Every finding on record at Asbury Health Center

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent resident elopement that created an immediate jeopardy situation for one of fourteen residents that were identified as at risk for elopement and did not reside on a secured unit (Resident R84).Findings Include: Review of the facility policy, Wandering and Elopements dated 3/1/26, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the clinical record revealed Resident R84 was admitted to the facility on [DATE]. Review of the Minimum Data Sets (MDS - periodic assessment of resident care needs) dated 2/19/26 and 5/20/26, included diagnoses of hemiplegia (paralysis on one side of the body), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated that Resident R84 has cognitive impairment. Review of an Elopement Evaluation assessments completed revealed:2/18/26 - Not at risk of elopement.4/12/26 - Assessment was incomplete.5/19/26 - Not at risk of elopement.7/18/26 - At risk of elopement.7/20/26 - At risk of elopement.7/30/26 - At risk of elopement. Review of the plan of care dated 4/13/26, indicated Resident R84 is an elopement risk/wanderer leaving the unit unattended related to impaired safety awareness. Further review of the care plan included one incomplete intervention in place for the risk for elopement from 4/13/26, through 7/20/26, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (no preferences included in care plan). Review of Resident R84's behavior monitoring for April through July 2026 revealed:April: No wandering documented, no documentation completed for 4/12/26, evening shift.May: Exit-seeking behavior documented on 5/21/26, evening shift.June: Exit-seeking and wandering behaviors documented on 6/21/26, evening shift.July: Exit-seeking behavior documented on 7/14/26, agitation, exit-seeking, frustration, and threatening others documented on 7/20/26, evening shift. Review of Resident R84's progress notes failed to reveal documentation related to the above instances of exit-seeking and wandering behaviors on 5/21/26, 6/21/26, and 7/14/26. Review of a new physician's order created 4/12/26, at 3:46 p.m. indicated for Resident R84 to have a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door) placed. Review of Resident R84's progress notes failed to include any progress notes created on 4/12/26. Review of a progress note dated 4/13/26, at 2:37 p.m. indicated, Had a long discussion with residents' brother regarding her wander guard. Answered all of his questions and explained that our main goal is just to keep her safe. He was satisfied with our conversation and all questions were answered. Review of a physician progress note dated 4/13/26, at 4:41 p.m., indicated, Yesterday (4/12/26) she was found wandering around outside on the curb and now has a wander guard on. Review of a progress note dated 4/14/26, at 12:21 p.m., indicated that Resident R84 had increased wandering behaviors. Review of an employee statement (undated) written by Nurse Aide (NA) Employee E18 stated, I was coming back from break when I seen a resident looking confused. I asked where she was from because she was sitting by the door on Hickory. She said 4. No one knew her so I took her to security. During a follow-up interview on 8/10/26, at 11:44 a.m. NA Employee E18 stated that this occurred at about 2:13 p.m. NA Employee E18 stated that Resident R84 was seated in a wheelchair and was trying to get outside the building. NA Employee E18 stated he was told that activities (Activities Department) had her and lost her. Review of the April 2026 Activities Calendar revealed that Church Service was scheduled on 4/12/26, at 2:30 p.m. Review of Resident R84's activity charting revealed documentation completed that Resident R84 attended worship services on 4/12/26. Review of an employee statement dated 4/12/26, written by Registered Nurse (RN) Employee E19, stated, This nurse was called by Redwood nurse (Licensed Practical Nurse, LPN) Employee E20, around 1:30 p.m. telling security told, resident was outside per [NA Employee E18]. Call [NA Employee E18] and ask him where he saw resident, he said on hallway at Hickory, not outside of building. Ask resident, how she came, she said someone with printed flower t-shirt lady get her down and told her to wait and said she will take her to church. So, she was waiting for her. For resident safety, Wanderguard on w/c (wheelchair), Review of an employee statement dated 4/12/26, written by RN Employee E24, stated, While this nurse was on break, another nurse from hall notified this nurse that a CNA (nurse aide, NA Employee E18) found the resident outside and took her to security, from where she was brought back to the unit. This nurse assessed the resident, stated, 'One lady with a flower shirt took me' and said she was getting ready for church. Supervisor was notified. This nurse and front hall nurse spoke with the security. This nurse spoke with the CNA, who stated he saw resident near to Hickory elevator area. Per CNA, resident was not outside the building. This nurse asked activities, stated it was not time for church and they did not escort the resident. Wanderguard applied for security for resident. Review of a progress note dated 7/17/26, at 11:13 p.m. indicated, [Responsible party] for this resident was notified about the