Every finding on record at Armstrong Rehabilitation and Nursing Center

Based on a review of facility policy, resident representative concern, observations, and staff interviews, it was determined that the facility failed to maintain an effective call system for one of four Nursing Units (Three A).Findings include: Review of the facility policy Call Lights: Accessibility and Timely Response last reviewed [DATE], indicated that the purpose of the policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. Review of a resident representative concern dated [DATE], indicated that The call bell system on the 3rd floor also doesn't work. During an interview on [DATE], at 9:33 a.m. Maintenance Employee E1 confirmed that the A side of the Third floor has call bell system that lights up, but that the Master Console device at the Nurses' Station doesn't ding. Staff can see the lights light up, but there is no activation of noise to alert them that a light is on. Maintenance Employee E1 stated that they would have to send the console out to another company to be repaired. During an observation on [DATE], at 12:09 p.m. State Agency activated the call bell in room [ROOM NUMBER] (Nursing Unit Three A). The indicator light above the room lit up, as well as the indicator light on the Master Console at the Nurses' Station, however no alarm or noise was activated. During an interview on [DATE], at 12:09 p.m. Nurse Aide Employee E2 confirmed the above findings, and stated that some of the lights don't even light up at all, and that the system has been broken on this unit since approximately February of 2026. During an interview on [DATE], at 12:54 p.m. Registered Nurse Employee E3 confirmed that the call system on Three A has been broken For a while and that some residents who have call lights that do not light up at all were given counter bells Like at a deli. During an interview on [DATE], at 1:58 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain an effective call system for one of four Nursing Units (Three A). 28 Pa Code 201.14 (a) Responsibility of licensee.28 Pa Code 201.18 (b)(1) Management.

Based on review of facility policy, documents, and staff interviews, it was determined that the facility failed to ensure an environment free of hazards which is likely to cause serious injury, harm, impairment, or death when an employee (RN Employee E1) entered the facility with a shot gun and ammunition. This failure created an immediate jeopardy situation for all residents.Findings include: Review of the facility's Employee Handbook dated 6/1/21, indicated the definition of an act of violence, for purposes of this policy, the facility will interpret an act of violence whether it is physical violence, verbal or non-verbal threats, damage to or theft of property and/or any related actions in the broadest sense possible to include (but not limited to) any of the following acts on facility property or facility sponsored function.-Possession of any firearm, knife, explosive or any other type of weapon covered by the law regardless of whether the person is licensed to carry the weapon or not. The possession or use of a weapon will be cause for immediate termination of employment. -Employees are required to report incidents of workplace violence or threats of such violence to their supervisor or any member of the management team immediately. No reprisal will be taken against any employee who in good faith reports or experiences workplace violence. -If any threat of violence exists, call 911 and notify law enforcement officials of the problem and request their assistance (e.g. police and/or ambulance). Inform those involved and contact the Chief Executive Officer. Review of the facility policy Workplace Violence last reviewed 5/21/26, indicated Weapons: the facility prohibits all Associates, residents, or visitors from possessing any weapons of any kind at the workplace. For purposes of this policy, the workplace is defined to include the Facility's building(s), outdoor areas, and parking lots. Weapons include but are not limited to guns, knives, [NAME], explosives, and any item with the potential to inflict harm that has no common purpose. Review of RN Employee E1's personnel file indicated a signature sheet for the employee handbook dated 9/22/23, indicating they agree to comply with the requirements in the employee Handbook and any other personnel policies issued by the facility. Review of an anonymous complaint filed with the state on 7/15/26, the Confidential Employee E2 indicated when they arrived at the facility in their car, they saw a man walk into the facility with a shot gun and ammunition in their hand. He walked right into the facility. Before Confidential Employee E2 left the facility parking lot two staff members in scrubs were there and they said, we saw that too. That's the Registered Nurse (RN) Supervisor Employee E1 of the building for daylight shift. Interview on 7/16/26, at 9:05 a.m. Social Services Director (SSD)Employee E3 indicated they walked into the facility around 7:05 a.m. on 7/15/26, and the Infection Preventionist (IP) Employee E4 was sitting outside my office and said, Before you go in there, there is a gun in the corner that RN Employee E1 brought in because the NHA wanted to look at it. SSD Employee E3 continued to state that there were bullets with it as well. They looked at the gun, shut the door and went down the hall. They did not indicate that they called anyone at that time. When asked if they thought it was odd that a firearm was in the facility, SSD Employee E3 indicated they did find it odd. They did not indicate they thought they should call the police. The reason they shut their office door was because it has a key code lock to enter. SSD Employee E3 indicated that herself and IP Employee E4 knew the code to the social services office door. Further interview with SSD Employee E3, indicated the Director of Nursing (DON) called the facility because she hadn't arrived yet, the DON instructed SSD Employee E3 and IP Employee E4 to go speak to RN Employee E1 on the second floor, then went outside to speak to an agency aide that was in the parking lot. Somebody arrived in a black vehicle, maybe RN Employee E1's spouse and saw RN Employee E1 give the shotgun and bullets to whomever was in the car who left the parking lot with it. SSD Employee E3 indicated they did not believe any resident saw or knew of the shotgun being in the first-floor office and that it never went to a resident unit. Telephonic interview on 7/16/26, at 9:27 a.m. with IP Employee E4 indicated whenever they were entering the facility they saw RN Employee E1 with a shotgun and asked why they had that. They responded that they were going to show it to the NHA, and they didn't want to take it to the floor. IP Employee E4 said I don't think you should have it in the facility. It was locked in SSD Employee E3's office. The DON called me and asked if RN Employee E1 was there and had him remove the gun from the facility immediately. IP Employee E4 contacted RN Employee E1 and instructed him to meet immediately at the SSD Employee E3's office entrance. RN Employee E1 then removed the shotgun from the office and took it out of the facility. One of the staff outside called the DON and that's when they received the call to remove the gun immediately. When asked if they saw the gun and why they didn't call the police, IP Employee E4 indicated they really didn't know what to do and that's why the gun was locked in the first-floor office. Interview on 7/16/26, at 9:15 a.m. the DON indicated this all occurred prior to her arrival to the facility. Once the DON arrived at facility, she called RN Employee E1 to her office and had a conversation about safety and not bringing weapons into the facility. The DON read to RN Employee E1 what they found online under Pennsylvania regulations and weapons in a long-term care facility as a very serious offense. The DON provided disciplinary action. RN Employee E1 told the DON her didn't mean anything by it, he was just going to show it to the NHA. The DON told them this can never ever happen again. RN Employee E1 stated I don't even think we have signs that say no guns. Interview on 7/16/26, at 9:35 a.m. the Nursing Home Administrator (NHA) indicated that he is a fan of guns, collects guns, and knows people that buy guns. The NHA had a conversation the day prior with RN Employee E1 who said he'd like to show a gun to me, that NHA might know someone who might want to buy it. The conversation occurred in the Social Worker's office. The NHA said according to policy the gun should not have been on the property. The NHA had a conversation with RN Employee E1 after the Director of Nursing provided disciplinary action and RN Employee E1 indicated that he used to carry the gun into this nursing home and has a permit to carry. On 7/16/26, at 11:50 a.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) was called due to the facility failing to ensure an environment free of hazards when an employee (RN Employee E1) entered the facility with a shot gun and ammunition. The NHA was provided with an Immediate Jeopardy template, and a corrective action plan was requested. On 7/16/26, at 3:00 p.m. an acceptable Corrective Action Plan was received which included the following interventions:The facility will create an environment free of potential accidents. The facility cannot retroactively correct the concern identified for the incident that occurred on 7/15/26.Actions:-Employee was notified to remove gun immediately from facility. -Employee received Final Warning discipline from Director of Nursing on 7/15/26 and educated by the DON and NHA on workplace violence and no tolerance for weapons. -All residents will be assessed for injuries, or any psychosocial or mental harm related to the incident by Nursing/designee by 7/17/26.-Any resident who had a negative effect will have a care plan and orders updated, family notification and receive any needed services by 7/17/26.-All residents' families and physicians will be notified by SSD/designee by 7/17/26, of the event.-Facility policy and procedure will be updated accordingly by NHA/designee by 7/17/26.-Determine the root cause of the event by 7/17/26.--Educate all facility staff and agency staff on policy regarding violence in the workplace and the definitions of acts of violence and weapons, and the procedure for emergency situations such as a weapon in the facility by 7/17/26.-The facility will develop a proper screening process for all staff/visitors to prevent weapons entering the facility by 7/17/26.-Notices will be posted by receptionist/designee at entrance doors indicating weapons are not permitted on facility property by 7/17/26-Educate if a staff member identifies a weapon entering the facility they are to notify their supervisor or call 911 by 7/17/26.-Review all Quality Assurance Quality Improvement meetings and make additional changes to ensure residents' safety as needed. On 7/17/26, the abatement plan was reviewed for completion as follows:-Employee was notified to remove gun immediately from facility. - verified 7/17/26-Employee received Final Warning discipline from Director of Nursing on 7/15/26 and educated by the DON and NHA on workplace violence and no tolerance for weapons. Verified 7/17/26.-90 of 90 in-house residents were assessed for injuries, or any psychosocial or mental harm related to the incident. Verified 7/17/26.-None of the 90 assessments revealed findings of anxiety, fear or negative effects on residents. Verified 7/17/26.-The Medical Director was notified of the incident relating to all residents on 7/16/26. Verified on 7/17/26.-All families were notified of the incident that occurred on 7/15/26. Verified on 7/17/26.-The facility policy Workplace Violence was reviewed on 7/16/26, by the Administrator and DON. Verified on 7/17/26.-Root caused was identified as lack of education and understanding by staff. Verified 7/17/26.-Education for all facility staff and agency staff regarding violence in the workplace and the definitions of acts of violence and weapons, and the procedure for emergency situations such as a weapon in the facility. Verified trainings on 7/17/26.-Staff signatures on education 58 facility and 49 agency = total of 107 of 115 staff signatures.-In person facility interviews across all disciplines totaling 23 staff and all expressed training and understanding.-The NHA developed a Workplace Violence Screening Policy dated 7/17/26, where all staff and visitors will enter through the front door only. The persons attending the door will ask them if they are in possession of any weapons. The person will be instructed to sign in and out at the desk. The only exception to this entry rule is for 911 services.-Notices posted by receptionist/designee at entrance doors indicating weapons are not permitted on the facility's property. Verified 7/17/26.-The incident will be reviewed at the next Quality Assurance and Performance Improvement Meeting scheduled for 7/21/26. The Immediate Jeopardy was lifted on 7/17/26, at 1:03 p.m. when the action plan implementation was verified. Interview on 7/17/26, at 2:50 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure an environment free of hazards likely to cause serious injury, harm, impairment, or death when an Employee (RN Employee E1) entered the facility with a shot gun and ammunition. This failure created an immediate jeopardy situation for all residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure a physician completed the initial comprehensive visit for two of five residents (Residents R1 and R2).Findings include: Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/26/26, indicated diagnoses of high depression, muscle weakness, and difficulty walking. Review of Resident R1's clinical record failed to include documentation that the initial comprehensive visit was completed by a physician. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and insomnia. Review of Resident R2's clinical record failed to include documentation that the initial comprehensive visit was completed by a physician. During an interview on 7/17/26, at 2:21 p.m. the Director of Nursing confirmed that the facility failed to ensure a physician completed the initial comprehensive visit for Residents R1 and R2. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code 211.5(f)(iv) Medical records.

