilities, elopement drills and protocol for identifying at-risk residents.- All residents were accounted for, and a safety check of the facility was completed.- The resident's responsible party was notified.- A door chime sensor was ordered to alert the receptionist and staff any time someone enters or exits through the front door.- Doors connecting the lobby to the unit were installed- Upon the resident's return, a wander guard device was placed on the resident and verified to be in good working condition.- The resident was placed on 1:1 monitoring immediately upon return. Skin assessment completed and noted no injuries or bruises.- All residents identified as being at elopement risk had their care plans reviewed and updated and their wander guards were checked to ensure proper functioning.- The elopement binder was reviewed and updated to ensure accuracy.- The facility elopement policy was reviewed and updated as needed.- The DON (Director of Nursing) or designee will conduct weekly audits of front desk monitoring practices and door alert functionality for a minimum of 12 weeks.- Audit results will be documented and submitted to the QAPI (Quality Assurance Performance Improvement) Committee monthly. A review was conducted of the education, elopement protocols, competencies and drills that were provided to facility staff related to the elopement event. Interviews conducted on April 14, 2026, with staff from various departments were able to describe the elopement protocols and drills that were conducted. Receptionist staff received additional training and competency reviews related to door monitoring to maintain a safe environment and elopement prevention. The facility's elopement binder was reviewed, and the lobby area was observed to have a door with a chime alarm installed between the lobby and clinical area. Facility audits were reviewed and residents who were identified by the facility as being at risk for elopement had appropriate elopement prevention measures in place. Audits of front desk monitoring were reviewed and noted that staff were observant to the front door and surroundings. Review of facility documentation revealed that the corrective action plan was immediately initiated on April 6, 2026. The facility's action plan was accepted on April 14, 2026, at 5:39 p.m 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on interview with resident and staff, review of facility policy and documentation as well as review of clinical record, it was determined that facility failed to provide respiratory care to one resident according to professional standards of practice for Resident R3. Findings include: Review of undated facility policy 'Respiratory Therapy Services in Long-Term Care,' revealed the purpose is to ensure safe, effective, and compliant respiratory therapy services for residents requiring respiratory care in the long-term care setting. Further review of same facility policy revealed staff are responsible for working collaboratively with physicians, nursing staff, rehabilitative services, and other interdisciplinary team members and document assessments/treatments, resident response, and education in the medical record. Review of Resident R3 clinical record revealed medical history of Toxic Encephalopathy (type of brain dysfunction caused by exposure to toxic substances that damage or disrupt brain function. It affects how the brain works, leading to problems with thinking, memory, behavior, or movement), Chronic Obstructive Pulmonary Disease (COPD - ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs) with exacerbation, Acute and Chronic Respiratory Failure with Hypoxia (low oxygen level) and Hypercapnia (too much carbon dioxide (CO ) in the blood), Pneumonia (infection that inflames the air sacs of one or both lungs), Dementia (describes a group of symptoms affecting memory, thinking and social abilities, which interfere with a person's daily life). Review of Resident R3's minimum data set assessment (MDS - periodic assessment of resident abilities and care needs) completed February 20, 2026, revealed a Brief Interview for Mental Status (BIMS) score of 14 (indicating functioning cognitive ability). Review of Resident R3's clinical record revealed the resident was hospitalized on [DATE], due to COPD exacerbation and was re-admitted to facility on February 18, 2026, status post for acute on chronic respiratory failure with hypoxia and hypercapnia leading of noncompliance with AVAPS (machine is a smart ventilator that automatically adjusts air pressure to ensure the lungs receive a consistent volume of air, specifically designed to 'blow off' excess CO-2 (carbon dioxide). Review of Resident R3's physician orders revealed an order placed on February 18, 2026, to clean CPAP/BIPAP/AVAPS (types of non-invasive positive pressure ventilation (NIPPV) used to support breathing, usually delivered through a mask rather than a breathing tube. They are commonly used for conditions like Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Failure) Reservoir in the morning. Review of Resident R3's physician orders revealed that on February 17, 2026, (11:00 PM), an order was issued to assist resident with application of the Trilogy V60 ventilator at bedtime (QHS). The ordered settings included: EPAP 5 cm H O, AutoPAP minimum pressure 16 cm H O, AutoPAP maximum pressure 25 cm H O, target tidal volume 365 mL, minimum EPAP 4.0 cm H O, set respiratory rate 8 breaths per minute, and FiO 45%. The order also instructed staff to document any refusal of AVAPS therapy during each evening and night shift. The intervention was ordered for management of Chronic Obstructive Pulmonary Disease with exacerbation and could be used as needed (PRN) for COPD symptoms. Further review of physician orders revealed an order placed on February 17, 2026, for oxygen at 3 liters/min via nasal cannula continuously - maintain SpO2 88% - 92% every shift. (typical SpO2 target for COPD residents is 88 - 92% while using AVAPS to avoid worsening Hypercapnia (condition where too much carbon dioxide (CO ) builds up in the bloodstream from excessive oxygen). Review of Resident R3's care plan revealed a focus of Trilogy settings as follows: VT 400ml, Rate 3.0 cmh2o, Pressure support min 8.0 cmh2o, Pressure support max 15.0 cmh2o, Epap min 4.0 cmh2o, Epap max 6.0 cmh2o, Avaps rate 3.0cm, Max pressure 21.0 cmh2o and interventions monitor/document changes in orientation, increased restlessness, anxiety, and air hunger and to monitor for signs and symptoms of respiratory distress and report to medical director as needed: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Diaphoresis; Headaches; Lethargy; Confusion; Hemoptysis; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey initiated on January 19, 2024 with revision on March 22, 2024. Further review of care plan revealed Resident R3 has altered respiratory status/difficulty breathing related to COPD with exacerbation and oxygen therapy related to COPD with interventions to Assist with head of the bed to 45-degrees, Change residents position every 2 hours to facilitate lung secretion movement and drainage, Monitor resident for shortness of breath while lying flat, and O2 via nasal as ordered every shift, revised January 16, 2025. Interview conducted with Resident R3 on March 3, 2026, at 12:00 pm, revealed that he/she is unable to differentiate between CPAP/BIPAP/AVAPS machines. Review of electronic treatment administration record (e-TAR) for month of February 2026, revealed oxygen levels (SpO2) have been maintained between 94% - 99%, contradictory to the physician ordered of February 17, 2026, for oxygen at 3 liters/min via nasal cannula continuously - maintain SpO2 88% - 92% every shift. (typical SpO-2 target for individuals diagnosed with COPD is 88 - 92% while using AVAPS to avoid worsening Hypercapnia from excessive oxygen). Further review of e-TAR (electronic treatment administration record between February 17, 2026, and February 25, 2026, revealed of 15 required evening/nightly shift AVAPS applications, 8 shifts (53%) contained missing or unclear documentation of treatment or refusal. Further review of e-TAR revealed missing documentation related to cleaning Resident R3's respiratory appliances on the following dates: day shifts on February 21, 2026, and February 23, 2026. Review of Resident R3's clinical record including nursing note, dated February 24, 2026, (6:00 pm), revealed AVAPS was applied due to pulse