resident 's attempt to elope from the unit. On call [provider] was also notified regarding this incident. Review of a progress note dated 7/17/26, at 11:27 p.m. indicated, this nurse did not see [Resident R84] in the room, this nurse asked CNA who was assigned to [Resident R84] and other CNA's and no one have seen her, this nurse started looking in each room plus bathrooms and other floors, 3-11 notified and helped looking for [Resident R84], then 1 CNA (not named) reported that she saw [Resident R84]wheeling her wc (wheelchair) to the front hall area, [Resident R84] could escape through the security door because the alarm was broken and haven't been fixed yet, all staffs searching all areas and then found [Resident R84]sitting in her wheelchair in front of 1 of apartment on the right hall area, brought resident back to floor, full skin assessment did not find any injuries. Note: [Resident R84] has her wander guard in her wheelchair back seat socket AAT (at all times) even while her elopement this time. Review of a progress note dated 7/20/26, at 3:25 p.m. indicated, Investigation into reported elopement: Through resident and staff interviews, it has been determined that an unknown visitor left resident off of her unit. (Staff interviews revealed no staff member allowing resident through door, resident interview reveals a visitor let her through the door. Resident with BIMS of 12 (moderate cognitive impairment), able to recall events from 7/17/26, at this time.) Resident cognitively unable to recognize door in question requiring a code to open and due to weight of door in question, would be physically unable to open door without assistance. Door check completed and alarm/door functioning properly. Door alarm company contacted to inspect for proper functionality, as an added safety measure. Door monitoring by staff has been implemented, pending completion of inspection by door alarm company. Review of information submitted by the facility dated 7/20/26, indicated, On 7/17/26 at approximately 10pm resident [Resident R84] was found off the unit near the vending machine and kitchenette area. Staff did not see her in her room when they went to give her medication and were unsure of where she was. Elopement protocol was initiated and resident was located approximately 5 minutes after identified as missing directly off the unit in the common area adjacent to her unit. Resident had wander guard in place and was stable with no incident or injury. Resident's most recent BIMS was 5/14/2026 and she scored an 11. Family and MD (Doctor of Medicine) notified of incident. Review of facility investigation documents dated 7/20/26, indicated, Resident found off unit in common area adjacent to unit. Stated she was let off by unknown visitor and wanted to go look outside unit. Stated no desire or intent to leave. Review of an employee statement dated 7/17/26, written by NA Employee E25 indicated, Around 9:30 p.m. I saw [Resident R84] in the front hall near my section. I redirected her toward her room. The door to exit Redwood had been alarmin for some time. I called security to ask them to shut off alarm and he said, 'Somebody already called, I'm by myself, I'll get up there.' Around 10:13, [RN Employee E4] asked if I'd seen [Resident R84], I told her I hadn't seen her for awhile. [RN Employee E4] called security to report her missing and I started looking on the 2nd floor. When I returned to the 3rd floor by administration, [RN Employee E28] said they found her. Review of an employee statement dated 7/17/26, written by NA Employee E26 indicated Resident R84 was found by the apartments off of Redwood (nursing unit). Review of an employee statement dated 7/17/26, written by NA Employee E27 indicated Resident R84 last seen in her room around 9:00 p.m. and was located in the assisted living area. Review of an employee statement dated 7/17/26, written by RN Employee E4 indicated, The resident was last seen at approximately 9:45 p.m. in the hallway outside the dining room while this nurse entered [room number] to perform wound care. About 10 minutes later, upon exiting the room, this nurse noticed the Fishbowl exit door alarming. The assigned nurse, CNAs, supervisor, immediately searched for the resident. This nurse notified security of the missing resident. Approximately 10:45 p.m., the assigned nurse located the resident in the independent living building and safely returned the resident to the unit. On 8/4/26, at 2:40 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware that an Immediate Jeopardy situation existed and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration on 8/4/26, at 2:52 p.m. Review of clinical records revealed that the facility was out of compliance with resident safety and supervision since 4/12/26. On 8/4/26, at 7:05 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions: All residents were assessed in the facility for elopement risk on 7/20/26, no new residents were identified. Intervention for other residents identified as elopement risks included Wanderguard and door checks on all doors on 7/20/26, to address like resident safety. All units passed inspection except one door on redwood on 7/20/26. A door monitor was put into place on 7/20/26, for affected residents until room moves could be completed. [Resident R84] was moved to secured unit