Based on review of facility policy and documents, and staff interviews it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to ensure an environment free of accidents likely to cause serious injury, harm, impairment, or death when a staff member saw a man walk in with a shot gun and ammunition in his hand. This failure created an immediate jeopardy situation for all residents.Findings include: Based on findings identified in this report the facility failed to ensure an environment free of accidents likely to cause serious injury, harm, impairment, or death when a staff member saw a man walk in with a shot gun and ammunition in his hand , placing all residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 7/17/26, at 2:50 p.m. the NHA and DON were notified that they failed to effectively manage the facility by failing to create a safe environment free of accidents likely to cause serious injury, harm, impairment, or death when a staff member saw a man walk in with a shot gun and ammunition in his hand. This failure created an immediate jeopardy situation for all residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, facility records, observations, and resident and staff interviews, it was determined that the facility failed to ensure comfortable room temperature levels were provided for eight out of 22 sampled residents (Residents R1, R2, R3, R4, R5, R6, R7, and Resident R8). Findings Include: Review of the facility policy Safe and Homelike Environment, dated 4/27/26, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. Review of Room temperature audits dated 6/10/26, indicated 21 resident rooms temperatures were over 80 degrees Fahrenheit. Room temperature logs dated 6/11/26, indicated five resident rooms over 79 degrees Fahrenheit. Review of service provider repair proposal dated 6/10/26, indicated air conditioning repair estimate was completed, total repair costs were $13,900, and the proposal was not signed yet by the facility ownership. Review of resident council minutes from May 2026 identified concerns with air conditioning units needing repair. During observations of the 200-nursing unit with Maintenance Supervisor Employee E1, room temperatures were taken at 10:20 a.m. Room temperatures over 79 degrees were found. All temperatures were in Fahrenheit and were as follows:Resident R1's room: 82 degreesResident R2's room: 80 degreesResident R3's room: 82 degreesResident R4's room: 80 degrees During observations of the 300-nursing unit with Maintenance Supervisor Employee E1, room temperatures were taken at 10:26 a.m. Room temperatures over 79 degrees were found. All temperatures were in Fahrenheit and were as follows:Resident R5's room: 80 degreesResident R6's room: 82 degreesResident R7's room: 80 degreesResident R8's room: 81 degrees During an interview on 6/11/26, at 11:48 a.m. Resident R10 was asked about his room temperature and he stated: I can tell you-it's hot. Was hot all day yesterday. Would like some air conditioning that works. During an interview on 6/11/26, at 11:51 a.m. Resident R2 was asked about the temperature in her room and she stated: I am hot. Been for a while. Not sure how long. During an interview on 6/11/26, at 11:53 a.m. Resident R1 stated I am hot. Been hot for one week. Got my own personal fan. During an interview on 6/11/26, at 11:57 a.m. Registered Nurse (RN) Employee E2 was asked about the room temperatures in the facility: I was here on Sunday. No issues on that day. Some of the resident today said it was hot. During an interview on 6/11/26, at 12:01 p.m. Resident R9 was asked about the temperature in the facility and stated: The air conditioning in my room is good now. A couple of days ago, it was 85 degrees in here. This happened last year. Air conditioning was out. I think the residents should have been notified if they have a bad part; they should tell us. During an interview on 6/11/26, at 12:17 p.m. Licensed Practical Nurse (LPN) Employee E3 was asked about the room temperatures in the facility and stated: Its better today; It was really hot yesterday. During an interview on 6/11/26, at 1:26 p.m. Social Services Employee E4 was asked if any residents complained about room temperatures before the 6/11/26: yes, resident council did. Additional observations of the 200-nursing unit with Maintenance Supervisor Employee E1, room temperatures were taken at 1:58 p.m. Room temperatures over 79 degrees were found. All temperatures were in Fahrenheit and were as follows:Resident R1's room: 80 degreesResident R3's room: 80 degreesResident R4's room: 80 degrees Additional observations of the 300-nursing unit tour with Maintenance Supervisor Employee E1, room temperatures were taken at 2:03 p.m. Room temperatures over 79 degrees were found. All temperatures were in Fahrenheit and were as follows:Resident R5's room: 80 degreesResident R6's room: 82 degreesResident R7's room: 80 degrees During an interview on 6/11/26, at 2:12 p.m. in Maintenance Supervisor Employee E1 confirmed that some residents' rooms were still over 80 degrees Fahrenheit. During an interview on 6/11/26, at 2:55 p.m. information disseminated to Director of Nursing (DON) and Social services Employee E4 that the facility failed to ensure comfortable room temperature levels were provided for Residents R1, R2, R3, R4, R5, R6, R7, and Resident R8 as required. 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c)(d) Resident Rights

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for one of three residents reviewed (Resident R1).Findings Include: Review of the facility's Resident Accidents and Incidents policy dated 4/27/26, indicated it is the facility policy to ensure all incidents involving a resident a reported, documented and investigation initiated after the incident is identified. The nursing supervisor immediately notified of incidents. The resident's care plan is updated by the assigned Nurse, Clinical Manager, or Nursing Supervisor. The clinical manager or assigned nurse will ensure the resident care plan is updated with any new interventions identified during clinical rounds. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of metabolic encephalopathy, intellectual disabilities, and paraphilias (intense persistent sexual interests, urges or fantasies involving atypical objects, situations, or non-consenting partners). Review of Resident R1's care plan dated 4/13/23, indicated the resident was care planned for agitation and discussing masturbation with roommate. On 1/14/25, it was revised for the resident inappropriate touching. Interventions included to administer medications as ordered, redirect to stay out of others rooms, stop sign has been placed on door way of frequently approached room. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/12/26, indicated diagnoses were current. Review of information submitted to the State Agency on 5/21/26, by the Director of Nursing revealed on 5/21/26, it was reported a resident (Resident R2) witnessed Resident R1 touching up and down the front of Resident R3's blouse. Resident R2 yelled at Resident R1 to stop and the alleged perpetrator started to yell and make mean faces, then left the dayroom. Review of Resident R1's care plan revised on 5/22/26, revealed the resident likes to be naked and interventions included the resident was seen by psych services on 5/22/26. The care plan failed to include a revision that addressed the inappropriate touching and interventions to prevent reoccurrence. The facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status. Review of information resubmitted to the State Agency on 5/23/26, by the Director of Nursing, revealed the interdisciplinary team met and reviewed care plan and interventions. Staff education to round very frequently and check on residents in the day rooms on all units. Physicians and responsible parties were notified and in agreement with interventions and care plan updated. Review of Resident R1's physician order dated 5/24/26, indicated to observe frequently when in dayroom, assure rounding frequently. Review of Resident R1's care plan initiated on 5/26/26, a total of five days after incident, stated 5/24/26 observed frequently when in dayroom; assure rounding as per orders. The facility failed to ensure the care plan was reviewed and revised to accurately and timely to reflect the resident's current status. During a phone interview on 6/9/26, at 12:41 p.m. the Registered Nurse Assessment Coordinator (RNAC), Employee E6 stated it is expected revisions of care plans are made as soon as changes are made. RNAC, Employee E6 stated resident's care plan should be reflective of what is currently going on. During an interview on 6/9/26, at 2:30 PM, the Director of Nursing the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for one of three residents reviewed (Resident R1). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and documentation, staff interviews it was determined that the facility failed to protect resident from sexual abuse for one of three residents (Resident R3).Findings include: Review of facility's Abuse, Neglect, and Exploitation policy dated 4/27/26, stated it is the facility policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defines as non-consensual sexual conduct of any type with a resident. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of metabolic encephalopathy, intellectual disabilities, and paraphilias (intense persistent sexual interests, urges or fantasies involving atypical objects, situations, or non-consenting partners). Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/12/26, indicated diagnoses were current. Section C-Cognitive Patterns revealed the resident is rarely/never understood. Review of Resident R1's care plan dated 4/13/23, indicated the resident was care planned for agitation and discussing masturbation with roommate. On 1/14/25, it was revised for the resident inappropriate touching. Interventions included to administer medications as ordered, redirect to stay out of others rooms, stop sign has been placed on door way of frequently approached room. Review of Residents R3's admission record indicated the resident was admitted on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/25/26, indicated diagnoses of anxiety, depression, and mild intellectual disabilities. Section C-Cognitive Patterns revealed the resident is rarely/never understood. Review of information submitted to the State Agency on 5/21/26, by the Director of Nursing revealed on 5/21/26, it was reported a resident (Resident R2) witnessed Resident R1 touching up and down the front of Resident R3's blouse. Resident R2 yelled at Resident R1 to stop and the alleged perpetrator started to yell and make mean faces, then left the dayroom. Review of Resident R2's witness statement dated 5/21/26, stated I witnessed Resident R1 touching Resident R3 up and down the front of her shift. I told him to stop and to get away and he started yelling at me. Resident R1 was making mean faces like he wanted to fight saying what am I talking about. Review of Licensed Practical Nurse (LPN) Infection Preventionist (IP), Employee E1 witness statement stated they were alerted by Resident R2 that Resident R1 touched Resident R3 inappropriately. Resident R1 exited room after she told him to stop. LPN, Employee E1 went to dayroom and Resident R1 was not in the day room. It was indicated the Registered Nurse, Supervisor was alerted. Review of Resident R4's undated witness statement completed by Assistant Director of Nursing (ADON), Employee E2 revealed per verbal in-person interview Resident R4 heard her say stop it once then two to three times more. During an interview on 6/9/26, 10:59 a.m. Resident R4 stated on 5/21/26, he heard Resident R2 yelling at Resident R1 to stop, however Resident R1 does not understand much. Resident R4 stated he heard her yelling for about five minutes and she told staff about the incident. During an attempted interview on 6/9/26, at 11:05 a.m. Resident R2 was out of the facility and unavailable. During an interview on 6/9/26, at 12:19 p.m. Registered Nurse (RN) Supervisor, Employee E3 confirmed she was present when the incident between Resident R1 and Resident R3 occurred on 5/21/26. RN Supervisor stated she was unsure who alerted her of the incident, but stated it occurred after 3 p.m. and since the Director of nursing was still in the building she took charge. It was indicated Resident R1 went back to his room and checks were completed every 15 minutes. During an interview on 6/10/26, at 12:23 p.m. Licensed Practical nurse (LPN), Employee E4 stated she was assigned on the unit on 5/21/26, when the incident between Resident R1 and Resident R3 occurred. It was indicated the incident occurred during the 7 a.m. to 3 p.m. shift. LPN, Employee E4 indicated she was not present in dayroom when it happened, but Resident R3 approached her and stated Resident R1 had his hands on the outside of Resident R3's shirt. Resident R3 told Resident R1 to stop, and he did it more than once. LPN, Employee E4 then alerted the RN Supervisor and administration. Resident R1 was placed on every 15 minute checks and Resident R3 was assessed. During an attempted interview on 6/9/26, at 2:20 p.m. Resident R2 was out of the facility and unavailable. During an interview on 5/20/26, at approximately 2:30 p.m. the Director of Nursing confirmed the facility failed to protect resident from sexual abuse for one of three residents (Resident R3). 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.10 (a) (d) Resident care policies

Based on review of facility documents, facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse for one of three residents (Resident R3).Findings include: Review of facility's Abuse, Neglect, and Exploitation policy dated 4/27/26, stated it is the facility policy to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defines as non-consensual sexual conduct of any type with a resident. The facility will identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The facility must provide complete and through documentation of the investigation. Review of the facility's Resident Accidents and Incidents policy dated 4/27/26, indicated it is the facility policy to ensure all incidents involving a resident a reported, documented and investigation initiated after the incident is identified. The nursing supervisor immediately notified of incidents. Statements must be obtained at the time incident is identified and should include pertinent information such as witnessed details of event, last time employee provided care or saw resident, resident's status/behavior when last seen prior to event, any additional facts pertinent to the extent and contributing factors resulting in the event. Review of information submitted to the State Agency on 5/21/26, by the Director of Nursing revealed on 5/21/26, at 4:00 p.m. it was reported Resident R2 (Brief Interview Mental Status (BIMS) Score of 15/15, cognitively intact) witnessed Resident R1 touching up and down the front of Resident R3's blouse while in the dayroom on the second floor. Resident R2 yelled at Resident R1 to stop and the alleged perpetrator started to yell and make mean faces, then left the dayroom. Review of the facility's documentation for mandatory abuse reporting revealed the incident occurred on 5/21/26, at 3:30 p.m. Review of the facility's assignment sheet for 5/21/26, revealed Registered Nurse Supervisor, Employee E3 was the facility's RN Supervisor for the day and evening shift from 7 a.m. to 7 p.m. Licensed Practical Nurse (LPN), Employee E4 was the floor nurse on 2AB from 7 a.m. to 3 p.m. Review of the facility's investigation dated 5/21/26, revealed a copy of a police statement signed by the Director of Nursing (DON) indicated Resident R2 stated that she witnessed resident R1 touching Resident R3 up and down the front of her blouse. Resident R3 stated that she told Resident R1 to stop then Resident R1 started to yell at her, but he left the dayroom at that time. Resident R2 reported to the charge nurse, LPN, Employee E4. Review of Nurse Aide (NA), Employee E5 undated and unsigned witness statement completed by ADON, Employee E2 stated per verbal phone interview it was indicated NA, Employee E5 was not aware of the situation. The facility failed to obtain signed witness statements from the witness. Review of Resident R4's undated witness statement completed by Assistant Director of Nursing (ADON), Employee E2 revealed per verbal in-person interview Resident R4 heard Resident R2 say stop it once then two to three times more. The facility failed to obtain signed witness statements from the witness. During an interview on 6/9/26, at 11:18 a.m. the Director of Nursing (DON) stated she was present in the facility when the incident between Resident R1 and Resident R3 occurred on 5/21/26, in the dayroom. The DON stated when an incident happens, I always come in, I always run it. The Director of nursing stated she obtained witness statements. The DON stated she would have to ask the Assistant Director of Nursing when verbal and phone interviews were completed. The DON confirmed the facility failed to obtain signed and dated witness statements for Resident R4 and NA, Employee E5. During a phone interview on 6/9/26, at 12:04 p.m. NA, Employee E5 confirmed she was not present when the incident between Resident R1 and Resident R3 occurred. Review of LPN, Infection Preventionist (IP), Employee E1 signed witness statement dated 5/21/26, stated they were alerted by Resident R2 that Resident R1 touched Resident R3 inappropriately. Resident R1 exited room after she told him to stop. LPN, Employee E1 went to dayroom and Resident R1 was not in the day room. It was indicated the Registered Nurse, Supervisor was alerted. During a phone interview on 6/9/26, at 12:10 p.m. IP, Employee E1 stated she was not involved with the incident that occurred on 5/21/26, between Resident R1 and Resident R3. She stated the daylight nurse was more involved and she did not work until 3 p.m. to 11 p.m. LPN, IP, Employee E1 stated I did not complete a witness statement. It was indicated LPN, Employee E4 was the nurse present when it occurred. During an interview on 6/9/26, at 12:19 p.m. Registered Nurse (RN) Supervisor, Employee E3 confirmed she was present when the incident between Resident R1 and Resident R3 occurred on 5/21/26. RN Supervisor, Employee E3 stated she was unsure who alerted her of the incident, but since the Director of Nursing was still in the building she took charge. RN, Supervisor, Employee E3 confirmed she did not complete a witness statement. During an interview on 6/9/26, at 12:23 p.m. LPN, Employee E4 stated on 5/21/26, she was the floor nurse on the unit when the incident between Resident R1 and Resident R3 occurred. It was indicated the incident occurred during the 7 a.m. to 3 p.m. shift. LPN, Employee E4 stated she was not present in dayroom when it happened, but Resident R3 approached her and stated Resident R1 had his hands on the outside of Resident R3's shirt. Resident R3 told Resident R1 to stop, and he did it more than once. LPN, Employee E4 then alerted the RN Supervisor and Director of Nursing and Nursing Home Administrator. LPN, Employee E4 confirmed she did not complete a witness statement. Review of the facility's investigation failed to include witness statements from RN, Supervisor Employee E3 and LPN, Employee E4. During an interview on 5/20/26, at 2:26 p.m. the Director of nursing confirmed that the facility failed to conduct a thorough investigation, and obtain all witness statements for one of three residents (Resident R3). 28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations, facility policy, and staff interview, it was determined that the facility failed to ensure comfortable air temperature levels were provided for eight of ten resident rooms/areas (Rooms 211-2, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, and room [ROOM NUMBER]-1).Findings Include: Review of the facility policy Safe and Homelike Environment, dated 7/1/25, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. During an interview and tour on 4/20/26, at 9:28 a.m., with the Maintenance Director Employee E1 the following areas indicated inadequate temperatures: 2nd Floor:room [ROOM NUMBER]-2 - 69 degrees FahrenheitDay room [ROOM NUMBER]A Unit - 66 degrees FahrenheitDay room [ROOM NUMBER]BC Unit - 68 degrees Fahrenheitroom [ROOM NUMBER]-2 - 69 degrees Fahrenheit 3rd Floor:room [ROOM NUMBER]-1 - 69 degrees FahrenheitDay room [ROOM NUMBER]A Unit - 66 degrees FahrenheitDay room [ROOM NUMBER]BC Unit - 69 degrees Fahrenheitroom [ROOM NUMBER]-1 - 70 degrees Fahrenheit During an interview on 4/20/26, at 9:38 a.m., Resident R1 stated It is cold in here. During an interview on 4/20/26, at 9:48 a.m., Resident R2 was sitting in the Day room [ROOM NUMBER]BC Unit and stated, It's freezing in here today. During an interview on 4/20/26, at 9:50 a.m. Maintenance Director Employee E1 confirmed the facility failed to ensure comfortable air temperature levels were provided for eight of ten resident rooms/areas (Rooms 211-2, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, room [ROOM NUMBER]-2, room [ROOM NUMBER]-1, Day room [ROOM NUMBER]A Unit, Day room [ROOM NUMBER]BC Unit, and room [ROOM NUMBER]-1). 28 Pa. Code: 201.18(b)(3) Management