ox (non-invasive device that measures how much oxygen is in the blood) dropping to 60%, and Resident R3 was noted to have confusion. Further review of progress notes revealed Resident R3 refused AVAPS application last night/overnight shift from February 23, 2026, 11:00 pm through February 24, 2026, 7:00 am. Review of Resident R3's e-TAR documentation of same time frame revealed AVAPS was applied. Further review of e-TAR revealed N/A and 0 documented under AVAPS application on February 18, 2026 night shift, February 20, 2026 evening shift, February 22, 2026 evening shift, February 23, 2026 evening shift. Interview conducted on March 4th, 2026 at 2:00 p.m. with the facility's director of nursing was unable to provide clarification on what 0 and NA notation on Resident R3's February 2026 e-TAR indicates. Review of Resident R3's care plan revealed refusal of avaps at times, initiated and revised on March 4, 2026, with no follow-up interventions related to refusing AVAPS. Further review of the clinical record failed to reveal evidence the AVAPS treatment refusals were communicated to physician. Further review of Resident R3's clinical record revealed Resident R3 was transferred to emergency room again on morning of February 25, 2026, per family member's request and was seen for shortness of breath and carbon dioxide at the upper end of the normal range (45). The resident's presentation of shortness of breath; with, CO-2 levels were measured at 45 mmHg. Further review of clinical record revealed Resident R3 was re-admitted to facility on morning of February 26, 2026, and was placed on AVAPS machine with 3L oxygen. Interview with licensed Nurse Practitioner (NP) Employee E4, on Wednesday, March 4, 2026, at 11:45 am, revealed she was unaware of physician orders related to frequency of AVAPS application and maintenance of oxygen levels. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of policy, review of clinical record, and interview with staff and resident, it was determined that facility did not ensure timely revision and implementation of a care plan related to respiratory care for one resident (Resident R3)Findings include:Review of facility policy 'Comprehensive Person - Centered Care Plans,' revised March 2022, indicates that 'assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of Residents R3 clinical record revealed medical history of toxic encephalopathy (type of brain dysfunction caused by exposure to toxic substances that damage or disrupt brain function. It affects how the brain works, leading to problems with thinking, memory, behavior, or movement), chronic obstructive pulmonary disease (COPD) with exacerbation, acute and chronic respiratory failure with hypoxia (low oxygen level) and hypercapnia (too much carbon dioxide (CO ) in the blood), pneumonia, dementia.Review of Resident R3's minimum data set/resident assessment and care screening, completed February 20, 2026, indicates Brief Interview for Mental Status (BIMS) score of 14.Review of physician orders revealed an order placed on February 17, 2026 for oxygen at 3 litres/min via nasal cannula continuously - maintain SpO2 88% - 92% every shift. (typical SpO2 target for COPD residents is 88 - 92% while using AVAPS to avoid worsening hypercapnia from excessive oxygen)Further review of physician orders revealed an order placed on February 17, 2026 at 11:00 pm to Assist resident to apply Trilogy V60 QHS- settings as follows:EPAP (cm H20) 5 AutoPAP Min Pressure 16 AutoPAP; Max Pressure 25 PrTidal Volume set 365ml Epap min 4.0 cmh2o Set Rate (Breaths/Min) 8 Fi02(%)45.Document refusal of AVAPS. - every evening and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH EXACERBATION, and as needed (PRN) for COPD.During interview with Resident R3 on March 3rd, 2026, at 12:00 pm, room [ROOM NUMBER]-C, R3 stated he/ she is unable to differentiate between CPAP/BIPAP/AVAPS machines; (AVAPS is a non-invasive ventilatory mode that delivers variable pressure support to achieve a target tidal volume, thereby maintaining adequate ventilation and preventing hypercapnia)Review of R3's care plan revealed no evidence of timely update and revision of goals and specific interventions related to hospitalization, change in mental status, assisting resident with applying AVAPS , resident's refusal of AVAPS, frequency of application, and maintaining oxygen levels between 88-92%.28 Pa Code 211.10 ( c)(d) resident care policies28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, staff interviews, and review of facility policy, it was determined that the facility failed to ensure accurate completion and updating of the Pre-admission Screening and Resident Review (PASRR) in accordance with residents documented mental health diagnoses. This resulted in inaccurate and incomplete PASRR Level I screenings for four (4) of five (5) residents reviewed (Residents R94, R107, R128, and R142).Findings include: Review of the facility policy titled admission Criteria last revised March 2019, revealed the purpose of the policy is to: Provide uniform criteria for admitting residents to the facility.Admit residents whose needs can be adequately met by the facility.Address concerns of residents and families during the admission process.Review facility policies and procedures with the resident.Ensure receipt of appropriate medical and financial records prior to or upon admission. The policy further states that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders in accordance with the Medicaid PASRR process. The facility conducts a Level I PASRR screening for all potential admissions, regardless of payer source, to determine if the individual meets criteria for serious mental illness (SMI), intellectual disability (ID), or related disorders (RD). If the Level I screening indicates the individual may meet criteria for SMI ((serious mental illness), ID((intellectual disability), or RD(related condition), the resident must be referred to the state PASRR authority for a Level II evaluation. The social worker is responsible for initiating referrals. The interdisciplinary team then determines whether the facility can meet the identified needs. The policy notes that PASRR requirements do not apply to residents transferred to a hospital after admission. Review of the Pennsylvania PASRR Level I Identification Form revealed: The process applies to all nursing facility applicants regardless of payer source.PASRR Level I and, if indicated, Level II evaluations must be completed prior to admission in accordance with federal regulations.Screenings must accurately identify diagnoses meeting definitions of SMI, ID, or related conditions.Omission of relevant diagnoses may result in failure to identify the need for a Level II evaluation and specialized services, constituting noncompliance with federal PASRR regulations. Review of Resident R94's Quarterly Minimum Data Set (MDS- a federal mandated assessment for all residents)) dated December 30, 2025, revealed that the resident was admitted to the facility on [DATE]. The assessment indicated a Brief Interview for Mental Status (BIMS) score of 10, reflecting moderate cognitive impairment. The resident's documented diagnoses included seizure disorder, (neurological condition characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain, which can affect consciousness, movement, or behavior, depression (a mood disorder marked by persistent sadness, loss of interest or pleasure in activities, changes in sleep or appetite, decreased energy, impaired concentration, and possible thoughts of death or suicide, significantly affecting daily functioning). schizophrenia (a chronic psychiatric disorder characterized by disturbances in thought, perception, and behavior, often including hallucinations, delusions, disorganized thinking, and impaired social or occupational functioning), and Post-Traumatic Stress Disorder (PTSD-is a mental health condition that can develop after experiencing or witnessing a traumatic event, and is characterized by intrusive memories, flashbacks, nightmares, avoidance of reminders of the trauma, negative changes in mood or cognition, and heightened arousal or reactivity). Review of the Resident R 94's PASRR Level I Identification Form, dated April 45, 2028, revealed that the resident was identified as having schizoaffective disorder and Post-Traumatic Stress Disorder (PTSD). However, further review of the clinical record demonstrated additional documented