on 7/21/26. [Resident R91]1 was moved to new room on 7/22/26. Education regarding elopements was provided to all departments on 7/20/26, and completed on appropriate actions to take when the alarm system is activated and when a resident is noted to be missing. On 8/4/26, additional education initiated immediately related to IJ compliance for resident rights, comprehensive care plan, understanding elopement protocol and Wanderguard system and will be completed by 9am on 8/5/26. Root cause analysis conducted on 7/20/26 to determine R1 got off the unit by a visitor. Facility reviewed the policy Wandering and Elopements for elopement prevention and post-elopement procedures on 8/4/26. DON or designee will audit to ensure all new admission, readmissions, quarterly assessments, and assessments with changes in condition will be reviewed that no change in elopement status occurred weekly x four, monthly x two beginning on 8/4/26. Care plan review audit will be conducted on 8/4/26, for like residents identified as elopement risk, to ensure appropriate monitoring and support are in place All POC (plan of correction) audit results and incidents will be reviewed at QAPI (Quality Assurance and Performance Improvement) monthly. Following a review of the Corrective Action Plan implementation on 8/5/26, the following was noted to have not been completed: Review of clinical records revealed the following residents, that were not reassessed for elopement on 7/20/26, were later identified as an elopement risk when reassessed on 8/5/26.Resident R26 identified as an elopement risk on 8/5/26.Resident R55 identified as an elopement risk on 8/5/26.Resident R73 identified as an elopement risk on 8/5/26. Review of clinical records revealed the following residents, that did not reside on a secure unit, to have been identified by the facility through elopement evaluations to be at risk to elope, without care plans developed to address wandering or elopement.Resident R46 identified on 7/20/26, and again on 8/5/26, as an elopement risk. Care plan was not initiated at the time of the survey.Resident R56 identified on 6/8/26, and again on 7/20/26, as an elopement risk. Care plan for wandering and elopement was not initiated until 8/4/26.Resident R95 identified on 3/18/26, 6/18/26, and again on 8/5/26, as an elopement risk. Care plan for wandering and elopement was not initiated until 8/4/26.Resident R114 identified on 2/14/26, 4/14/26, 7/14/26, and again on 8/5/26, as an elopement risk. Care plan for wandering and elopement was not initiated until 8/4/26.Resident R139 identified on 3/5/26, and again on 7/20/26, as an elopement risk. Care plan for wandering and elopement was not initiated until 8/4/26. Additionally, review of clinical records revealed the following residents, that did reside on a secure unit, to have been identified by the facility through elopement evaluations to be at risk to elope, without care plans developed to address wandering or elopement.Resident R42, identified on 6/16/26, and again on 8/5/26 as an elopement risk. Care plan was not initiated until 8/4/26.Resident R53, identified on 3/3/26, 6/3/26, and again on 8/5/26 as an elopement risk. Care plan was not initiated until 8/4/26.Resident R129, identified on 3/3/26, 6/3/26, and again on 8/5/26 as an elopement risk. Care plan was not initiated until 8/4/26. Review of resident clinical records on 8/5/26, revealed that only residents residing on the Redwood unit were reassessed for elopement, rather than All residents stated in the plan of correction above. Further review of Corrective Action Plan on 8/5/26, reviews of clinical records revealed all residents were reassessed for elopement on 8/5/26. Review of facility-provided sign-in sheets, dated 8/4/26, and 8/5/26, confirmed reeducation was provided to all facility staff on elopement risk identification, prevention, and actions to take in the event of an elopement. During interviews conducted on 8/5/26, 46 of 46 facility staff facility staff confirmed they received reeducation on:Whether they received reeducation.How to identify residents as risk for elopement (staff who were responsible for identifying elopement risk).What steps to take immediately and thereafter if a resident is missing.What actions to take if the resident refuses to return to the facility/unit.Whether they understand how the Wanderguard system functions. Further review of clinical records on 8/5/236, now revealed that care plan audits were completed, and new care plans were initiated for residents identified as at risk for elopement. On 8/5/26, review of review of facility documents confirmed a root cause analysis was completed. The Immediate Jeopardy was lifted on 8/5/26, at 3:28 p.m. when the action plan implementation was verified. During an interview on 6/30/26, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent resident elopement that created an immediate jeopardy situation for one of fourteen residents that were identified as at risk for elopement and did not reside on a secured unit. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.