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information and failed to set up home care services in preparation for discharge for one of four residents reviewed (Resident R3).Findings include: Review of the facility policy Transfer and discharge date d 7/1/25, indicated for anticipated discharge to the community, the facility will obtain a physician's order for discharge and instructions on precautions for ongoing care. A post discharge plan of care that is developed with the participation of the resident, and the residents' representative which will assist the resident to adjust to his or her new living environment. Review of the admission record indicated Resident R3 admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/13/26, indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R3's care plan dated 3/5/26, indicated resident would like to discharge back to the community. Review of Resident R3' progress note dated 4/17/26, at 12:20 p.m. indicated resident discharged from facility via stretcher van. All belongings and medications with resident. Medication list faxed to primary care physician. Discharge instructions explained to resident and wife this morning. Both verbalized understanding. Review of Resident R3's Discharge Transition Packet dated 4/10/26, on 4/20/26, at 12:30 p.m. indicated the Social Services Section was blank, including services that has been recommended upon discharge such as home health nursing services, home therapy services, outpatient therapy services, etc. Review of facility provided documentation on 4/20/26, at 12:35 p.m. indicated Resident R3's spouse called the facility on 4/17/26, at 10:00 p.m. concerned that resident services had not been set up by Social Services. Interview on 4/20/26, at 1:02 p.m. Social Service Employee E2 indicated they had a day off on 4/17/26, and ordering the home care services and therapy simply got missed. Interview on 4/20/26, at 1:03 p.m. Social Service Employee E2 confirmed that the facility failed to provide the resident/resident's responsible party with complete information and failed to set up home care services in preparation for discharge for one of four residents reviewed (Resident R3). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management

Based on facility policy review, clinical record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Findings Include: Review of the facility policy Missing Resident / Elopement Procedures dated 8/8/25, defined elopement: Occurs when a resident leaves a safe area without staff knowledge OR the patient enters an unsafe area without staff knowledge or presence. This can include locations within the building. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/31/25, included diagnoses of bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and moyamoya disease (progressive cerebrovascular disorder where the internal carotid arteries narrow, reducing blood flow to the brain and causing strokes, TIAs (mini-strokes), or hemorrhage). Review of Section C: Cognitive Patterns revealed Resident R1 had moderate cognitive impairment. Review of Resident R1's Elopement Risk Assessments completed revealed:9/8/25: Not an elopement risk.10/17/25: Elopement Risk12/27/25: Not an elopement risk. Review of the physician's orders indicated Resident R1 was ordered an electronic monitoring bracelet (electronic bracelet usually worn either on the resident or on their wheelchair that alarms when near doorways connected to the monitoring system) on 2/10/25; and remained a current order. Review of Resident R1's plan of care for Resident exhibits behavior symptoms such as wandering, suicidal ideations initiated 10/22/25, revised on 11/3/25, with the goal of The resident's safety will be maintained and included interventions of:-Check placement of Wanderguard (electronic monitoring bracelet).-Distract resident from wandering by offering pleasant diversions.-Provide a Wanderguard. Review of a progress note dated 3/19/26, 3:45 p.m. At 1545 (3:45 p.m.) writer was informed by activities aide that the resident could not be found post cooking club activity. @1547 (3:47 p.m.) code white was called as resident was not found in any of the nearby rooms or restrooms. After code white was called all employees responded appropriately and were actively searching for resident. @1553 (3:53 p.m.) resident was found outside, in a nearby alley, safely on the berm as to avoid traffic, attempting to go to [NAME] (local convenience store), as she does when she goes on LOAs (leaves of absence) w/ her family. Resident was safely escorted back to facility and up to the third floor where her nurse proceeded to check her vitals and do a head-to-toe assessment assisted by CNA (nurse aide). The LPN (licensed practical nurse) & aide reported directly to writer afterwards, as writer was on the phone w/ [nurse practitioner]., and together we informed NP that vital signs are stable, and no skin alterations or injuries were found. Resident was in no distress, had no complaints of pain, but was tearful as she stated, she was not trying to cause any trouble. Additionally stated in this progress note was resident was dressed appropriately. No new orders were given from NP (nurse practitioner). Writer then called residents RP (responsible party), her mother, to inform her of the incident, there was no answer. Writer then called a second time, still with no answer, and left a message for [Resident R1's mother] to please return call as soon as possible but did inform that the resident was safe. All clear was called @ 1614 (4:14 p.m.). Review of a progress note dated 3/19/26, at 4:20 p.m. indicated, @1600 (4:00 p.m.) resident was escorted back to 3rd floor, able to self-propel in wheelchair to her room, and asked if we could do a head-to-toe assessment as well as vital signs. The resident agreed and the CNA helped writer w/ assessment. Wanderguard noted to be in place on L wrist, and the alarm did sound when resident returned to 3rd floor. Resident alert & oriented x3 w/ no obvious injuries noted. Resident w/ no c/o pain or discomfort but is tearful and feels as though she is in trouble. Writer reassured resident that we are simply happy she is safe, educated resident on the risks of leaving the floor/facility, to which she verbalized understanding. Resident has not had exit seeking behavior this week prior to elopement this evening. Review of an undated employee statement written by Activities Aide Employee E1 indicated, On March 19th I was transporting residents from the 1st floor to 2nd and 3rd. As I was getting them from the dining room to the elevator [Resident R1] had left the 1st floor from sitting at the elevator waiting to go back to her room on 3rd floor. Review of a second undated statement written by Activities Aide Employee E1 indicated, On Thursday March 19th I was taking residents on the elevator back upstairs after an activity. The elevator only holds four people at a time. I had to leave some residents. I dropped the residents off on the third floor. Came back to the first and [Resident R1] was not there, just the other residents. I went to other staff to get help finding her and they found her at [NAME]. She had taken the outdoor elevator. Review of an employee statement dated 3/19/26, Environmental Services (EVS) Employee E2 stated, At approximately 3:30 pm on 3-19-2026 l, [EVS Employee E2], was on the first floor and saw [Resident R1] and another resident but I can't recall whom sitting by the A side elevator, waiting to be taken up from the activity. I walked through the green hallway to retrieve something and came back to the A side to find [Resident R1] gone and assumed she had been taken back to her floor. About 5 minutes later the activities aide, [Employee E1] came back to the elevator asking if I had seen [Resident R1] and instantly we both realize she has managed to make for an exit. I went to the basement first to alert other people to be on the lookout and then ran out of C-side side door to the outside and headed toward family counseling. I then turn right down the alley to go around the building, swing wide into our parking lot to see if I see her and that's when I run into the Dietary supervisor [Employee E3], and the transport coordinator [Employee E4], and I tell them I saw three gentleman around an suv and because I'm a suspicious person, I was worried they loaded her and were blocking her from view. So the three of us head over and politely ask if they'd seen her, per [Employee E4's] less suspicious mind and bless 'em they had seen her and pointed down [NAME]. The three of us begin to sprint because we don't see her in sight still. Halfway down [NAME], in the alley to [NAME], we see [Resident R1], we call out to her and she stops moving. We caught up to her and brought her back to the facility. Review of an employee statement (incorrectly dated 8/19/25), NA Employee E3 stated, I was coming out of the bathroom when the LPN notified me that [Resident R1] was missing. I notified the other aide on the floor and I went to the first floor. I then went outside. When [LPN Employee E4] and I meet we went opposite ways outside. I ask the dietary people if they seen [Resident R1] they said no. Both [LPN Employee E4] and I didn't see her outside. I went to the fourth floor next. I was alerted she was found. When she came back up I helped the LPN Employee E4 with the body check. Review of an employee statement dated 3/19/26, LPN Employee E4 indicated, I was informed by Activities that they could not locate [Resident R1]. I immediately notified my aides and went to notify RN (Registered Nurse) Supervisor. [Employee E3] and I both went outside to look for her and searched inside the building. [Employees E5 and E6] found her. Upon her return all vitals found to be stable and body check was clear. Review of an employee statement dated 3/19/26, Transportation Employee E5 indicated, Announcement went out over intercom stating code white. I went to go look for resident with staff, went outside searching, and asked fellow bystanders if they saw a woman in a wheelchair. They said yes and pointed in the direction she went. Staff and I went in that direction and found her in the alley way beside [NAME]. Staff and I safety returned her to the facility. When she returned to facility we took her to supervisor on duty, and the supervisor stated to take her to her floor. Staff and I returned her to her floor and told her nurse she was back. Review of an employee statement dated 3/19/26, Dietary Manager Employee E6 indicated, I saw Activities taking residents to the elevator. I asked if they needed help, they said yes. took [Resident R6, R7, R8, and R9] to the line outside the elevator. [Resident R9] was the last resident after I took her to the line I went to HR's office. I heard Code [NAME] over the intercom. Went to the Kitchen to instruct my employees to search and watch the basement. When I found out it was [Resident R1] missing, I went outside to search. [Employee E5] from transports and [Employee E2] from housekeeping joined me and ran down the alley saw three men in the parking lot asked them, did you see a woman in a wheelchair with dirty blond hair? They said yes, she went that way pointing down toward Water St. So, we ran down the road looking down at the alleys and saw her in the alley behind [NAME]. Ran up to her and asked where she was going. She said [NAME]. Pushed [Resident R1] back to the building and took her to 3bc nursing station for the LPN to evaluate. Review of an employee statement dated 3/19/26, Activities Aide Employee E7 indicated, Activity concluded approx. 3:00 p.m. [Employee E1] began transporting 2nd floor residents to elevator. I stayed in dining room. Once 2nd floor residents were returned, we began 3rd floor resident transporting. I would take residents down C hall where [Employee E1] would meet. [Employee E1] would take up the elevator. Manager [Employee E6] in hallway, I asked if she could help. She pushed a few residents to [Employee E1], when she returned, I'd take someone over. The final two residents [Resident R8 and R10] are unable to propel self, were by the elevator. [Employee E1] came over and asked if I took [Resident R1] up, which I did not on my turn. I pushed other residents on elevator with [Employee E1] and asked her to let me know. I proceeded to double check dining room and restroom. After approx. 15 minutes I did not hear form [Employee E1] or 3rd floor or a code page, I misguidedly assumed all was OK, and left for the day. Shortly after, [Employee E1] called to tell me a code was called and [Resident R1] was found outside. Review of information submitted to the Pennsylvania Department of Health state agency on 3/19/26, indicated, Resident admitted from a personal care home. At time of admission, resident did have a positive elopement risk screening, indicating that she desires to leave the facility. At this time, resident was ordered a Wander guard which remains on her person. She resides on the third floor of the facility. Resident does have a standing Leave of Absence order and does leave the facility on outings frequently with her family. There is no evidence that she has attempted to leave the facility unattended since admission. Resident is alert and oriented with a BIMS of 15. She is aware of her surroundings and environment. While waiting to return to her home unit after group activity, resident left the elevator area and went to the elevator that leads to the parking lot, as this is where she exits when she goes on leave of absence with her family. She indicates she did this because she wanted to go to [NAME], a frequent place she visits with her family when out on a leave of absence. Resident was noted as missing at 1546 (3:46 p.m.), code white was immediately called. Staff started to search premises when an unknown individual outside indicated that they saw a female in a wheelchair wheeling not far past the facility toward a nearby [NAME]. Staff proceeded up the alley way adjacent to the back of the facility and noted this resident to be wheeling up the side of the road, out of the line of direct traffic, safely in the berm area. Staff approached resident and resident indicated she just was going to [NAME]. Staff wheeled resident back to the facility without incident. Upon arrival to facility, nursing staff completed a head-to-toe assessment of residents with negative findings. Resident was tearful indicating she did not want to cause trouble or get anyone in trouble; she just wanted to go to [NAME]. During an interview on 3/23/26, at 3:15 p.m. NA Employee E6 and LPN Employee E4 confirmed their above statements. NA Employee E6 stated that Resident R10 pointed to the elevator when asked where Resident R1 was. At this time, LPN Employee E4 displayed the elopement binder present at the nurse's station. Review of the elopement binder displayed by staff were ten residents documented as an elopement risk (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). During an interview on 3/23/26, at approximately 3:25 p.m. the Activities Director was asked if the Activities Department had an elopement binder for use by their staff. The Activities Director stated she believed there was one, but did not know where it was. A list of the residents who were at risk for elopement was found and produced at approximately 4:00 p.m. The Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for residents on 3/23/26, at 4:08 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at 4:09 p.m. The facility plan of correction was accepted on 3/23/26, at 6:30 p.m. to include:The resident was returned to the facility. Full body assessment was completed with no negative findings. Resident is alert and oriented and indicated she just wanted to go to [NAME] where she frequently goes out on Leave of Absence with her family. Physician and family were notified. Resident care plan will be updated to include that resident will be supervised at all times outside of her living unit. Her LOA order already states that she cannot be unsupervised. Immediately, Nursing Home Administrator completed on Elopement/Accidents and Hazards (attached) with Activities Staff that residents coming to the first floor dining room for activities that have a Wanderguard device or deemed at risk for elopement will not be unsupervised at any time, before, during or after the activity until they are returned safely to their respective living area. Immediately, whole house education on Elopement/Accidents and Hazards (attached) was initiated and completed. Elopement assessments were completed on current residents, which are under evaluations in the resident medical chart, elopement binders were verified for accuracy and completion. Activities on the first floor will be continued; however, the following plan has been implemented to ensure resident safety and decreased risk of elopement: Facility leadership, including Social Services Director, admission Director, Human Resources Director, LPN Unit Manager, Infection Preventionist, Business Office Manager, Appointment Scheduler, Staff Scheduler, Director of Rehabilitation, Medical Records, and Maintenance Director will assist during large group activities planned for the first floor dining room to ensure direct supervision support. Leadership will support activities staff in transporting residents to/from first floor dining room where the activity is taking place as well as provided additional supervision during the activity. Activity Director will verbalize the need for help in morning standup meeting as well as provide a sign-up sheet for leadership to secure. At no time will residents with Wanderguard device or residents at risk of elopement be left unsupervised. 