psychiatric diagnoses that were not reflected on the PASRR form. As a result, the Level I screening did not accurately capture the full scope of the resident's mental health conditions, rendering the PASRR incomplete and inconsistent with the resident's documented medical record. Review of the Resident 107's Quarterly Minimum Data Set (MDS-H Play federal mandate this assessment tool for all residents) dated December 9, 2025, revealed the resident re-entered the facility on July 19, 2024, and had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS documented diagnoses including anxiety is a chronic mental health condition involving excessive, persistent worry and anxiety that is difficult to control and interferes with daily functioning, depression (a medical and psychological condition that affects mood thoughts behavior and physical health and affects daily functioning), psychotic disorder (a mental health condition in which a person loses touch with reality people with psychotic disorders may experience hallucinations delusions or disorganized thinking which can significantly affect daily functioning), and dementia (a broad term used for a decline in cognitive function that is fair enough to interfere with daily life it is not a single disease but a syndrome caused by various underlying conditions) Review of Resident R 107's PASRR Level I Identification Form, dated October 27, 2020, indicated No under Section III regarding the presence of a mental health condition other than dementia. This response was inaccurate and inconsistent with the resident's documented diagnoses of major depressive disorder with psychotic features and psychosis, resulting in an incomplete and inaccurate PASRR screening. Review of Resident R 128's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident re-entered the facility on September 19, 2025, with documented diagnoses including anxiety (excessive worry or fear that interferes with daily life disorder, depression, and bipolar disorder (mental health condition characterized by the extreme mood swings that include periods of mania and depression). However, review of the PASRR Level I Identification Form, dated August 30, 2024, under Section III (Mental Health), failed to accurately reflect the resident's documented psychiatric diagnoses and did not indicate the need for further evaluation. This discrepancy resulted in an incomplete and inaccurate PASRR screening in relation to the resident's established mental health conditions. Review of Resident 142 Minimum Data Set (MDS) revealed the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. The MDS documented diagnoses including depression and bipolar disorder. Review of the PASRR Level I Identification Form completed on May 8, 2024, under Section III (Mental Health), listed only anxiety as a diagnosis and failed to include the documented diagnoses of bipolar disorder and depression. This omission resulted in an inaccurate and incomplete PASRR screening that did not fully reflect the resident's psychiatric history or clinical condition. Interview with Social Service employee E17 was conducted on February 19, 2026, at 11:40 a.m. During the interview, Employee E17 confirmed that he had not reviewed past PASRR forms to audit or verify their accuracy and completeness. The employee stated that he had recently started at the facility and had only been reviewing current PASRRs. He was unaware that he was responsible for ensuring all PASRRs, including past forms, were complete and accurately reflected residents' diagnoses. 28 Pa. Code 201.24 Admissions28 Pa. Code 211.5(f)(iv) Medical records

Based on a review of facility documentation and interview with staff, it was determined that facility failed to provide verifiable documentation of the mandatory 12-hour annual training for five of five employees reviewed. (Employee E19, E20, E21, E22, and E23) Review of Employees E19, E20, E21, E22, and E23's personnel files including documentation of annual mandatory 12-hour training for nursing assistants revealed there was no documentation of the nursing assistant twelve hours trainings. On February 20, 2025, at approximately 1:00 p.m., the Director of Nursing (Employee 2) provided the survey team with sign-in sheets for annual mandatory education. Further review of documentation provided by the facility included tests on topics such as abuse prevention, blood or body fluid exposure compliance, ethics, dementia, elopement prevention, fire and emergency procedures, hand hygiene, HIPAA, human trafficking, PPE and COVID-19 precautions, resident rights, TB testing, and trauma-informed care. There were no dates of completion, no employee names associated with the training, and no verification that staff had completed the 12-hour annual education requirement. Based on this review, the facility failed to provide any verifiable documentation that the mandatory 12-hour annual training was completed as required. 28 Pa. Code 201.20 Staff Development

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that a resident was assisted with nail care for one of 35 residents reviewed. (Resident R138) Findings include:Findings Include: Review of facility policy titled, Fingernails/Toenails Care of revised February 2018 states, Purpose-the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Review of Resident R138's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Anoxic Brain Injury (permanent brain damage) and Chronic Respiratory Failure (a long-term condition where the lungs cannot adequately oxygenate blood or remove carbon dioxide). Observation on February 18, 2026 at 10:10 a.m. of Resident R138's left hand revealed the resident had a left-hand contracture. The resident was observed with elongated nails that were almost resting against the resident's palm. Interview held with the license nurse Employee E12 on February 18, 2026 at 12:14 p.m. confirmed the resident's nails were long and needing to be cut. Interview held on February 19, 2026 at 12:25 p.m. with licensed nurse Employee E13 revealed the nurse is familiar with the resident and has worked on the unit before. When asked about nail care, Employee E13 stated that the aides are in charge of completing nail care timely in unless the resident is diabetic. Employee E13 confirmed the resident's nail were elongated and needed to be cut. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, interviews with staff and review of facility policy, it was determined that the facility failed to provide an environment that promotes the maintenance and enhancement of each resident's dignity for four of four residents reviewed needing feeding assistance. (Residents 17, Resident 33, Resident R84, Resident R199). Findings Include: Review of facility policy titled, Resident Rights with a revision date of February 2021, The policy states, Policy Statement- Employees shall treat all residents with kindness respect and dignity. Further review of facility policy states, Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility these rights include a. the resident's rights to a dignified existence b. to be treated with respect, kindness, and dignity. Observations made on February 18, 2025 at 12:53 p.m. of the D-wing nursing unit. There were four residents seated by the nurses station Residents R17, R33, R84, and R199. The dietary cart arrived to the unit at 12:54 p.m. One nurse aide instructed the other nurse aide to take the feeders into the D-wing lounge. Residents R17, R33, R84, and R199 were taken one by one by the nurse aides into the D-wing lounge while carrying their trays. After being seated in the dining room it was observed that none of the dining tables had linen tablecloths, silverware set up, or a napkin set up like in the main dining room the red room. The residents were wheeled to individual tables. Interview held with the facility dietician Employee E4 on February 18, 2026 at 2:02 p.m. about only residents who receive feeding assistance being served in the D-wing lounge for their meals. Employee E4 stated residents from D-wing lounge do typically come to the main dining room the red room for meals so I don't know if there was some confusion because the State is here this week but they do come to the main dining room. Interview held with licensed nurse Employee E16 on February 20, 2026 at 10:55 a.m. revealed residents that are feeders can't go to the red room for dining because they have feeding assistance and are declining. Interview held with the Nursing Home Administrator Employee E1 on February 20, 2026 at 10:30 a.m. When asked about dining in the main dining room compared to dining in the D-wing lounge the Nursing Home Administrator Employee E1 when asked when they don't have the tables set with linens and silverware referred to residents that are in need of feeding assistance as feeders when saying, well they are feeders. 