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 facility policies, observations, and staff interview, it determined the facility failed to maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness.Findings include: During an initial observation of the kitchen from 10:15 a.m., through 10:52 a.m., the following was observed: -leaking water under kettle pan heaters-one of two Ice machine had a drainpipe sitting on floor with a black substance around pipe. The pipe is not over drain, and water is leaking onto floor.-Ice cream cooler has ice build up-wall cooler units had area leaking of first unit and fourth unit has broken hinge not allowing unit to close without force and the thermometer inside of cooler indicated 50-degree temperature and inside unit felt warm. During an interview on 8/4/26, at approximately 10:52 a.m., Certified Dietary Manager Employee E 23 confirmed that the facility failed maintain sanitary conditions in the Main Kitchen, which created the potential for cross contamination and food borne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, resident observations, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for four of six residents (Resident R3, R62, R124, and R128). Findings include:Review of the facility policy, Activities of Daily Living, Supporting dated 3/1/26, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility policy Call System, Resident, dated 3/1/26, with a previous review date of 3/25/25, indicated that calls for assistance are answered as soon as possible, but no later than 5 minutes. During an observation on 8/4/26, from 10:56 a.m. through 11:19 a.m., the call light was illuminating above resident R3's room, when MDS Coordinator Employee E21 answered the light Resident R3 indicated that she needed changed. MDS Coordinator confirmed that the call bell had been illuminating for 23 minutes. That is a long time to wait to be changed.During an observation on 8/4/26, from 10:56 a.m., through 11:15 a.m., the call light above Resident R124's room was illuminated, at 11:15 a.m., when the Nurse Aide entered the room, she closed the door behind her and proceeded to assist the resident. 18 minutes after the light was illuminated.During an interview on 8/4/26, at approximately 12:15 p.m., with the Nursing Home Administrator and Director of Nursing, they were made aware of the call light response times and confirmed they will review the call bell response with the staff.Review of the clinical record indicated Resident R62 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/7/26, included diagnoses of diabetes, atrial fibrillation, and the need for assistance with personal care. Review of Section GG: Functional Abilities indicated Resident R62 was needed substantial/maximal assistance to roll left and right in bed.Review of a progress note dated 7/28/26, at 2:12 p.m. indicated Resident R62 had moisture associated skin damage located at the base of her spine. Review of a physician's order dated 7/22/26, indicated Resident R62 required a wedge in bed at all times. During an observation on 8/5/26, at approximately 10:00 a.m. Resident R62 was noted to be lying in bed, on her back, without a wedge present.During an observation on 8/5/26, at approximately 2:27. Resident R62 was noted to be lying in bed on her back, with the wedge placed under the fitted sheet, at the same level as Resident R62's head.During an interview on 8/5/26, at approximately 3:00 p.m. Wound Nurse Employee E29 confirmed Resident R62's wedge should be placed at the level of her torso to assist in positioning Resident R62 on her side to alleviate pressure on her back.During an observation on 8/6/26, at approximately 11:31 a.m. Resident R62 was noted to be lying in bed on her back, with the wedge placed under the fitted sheet, at the same level as Resident R62's head.Review of the clinical record indicated Resident R128 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of diabetes, chronic kidney disease, and dementia. Review of Section C: Cognitive Patterns revealed Resident R128 had a moderate cognitive deficit. Review of Section GG: Functional Abilities indicated Resident R128 was dependent on staff for toileting hygiene. Review of Section H: Bladder and Bowel indicated Resident R128 was always incontinent of urine and frequently incontinent of stool. Review of Resident R128's plan of care for ADL Self Care Deficit indicated for staff to assist with toilet transfers and pericare (cleaning of the genitals and the anal area).During an observation on 8/4/26, at 9:50 a.m. Resident R128 was in bed. Upon entering Resident R128's room, a strong smell of urine was noted. Visible on the linen were two large discolored circles beneath Resident R128. After noting this, the surveyor exited the room to find staff to assist Resident R128.During an observation on 8/4/26, at 9:55 a.m. the surveyor and Licensed Practical Nurse (LPN) Employee E17 noted the bed linen was saturated. The surveyor, with a gloved hand, pressed a disposable facial tissue to the larger, outer circle on the bed linen, and it was dry. Then pressed the facial tissue to the smaller inner circle, and the facial tissue became wet. Additionally, the blanket covering Resident R128 was observed to also be wet.LPN Employee E17 confirmed the above observations and stated that at times Resident R128 refuses care. Review of Resident R128's progress notes on 8/4/26, failed to reveal documentation of a care refusal. Review of Resident R128's point of care record for 8/4/26, indicated Resident R128 was incontinent of urine and stool at 12:56 a.m. No additional bowel and/or bladder care was documented for Resident R128 until 8/4/26, at 10:18 p.m. The point of care record provided the option for documenting refusals of care. No refusals of care were documented for Resident R128 on 8/4/26. During an interview on 8/6//26, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided for four of six residents. 