4 people will be needed: one in room, one transporting in the hallway, one transporting the elevator, and one observing the hallway.Facility has reduced the number of activities in the first-floor dining room to the larger, primary activities such as auction, birthday party, cooking club, special events.Once all residents are in the dining room on first floor, the door will be closed. A bell has been placed on the door to alert staff if someone is attempting to open the door.Other activities will be modified to be completed on the resident floors in the dayrooms. Activities such as Church and Resident Council that are smaller integrated activities, will be scheduled in the 3A dayroom moving forward.New residents admitting will be evaluated for elopement. Discussion of findings will occur during the morning meeting process. If resident is deemed an elopement risk, elopement binders will be updated, Wanderguard will be placed, and interdisciplinary team will all be made aware for resident safety. Audits of group activities occurring in the first-floor dining room will be completed by Nursing Home Administrator for proper supervision of residents twice per week for two weeks, then once per week for two weeks, then weekly for two months. here have been no large group activities since the date of this occurrence to audit. Audits will begin with the next large group activity. All education, updates to care plan, modifications to activities will be completed by Wednesday, 03/25/2026. Audits will begin with next large group activity, scheduled for Wednesday 03/25/2026. Review of Resident R1's clinical record confirmed that Resident R1's responsible party and the nurse practitioner were notified on 3/19/26, at 3:45 p.m. and new interventions were placed in the plan of care. Review of clinical records on 3/24/26, confirmed the facility completed whole-house education to 116 of 116 staff members. A total of 98 of 116 confirmed education via signing the education in-service sheet. 20 of 116 staff members were educated via phone. 2 of 20 have returned to the facility and signed in-service sheet prior to the start of their shift. All other staff members will be required to verify they were educated via signing the in-service education sheet prior to the start of their next shift. During in-person interviews conducted on 3/24/26, 34 of 34 verified they were educated on the elopement procedure and to not leave residents unsupervised. Review of education documents indicated that on 3/19/26, the Nursing Home Administrator educated the activity staff members that when residents are brought to activities on the first floor from the third floor, at no time during the activity or after the activity should these residents be unattended. This includes when residents are transported to/from the elevator to go to the dining room and accompanied by activities staff to ensure their safety. During 32 staff interviews completed on 3/24/26, beginning at approximately 9:45 a.m. confirmed all staff had received education on elopement prevention and actions to take if a resident leaves the facility. During an interview on 3/25/26, at approximately 10:00 a.m. the Activities Director was asked if Activities staff had previously been provided education on ensuring the safety of residents at risk for elopement, to which she responded, Not really, probably during orientation. During observations on 3/24/26, the elopement binders were confirmed to be updated as of 1:00 p.m. Review confirmed that 94/94 elopement assessments were completed. 10/94 residents were identified at risk for elopement. The Immediate Jeopardy was removed on 3/24/26, at 2:56 p.m. when the action plan implementation was verified. During an interview on 3/25/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of two residents left unsupervised. This failure created an immediate jeopardy situation for 10 of 94 residents assessed by the facility to be at risk for elopement. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of the facility's job descriptions, employee attendance information, and staff interviews, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing (35 or more hours a week) in the facility.Review of the facility provided Director of Nursing (DON) job description, undated, indicated that the DON position purpose was, Planning, organizing, developing, and directing the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Included in the listing of Required Qualifications was Current unrestricted license as a Registered Nurse in practicing state. Information reported to the State Department of Health indicated that Registered Nurse Employee E1 started as the DON for the facility on 1/15/26. Review of facility provided Stand-Up sheets 2/2/26, through 3/23/26, failed to include documentation that the DON was present and acting in the capacity as Director of Nursing on 23 of 36 business days: Monday, 2/2/26: The DON was documented as not present in the building.Tuesday, 2/3/26: Stand-Up sheet not signed by the DON, unknown if present.Wednesday, 2/4/26: Stand-Up sheet not signed by the DON, unknown if present.Thursday, 2/5/26: The DON was documented as not present in the building.Friday, 2/6/26: The DON was documented as not present in the building. Monday, 2/9/26: The DON was documented as present in the building.Tuesday, 2/10/26: The DON was documented as not present in the building.Wednesday, 2/11/26: The DON was documented as not present in the building.Thursday, 2/12/26: The DON was documented as not present in the building.Friday, 2/13/26: The DON was documented as not present in the building. Monday, 2/16/26: The DON was documented as present in the building.Tuesday, 2/17/26: The DON was documented as present in the building.Wednesday, 2/18/26: The DON was documented as present in the building.Thursday, 2/19/26: The DON was documented as present in the building.Friday, 2/20/26: The DON was documented as not present in the building. Monday, 2/23/26: No Stand-Up sheet available.Tuesday, 2/24/26: The DON was documented as present in the building.Wednesday, 2/25/26: No Stand-Up sheet available.Thursday, 2/26/26: No Stand-Up sheet available.Friday, 2/27/26: No Stand-Up sheet available. Monday, 3/2/26: The DON was documented as present in the building.Tuesday, 3/3/26: The DON was documented as not present in the building.Wednesday, 3/4/26: The DON was documented as present in the building.Thursday, 3/5/26: Stand-Up sheet not signed by the DON, unknown if present.Friday, 3/6/26: The DON was documented as present in the building. Monday, 3/9/26: The DON was documented as not present in the building.Tuesday, 3/10/26: DON documented as arriving late.Wednesday, 3/11/26: Stand-Up sheet not signed by the DON, unknown if present.Thursday, 3/12/26: The DON was documented as present in the building.Friday, 3/13/26: No Stand-Up sheet available. Monday, 3/16/26: The DON was documented as not present in the building.Tuesday, 3/17/26: The DON was documented as not present in the building.Wednesday, 3/18/26: No Stand-Up sheet available.Thursday, 3/19/26: The DON was documented as not present in the building.Friday, 3/20/26: The DON was documented as not present in the building. Monday, 3/23/26: The DON was documented as not present in the building. Two additional Stand-Up sheets were present, undated, both documented that the DON was not present in the facility. Review of facility-provided employment information, the Assistant Director of Nursing had a final employment date of 2/16/26. Thereafter, no additional registered nurse was placed in an Interim Director of Nursing Position. During an interview on 3/23/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the DON was not currently in the building and was using paid time off through her last day of employment on 3/24/26. During an interview with the Nursing Home Administrator on 3/25/26, at approximately 1:15 p.m. confirmed that there was no documented evidence that Registered Nurse Employee E1 worked 35 or more hours a week in the facility in the capacity as DON. 28 Pa Code 201.3 Definitions.28 Pa Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code 211.12(b)(c)(d) Nursing Services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the building unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care. Review of the facility-provided Director of Nursing (DON) job description indicated, Planning, organizing, developing and directing the overall operations of the Nursing Service Deportment in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Based on findings identified in this report, the facility failed to prevent the failed protect residents from exiting the facility unsupervised. The NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 3/25/26, at approximately 12:30 p.m. the NHA and current DON confirmed that facility administration failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident, who was a known elopement risk, exiting the building unsupervised. This failure created an Immediate Jeopardy situation for 10 of 94 residents who were documented as elopement risks. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility staff failed to follow a physician order for a Bi-pap machine (used to facilitate breathing during sleep for certain types of sleep apnea. Sleep apnea is a condition that causes breathing to stop and start several times during sleep. A bi-pap machine pushes air into the lungs with two settings a higher pressure when you inhale and a lower pressure when you exhale) for one of three residents (discharged Resident R1).Findings include: Review of facility policy admission Orders last reviewed8/8/25, indicated A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. The orders should allow facility staff to provide essential care to the residents consistent with the resident's mental and physical status on admission. Review of the facility policy Oxygen Administration last reviewed 8/8/25, indicated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident's goals and preferences. Types of delivery systems include but not inclusive to Bi-level Positive Pressure Airway Pressure (BiPap) mask this mask is part of a system that is capable of generating two adjustable pressure levels during inhalation and exhalation. Review of the clinical record indicated discharged Resident R1 was admitted to the facility on [DATE]. Review of discharged Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/23/25, indicated diagnoses of with the diagnosis of cancer, high blood pressure and Chronic Obstructive pulmonary disease (COPD- lung condition that restricts breathing). Review of discharged Resident R1's physician order dated 11/12/25, indicated BiPap at hours of sleep at present parameters at bedtime and remove per schedule. The order start date was 11/13/25. Review of discharged Resident R1's physician order dated 11/13/25, indicated BiPap at hours of sleep at present parameters for 45% - 6.0 centimeters (CM) water (H2O) and remove per schedule. Review of discharged Resident R1's Treatment Administration Record (TAR) for November 2025, indicated three occurrences of physician ordered treatment for the BiPap was not provided 11/12/25, 11/19/25, and 11/20/25. During an interview completed on 3/18/26, at 3:10 p.m. Upon asking Registered Nurse RN Employee E1 concerning discharged Resident R1's Bi pap orders Stated The BiPap was not put on until 11/13/25, the orders were put in on 11/12/25, however, it was not scheduled until the 11/13/25. Upon asking RN Employee E1 what a 9 meant on the TAR for 11/19/25, and 11/20/25, stated see nursing note when asked about the nursing notes confirmed there were not any to coincide with the BiPap not being used on 11/19/25, and 11/20/25, and that the facility staff failed to follow a physician order for a Bi-pap machine for one of three residents (discharged Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility documents, facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1).Findings include: Review of facility Bowel Routine Policy last reviewed 7/1/25, indicated each resident will have routine bowel elimination. The purpose is to address the resident's individual needs with respect to routine bowel movements, initiate appropriate strategies and interventions, and monitor and evaluate resident outcomes. Give Milk of Magnesia 30 ml if no bowel movement in 72 hours (Day 3 without a bowel movement), if ineffective give Dulcolax Suppository. Administer fleet enema if Dulcolax Suppository is ineffective. Call physician if fleet enema is ineffective. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26. Review of Resident R1's clinical record for 2/12/26, failed to reveal Resident R1 had a bowel movement. Review of Resident R1's physician order dated 2/12/26, indicated to administer 30 milliliter (ml) Milk of Magnesia Suspension 7.75 % (Magnesium Hydroxide) by mouth as needed for constipation, if no bowel movement in 48 hours. Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Dulcolax Suppository 10 MG (Bisacodyl) suppository rectally as needed for constipation if Milk of Magnesia is ineffective. Review of Resident R1's physician order dated 2/12/26, indicated to insert 1 Fleet Enema 7-19 GM/118ML (Sodium Phosphates) applicatorful rectally as needed for constipation, if no bowel movement after Dulcolax suppository. Review of Resident R1's February 2026 Medication Administration Record (MAR) failed to include evidence the resident's medications were administered as ordered on 2/12/26. Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. I did not see her go to his room at all. NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 he couldn't come back here while the ambulance workers were there. Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, I already know what he wants. LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 Do you think I should send him out if he wants sent out? LPN, Employee E3 responded Yes and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current. During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview. During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's Discharge Transition Packet dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days. During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital. During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels. During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted , their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified. During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it. Review of Resident R1's Hospital Discharge Summary on 2/25/26, revealed the resident was hospitalized from [DATE], to 2/17/26 for a rectal fecal impaction, severe constipation, requiring oral laxatives, disimpacting and soap suds enema. During an interview on 2/25/26, at 12:27 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services needed for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five residents (Resident R1). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on review of clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1).Findings include: Review of facility's policy dated 7/1/25, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within a specific timeframe; immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital. The facility failed to report the allegation of neglect within 24 hours to the local state field office. During an interview on 2/25/26, at 12:37 p.m. the Director of Nursing confirmed allegations of neglect must be reported to the appropriate agencies within 24 hours. During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to report an allegation of neglect within 24 hours to the local state field office for one of two residents (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policy and documentation, staff and resident interview it was determined that the facility failed to protect resident from neglect for one of five residents (Resident R1).Findings include: Review of facility's policy dated 7/1/25, Abuse, Neglect, and Exploitation stated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse and neglect. Neglect means failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Registered Nurse, Employee E1's signed job description dated 11/4/25, revealed major duties and responsibilities include ensuring policies and procedures are complied with by nursing personnel assigned, participates in the admission, discharge, and transfers of residents as required, assesses for changes in resident's status, notifying the physician and resident family or representative and documenting according, prepares and administers medications as per physicians' orders and observes for adverse effects as indicated. Review of Residents R1's admission record indicated the resident was admitted on [DATE], with diagnoses of constipation, high blood pressure, and cervicalgia (neck pain). Review of Resident R1's progress note dated 2/12/26, at 9:16 a.m. entered by Registered Nurse (RN), Employee E1 revealed Resident R1 was admitted from another facility and his last bowel movement was 2/5/26. Review of Resident R1's progress note dated 2/12/26, at 5:35 p.m. entered by Registered Nurse (RN), Employee E1 revealed the resident requested to go to the hospital for abdominal pain and constipation. He called 911 himself. Review of facility documents revealed RN, Employee E1 was the RN, Supervisor on duty from 7 a.m. to 7 p.m. Review of Nurse Aide (NA), Employee E2's witness statement dated 2/12/26, stated at 3:20 p.m. Resident R1 rang and wanted to see RN Supervisor, Employee E1 to go to the emergency room. NA, Employee E2 notified RN, Supervisor, Employee E1. While walking down the hall to take a break, Resident R1 rang again and stated he was going to call. RN Supervisor, Employee E1 stated she did his paperwork and wasn't going back. I did not see her go to his room at all. NA, Employee E2 stated RN, Supervisor, Employee E1 told Resident R1 he couldn't come back here while the ambulance workers were there. Review of Licensed Practical Nurse (LPN), Employee E3's witness statement dated 2/12/26, revealed LPN, Employee E3 overheard Resident R1 tell NA, Employee E2 that he wanted to go to the hospital. RN, Supervisor, Employee E1 was made aware. LPN, Employee E3 stated Resident R1 told her he has been asking all day to be sent to the hospital. The resident was asked what was wrong and he indicated he has not had a bowel movement in 7-10 days and he had a short stay at hospital and the other facility he came from didn't really do anything for him. As LPN, Employee E3 was walking back down hall, RN, Supervisor Employee E1 stated she did his paperwork and didn't know what else she could do for him. Resident R1's call bell went off again and RN Supervisor, Employee E1 could be heard from desk saying, I already know what he wants. LPN, Employee E3 alerted the Social Worker of a grievance concern, and the Director of Nursing was notified. When LPN, Employee E3 returned to Resident R1's room, he was on the phone with 911. Later, RN Supervisor Employee E3 asked LPN, Employee E3 Do you think I should send him out if he wants sent out? LPN, Employee E3 responded Yes and entered the resident's room and told the resident to wait until after dinner and she would call 911 and get him out. RN Supervisor then went to feed resident. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/26, indicated the diagnoses were current. Review of information submitted to the State Agency on 2/16/26, by the Director of Nursing revealed on 2/13/26, Resident R1 stated he wanted to go to the hospital, and the Licensed Practical Nurse (LPN) and Nurse Aide (NA) reported to RN, Supervisor, Employee E1 that the resident was requesting to be sent out. RN Supervisor, Employee E1 refused to assess resident and refused to send him out to the hospital. During an attempted phone interview on 2/25/26, at 10:24 a.m. RN, Employee E1 was unavailable for an interview. During an interview on 2/25/26, at 10:38 a.m. the Director of Nursing (DON) confirmed Resident R1's Discharge Transition Packet dated 2/12/26, confirmed the resident's last bowel movement was 2/4/26, a total of eight days. During an interview on 2/25/26, at 10:50 a.m. Resident R1 confirmed when he was initially admitted to the facility he complained of abdomen pain and had to go to the hospital. During an interview on 2/25/26, at 10:58 a.m. Nurse Aide, Employee E2 stated Resident R1 wanted to go to the hospital and when she notified RN, Supervisor, Employee E1 she failed to go in and assess the resident. NA, Employee E2 stated the resident was complaining he hadn't moved his bowels. During an interview on 2/25/26, at 11:07 a.m. LPN, Employee E4 stated if a resident has not had a bowel movement in three days, the bowel protocol would be initiated. It was indicated for residents newly admitted , their last bowel movement is assessed upon admission. Medications for the bowel protocol are automatically put in place upon admission. Staff can also review discharge paperwork to see when a residents last bowel movement was. If a resident has a change in condition, they must be assessed, vitals obtained, and the physician is notified. During an interview on 2/25/26, at 11:09 a.m. LPN, Employee E3 stated she worked 3 p.m. to 11 p.m. on 2/12/26. LPN, Employee E3 was notified Resident R1 wanted to talk with a supervisor and go to the hospital. It was indicated Resident R1 was asking all day. Around 5 p.m. Resident R1 rang his call bell again and requested to see supervisor and go to hospital. RN, Supervisor R1 failed to assess resident and Resident R1 called 911 himself. LPN, Employee E3 stated the resident was having abdomen pain from a bowel obstruction. LPN, Employee E3 stated The resident had an order for citrus magnesium from the other facility, and I don't think he got any of it. During an interview on 2/25/26, at 1:18 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to protect resident from neglect for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10 (a) (d) Resident care policies

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in three of five medication rooms (Second Floor (2C) Medication Room, Third Floor (3A) Medication Room, and Third Floor (3C) Medication Room) and failed to properly store medication in two of three medication carts (3BC Medication Cart and 2BC Medication Cart). Findings include: Review of facility policy Medication Storage dated [DATE], indicated that medications will be stored in the medication rooms according to the manufacturer's recommendations. All medications rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. Review of facility Insulin Storage policy dated [DATE], indicated that insulin must be stored securely in a locked area. Follow specific instructions for opened insulin vials/pens. Often good at room temperature for 28 days. Insulin vials/pens must be dated on the date they are initially used. During a medication cart review (3BC Medication Cart ) on [DATE], at 12:40 p.m. the following were observed: (2) Lantus (a medication used to treat high blood sugars) vial with an opened date marked [DATE]. Insulin Lispro (a medication used to treat high blood sugars) vial with an opened date marked [DATE]. Lantus pen with an opened date marked [DATE]. Lispo vial with an opened date marked [DATE]. Insulin Aspart (a medication used to treat high blood sugars) vial with an opened date marked [DATE]. Lantus vial with an opened date of [DATE]. Novolog (a medication used to treat high blood sugars) was missing an opened and expired date. Lantus vial with an opened date marked [DATE]. Lispro vial with an opened date marked [DATE]. During an interview on [DATE], at 12:53 p.m. Licensed Practical Nurse (LPN) E13 confirmed the above findings and confirmed that they were expired. During a medication cart review (2BC Medication Cart ) on [DATE], at 1:20 p.m. the following were observed: Lantus vial with an expiration date marked [DATE]. Lantus vial with an opened date marked [DATE]. During an interview on [DATE], at 1:35 p,m, Registered Nurse Employee E14 confirmed the above findings and confirmed that they were expired. During an observation on [DATE], at 10:16 a.m. of the Second Floor (2C) Medication Room the following was observed: -(2) Gallons of opened undated Natural Spring Water -(1) Spedi Catheter Internment French 16 Expired [DATE] -(1) IV Tubing Administration Set Expired [DATE] -(3) IV Connecting Tubing 20' Length, 3/16' Diameter Expired [DATE] -(2) Gold Blood Tubes Expires [DATE] -(2) Blood Collection Set Expired [DATE] -(1) 300 milligram (mg) Bottle Fish Oil Expired 6/25 -(3) 50 mg Bottle Zinc Expired 7/25 -(1) Saccharomyces Boulardii Probiotic Expired 9/25 -(1) 1000 mg Bottle B12 Expired [DATE] -(2) 500 mg Bottle Vitamin C Expired 11/25 During an interview on [DATE], at 10:18 a.m. LPN Employee E19 confirmed the above items were expired. During an observation on [DATE], at 10:29 a.m. of the Third Floor (3A) Medication Room the following was observed: - (1) 50 mg Bottle Zinc Expired 7/25 -(1) 325mg Bottle of Iron Expired 8/25 During an interview on [DATE], at 10:30 a.m. LPN, Employee E16 confirmed the above items were expired. During an observation on [DATE], at 10:36 a.m. of the Third Floor (3C) Medication Room the following was observed: -(1) Secondary Administration Set Expired [DATE] -(1) 400 mg Bottle Fish Oil Expired 7/25 -(3) IV Administration Set Expired [DATE] -(1) 500 mg Bottle Vitamin C Expired 11/25 During an interview on [DATE], at 10:40 a.m. LPN, Employee E13 confirmed the above items were expired. During an interview on [DATE], at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly store medications and/or biologicals in three of six medication rooms. 28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility financial documents, interviews with residents, resident's families, and staff it was determined that the facility failed to pay bills in a timely manner.Findings include: Review of the Nursing Home Administrator job description indicated: position purpose: leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Resident R57 was admitted to the facility on [DATE]. Review of Resident R57 Minimum Data Set (MDS - a periodic assessment of resident needs) dated 11/14/25, indicated diagnosis of cerebral palsy (group of condition that affect movements and posture. I caused by damage that occurs to the developing brain, most often before birth) anxiety disorder (involve repeated episodes of sudden feelings of intense anxiety and or fear or terror), and abnormalities of gait (abnormal walking pattern). During an observation on the 2nd floor nursing unit on 12/11/25, at 329 p.m. Resident R57 Indicated they wanted to talk with a surveyor. Resident R57 with Resident R57 Family Member on the video screen and Nurse Aide in to help with communicating with Resident R57 - stated that he wanted to know why he couldn't go to his eye appointment. Resident R57 Family member wife expanded to say - they had made an original appointment in October that needed to be canceled but re-made his eye appointment for Friday - the facility cancelled it. The appointment was for eye surgery due to resident not being able to see well out of his eye. Resident R57 Family Member indicated that the eye appointment was cancelled due to facility not having transportation. During an interview on 12/12/25, at 10:24 a.m. Scheduler Employee E23 indicated the following: Scheduler Employee E23 is responsible for setting up appointments for residents for transportation and for taking residents who are in wheelchairs and able to walk independently/with cane/wheeled walker to appointments. Per Scheduler Employee E23 the appointment was cancelled by the facility and the reason for cancelling was due to the transportation company not being paid by the facility. Scheduler Employee E23 indicated that this has happened before, but this was the longest period of time (no exact date provided). Review of facility documentation: Optimal transport contract:This non-emergency wheelchair/stretcher transportation services agreement: Optimal transport is equipped and qualified to provide Non-Emergency Wheelchair/Stretcher transportation services to health care providers and assisted living facilities. Article 4- charges and billing - Optimal transport will invoice [NAME] Rehabilitation and Nursing monthly in accordance with the Fee schedule. Payment [NAME] Rehabilitation and nursing agree to pay Optimal Transport 100% of set rates. Review of facility documentation from October of 2025 to December 2025 indicated: 12 appointments being cancelled due to transportation not being available including Resident R57. During an interview on 12/12/25, at 2:00 p.m. Nursing Home Administrator confirmed that the facility failed to pay the transportation vendor in a timely manner. 28 Pa. Code 201.14 (a)( c) Responsibility of licensee28 Pa. Code 201.18(b)(1)( e)(1) Management

Based on review of facility policy, personnel records and staff interviews it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (NA) (NA Employees E4, E5, E6, E7, and E8).Findings include: Review of NA Employee E4's personnel record indicated a hire date of 9/19/11. Review of NA Employee E5's personnel record indicated a hire date of 9/21/18. Review of NA Employee E6's personnel record indicated a hire date of 2/26/23. Review of NA Employee E7's personnel record indicated a hire date of 8/27/23. Review of NA Employee E8's personnel record indicated a hire date of 10/2/23. Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employees E4, E5, E6, E7, and E8. During an interview on 12/9/25, at 1:57 p.m. Human Resources Employee E10 confirmed that the facility failed to complete annual performance evaluations for five of five nurse aides as required. 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

Based on review of facility policy, job description, clinical record review, facility documents, resident interview, and staff interviews it was determined that the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration for one of two residents reviewed (Resident R1) which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of the facility's Registered Nurse (RN) job description indicated the RN will prepare and administer medications as ordered by the physician. Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed: - Right resident - Right drug - Right dose - Right route - Right time - Right documentation Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and, weakness. Review of Resident R1's progress note dated 5/24/25, at 10:56 a.m. indicated that Resident R1 had been given the wrong medications that included amiodarone (medication used to regulate abnormal heart rhythms). Resident did not receive his own medications. Resident is complaining of mild chest pain and shortness of breath which started after med was given. Diagnosis, Assessment/Plan: Failure in dosage during medical care. This is an acute new problem. Condition is guarded given multiple meds including amiodarone, now symptomatic will send to ER (Emergency Room) for close monitoring. Orders: Transfer to emergency department for med error with amiodarone and complaints of chest pain and shortness of breath. Review of Resident R1's clinical record revealed that resident was not ordered amiodarone. Review of a written statement dated 5/24/25, indicated that Registered Nurse (RN) Employee E1 stated the following: I went into the room to give medication and gave the wrong medication to Resident R1. I realized at once I made a mistake. I assessed patient and got vitals and called for supervisor. I didn't realize it was 3 person room at this time. I try to double check myself. Review of documentation provided by the facility indicated that RN Employee E1 was suspended pending investigation, and opted to resign. The facility implemented a plan of correction that included the following: · Facility initiated education on 5/24/25, for all nursing staff including Registered Nurse's (RN's), and Licensed Practical Nurses (LPN's) for Safe Medication Administration. All nurses completed training and a quiz to demonstrate their understanding. · Reviewed RN Employee E1's file to ensure she had received education on Safe Medication Administration prior to the incident. This was verified to have been completed 2/12/25. · Evaluated all other residents on the same unit as Resident R1 to observe for adverse effects, which included obtaining vitals every four hours for 24 hours. · Ensured resident photos are up to date in the Electronic Charting System, which was completed on 5/28/25. · Audit medication carts starting 6/2/25. · Randomly observe Medication Pass to ensure 6 Rights of medication administration are being completed prior to medication administration, which began on 5/27/25. · QAPI (Quality Assurance Performance Improvement) conducted 5/24/25. During an interview on 7/1/25, at 9:50 a.m. LPN Employee E2 verified that he had received education on Safe Medication Administration and was able to verbalize understanding, adding You have to double check. During an interview on 7/1/25, at 9:56 a.m. RN Employee E3 verified that she had received education on Safe Medication Administration and was able to verbalize understanding, adding I check the orders at least twice, as well as the photo in the chart. During an interview on 7/1/25, at 10:06 a.m. LPN Employee E4 verified that she had received education on Safe Medication Administration and was able to verbalize understanding. She added that all residents have an updated picture in their chart, and that you have to look at their picture to make sure you have the right person. The facility has demonstrated compliance with the above since 5/24/25. Information was verified via review of Plan of Correction binder. During an interview on 7/1/25, at 1:42 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration. During an interview on 7/1/25, at 3:08 p.m. the Nursing Home Administrator, and Director of Nursing confirmed the facility failed to ensure that nursing staff possessed the specific competencies and skill sets related to medication administration, which resulted in harm for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that residents were free from any significant medication errors which resulted in actual harm (chest pain, shortness of breath, and hospital transfer) for one of two residents (Resident R1). This was identified as harm for past non-compliance for Resident R1. Findings include: Review of facility policy Medication Administration dated 12/3/24, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compare medication source (such as, bubble pack and vials). Ensure that the six rights of medication administration are followed: - Right resident - Right drug - Right dose - Right route - Right time - Right documentation Review of the admission record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and, weakness. Review of Resident R1's progress note dated 5/24/25, at 10:56 a.m. indicated that Resident R1 had been given the wrong medications that included amiodarone (medication used to regulate abnormal heart rhythms). Resident did not receive his own medications. Resident is complaining of mild chest pain and shortness of breath which started after med was given. Diagnosis, Assessment/Plan: Failure in dosage during medical care. This is an acute new problem. Condition is guarded given multiple meds including amiodarone, now symptomatic will send to ER (Emergency Room) for close monitoring. Orders: Transfer to emergency department for med error with amiodarone and complaints