28 Pa. Code 201.29 (j) Resident Rights 28 Pa. Code 211.12 (d)(1) Nursing Services 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on observations, review of policy, review of facility provided documentation and interview with staff, it was determined that facility failed to ensure resident's comprehensive care plans were updated and implemented in regard to wandering, exercise and code status for 3 of 35 residents reviewed (Resident R18, R95, and R225). Findings include: Review of facility policy titled Care Plans, Comprehensive Person Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident R18's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis of Chronic respiratory failure and pain in left knee. Review of Resident R18's physical therapy discharge summary revealed recommendation to continue independent exercise program as educated. Review of Resident R18'a care plan revealed no care plan in place for exercise program to increase strength, balance and endurance. Interview with Employee E2, Director of Nursing on February 18, 2026 at approximately 12:00 p.m. confirmed no care plan in place for Resident R18 exercise program. Review of Resident R95's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of dementia and schizophrenia. Review of Resident R95's progress note dated February 7, 2026 at 10:25 a.m., revealed Resident entered a female resident's room and walked in. Female resident was yelling while Resident R95 placed himself into her bed. Review of Resident R95's progress note dated February 7, 2026 at 11:04 a.m., revealed resident observed entering another resident's room and getting into another resident's bed. Review of Resident R95's care plan revealed no care in place for wandering behaviors. Interview with Employee E2, Director of Nursing on February 17, 2026 at approximately 12:00 p.m. confirmed no care plan in place for wandering behaviors. Review of Resident R225's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of Pulmonary (Lung) disease and Heart Failure. Review of Resident R225's physician order, dated January 7, 2026 at 2:43 p.m., revealed order to Do not intubate. DNR (do not resuscitate). Revie of Resident R225's care plan, initiated on October 14, 2021, revealed Resident 225 advance directives resident choses to be a full code. Interview with Employee E2, Director of Nursing on February 19, 2026 at 11:15 a.m. confirmed that care plan was not updated when the resident's advanced directives changed. 28 Pa. Code 211.10(d)(1)(5) Nursing services

Based on clinical record reviews, interviews with staff and reviews of facility policies and procedures, it was determined that the facility failed to conduct complete and thorough investigations into allegations of neglect for one of 35 residents reviewed. (Resident R19)Findings include:Review of the facility's policy titled, Grievances/Complaints, recording and investigating revised April 2017, states, All grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievance(s). The investigation and report will include, as applicable: a. the date and time of the alleged incident; b. the circumstances surrounding the alleged incident; c. the location of the alleged incident; the names od any witnesses and their accounts of the alleged incident; e. the resident's account of the alleged incident; f. the employee's account of the alleged incident; g. accounts of any other individuals involved (i.e., employee's supervisor, etc.); and h. recommendations for corrective actions. Review of the facility's policy titled, Compliance and Ethics- Internal Investigations revised December 2020, states, All potential compliance or ethics violations are investigated by the compliance and ethics committee under the direction of the compliance and ethics officer and administrator. Documentation of the investigation(s) include: a. detailed description of the suspected violation(s); b. details of the investigative process; c. copies of notes and interviews; d. results and conclusions of the investigation(s); e. disciplinary action taken; and f. corrective actions or remedies taken. Review of Resident R19's clinical record revealed resident was admitted to the facility on [DATE], with the diagnosis of Schizophrenia (Chronic mental health disorder), Dementia. Review of Resident R19's clinical record revealed progress note, dated February 7, 2026, stating A male resident entered Resident R19's room and placed himself in her bed. Resident R19 was yelling. When staff entered room, Resident R19 was lying on her side away from male resident. Male resident assisted from bed and room. Resident R19 states she is fine and he did not touch her with his hands. Skin check completed and no swelling or discoloration noted. Review of facility investigation dated February 7, 2026, incident description states Resident R95 walking and stomping up and down the hallway. Aggressive towards other residents and staff. Resident R95 entered a female resident's room and walked in. Female resident was yelling while Resident R95 placed himself into her bed. Staff entered as Resident R95 attempted to take off his shirt. Interview with Employee E??, Licensed Practical Nurse on February 17, 2026 at 2:37 p.m., revealed she was the first staff member to enter the room I was notified by another person, unsure if it was a staff member or another resident that Resident R95 entered Resident R19's room. I was sitting at the nursing station. Resident R95 was found in the bed with Resident R19, shirt halfway off. I entered the room and was unsuccessful in redirecting the resident, so then I got the other nurse and notified the supervisor. Review of facility investigation dated February 7, 2026, revealed no details of the investigation process, no statements from staff, residents or other witnesses and no conclusion of the investigation. Interview with Employee E2, Director of Nursing on February 18, 2026 at 12:10 p.m. revealed no statements or records are available. The statements are missing. Confirmed incomplete investigation. Interview with Employee E1, Nursing Home Administrator on February 19, 2026 at approximately 11:00a.m. revealed no statements or records were found however we are working on getting the statements now from the nurse and from the resident that alerted the nurse. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee 28 Pa . Code 211.12(c) Nursing services

Based on review of facility policy, observations, interviews with staff, it was determined that the facility did not ensure a clean, comfortable, and homelike environment in resident care areas for two of two nursing units observed (First Floor and Second Floor).Findings Include: Review of facility policy, last revised February 2021 titled, Homelike environment, policy statement states, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of facility policy revealed policy interpretation and implementation . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized home like setting these characteristics include: a. A clean sanitary and orderly environment. An initial tour was taken on February 17, 2026 of the first floor D-wing unit at 10:00 a.m. revealed the following: Observation of room [ROOM NUMBER] at 10:30 a.m. revealed the wall behind the air conditioning unit was patched but not yet painted. Wall was green board and white plaster. Further observation revealed B-bed area walls had writing all over multiple areas. Observation of room [ROOM NUMBER] at 10:39 a.m. multiple ceiling tiles with brown splattered stains above A-bed. Further observation of the room revealed the wall behind the air conditioning unit was patched but not yet painted. Wall was green board and white plaster. Observation of room [ROOM NUMBER] C-bed revealed the wall behind the air conditioning unit was patched but not yet painted. Wall was green board and white plaster. Further observation of the room revealed one corner of the ceiling had wallpaper peeling. Observation of room [ROOM NUMBER] revealed the wall behind the air conditioning unit was patched but not yet painted. Wall was green board and white plaster. Further observation of the room revealed one soiled window curtain. Observation of room [ROOM NUMBER] revealed multiple ceiling tiles with brown splattered stains. Observation of room [ROOM NUMBER] revealed multiple stained ceiling tiles. Further observation of the second-floor nursing units on February 18, 2026 at 10:10 a.m. revealed room [ROOM NUMBER] had multiple floor tiles cracked with pieces of the tile missing. Interview with Nursing Home Administrator Employee E1 on February 19, 2026 at 1:47 p.m. revealed the facility was aware of the writing on the wall in room [ROOM NUMBER] and stated, the resident does do that, he gets physically violent with staff so how are we supposed to go in and do the painting in the room. Further interview with Nursing Home Administrator Employee E1 revealed the facility is aware of multiple rooms needing painting. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on record review, staff interview and review of facility policy, the facility failed to ensure a physician order for code status was obtained and documented in the medical record for two of 35 residents reviewed with Advance Directives (Residents R5, and R9). Findings include: Review of the facility policy on Advance Directives/Code Status, indicated the facility will obtain and maintain a current authorized practitioner order for each resident's code status and ensure it is accurately reflected in the medical record. Review of Resident R5's clinical record revealed no documented code status (e.g., Full Code, Do not Resuscitate, Do not Intubate) in the physician order section of the record. Further review of the electronic medical record showed no active or historical order indicating the resident's code status . Review of the admission record and care plan did not reveal a current, authenticated practitioner order addressing code status. During an interview on February 18, 2026, at 12:57 p.m., the Charge Nurse, a Licensed Nurse, E14, confirmed that there was no physician order for code status documented in Resident R5's clinical record. Employee E14 acknowledged that a physician order was required to validate and implement a resident's code status. Record review of Resident R9's clinical record on February 18, 2026, revealed no documented code status in the physician order section. Further review of the electronic medical record showed no active or historical order indicating the resident's code status. Review of the admission record and care plan did not reveal a current, authenticated practitioner order addressing code status. During an interview on February 18, 2026, at 1:11 p.m., the Charge Nurse, a Licensed Nurse, E12, confirmed that there was no physician order for code status in Resident R9's clinical record. Employee E12 acknowledged that a physician order is required to validate and implement a resident's code status. 28 Pa Code 211.10(d) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services.

Based on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency and the State Long-Term Care Ombudsman program phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units) Findings Include: A tour was taken with the Director of Social Services Employee E3 on February 18, 2026 at 2:11 p.m. Observation during a tour of the second floor revealed that there was no State Survey Agency information posted. Further observations revealed the State Long-Term Ombudsman posting was located behind the nursing station desk but not posted in an area where residents and/or visitors could access it. A tour was taken of the first-floor nursing units at 2:21 p.m. On A-wing there was a State Survey Agency posting, but the contact phone number was incorrect. On B-wing there was no posting for the State Survey Agency or the State Long-Term Care Ombudsman. On D-wing there was no posting for the State Survey Agency or the State Long-Term Care Ombudsman.At the main entrance there was a posting with the incorrect phone number. Resident Council meeting was held on February 19, 2026 with awake, alert, and oriented residents. Residents R12, R99, and R147 when asked stated they did not know where the State Survey Agency or State Long-Term Care Ombudsman contact information was located in the facility. Interview held on February 18, 2025 at 2:40 p.m. with the Nursing Home Administrator E1 confirmed the above findings. 28 Pa. Code: 201.18(a)(e)(1) Management28 Pa. Code: 201.18(b)(1) Management

Based on observations, review of policy, and interview with residents, it was determined that facility did not provide reasonable accommodations related to privacy curtains for two of 35 residents reviewed. (Residents R52, and R27) Findings include:Review of facility policy 'Resident rights,' revised February 2021, indicates that employees shall treat all residents with kindness, respect, and dignity including supporting residents' right to privacy and confidentiality. Review of facility policy 'Homelike environment,' revised February 2021, indicates that staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. During interview with alert and oriented Resident R52 on Tuesday, February 17th, 2026 at 10:00 am, on D-wing - room [ROOM NUMBER]A, observed a missing privacy curtain. Upon further review with Resident R52, it was revealed that the privacy curtain has been missing for two months. During interview with alert and oriented Resident R27, on Thursday, February 19, 2026 at 10:30 am, it was observed that Resident R27 who had bilateral above knee amputations was completing morning hygiene care. The privacy curtain was observed to be only halfway closed. Upon further interview with Resident R27 at the time of the observation revealed that the resident would like to complete as many tasks as possible in order to continue autonomy and independence but would like to have complete privacy to maintain dignity. Upon further interview with Resident R27, it was revealed that (she/he) has been communicating with staff about adding additional privacy curtain but the resident has been continuously told to pass (her/his) concern on to someone else. 28 Pa. Code 211.10 (d)) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy, observation, record review, and staff interview, the facility failed to ensure that residents who entered the facility without limited range of motion did not experience avoidable decline, and failed to provide appropriate treatment and services to increase or prevent further decrease in range of motion and mobility for one of thirty-five residents reviewed (Resident R138) Findings Include: Review of facility policy titled, Activities of Daily Living (ADL), Supporting last revised March 2018 states, Policy Statement- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Continued review of the facility policy revealed, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care. Review of Resident R138's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Anoxic Brain Injury (permanent brain damage), Chronic Respiratory Failure (a long-term condition where the lungs cannot adequately oxygenate blood or remove carbon dioxide). Review of Resident R138's care plan dated January 14, 2026 states, Resident is at risk for skin break down due to incontinence and mobility. For interventions and tasks it lists, Apply left palm protector as tolerated for up to 6 hours a time daily. Check skin prior to application and after removal of palm protector. Observations on February 17, 2026 at 11:01 a.m. of Resident R138 revealed the resident has a left hand contracture with no palm guard, splint, or rolled wash cloth in place. Interview held on February 18, 2026 at 12:14 p.m. with licensed nurse Employee E13 revealed the nurse has been working with the resident since (he/she) arrived and the resident has not had a splint in place. Observations on February 19, 2026 at 10:55 a.m. of Resident R138 revealed the resident has a left-hand contracture with no palm guard, splint, or rolled wash cloth in place. Interview held on February 19, 2026 at 12:25 p.m. with licensed nurse Employee E13 revealed the nurse was familiar with the resident and worked on the unit before. When asked about a palm guard, splint, or rolled wash cloth the nurse was unaware of any currently in place. The licensed nurse Employee E13 looked in the bedside table and drawers and was unable to locate anything for Resident R138's contracture. 28 Pa. Code 211.12 (d)(5)(5) Nursing Services.