28 Pa. Code: 210.10(d) Resident Care Policies. 28 Pa. Code: 211.12(d)(1) Nursing service.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain a monthly weight for one of six residents (Resident R6) and failed to identify and reassess residents for need for nutritional interventions for weight loss and/or skin issues for two of six residents. (Resident R97 and R9).Findings include: Review of the facility policy, Weight Assessment and Intervention dated 3/1/26, indicated, Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Review of the clinical record indicated Resident R97 was re-admitted to the facility on [DATE]. Review of Resident R97's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/19/26, included diagnoses of Progressive Supranuclear Palsy (brain disease which affects movement, balance, vision and swallowing), history of a stroke, cognitive deficit. and malnutrition (lack of sufficient nutrients in the body). Review of Resident R97's current plan of care for potential nutritional problem, revised on 5/19/26, indicated for the facility Resident will maintain adequate nutritional status as evidenced by no unplanned significant weight changes and safely consume/tolerate food/fluids to meet 75% of estimated nutritional needs to support healthy skin integrity and to Monitor weights as ordered. Review of Resident R97's current plan of care risk for pressure ulcer development, revised on 1/30/26, indicated for the facility to monitor Resident R97's nutritional status. Review of Resident R97's nutritional assessment indicated the most recent assessment was completed on 5/15/26, and indicated to monitor as needed. Review of a physician's order dated 6/1/25, indicated to monitor weights for prevention. Review of Resident R97's weight record indicated that on 7/5/26, Resident R97 weight 124.0 pounds, and on 8/1/26, weighed 116.5 pounds, a loss of 7.5 pounds (6.05%) in one month. Review of a nutritional assessment dated [DATE], the last time Resident R97 was assessed by a Dietician, identified Resident R97 at risk for weight loss and actual weight loss with no interventions identified as being recommended or ordered. Review of the clinical record identified Resident R97 developed a 1cm x 1cm open area of her coccyx on 7/1/26, requiring treatment. The wound worsened per a progress note dated 7/28/26, during this time the dietician did not assess Resident R97 for potential additional nutritional interventions to assist with wound healing. During an interview on 8/6/26, at approximately 2:26 p.m., Dietician Employee E22 confirmed Resident R97 had not been reassessed after the development of a pressure ulcer on 7/1/26, and did not have nutritional interventions in place Review of the clinical record indicated Resident R6 was re-admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], included diagnoses of epilepsy (a long-term brain disorder that causes repeated and unprovoked seizures) and atrial fibrillation (an irregular and often very rapid heart rhythm). Review of Resident R6's current plan of care, initiated 6/20/26, indicated for the facility to, Monitor wts (weights) trends as ordered. Review of the nutritional assessment dated [DATE], indicated that, Upon re-admission a suggested wt loss- request reweigh. Review of a physician's order dated 6/29/26, indicated, Weekly weights every day shift for one day. Review of Resident R6's weight record from 6/28/26 through 8/4/26, failed to include a weight evaluation. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), anemia (too little iron in the body causing fatigue), and malnutrition. Review of Resident R97's current plan of care for potential nutritional problem, revised on 6/25/26, indicated for the facility Resident will maintain adequate nutritional status as evidenced by no unplanned significant weight changes and safely consume/tolerate food/fluids to meet 75% of estimated nutritional needs to support healthy skin integrity and to Monitor weights as obtained. Review of a physician's order dated 5/14/26, indicated Resident R9 received Glucerna (carbohydrate controlled nutritional supplement) for weight stabilization. Review of Resident R9's weight record indicated that on 5/3/26/26, Resident R9 weight 142.5 pounds, on 7/1/26, weighed 136.3 pounds, and on 8/3/26, weighed 125.00 pounds, a loss of 11.3 pounds (8.29%) in one month, and 17.5 pounds (12.28%) in three months. During an interview on 8/6/26, at approximately 2:26 p.m., Dietician Employee E22 confirmed Resident R9 did not have a reassessment or new interventions put in place to address her weight loss. During an interview on 8/6/26, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly monitor weight and nutrition status by failing to obtain a monthly weight for one of six residents and failed to identify and reassess residents for need for nutritional interventions for weight loss and/or skin issues for two of six residents. 