of chest pain and shortness of breath. Review of Resident R1's clinical record revealed that resident was not ordered amiodarone. Review of a written statement dated 5/24/25, indicated that Registered Nurse (RN) Employee E1 stated the following: I went into the room to give medication and gave the wrong medication to Resident R1. I realized at once I made a mistake. I assessed patient and got vitals and called for supervisor. I didn't realize it was 3 person room at this time. I try to double check myself. Review of documentation provided by the facility indicated that RN Employee E1 was suspended pending investigation, and opted to resign. The facility implemented a plan of correction that included the following: · Facility initiated education on 5/24/25, for all nursing staff including Registered Nurse's (RN's), and Licensed Practical Nurses (LPN's) for Safe Medication Administration. All nurses completed training and a quiz to demonstrate their understanding. · Reviewed RN Employee E1's file to ensure she had received education on Safe Medication Administration prior to the incident. This was verified to have been completed 2/12/25. · Evaluated all other residents on the same unit as Resident R1 to observe for adverse effects, which included obtaining vitals every four hours for 24 hours. · Ensured resident photos are up to date in the Electronic Charting System, which was completed on 5/28/25. · Audit medication carts starting 6/2/25. · Randomly observe Medication Pass to ensure 6 Rights of medication administration are being completed prior to medication administration, which began on 5/27/25. · QAPI (Quality Assurance Performance Improvement) conducted 5/24/25. During an interview on 7/1/25, at 9:50 a.m. LPN Employee E2 verified that he had received education on Safe Medication Administration and was able to verbalize understanding, adding You have to double check. During an interview on 7/1/25, at 9:56 a.m. RN Employee E3 verified that she had received education on Safe Medication Administration and was able to verbalize understanding, adding I check the orders at least twice, as well as the photo in the chart. During an interview on 7/1/25, at 10:06 a.m. LPN Employee E4 verified that she had received education on Safe Medication Administration and was able to verbalize understanding. She added that all residents have an updated picture in their chart, and that you have to look at their picture to make sure you have the right person. The facility has demonstrated compliance with the above since 5/24/25. Information was verified via review of Plan of Correction binder. During an interview on 7/1/25, at 1:42 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety during medication administration. During an interview on 7/1/25, at 3:08 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure that residents were free from any significant medication errors for one of two residents, which resulted in harm for Resident R1. 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies

Based on review of facility policy, clinical records, facility provided documents, and staff interview, it was determined that the facility failed to provide adequate supervision for two residents resulting in an elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision). This failure created an immediate jeopardy situation for two of eleven residents (Closed Record Resident CR1 and Resident R2). Findings include: The facility Elopements and wandering residents policy last reviewed on 2/21/23, indicated that the facility ensures that residents who exhibit wandering behaviors or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care. An elopement is when a resident leaves the premises or a safe area without authorization or necessary supervision. The facility shall utilize a systematic approach to monitor and manage residents at risk for elopement. Procedure post elopement include staff education on reasons for the elopement and possible strategies for avoiding such behaviors. Review of Closed Resident Record CR1's admission record indicated they were admitted on [DATE]. Review of Closed Resident Record CR1's nurse admission assessment dated [DATE], indicated resident had diagnoses that included traumatic brain injury (violent blow to the head resulting in psychological and physiological changes to the brain), depressive disorder, hypertension (condition impacting blood circulation through the heart related to poor pressure) and seizure disorder. Review of Closed Resident Record CR1's clinical record indicated they were admitted from an inpatient hospital (psychosis unit) from a 302 (An involuntary commitment an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness. A person applying for a 302 because they are concerned about another is referred to as a petitioner) after attacking a staff member at her memory care home. Per inpatient progress notes Closed Resident Record CR1 was evicted from her facility and so remained on our unit for quite some time as we sought placement for her at a TBI focused SNF. Review of Closed Resident Record CR1's hospital record indicated: Psychiatric - legal 305 (A 305 hearing requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days ) as of 2/10/23 the following was indicated: Precautions : Elopement, aggression, aspiration , falls Review of Closed Resident Record CR1's care plan dated 3/28/23, indicated that resident required supervision with decision making and has deficit in short term memory. Review of Closed Resident Record CR1's clinical record showed two MDS's (minimum data set - a periodic brief assessment of resident needs) dated 3/28/23 and 4/7/23, which failed to include a BIMS (brief interview for mental status). On the MDS dated [DATE], under cognitive skills for daily decision making Closed Resident Record CR1 was listed as independent. Review of Closed Resident Record CR1's physician orders dated 3/29/23, indicated to place wander guard to right ankle, placement is for safety, check placement every shift, and check function every night. Review of Closed Resident Record CR1's fall incident report dated 3/30/23, indicated that around 9:45 a.m. Closed Resident Record CR1 requested to go outside to staff on the third floor. Ten minutes later, staff on the third floor received a call from Receptionist Employee E6 stating the resident was on the first floor and fell while trying to leave. Closed Resident Record CR1 was sent to the emergency department due to a potential head injury from the fall. Facility investigation form dated 3/30/23, determined that Closed Resident Record CR1 had removed wander guard that was placed on 3/29/23. The wander guard was placed on 3/29/23, due to elopement attempts via the third-floor elevator. Closed Resident Record CR1 was re-educated upon return from the hospital 3/30/23, and the wander guard was discontinued. Review of Closed Resident Record CR1's clinical record dated 3/30/23 to 4/5/23, did not include any new interventions to prevent any wandering off the nursing unit (supervision, redirection, activities, planned leave of absences). Review of Closed Resident Record CR1's clinical record failed to include care plan for elopements. Review of Closed Resident Record CR1's elopement incident report dated 4/6/23, indicated that 10:00 a.m. Receptionist Employee E6 staff went to front exit and saw Closed Resident Record CR1 walking out of the facility. Receptionist Employee E6 requested help. Admissions Coordinator Employee E10 and Assistant Director of Nursing (ADON) spoke to Closed Resident Record CR1 and assisted in redirecting back to the facility. Approximately 30 minutes later, Closed Resident Record CR1 was at the front lobby again and was redirected by the Director of Nursing (DON). Closed Resident Record CR1 was then placed on 15-minute observations. Per facility information submitted to the state survey agency Closed Resident Record CR1 was re-educated after trying to elope 30 minutes after Closed Resident Record CR1's first attempt to elope - re-education was on Closed Resident Record CR1 not being able to go outside unattended, at which time CR1 became irate and was slamming walker on the ground-eventually convinced to return to third floor room. Per facility information submitted to the state survey agency Closed Resident Record CR1 was placed on Q15 minute checks for safety due to being difficult to redirect on 4/7/23, resident was placed on a 1:1 for safety until resident was seen by CRNP and decision was made to send resident to the ER for evaluation. Review of Admissions Coordinator Employee E10's incident statement dated 4/6/23, indicated that Admissions Coordinator Employee E10 overheard Receptionist Employee E6 saying she heard a walker at the front door. Admissions Coordinator Employee E10 went outside to find Closed Resident Record CR1 down the block about 100 feet with walker and no jacket. Weather was between 42 and 64 degrees. Admissions Coordinator Employee E10 requested assistance from the Assistant Director of Nursing (ADON). Admissions Coordinator Employee E10 asked Closed Resident Record CR1 to return to the facility. Review of Closed Resident Record CR1's clinical record indicated they were placed on one-to-one observations on 4/7/23, and then discharged to the hospital for an evaluation. During an interview on 4/10/23, at 9:05 a.m. Nurse aide Employee E1, Licensed Practical Nurse (LPN) Employee E2, and Registered Nurse (RN) Employee E3 did not recall having any recent training about residents wandering or at risks of elopement. During a tour of the third floor on 4/10/23, at 9:14 a.m. a posting of residents with wandering/elopement residents was observed dated 1/17/23. Closed Resident Record CR1 was not observed on the list of potentially wandering/ elopement residents. During an interview on 4/10/23, at 9:14 a.m., LPN Employee E7 stated did not recently receive any training about residents wandering or elopements. During an interview on 4/10/23, at 10:46 a.m., Therapy office manager Employee E5 stated the following about Closed Resident Record CR1's elopement on 3/30/23: I was leaving the morning meeting. I saw Closed Resident Record CR1 laying at the front entrance in the lobby. Closed Resident Record CR1 was holding their walker with one hand. I called Receptionist Employee E6 and told her to get help. I went to assist Closed Resident Record CR1. I thought Closed Record Resident R1 was a family member because of how they were dressed. I did not see a wander guard. Closed Resident Record CR1 told me he/she was trying to go out the front door. The ADON then came to assist. The front entrance is locked to enter but not to leave the facility. During an interview on 4/10/23, at 10:55 a.m., with LPN Employee E4, about Closed Resident Record CR1 elopement 3/30/23: I was here that morning. I was told Closed Resident Record CR1 had a wander guard on. It was found ripped off her ankle. I was told her BIMS was 15; way too high and she did not qualify for a 2nd wander guard placement. She was on the Third floor when this occurred. During an interview on 4/10/23, at 11:14 a.m., Receptionist Employee E6 was asked about Closed Resident Record CR1's elopement 3/30/23: I did not hear Closed Resident Record CR1 coming in the hallway. I was on the phone. I heard a bang when Closed Resident Record CR1 fell . I went out and Admissions Coordinator Employee E10 was there. The resident was down the stairs and Admissions Coordinator Employee E10 was with the resident. Staff brought Closed Resident Record CR1 to the front desk area to sit down and we talked and explained that he/she could not go outside. The Emergency Medical Technicians came and took Closed Resident Record CR1 to the hospital. During an interview on 4/10/23, at 12:04 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E9 stated that Closed Resident Record CR1's wander guard order was put in on 3/29/23, because he/she was an elopement risk. During an interview on 4/10/23, at 12:15 p.m. the DON stated Closed Resident Record CR1's wander guard was in place on 3/29/23 because he/she attempted to elope from the third floor using the elevator. During an interview on 4/11/23, at 11:56 a.m. RN Employee E3 confirmed that the facility failed to provide adequate supervision to prevent Closed Resident Record CR1 elopement, as required. During an interview on 4/11/23, at 3:00 p.m. the Nursing Home Administrator (NHA) and DON confirmed that Closed Resident Record CR1 did get out of the facility on 4/6/23, but was next to the facility, never made it past the parking lot and was not 100 feet away. Review of Resident R2's clinical record admission record indicated they were admitted on [DATE]. Review of Resident R2's MDS (minimum data set - a periodic assessment of resident needs) dated 3/20/23, indicated that they had the following diagnoses, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), anxiety disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem) , and schizophrenia (a breakdown in the relation between thought, emotion and behavior leading to faulty perception) and had a BIMS (brief interview of mental status) of 15 cognitively intact. Resident was allowed to go outside based on clinical note dated 3/26/23, Resident R2 was to stay either in the courtyard or on the parking lot adjacent to the facility. Review of Resident R2's clinical record progress notes dated 3/26/23, indicated the following: DON alerted by LPN on unit that resident was not on unit and had stated going to sit outside but was not in the courtyard or parking lot. Immediate search of area resulted in finding resident at [NAME] with alcohol in possession, approximately 0.2 miles away (greater than 1000 feet). Review of Resident R2's clinical record revealed that the facility failed to complete an elopement assessment after the first elopement dated in the progress note on 3/26/23. Review of Resident R2's clinical record progress notes dated 4/16/23, indicated that Resident R2 was found in the kitchen area (located on the ground floor of the facility - not an approved area without staff). Per clinical note Resident R2 stated they were going to heat something up. During an interview on 4/19/23, at 10:30 a.m. Resident R2 stated that he/she went outside and down to the kitchen. Resident R2 stated he didn't agree with having to tell the facility his whereabouts. Review of Resident R2's clinical record failed to identify additional information on elopements. Elopement assessment on admission not an elopement risk. Review of Resident R2's clinical record did not include a care plan for elopement on the first elopement or the second. Care plan not completed until after an interview with the surveyor that was on -site regarding the 2nd elopement as the facility did not feel Resident R2 going to kitchen was an elopement. During an interview on 4/19/23, at 3:00 p.m. the NHA and DON confirmed that Closed Record Resident CR1 did leave the nursing unit without staff knowledge, one time made it out of the building and the other time fell down the stairs while attempting to leave the facility. Resident R2 left the facility and made it to the convenience store and a second time made it to the ground floor kitchen area unattended without staff knowledge. The NHA and the DON confirmed that Residents until properly assessed are not permitted off the nursing unit without staff approval, potentially an escort family, etc. The NHA and DON confirmed that residents are not to leave the building or unit without knowledge of the staff - and that these are elopements. The NHA and the DON confirmed that immediate jeopardy was identified. The NHA and the DON were made aware that an Immediate Jeopardy situation existed for residents and an immediate action plan was requested at 3:02 p.m. On 4/19/23, an Immediate Jeopardy template was provided to the facility at 3:02 p.m. On 4/19/23, at 8:14 p. m. An acceptable plan of correction was received which included the following interventions: 1. Elopement evaluations completed by 4/12/23, of all residents living in the facility. If a current resident was identified as exit-seeking, an alert bracelet was applied, and care plan updated. 2. QAPI completed 4/19/23. 3. Whole house education for all departments including agency and hospice staff conducted and completed by 4/20/23 by 4:00 p.m. The training consists of putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. 4. Missing person and elopement checklist was implemented on 4/19/23. 5. Audits of the doors were initiated by maintenance to ensure proper functioning for wander guard for elopement risks. 6. Audits for new admission/returns and quarterly exit-seeking assessment to ensure care plan with appropriate interventions. 7. Wander guards are audited Q (every) shift by nursing staff through orders to check placement, and function daily on night shift. 8. Ongoing results will be submitted to QAPI. During an interview on 4/20/23, at 11:27 a.m. Registered Nurse (RN) (Shift 7am/3pm) Employee E10 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 11:30 a.m. RN (Shift 7am/3pm agency) Employee E11 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 11:33 a.m. Housekeeping Employee E12 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4?20/23, at 11:58 a.m. Housekeeping Employee E13 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 12:00 RN (Shift 7am/3pm and 3pm/11pm) Employee E14 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 12:05 p.m. LPN (Shift 7am/3pm and 11pm/7am) Employee E15 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 12:31 p.m. NA Employee E16 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 12:53 p.m. Dietary Aide Employee E17 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 12:57 p.m. Receptionist Employee E18 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. During an interview on 4/20/23, at 1:01 p.m. Director of Activities Employee E19 confirmed that they received training on putting interventions in place after incidents/accidents, behavior management, dementia, exit-seeking and wandering interventions for behaviors and wandering/exit - seeking, elopement protocol including root cause analysis and checking all exits at time of incident, updates on door functioning. The review of the documentation received from the facility 4/20/23, at 4:00 p.m. revealed all elements of the Corrective Action Plan were substantially completed per the facility action plan. Verification of the facility's plan was completed, and the Immediate Jeopardy was lifted on April 20, 2023, at 4:05 p.m. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility 28 Pa. Code 211.12(a)(c)(d)(3)(5)Nursing services.