Based on clinical record review, and interview with staff, it was determined that the facility failed to to ensure that hospice recommendations were communicated to the attending physician for one of two residents reviewed receiving hospice care (Resident R97)Findings include: Based on record review and staff interview, the facility failed to ensure timely follow-up and provider review of a hospice medication recommendation for one of one resident reviewed for hospice services (Resident R97). Physician order dated March 1, 2025, indicated that R 97 was admitted to hospice services with diagnosis of Senile Degeneration of the Brain (a progressive, age-related decline in cognitive functions such as memory, language, reasoning, driven by neurodegenerative diseases). The order revealed specifically to call for all changes in status and needs, the staff must notify in-house Practitioner of all changes, every shift. On February 19, 2026, review of hospice documentation for Resident R97, dated January 2, 2026, revealed a recommendation for Ativan (Lorazepam) 0.5 mg by mouth every six (6) hours as needed for anxiety or restlessness. Continued review of the clinical record revealed no evidence the recommendation was communicated to the attending provider or acted upon at the time it was made. There was no documentation of provider review, order initiation, or documented clinical rationale for declining the recommendation. Further review showed the Ativan order was not obtained until February 19, 2026, approximately seven (7) weeks after the initial hospice recommendation. Interview with nursing staff and DON on February 19, 2026, at 12:19 p.m. confirmed awareness of the hospice recommendation for Resident R97. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policies and procedures, review of clinical records, and interviews with staff and residents, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of three residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who experienced lethargy, [CONDITION(S)] (elevated heart rate) and slurred speech and was admitted to the hospital for further monitoring and treatment. Findings include: A review of an undated facility policy Administering Medications, revealed: Policy Statement . Medications are administered in a safe and timely manner, and . 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] high blood pressure, Senna Tablet 8.6 mg (Sennosides) give 2 tablets for constipation, and [MEDICATION(S)] tablet 800 mg give 1 tablet for neuropathic pain. A review of Resident R1's Quarterly Minimum Data Set (MDS-a periodic assessment of needs) dated June 8, 2021, revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15 indicating that the resident was cognitively intact. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R2's clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident R1 on July 28, 2021, at 10:25 a.m., revealed that last week (July 19, 2021) they gave me the wrong meds (medications) which caused slurring speech and my legs felt really heavy around lunchtime. My friend at lunchtime noticed and said to staff that we need some help over here. I went to the hospital overnight. They had three IV's (intravenous lines) in me. At lunchtime (July 19, 2021) it hit me all at once. I don't want anyone to feel that way. I don't even remember being in the ED (Emergency Department). I woke up in hospital and said what the heck when I saw the IV's. They kept on pushing fluids (in the hospital). Review of documentation of the facility's investigation related to the medication error to Resident R1 revealed that on July 19, 2021, the unit manager had been notified by one of the nurse's that she may have given the wrong medicine to Resident R1. Resident R1 was noted with lethargy, grogginess and slurred speech around 12 noon. The resident was assessed and noted with an elevated heart rate and lethargy. Staff called 911 and transferred the resident to the hospital. Fcaility documentation of the investigation indicated that Resident R1 was admitted to the hospital for further monitoring and administration of intravenous fluids. Continued review of the facility's investigation indicated that during an interview with Resident R1 on July 21, 2021, the resident had indicated that the new girl had brought in her meds in a cup as usual, but when I looked in the cup I asked where the rest of them were. She said they are your meds please take them, so I did. I finished getting myself ready for the dining room and while I was sitting there, I felt very sleepy, and my words were slurring, and my feet felt like rocks. I asked if someone could take me back to my room. I don't remember much after that but the doctor at the hospital said I may have been given someone else's meds. Further review of facility documentation indicated that upon interview, Employee E3, had indicated that she may have gotten Resident R1 and R2 confused while administering their medications,as they look alike. Review of Resident R2's [MEDICATION(S)] sign out sheet revealed that Employee E3, RN, had signed out 200 mgs on July 19, 2021, at 9:00 a.m. and additionally signed out a second dose of 200 mgs on July 19, 2021, at 9:00 a.m Review of Resident R1's Hospital Discharge Record dated July 19, 2021, revealed that the nursing home had reported to the hospital that Resident R1 had the following sequence of events: medications administered at 11 a.m., symptoms started at 11:10-11:15 a.m., more lethargic and diaphoretic (sweaty); pt went down to get lunch then about 11:30 a.m., pt was lethargic, couldn't wake her up, generalized weakness. BS(blood sugar) was 206, BP 103/77, HR 135. Medications administered were [MEDICATION(S)] 100 mg, [MEDICATION(S)] 20mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] 200mg, [MEDICATION(S)] 7.5 mg and MVI(multivitamins). Continued review of Resident R1's hospital record dated July 19, 2021, revealed . Pt arrived somnolent (drowsiness) with some alteration in mentation. Pt [CONDITION(S)] (rapid heart rate), hypotensive (low blood pressure) which responded to IVF( intravenous fluids). Poison control consulted, recommended observation. Resident R1's hospital record indicated that the hospital planned on admitting the resident for observation on a telemetry unit (unit with cardiac monitoring) and continuing intravenous fluids for hydration. A review of Resident R1's Hospital Discharge Record dated July 20, 2021, revealed that the resident was in the hospital for an altered mental status due to accidental ingestion of wrong medications. The discharge records further indicated that Resident R1 was given IV fluids during her stay. Interview with the DON on July 28, 2021, at 12:30 p.m., revealed that Employee E3, RN, hasn't been back to work at the facility since July 19, 2021. The DON further indicated that the facility's conclusion was that Resident R1 got Resident R2's medications because Employee E3, RN, said that she confused the two residents. Further interview with the DON, on July 28, 2021, at 2:40 p.m. revealed that the DON suspected that Employee E3, RN, may have caught her own medication error. After Employee E3 gave Resident R1 the wrong medications, she then went to sign out Resident R2's medications and realized that she had already signed out the [MEDICATION(S)] and had erroneously given it to Resident R1. Interview with Employee E4, RN, on July 28, 2021, at 1:10 p.m., revealed that on July 19, 2021, Employee E3, RN, had stated to her that there was a possibility that Resident R1 might have gotten the wrong medications. Employee E4 further indicated that she had told the hospital and EMS that there might be a medication error. The facility failed to ensure that one resident was free of significant medication errors which resulted in Resident R1 experiencing experiencing lethargy, grogginess, and slurred speech,additionally, the resident was [CONDITION(S)] and hypotensive which which required hospitalization and intravenous fluids. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.14(c) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 207.2(a) Administrator's Responsibility 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to ensure that two residents (Residents CL1 and R11) were free from significant medication errors and resulted in actual harm to one resident when [MEDICAL CONDITION] medication was not administered as ordered which resulted in hospitalization and further invasive treatment (Resident CL1). Findings include: Review of the facility policy titled, Change of Condition: Notification of dated November 28, 2016, stated, A center must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker, where there is: a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set assessment (MDS- a periodic assessment of resident needs) dated April 16, 2017, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 6 indicating that the resident was severely impaired cognitively. Review of Resident CL1's clinical record revealed a progress note dated May 29, 2017, that stated the facility was notified by an outside laboratory that Resident CL1 had a critical high [MEDICATION NAME] ([MEDICATION NAME] - medication used to treat and prevent [MEDICAL CONDITION]) level of 29.7 ug/mL (usual reference range for adults is 10-20 ug/mL). The physician was notified and orders were received to hold Resident CL1's current order of [MEDICATION NAME] 200 milligrams one capsule by mouth two times per day and re-check the [MEDICATION NAME] level in the morning. The staff were to monitor the resident for [MEDICAL CONDITION]. Further review of the facility documentation revealed a progress note dated May 30, 2017, that stated the physician was notified that Resident CL1's new [MEDICATION NAME] level was 23.2 ug/mL and orders were received to continue to hold the medication until the [MEDICATION NAME] level returned to normal. On May 31, 2017, the laboratory notified the facility that Resident CL1's [MEDICATION NAME] level was 22.8 ug/mL. The physician reviewed the laboratory results and orders were given to continue to hold the medication on May 31, 2017, and start [MEDICATION NAME] 100 milligrams three times per day on June 1, 2017. Review of Resident CL1's June 2017 MAR (Medication Administration Record) and the June 2017 physician's orders revealed that the order received from the physician for [MEDICATION NAME] 100 milligrams three times per day was entered incorrectly as [MEDICATION NAME] 100 milligrams three times per day for seven days. Resident CL1 received this medication June 1, 2017 through June 7, 2017, and the order was then stopped on June 7, 2017. Resident CL1 did not receive the medication June 8th, 2017, through June 13, 2017, missing a total of 18 doses (1 week) of [MEDICATION NAME] 100 milligrams three times per day. Review of the facility documentation revealed that an outside consultant identified on June 13, 2017, upon review of Resident CL1's record, that the resident had not received the medication as previously ordered. The medication, [MEDICATION NAME] 100 milligrams by mouth three times per day, was ordered and started on June 13, 2017. Review of nursing documentation revealed that on June 16, 2017, Resident CL1's [MEDICATION NAME] level was 3.3 ug/mL (below range). Further review of the facility documentation revealed a witness statement that stated on June 19, 2017, Employee E18, Nursing Assistant, notified Employee E17, Licensed Practical Nurse, before lunch, that it looked like Resident CL1, was having a [MEDICAL CONDITION], she had a blank stare and she was jerking. Employee E17 went into Resident CL1's room and instructed Employee E18 to leave the resident in bed for the day. Fifteen to twenty minutes later, Employee E18 went back into Resident CL1's room to check on the resident and noted the resident, was leaning to the side, arm was hanging and the resident was twitching a little and Employee E18 then notified Employee E17 about the resident's condition. Review of a Change in Condition Followup Note, written by Employee E17 and dated June 19, 2017, at 2:30 p.m. stated, resident is being monitored for [MEDICAL CONDITION] (low [MEDICATION NAME] level) and behaviors. No [MEDICAL CONDITION] and behaviors noted on this shift. There was no documentation available for review that Employee E17 assessed Resident CL1 or notified the physician about Resident CL1's condition. Further review of facility documentation revealed a witness statement that stated on June 20, 2017, Employee E19, Nursing Assistant, noticed the resident's arm was really limp and it looked like the resident had a stroke. The resident started to have a [MEDICAL CONDITION] and Employee E17 was notified. Employee E20, Nursing Assistant, told Employee E19 that the resident had three [MEDICAL CONDITION] on June 19, 2017, in the morning. The Nurse Practitioner (NP) was called to the resident's room and Employee E19 notified the NP that the resident had three [MEDICAL CONDITION] on June 19, 2017. Further review of facility documentation revealed a witness statement from Employee E20 that on June 19, 2017, at 8:15 a.m. the resident, was twitching and one are arm was twitching and Employee E20 notified Employee E17. Resident CL1 was evaluated by the Nurse Practitioner on June 20, 2017, and orders were written to check a stat (immediate) [MEDICATION NAME] level, continue [MEDICATION NAME] 100 milligrams by mouth three times per day, and start [MEDICATION NAME] (sedative used to treat [MEDICAL CONDITION] disorders and anxiety) 0.25 milligrams by mouth every 12 hours. The [MEDICATION NAME] level was receivied by the facility on July 20, 2017 at 10:00 p.m. and was listed as being a 9 ug/ml, with a reference range of 10 to 20 ug/ml. Review of a Change in Condition Followup Note dated June 20, 2017, at 4:30 a.m. stated, resident noted with multiple [MEDICAL CONDITION] activity, NP (Nurse Practitioner) notified, new order noted to sent resident to hospital ER to be evaluate and treated. Resident CL1 was admitted to the hospital with [REDACTED]. Review of the nursing documentation revealed that Employee E21, Registered Nurse, dated July 14, 2017, observed Resident CL1 while in the hospital and the resident was noted to be, resting in bed comfortably at time of visit, [MEDICAL CONDITION] with tube feeding infusing. Interview with Employee E2, Director of Nursing, on August 3, 2017, at 11:30 a.m. and interview with Employee E21, on August 3, 2017, at 12:15 p.m. confirmed that Resident CL1 required a [MEDICAL CONDITION] (a tube is inserted into the windpipe to open restricted airway and allow breathing) while in the hospital due to the resident continuing to have multiple [MEDICAL CONDITION]. The facility failed to ensure one resident received [MEDICAL CONDITION] medication as ordered requiring hospitalization and further invasive treatment. Review of the facility policy, Medication Shortages/Drugs Not Available, revised December 15, 2008, revealed that the purpose of the policy was to ensure that unavailable drug products do not delay or compromise a patient's pharmaceutical care. The process included for the licensed nurse to call the pharmacy and speak to a registered pharmacist to determine the status of the order. If not ordered, place the order or re-order to be sent with the next scheduled delivery and if the next available delivery causes delay or missed dose in the patient's medication schedule, then to take the medication from the emergency stock supply to administer the dose. Review of the facility emergency supply stock revealed a list of medications the facility stored in case a resident's medication were not available. The emergency supply stock included [MEDICATION NAME]. Review of Resident R11's physician orders revealed the resident's orders included, but were not limited to, [MEDICATION NAME] (medication that affects the heart and circulation (blood flow through arteries and veins)) 100 mgs daily. Observation on August 1, 2017, of the medications being administered to Resident R11, by Employee E4, Licensed Practical Nurse (LPN), revealed Resident R11's [MEDICATION NAME] was not available and Employee E4 stated that she was going to reorder the [MEDICATION NAME] from the Pharmacy. Further observation revealed Employee E4 did not attempt to go to the facility's emergency stock supply to attain the [MEDICATION NAME]. Review on August 2, 2017, of Resident R11's Medication Administration Record [REDACTED]. Interview on August 3, 2017, at 9:00 a.m. with Employee E2, Director of Nursing (DON), where the DON confirmed that the Employee E4 did not follow facility policy by taking the [MEDICATION NAME] from the emergency stock supply to administer the dose. Employee E4 confirmed the resident did not receive the [MEDICATION NAME] on August 1, 2017. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/22/16, 09/30/16, 09/12/16, 07/28/15 28 Pa. Code 201.18(b)(1) Management Previously cited 12/22/16, 09/12/16, 06/20/16, 07/28/15 28 Pa. Code 211.5(f) Clinical records Previously cited 07/28/15 28 Pa. Code 211.5(g) Clinical records 28 Pa. Code 211.9(a)(1)(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/22/16, 06/20/16, 07/28/15 28 Pa. Code 211.12(c) Nursing services Previously cited 12/22/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 07/28/15, 06/20/16, 12/22/16, 04/25/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 07/28/15, 06/20/16, 12/22/16