Based on review of the clinical record, court documents, and resident, Ombudsman, and staff interviews, it was determined that the facility failed to provide medically-related social services to maintain the psychosocial needs, resulting in psychosocial harm for one of three residents (Resident R1). Findings include: A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R1 dated 10/27/22, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and a seizure disorder. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 15, cognitively intact. Review of Resident R1's plan of care for dischage initiated on 3/17/22, indicated that Discharge plans are long-term care as needs are too great to be met at any lesser level of care. The plan of care was not updated to reflect Resident R1's request for a medical evaluation to release guardianship, and his desire to return to the community. Review of Court of Common Pleas, Orphans' Court Division, Expert Report (report is undated, but information in the report indicated that Resident R1 was evaluated on 9/16/21) completed by Doctor of Medicine (MD) Employee E1, indicated that Resident R1 is totally impaired and considered an incapacitated person (an adult whose ability to receive and evaluate information effectively and communicate decisions in a way is impaired to such a significant extent that he/she is partially or totally unable to manage her/her financial resources or to meet essential requirements for his/her physical health and safety). Review of Court of Common Pleas, Orphans' Court Division, Final Decree dated 11/18/21, indicated Resident R1 to be adjudged a totally incapacitated person; Family Member of Resident R1 (FM R1), to be the Plenary Guardian (a Plenary Guardian is given the full authority to make all decisions for the incapacitated person) of Resident R1. Review of Court of Common Pleas, Orphans' Court Division, Order of Court dated 7/11/22, indicated Resident R1 was the Petitioner for a Review Hearing, to be held on 8/16/22. Review of Court of Common Pleas, Orphans' Court Division, Order of Court dated 8/16/22, indicated that hearing needed to be continued 9/22/22, at 11:00 a.m., to allow MD Employee E1 or another attending physician to prepare the Orphans' Court Medical Expert Report. Review of a progress note dated 9/11/22, at 9:35 p.m. indicated FM R1 stated that he will be dropping the guardianship of Resident R1 on 9/22/22, and does not want any calls after that date. Review of Court of Common Pleas, Orphans' Court Division, Order of Court dated 9/22/22, indicated the review hearing needed to be continued 10/12/22, at 11:00 a.m., for the convenience of the court. Review of Ombudsman provided email communication dated 9/26/22, at 1:39 p.m. revealed the Ombudsman notified facility staff of the date and time of the hearing scheduled on 10/12/22. A confirmatory reply email from Facility Employee E2 on 9/26/22, at 1:41 p.m. indicated I will arrange transportation. Review of Ombudsman provided notes dated 10/14/22, indicated the following: -10/12/22, OMB (Ombudsman), at the resident's request, attended resident's second court hearing to determine whether guardianship is required and if he can leave the nursing home and live in a less restrictive setting. -The resident's facility failed to arrange transportation through the resident had the OMB email Facility Employee E2 at the facility and request transportation weeks in advance. Facility had confirmed to OMB that transportation will be arranged. Facility ended up getting maintenance crew to drive resident to courthouse. -Upon arrival at the courthouse, the lawyer stated he wanted to speak with the judge. Ten minutes later the lawyer returned to tell the resident that the hearing was canceled again. The doctor did not complete the medical report so the hearing has to be postponed again. -(Resident) was visibly upset and began to weep. Review of Court of Common Pleas, Orphans' Court Division, Order of Court dated 10/12/22, indicated no expert report concerning the condition of (Resident R1) has yet been obtained. The review hearing was continued 12/8/22, at 11:00 a.m. Review of an Ombudsman provided information dated 11/3/22, at 4:29 p.m. indicated that the lawyer was still attempting to get the report from MD Employee E1. Review of a progress note dated 11/6/22, at 9:05 p.m. indicated Resident R1 received a phone call with the nurse hearing Resident R1 yelling I hate this fucking nut house a bunch of fucking nuts work here I am going to walk out of the fucking door I swear I'm going to walk right out the front fucking door I want my freedom. Review of Ombudsman provided information dated 11/29/22, at 11:32 a.m. indicated that the lawyer was still attempting to get the report from MD Employee E1 and/or the facility. Review of a Social Services progress note dated 11/30/22, at 1:44 p.m. indicated SW (social worker) called the Ombudsman about the resident. The Ombudsman reported that paperwork from the doctor needed filled out before the hearing. The Ombudsman contacted the attorney on the case who then forwarded the paperwork to the SW. The SW printed that paperwork for the doctor and gave it to the Assistant Director of Nursing to give to the doctor. Review of Ombudsman provided information dated 12/12/22, at 9:16 a.m. to the lawyer indicated that Resident R1 had not been told he had a hearing, that the facility had not provided transportation to the hearing, and that the expert report MD Employee E1 or another attending physician had yet to be completed. Review of Ombudsman submitted information dated 1/10/23, at 11:28 a.m. stated: Resident R1 has been put through a demeaning and depressing by the facility physician ignoring a court order and not completing a medical examination in a timely manner. Resident R1 was admitted into the facility in August 2021, due to brain surgery. The surgery left him incapacitated. A guardian was appointed. In May of 2022, Resident R1 called the ombudsman and requested help getting released from the facility. He was no longer incapacitated and wanted to live in a less restrictive setting. Resident's attorney arranged the first hearing to get the guardianship revoked and start the process to get Resident R1 released. On 8/25/22, the judge ordered a medical evaluation be completed by the facility physician and another hearing was scheduled. Second hearing was on 9/22/22. Resident R1 was present at hearing. Hearing cancelled. Facility physician did not complete the court ordered medical examination. Resident R1 was crushed and distraught. Third hearing was on 10/12/22. Resident R1 did not attend. This ombudsman did not feel he could tolerate another disappointment. The third hearing was postponed because the physician did not complete the court ordered medical examination. Now it is January 2023 and Resident R1 is extremely upset, depressed and often talks of helplessness and suicide. At this point Resident R1's mental health is shaky. He has been waiting since May 2022 for a ruling and a release from the nursing facility. Review of a Social Services note dated 1/10/23, at 3:05 p.m. indicated SW explained to resident that there will be people coming to talk to him about the papers that need filled out for court he agreed. The SW did do a typical BIMS on the resident at this time he scored a 14. Resident was also able to tell SW about his police career and past people in the community that he knows. Review of a Social Services note dated 1/19/23, at 12:30 p.m. indicated SW emailed copies of the paperwork ordered by the court. Review of Ombudsman provided information dated 1/19/23, at 9:15 p.m. indicated the expert report was completed on 1/13/23, and received by the lawyer on 1/19/23. During an interview on 1/20/22, at 10:00 a.m. the Ombudsman confirmed the accuracy of the emails and notes that had been provided, and confirmed that during multiple conversations with Resident R1, he had become despondent, tearful, made statements about harming himself, and had stated that he felt trapped in the facility. During an interview on 1/20/22, at 12:00 p.m. the Social Worker (SW) Employee E3 stated that she had begun her employment at the facility in September 2022, and there had been no one in the position for a few weeks prior to her starting, to alert her to the need of the report being completed. During an interview on 1/20/22, at 12:45 p.m. Resident R1 stated the legal process had been too long, too God damn long. This is God damn stupid, it screwed my whole life up. I'm here today, fighting for my life, fighting for my respect. It's hell, I hate it. When asked, Resident R1 confirmed that suicide had crossed his mind. Resident R1 stated, I spent nine years in the Army, and [AGE] years carrying a badge, and then this happens, what am I supposed to do? When asked if he was still feeling suicidal, Resident R1 stated, Not now. Observation of Resident R1's room revealed monthly wall calendars, with the only item written on them was the dates his hearing were scheduled. During an interview on 1/20/22, at 1:10 p.m. the Nursing Home Administrator confirmed the facility failed to provide medically-related social services to maintain the psychosocial needs, resulting in psychosocial harm for one of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1))(3)(e)(1) Management. 28 Pa. Code 201.29 (a)(j) Resident rights. 28 Pa. Code 211.2 (a) Physician services. 28 Pa. Code 211.16 (a) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy and records, observations, and staff interviews, it was determined that the facility failed to consistently assess and provide prescribed treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing, and prevent worsening of pressure injuries as required for three of three residents reviewed (R2, R3 and R7), resulting in harm for one of three residents due to inappropriate treatment and dressing changes, a wound increased in size. (Resident R3). Findings include: A review of the facility policy, Completing an Accurate Assessment Regarding Pressure Injuries dated 1/3/23, indicated the facility will ensure that all residents receive an accurate assessment of pressure injures, including risk, presence, appearance, and change of pressure injuries. Policy explanation and compliance guidelines indicate the following: 1. Accurate assessments addressing each resident's skin status will be conducted by qualified staff and correctly documented in the medical record. 2. A nurse will document the resident risk for pressure ulcer in accordance with procedures for a pressure injury risk assessment via the Braden Scale. 3. A qualified health professional will document the presence, number, stage, and pertinent characteristics of any pressure injury on the wound documentation form in the medical record. A review of the facility policy, Clean Dressing Change dated 1/3/23 indicates the facility will provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify the type of dressing and frequency of changes. Wounds are cleansed as ordered and measured using disposable measuring guide. A review of the facility policy, Documentation of Wound Treatments dated 1/3/23 indicates the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and change in treatment. Policy explanation and compliance guidelines indicate the following: 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of wound, if pressure injury (stage 1,2,3,4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure partial or full thickness) c. Measurements: height, width, depth, undermining, tunneling d. Description of wound characteristics: i. Color of wound bed ii. Type of tissue in the wound bed (i.e., granulations, slough, eschar, epithelium) iii. Condition of the peri wound skin (dry, intact, cracked, warm, inflamed, macerated) iv. Presence, amount, and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain 3. Wound treatments are documented at the time of each treatment, if no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact.) Review of Resident R3's MDS dated [DATE], indicated his most recent admission was on 10/25/22 with diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and a contracture (an abnormal, often permanent shortening, as of muscle or scar tissue, that results in distortion or deformity) of the right knee. A further review of Resident R3's MDS Section I: Active Diagnoses does not include a diagnosis of a pressure ulcer. Section M: Skin Conditions M0300. indicates Resident R3 has an unstageable pressure ulcer that was not present upon admission. Review of Resident R3's progress note dated 9/5/22 created by Registered Nurse, Employee E9 indicated a Braden Scale was completed with a score of 15, low risk of developing a pressure ulcer. No further Braden Scale Assessments were documented in the clinical record from 9/6/22 through 1/4/23. Review of Resident R3's medical record indicated a Braden Scale Assessment was not completed after his readmission to the facility on [DATE]. Review of Resident R3's physician order with a start date of 7/11/22, indicated to reposition every two hours for preventative care. A review of Resident R3's November TAR revealed a total 17 boxes that were left blank and not signed off for completion for the above-mentioned treatment. Review of Resident R3's physician order with a start date of 7/15/22, and an end date of 11/8/22, indicated to elevate/float heels off bed using heels up every shift for wound care. A review of Resident R3's November TAR revealed two boxes were left blank and not signed off for completion for the above-mentioned treatment. Review of Resident R3's physician orders (from 10/8/22 through 11/29/22) indicated there are multiple wound care orders for Resident R3's right heel unstageable pressure ulcer with different prescribed treatment. Review of Resident R3's physician order with a start date of 10/8/22, and an end date of 11/29/22, indicated to cleanse right heel-with 0.125% Dakin's solution, apply nickel thick layer of Santyl ointment edge to edge, add a layer of calcium alginate ag+ cut to fit, cover with dry dressing daily. May use tubigrips to keep dressing in place every day and evening shift. A further review of Resident R3's physician orders with a start date of 10/26/22, and end date of 1/4/23, indicated to apply Santyl Ointment 250 UNIT/GM(Collagenase) to right heel topically one time a day for wound care. Both above-mentioned orders remained active from 10/26/22 through 12/29/22. Review of Resident R3's November TAR indicated Resident R3 did not have his right heel cleansed with 0.125% Dakin's solution, a nickel thick layer of Santyl ointment applied edge to edge, a layer of calcium alginate ag+ cut to fit applied and covered with a dry dressing on 11/2/22, 11/14/22. 11/19/22, 11/23/22, and 11/28/22. Review of Resident R3's November TAR indicated that on 11/2/22 the treatment order was left blank and not signed off for completion. Review of Resident R3's eMAR progress note dated 11/14/22, indicated calcium alginate not available to apply. Review of Resident R3's November TAR indicated that on 11/19/22, the treatment was left blank and not signed off for completion. Review of Resident R3's November TAR indicated 11/23/22, the treatment was left blank and not signed off for completion. Review of Resident R3's eMAR progress note dated 11/28/22 indicated no supplies available. Review of Resident R3's progress Skin/Wound Note Follow-up note dated 11/4/22 entered by Registered Nurse, Employee E9 indicated Resident R3 is receiving treatment to his right heel pressure ulcer that measures 1.5cm x2.5cm x 0.2 cm. The treatment included to clean with Dakin's, apply Santyl, alginate, and border dressing daily. Recommendations included offloading, side to side turning, and to float heels at all times (patient has heel float and bunny boots). Review of Resident R3's progress Skin/Wound Note Follow-Up note dated 11/11/22 indicated Resident R3 had a stage 3 right heel pressure ulcer that worsened, measuring 2 x 2.5 x 0.3 (the previous measurement as of 11/4/22 was 1.5cm x2.5cm x 0.2 cm.) The treatment is to continue Dakin's, Santyl, Alginate, border daily. Recommendations include offloading, side to side turning, and to float heels at all times (patient has heel float and bunny boots). A further review of Resident R3's progress Skin/Wound Note Follow-Up note dated 11/11/22, failed to include documentation that the physician order to elevate/float heels off bed, every shift for wound care was discontinued on 11/8/22. Review of Resident R3's Weekly Skin Observation note dated 11/15/22 indicated he has a wound to his right heel that is receiving treatment as ordered. A further review of Resident R3's clinical record revealed no further Weekly Skin Observation assessments were completed from 11/16/22 through 1/4/23. Review of RN, Employee E9 facility documentation titled Weekly Wound Report dated 11/18/22, indicated Resident R3 had a stage 3 right heel pressure ulcer that was measuring 3 x 2.4 x 0.2 which worsened since the previous measurement on 11/11/22 (2 x 2.5 x 0.3cm). Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 11/25/22, indicated Resident R3 had an unstageable right heel pressure ulcer that was measured 1.9 x 1.5cm. The description of wound states fascia over bone?, moderate drainage. The above-mentioned information regarding Resident R3's wound was never entered into her medical record. Review of Resident R3's progress notes for the month of December failed to include a Skin/Wound Note Follow-Up note. Review of Resident R3's physician order dated 12/21/22, indicated to cleanse right heel with normal saline solution, apply Medi honey to wound base, cover with Opti foam daily, every day shift for wound care. Review of Resident R3's progress notes indicated the above treatment on 12/21/22 was not completed as ordered and stated, Order needs confirmed; two orders in for right heel. Applied Santyl ointment. A further review of Resident R3's progress notes failed to include documentation that the two orders were clarified. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated for the month of December, it was revealed only one week of assessments were partially completed. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 12/21/22 indicated Resident R3 had a wound that measured 1.3 x 1.3cm with <20% slough edge and the current treatment included to apply Medi honey and covering with Opti foam. The above-mentioned information regarding Resident R2's wound was never entered into her medical record. A further review of Resident R3's medical record failed to include documentation of his right heel pressure ulcer for the month of December. During an interview on 1/3/23 at 10:12 a.m., Licensed Practical Nurse, LPN, Employee E8 confirmed Resident R3 had duplicate wound care orders for the right heel pressure ulcer. The care plan dated 9/18/22 indicated Resident R3 is to receive treatment as prescribed and to cleanse right heel with Dakin's 0.125% solution, apply nickel thick layer of Santyl, ointment edge to edge, add alginate, cover with dry dressing daily. During an observation of Resident R3's dressing change on 1/3/23 at 11:48 a.m., LPN Employee E8 confirmed that Resident R3 does not have Opti foam applied to right heel as ordered and the heels are not off-loaded as recommended from the last Skin/Wound Follow Up note dated 11/11/22. LPN Employee E8 stated bordered gauze was being used in replace of the prescribed treatment of Opti foam as long as she can remember. LPN Employee E8 also stated they try to make do with the supplies the facility has. LPN Employee E8 also confirmed Resident R3 has some depth to his right heel wound. Review of Resident R3's medical record failed to include documentation that the physician was notified that Opti foam was not available. During an observation of a wound assessment on 1/3/23 at 2:13 p.m., completed by Registered Nurse (RN) Employee E9, indicated Resident R3's wound of the right heel measured as a stage 3 pressure ulcer with measurements of 1.3cm x 1.3cm x 0.4cm. Registered Nurse, RN Employee E9 confirmed upon review of the most recent facility documentation Weekly Wound Report dated 12/21/22, the wound has worsened and developed a depth of 0.4 cm. Review of Resident R2's Minimum Data Set (MDS, periodic assessment of care needs) dated 11/2/22 indicated her most recent admitted as of 4/22/21. Her diagnosis include a stage 4 sacrum region pressure ulcer that was present on admission and an unspecified pressure ulcer of the right scapula. Section M: Skin Conditions indicated she had one Stage 3 pressure ulcer that was not present upon admission and one Stage 4 pressure ulcer that was present on admission. A further review of Resident R2's MDS indicated no other pressure ulcers were present. Review of Resident R2's clinical record revealed that no risk assessment via the Braden Scale was completed from 11/11/22 through 1/4/23. Review of Resident R2's care plan dated 8/22/22 indicated she had a Stage 3 pressure ulcer to her right scapula, a Stage 4 pressure area to sacrum, and a Stage 2 pressure area to her buttocks. Interventions last revised on 9/11/22 by Employee E13, indicated the doctor and nurse is to follow up with wound dressing. Current physician orders for this care plan dated 8/22/22 last revised by Registered Nurse, Employee E13, on 9/1/22 indicated to cleanse left buttock with soap and water, apply calmoseptine three times a day and as needed. On 9/5/22 it was initiated to cleanse right scapula with include with NSS (resident refused to use Dakin's solution), apply a nickel thick layer of Santyl ointment edge to edge, apply drawtex, cover with silicon backed foam dressing. A further review of the care plan last revised by Employee E13 on 9/5/22 indicated to cleanse coccyx with NSS, apply thick layer of Medi honey, pack with Nu Gauze, and cover with silicon backed foam sacral dressing. A review of Resident R2's clinical record revealed this was the last care plan completed. Review of Resident R2's physician Order Summary Report dated 1/5/23, indicated Resident R2 has active orders for her right upper shoulder (scapula), coccyx, and buttock wounds. A physician order dated 10/29/22 indicated to apply prisma border foam dressing (a dressing used for the management of exuding wounds) to left buttock pressure ulcer, one time a day, every night shift. A physician order dated 11/4/22, indicated to cleanse coccyx wound with Dakin's 1/4 strength wet to dry, pack in wound with 4x4 gauze, cover with foam border dressing daily, and as needed when soiled, every night shift. A physician order dated 11/21/22 indicated to cleanse scapula with normal saline solution, apply layer of adaptic (non-adhering dressing) then a layer of alginate (dressing used for wounds that have large drainage), cover with large dry dressing daily, every night shift on Monday, Tuesday, Wednesday, and Thursday. The wound doctor applies a biologic graft every Friday so the dressing should not be changed Saturday or Sunday. Review of Resident R2's late entry progress note Skin/Wound Note Follow-Up created on 11/7/22 and entered by Registered Nurse (RN), Employee E9, with an effective date of 11/4/22 indicated she was noted to have a wound to her left buttock on 8/12/22, and patient states she had it for several days and that she got a pressure sore from sitting in the chair and in bed so much and didn't seem phased about it, thought staff was putting creams on it. It was indicated her left buttock pressure ulcer is a stage 3 and a new stage 3 pressure ulcer is located on the same side. A further review of the Skin/Wound Note Follow-Up did not include documentation of the measurements of Resident R2's left buttock wounds. It is indicated Resident R2's Coccyx wound getting a bit bigger despite our efforts. A further review of the Skin/Wound Note Follow-Up did not include documentation of the measurements of Resident R2's coccyx wound. It also indicates she has a chronic stage 4 scapula pressure ulcer that measures 14 x 6.5 x 0.3 centimeters (cm) and the wound team will continue to follow through graft applications. A further review of Resident R2's progress notes (from 11/5/22 through 1/3/23) indicated no other Skin/Wound Follow-Up notes were completed and failed to include any assessment or documentation of the resident's wounds. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 11/11/22, indicated Resident R2 had a Stage 4 pressure ulcer to her right scapula measuring 14 x 6.6 x 0.3 cm. A description of the wound is not documented. Resident R2's pressure ulcer to her sacrum and buttocks were not documented. The above-mentioned information regarding Resident R2's wound was never entered into her medical record. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 11/18/22, indicated Resident R2 had a Stage 4 pressure ulcer to the right scapula measuring 14 x 6.5 x 0.2 cm. The report failed to include an accurate description of the wound. The description of the wound indicated there are five new areas of epi tissue (thin tissues that cover all the exposed surfaces of the body) pink, red, granulation, dusky areas with some exudate and no slough. Resident R2's pressure ulcer to the sacrum and buttocks were not documented. The above-mentioned information regarding Resident R2's wound was never entered into her medical record. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 11/25/22, indicated Resident R2 has a right scapula wound that measures 13.8 x 6.5 x 0.2 cm. The report has missing information and blanks. The report failed to include the stage of the pressure ulcer and an accurate description of the wound. The description of the wound stated, larger epi bridges. Resident R2's pressure ulcer to her sacrum and buttocks were not documented. The above-mentioned information regarding Resident R2's wound was never entered into her medical record. Review of Resident R2's December Treatment Assessment Record (TAR) indicated to gently cleanse scapula with normal saline, apply layer of Adaptic then a layer of alginate, cover with large dry dressing daily. Will need to be changed on 12/18/22 - no biologic graft was applied on 12/16/22 as ordered. Review of December TAR indicated the above-mentioned treatment was administered on both days 12/18/22 and 12/19/22. Review of RN, Employee E9, facility documentation titled Weekly Wound Round dated 12/21/22 failed to include an assessment of Resident R2's pressure ulcers. During observation of wound rounds on 1/3/23 at 2:24 p.m., with Registered Nurse Employee E9, Resident R2 was away at an activity and unavailable for assessment and observation by the surveyor. During an interview on 1/3/23, at 10:41 a.m., RN Employee E9 confirmed she failed to manage and track and accurately assess Resident R2's pressure ulcers. Review of Resident R7's MDS dated [DATE], her most recent admission to the facility was 7/22/19 with diagnoses of anemia (condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues.) and malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients.) Section M: Skin Conditions M0300. indicates Resident R3 does not have a pressure ulcer and is at risk for developing a pressure ulcer. Review of Resident R7's Weekly Skin Observation dated 12/7/22 indicated buttocks red, applied cream to area. Who documented and who applied the cream? Note I have downloaded does not include who it is written by. A review of Resident R7's Order Summary Report dated 1/5/23 indicated Resident R7 began receiving treatment to her buttocks on 12/9/22. A physician order dated 12/9/22 indicated cleanse buttocks with soap and water, pat dry, apply thick layer of ZGaurd (skin protectant paste) and cover with dry dressing daily, and as needed when soiled. A review of Resident R7's care plan last updated 8/27/22 was not revised to include interventions for treatment regarding Resident R7's buttocks. Review of Resident R7's progress notes dated 12/14/22 indicated, Hospice CNA alerted this writer that client's left outer ankle has an area that measures approximately 5 cm. RN supervisor aware, wound nurse aware. Resident R7's progress notes failed to include documentation that a wound follow-up assessment was completed. A further review of Resident R7's progress note failed to include documentation of an assessment of Resident R7's left ankle or buttock from 12/15/22 through 1/4/22. Review of Resident R7's care plan dated 8/27/22 indicated resident R7 was admitted to hospice and care would be coordinated with hospice. A review of Resident R7's physician orders do not include any treatment orders to her left ankle until 12/21/22, seven days later. Review of R7's physician orders dated 12/21/22, indicated cleanse left lateral ankle with soap and water, pat dry, apply layer of Medi honey to open areas and cover with Opti foam daily, every day shift. Review of R7's physician orders dated 12/21/22, indicated cleanse buttocks with soap and water, pat dry, apply layer of Medi honey to open areas and cover with Opti foam daily, every day shift. Review of RN, Employee E9, facility documentation titled Weekly Wound Report dated 12/21/22, indicated Resident R7 has a wound to the left ankle that measures 1.5 x 1.5 cm with slough and serosanguinous (discharge that contains both blood and a clear yellow liquid known as blood serum.) drainage. The above-mentioned information regarding Resident R2's wound was never entered into her medical record. No information regarding Resident R7's pressure ulcers were documented in the medical record for the month of December. During an interview with RN Employee E9 on 1/3/23 at 10:41 a.m., she confirmed she has been the wound nurse since 7/18/22 and is responsible for managing and tracking resident's wounds. During the interview RN, Employee E9 stated 90% of the wound team does skin evaluations on admission and confirmed she failed to accurately assess and document resident wounds in the clinical record. During an observation of a wound assessment on 1/3/23, at 2:21 p.m., RN Employee E9 confirmed she failed to manage and track and accurately assess Resident R7's pressure ulcers and she developed a new stage 2 pressure ulcer her left buttock measuring 2cm x 0.3cm x <0.1cm. During an interview on 1/4/23, at 12:17 p.m., the Assistant Director of Nursing, Employee E1, confirmed the staff member responsible for ordering supplies is the Environmental Service Manager and is not ordering appropriate nursing supplies for wound care treatments. ADON, Employee E1 also confirmed the facility does not have enough wound care supplies to perform wound care treatments as ordered. During an interview on 1/4/23, at 2:04 p.m., the Assistant Director of Nursing, Employee E1, confirmed the facility failed to consistently assess and provide prescribed treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing, and prevent worsening of pressure injuries as required for two of three residents reviewed (Resident R2, R3 and R7), resulting in harm for one of two residents due to inappropriate treatment and dressing changes, a wound increased in size and failed to progress towards healing as anticipated (Resident R3). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.10 (c) Resident care policies.

Based on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from verbal abuse resulting in mental anguish for one of eight residents (Resident R1). Findings include: The facility policy entitled Abuse and Neglect Prevention dated 10/22/21, indicated that abuse definitions include intimidation resulting in physical harm, pain, or mental anguish Verbal abuse is defined as oral, written or gestured language that willfully includes disparaging and derogatory terms, to the resident or their families, to describe resident, regardless of age, ability to comprehend or disability. Review of the Minimum Data Set (MDS- periodic assessment of care needs), dated 10/27/21, indicated that Resident R1 was admitted to the facility on [DATE], with dx that included diabetes Type 2, acute kidney failure, high blood pressure depression and anxiety disorder. Review of Section C: Cognitive Patterns on the 10/27/21 MDS, indicated that Resident R1 had no cognitive impairment. Review of the Care Plan dated 10/21/21, indicated that Resident R1 had a problem identified related to mood disorder, including anxiety, panic disorder and depression and was to have mood and behavior monitored for changes and to notify psychiatric physician of any concerns. Review of the MDS- (periodic assessment of care needs), dated 10/8/21, indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns on the 10/8/21 MDS, indicated that Resident R1 had no cognitive impairment. During an interview on 12/21/21, at 2:20 p.m., Resident R2 confirmed that she witnessed Nurse Aide (NA) Employee E1 yelling and screaming at Resident R1. Resident R2 stated that NA Employee E1 used profanity and derogatory language toward Resident R1 and that she was upset after witnessing the incident. Resident R2 indicated that no staff member had ever interviewed her regarding the incident. During an interview on 12/21/21, at 4:00 p.m., Resident R1 confirmed that Nurse Aide Employee E1 had yelled and screamed at her on 12/11/21 after she asked for another blanket to be put on her bed. She stated that the NA Employee E1 refused to give her a blanket and screamed at her, swore at her and called her names when she objected. Resident R1 confirmed that she suffered anxiety and mental anguish due to the incident and that no staff or administration had ever interviewed her regarding the incident. During an interview on 12/21/21, at 4:35 p.m, the Nursing Home Administrator and Director of Nursing confirmed that they had been notified of the incident involving Resident R1 and NA Employee E1 on 12/12/21, and confirmed that the NA Employee E1 engaged in verbal abuse toward Resident R 1 during the incident on 12/11/21. *** 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 3/26/21. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(j) Resident rights. Previously cited 3/26/21. 28 Pa. Code 207.2(a) Administrator's Responsibility. Previously cited 10/21/21. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 10/21/21.

Based on review of facility policy, facility and hospital clinical records and staff interview, it was determined that the facility neglected to provide goods and services necessary to avoid physical harm regarding the use of a mechanical lift and the assist of two for a transfer, resulting in harm in the form of a [MEDICAL CONDITION] distal femur for one of three residents reviewed (Resident CR1). Findings include: A review of facility policy titled, Abuse Prevention updated 7/2/18, defines neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A review of facility policy titled, Transfer Activities updated 7/2/18, indicated it is the policy of the facility to transfer the resident from the bed to the chair, toilet or tub, safely. To use a mechanical lift if necessary, and obtain help when necessary. A review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated 7/23/18, indicated that Resident CR1 had [DIAGNOSES REDACTED]. A review of Section C0500 Brief Interview for Mental Status (test for cognitive function) revealed a score of 13 indicting that Resident CR1 was cognitively intact. A review of Resident CR1's Kardex (electronic information for nursing staff which included the resident's transfer status) undated, indicated that Resident CR1 required the assistance of two staff and the use of a Sara lift for transfers (mechanical lift to transfer the resident from one surface to another, the resident does not pivot and the machine bears the majority of the weight). A review of Resident CR1's Plan of Care updated 7/16/18, indicated that Resident CR1 required the assistance of two staff for Sara lift transfers. A review of Resident CR1's physician order [REDACTED]. A review of a witness statement by Nurse Aide (NA) Employee E1, dated 8/14/18, not timed, indicated I went to get Resident CR1 up from the bed, I asked her if she transferred with the Sara lift to the shower chair, she then said no. Then as I was transferring her to the chair her legs buckled which then I had slowly eased her to the floor. A review of a Facility Incident Report dated 8/14/18, at 7:25 a.m. indicated that NA Employee E1, stated she was informed by other staff that Resident CR1 was to be a Sara lift transfer, but when asked if she was transferred with a lift, Resident CR1 said no. NA Employee E1, then proceeded to transfer Resident CR1 from the bed to the shower chair as a pivot transfer (resident bears majority of weight and must step and pivot). Resident CR1's knees buckled and NA Employee E1, lowered her to the floor. NA Employee E1, called for help. A review of Employee E2's Registered Nurse, note dated 8/14/18, at 8:04 a.m. indicated that Resident CR1 was being transferred over to the shower chair when her legs buckled and she was lowered to the floor. Her right leg was in an L shape and her knees were inverted, bent toward each other. A review of Resident CR1's X-ray report dated 8/14/18, indicated a comminuted (bones broke into two or more pieces) impacted (bones pushed together) [MEDICAL CONDITION] distal femur (the longest bone in the leg). A review of Resident CR1's hospital physician's discharge hospital course note dated 8/22/18, indicated that Resident CR1 was admitted with an acute right distal femur fracture with orthopedics consulted. Resident CR1 was scheduled for Open Repair Internal Fixation (surgery on the fracture). The patient herself voiced wishes for no further intervention to assist in her care and hospice (end of life care focusing on symptom management) services were arranged. During an interview on 10/31/18, at 11:30 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility neglected to transfer Resident CR1 with the assist of two staff and the use of a mechanical lift which resulted in harm when the resident fell and sustained a right distal femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/9/18, 3/10/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 4/9/18, 3/10/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/17/17, 3/10/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/10/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/9/18, 3/27/18, 5/17/17, 3/10/17.