Based on review of facility policies, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to assure that residents were free from mistreatment and neglect in regards to an unsafe transfer, which resulted in a fractured ankle for one of four residents reviewed (Resident R2). Findings include: Review of the clinical record for Resident R2 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated November 11, 2016, revealed that the resident needed extensive assistance, requiring two people to physically assist with transfers. Additional nursing documentation dated December 6, 2016, at 8:17 p.m. revealed that Resident R2 had a change in medical condition. The nursing notes stated that the level of the resident's consciousness was alert with confusion and that the resident was observed with a swollen lower left extremity. The Certified Registered Nurse Practioner (CRNP) ordered a venous doppler test (a test that uses sound waves to produce pictures of the body's veins and is commonly used to search for blood clots) on the resident's thigh and calf to rule out a [MEDICAL CONDITIONS]. A nursing note date December 7, 2016, at 12:17 p.m. stated, resident was negative for a [MEDICAL CONDITION]. A nursing note on December 9, 2016, stated that the resident was observed with the lower left extremity swollen but now with a bluish discoloration. The CRNP ordered an X-ray of the lower left extremity and the left foot. On December 9, 2016, the resident was diagnosed with [REDACTED]. Review of the facility's documentation revealed that the facility immediately began an investigation. An initial statement was obtained from the Nursing Assistant (NA) that was assigned to the resident on December 5, 2016. In the initial statement, the NA stated she transferred the resident to bed by picking her up with the bed position close to the chair. The Director of Nursing obtained an additional statement on December 11, 2016, via a telephone call to the NA who admitted the Hoyer lift (also known as a total lift, an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, using hydraulic power) was not used, nor was another staff member asked to help the NA. A review of the telephone statement dated December 11, 2016, revealed that the NA admitted he/she, grabbed the back of her pants and just picked her up. The resident was not able to stand and pivot, both of her legs are contracted. The NA further admitted that he/she was not sure of the resident's lift/transfer status and did not ask anyone because, I knew I could handle the resident. A review of the facility's policy and procedure titled, Safe Resident Handling/Transfer Equipment, dated March 1, 2016, stated, The total lift will be used as the primary intervention to manual lifting, transferring, and repositioning and requires a minimum of two persons to perform the lift. The Total Lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing. In addition, the total lift will be used to lift patients off of the floor. An interview with the Director of Nursing on December 22, 2016, at 10:30 a.m. revealed that the facility immediately conducted an internal investigation into the details of Resident R2's fracture on December 9, 2016. The Director of Nursing indicated that the conclusion of the investigation on December 11, 2016, had determined that Resident R2 had been incorrectly transferred from the chair to the bed by only one staff member, without using the Hoyer lift as the facility's policy required. The facility failed assure that residents were re free from mistreatment and neglect regarding an unsafe transfer for one resident that caused serious injury. 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/28/15, 06/20/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 07/28/15, 06/20/16, 09/12/16, 09/30/16 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 07/28/15, 06/20/16

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent resident' falls for two of thirty residents reviewed (Resident R81, and R18), resulting in actual harm to resident R81, and did not monitor tools and equipment to maintain a safe environment (Resident R194). Findings include: A review of Resident R81's care plan titled" ambulation,"dated July 29, 2010 and updated March 3, 2011, revealed that the resident demonstrates a deficit in ambulation, cognitive loss, dementia and functional deterioration. The care plan revealed that the resident needed supervision and staff were to provide verbal cueing and to walk along with the resident. Review of Resident R81's MDS(minimum data set - a periodic assessment of the residents' needs), dated April 25, 2011 revealed that the resident was severely cognitively impaired and needed extensive assistance for activities of daily living. The resident also needed the assist of one when ambulating. [DIAGNOSES REDACTED]. A review of the fall risk assessment dated [DATE] revealed that the resident was a high risk for falls. A review of facility documentation revealed that the resident had a history of [REDACTED]. Staff were attending to other residents and left the resident unsupervised at the nurse's station. When staff returned the resident was not in the chair. The staff found the resident in another resident's room on the floor bleeding from a laceration of the head. The resident was sent to the hospital and received eight sutures to her head. An interview with Employee E3, unit manager on July 19, 2011 at 1:00 p.m. confirmed that the resident needed the assist of one when ambulating and was unsupervised when she had a fall that required 8 sutures to her head. The facility failed to adequately supervise and assist the resident when ambulating, resulting in actual harm to the Resident R81. Review of Resident R18's significant change MDS (minimum data set, a tool to assess a resident's needs and abilities), dated June 23, 2011, found that the resident required the extensive assistance of two plus persons to transfer from surfaces, and that ambulation/walking did not occur during the assessment period. [DIAGNOSES REDACTED]. Review of nurse's documentation, dated July 7, 2011, indicated that one aide was assisting to transfer Resident R18 from the shower chair to the wheelchair when the resident slid to the shower room floor. An interview with licensed nurse Employee E4 on July 22, 2011, at 11:15 a.m., confirmed that on July 7, 2011, Resident R18 was assisted in transfer by one aide and fell , while the resident was assessed to require at least two persons for safe transfer. Observations on July 20, 2011 at 8:30 a.m. revealed a ladder up against the wall in room 223, bed A, second floor. Resident R194 was lying at the foot of bed A, approximately one foot from the ladder. Further observations revealed an out of order sign on the bathroom door, and when the bathroom door was opened (not locked), a drill was lying on the floor. The ladder and drill were unattended. Review of facility documentation revealed 22 cognitively impaired residents on this floor. The facility failed to provide an environment that is free from accident hazards. 28 Pa. Code: 201.18(a)(b)(1) Management. 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 PA Code 211.12(d)(1)(5) Nursing services. Previously cited 6/11/2010.