28 Pa. Code 201.18(b)(1)( Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and resident and staff interviews, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of twelve residents (Resident R19, R21, R22, R51, R58, R93, and R118). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that: Section B: Hearing, Speech, and Vision, defined Makes Self Understood as Able to express or communicate requests, needs, opinions, and to conduct social conversation in their primary language, whether in speech, writing, sign language, gestures, or a combination of these. Deficits in the ability to make one's self understood (expressive communication deficits) can include reduced voice volume and difficulty in producing sounds, or difficulty in finding the right word, making sentences, writing, and/or gesturing. Review of the coding instructions indicated Rarely or never understood should be coded when if, at best, the resident's understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language. Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of kidney disease, Alzheimer's disease, and malnutrition. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R19 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R19 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R19 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 8/6/26, at approximately 11:55 a.m. the surveyor held a conversation with Resident R19. Resident R19 had clear speech, was able to provide her name, stated her birthday was in [birth month], and answered questions if she enjoyed the meals provided. Review of the clinical record confirmed Resident R19's birth month was as Resident R19 had stated. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes, osteoporosis, and dementia. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R21 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R21 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R21 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 8/6/26, at approximately 12:00 p.m. the surveyor held a conversation with Resident R21. Resident R21 was confused, but had clear speech and was able to be understood. Review of the clinical record indicated Resident R58 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of kidney disease, diabetes, and dementia. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R58 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R58 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R58 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 8/6/26, at approximately 12:04 p.m. the surveyor held a conversation with Resident R58. Resident R58 had clear speech, was able to provide her name, when asked if she liked the food said it was, real good, answered questions on if the staff treat her respectfully and assist her with care, and when asked her birthday, stated it was the [day] of [month]. Review of the clinical record confirmed Resident R58's was as Resident R58 had stated. Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure, diabetes, and dementia. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R22 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R22 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R22 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 8/6/26, at approximately 12:10 p.m. the surveyor held a conversation with Resident R22. When asked his name, Resident R22 provided the preferred name listed in his clinical record. Resident R22 had clear speech, when asked if he liked the food said it was, good, answered questions on if the staff treat him respectfully and assist him with care, and when asked his birthday, stated the month, day, and year in numerical form. Review of the clinical record confirmed Resident R22 correctly stated his birthdate. Review of the clinical record indicated Resident R93 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of osteoporosis, malnutrition, and dementia. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R93 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R93 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R93 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 8/6/26, at approximately 12:15 p.m. the surveyor held a conversation with Resident R93. Resident R93 had clear speech, was able to provide her full name, when asked if the food tasted good said, it really does, answered questions on if the staff treat her respectfully and stated, pretty much, and was able to answer questions regarding ADL care and assistance in and out of bed. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of anxiety, depression, and dementia. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R51 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R51 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R51 is rarely understood, and the Resident Mood Interview assessment was not completed. Review of the clinical record indicated Resident R118 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of kidney disease, malnutrition, and Alzheimer's disease. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R118 is Rarely/never understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R118 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R118 is rarely understood, and the Resident Mood Interview assessment was not completed. During an observation on 8/6/26, at approximately 12:20 p.m. Residents R51 and R118 were seen seated with Activities Department Employee E18. Resident R51 and R118 were speaking to Activities Department Employee E18. The surveyor sat at the table with Resident R51 and R118 and engaged them in conversation. Both residents had clear speech and were able to hold a simple conversation. Resident R51 answered questions about the food activity the day prior, and when asked if she knew her birthday stated, I wasn't awake, but my mother would know. Resident R118 answered questions appropriately, and when asked if she had any concerns about her care, shook her head negatively. During an interview on 8/6/26, at 12:36 p.m. the Registered Nurse Assessment Nurse Employee E19 confirmed that if a resident is at least somewhat understood the resident should not be coded as Rarely/never understood and the BIMS and PHQ-9 assessments should be attempted. During an interview on 8/6/26, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of twelve residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on facility policy and clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for four of seven residents reviewed for ADLs (activities of daily living) concerns (Residents R23, R26, R91, and R99).Findings include: Review of the facility policy Restorative Nursing Services dated 3/1/26, indicated the residents will receive restorative nursing care as needed to help promote optimal safety and independence. During an interview on 8/6/26 at 10:30 a.m., the Director of Nursing (DON) revealed that restorative activities are documented on the daily Documentation Report (Nurse Aide Documentation of Activities of Daily Living - ADL's.) Clinical record review for Resident R23 revealed a diagnoses list that included cognitive impairment, lack of coordination, and a history of falls. Review of the current care plan revised on 3/15/26, for Resident R23 revealed the resident requires assistance with transferring. An intervention included dependent assistance with all ADLs and restorative exercises for upper and lower extremities. Review of the current Therapy/Nursing Recommendation form status indicated Resident R23 was discharged from therapy and required active range of motion (AROM) to bilateral upper and lower extremities. Review of the daily Documentation Report dated July and August 2026 did not include documentation that the restorative tasks were completed daily as required. Clinical record review for Resident R26 revealed a diagnoses list that included stroke and paralysis on the right side of the body. Review of the current care plan revised on 3/27/26, for Resident R26 revealed the resident requires assistance with ambulating. An intervention included assist of one person with all ADLs and restorative exercises to upper extremities to include range of motion and lifting weights. Review of the current Therapy/Nursing Recommendation form status indicated Resident R26 was discharged from therapy and required AROM to bilateral upper and lower extremities, weight strengthening, and assist with walking up to 90 feet. Review of the daily Documentation Report dated July and August 2026 did not include documentation that the restorative tasks were completed daily as required. Clinical record review for Resident R91 revealed a diagnoses list that included anoxic brain damage (loss of blood circulation to the brain), dementia, and difficulty with walking and mobility. Review of the current care plan revised on 4/30/26, for Resident R91 revealed the resident requires assistance with ambulating and transfers and to utilize therapy recommendations. An intervention included restorative program for strengthening, transfers, and walking. Review of the current Therapy/Nursing Recommendation form status indicated Resident R91 was discharged from therapy and required AROM to bilateral upper and lower extremities, weight strengthening, and sit to stand exercises. Review of the daily Documentation Report dated July and August 2026 did not include documentation that the restorative tasks were completed daily as required. Clinical record review for Resident R99 revealed a diagnoses list that included diabetes, high blood pressure, muscle weakness, and lack of coordination. Review of the current care plan revised on 3/15/26, for Resident R99 revealed the resident requires partial to moderate assistance with ambulating and transfers and to utilize therapy recommendations. Interventions included a restorative program for AROM, and walking. Review of the current Therapy/Nursing Recommendation form status indicated Resident R99 was discharged from therapy and required assistance with walking with a wheeled walker up to 100 feet. Review of the daily Documentation Report dated July and August 2026 did not include documentation that the restorative tasks were completed daily as required. During an interview on 8/6/26 at 10:30 a.m., The Director of Nursing confirmed the above findings and that the facility failed to complete a restorative nursing program for ADLs concerns for Residents R23, R26, R91, and R99.

Based on a review of facility policy, employment records and staff interviews, it was determined that the facility failed to maintain documentation that facility nursing personnel have current education and certification to provide basic life support, including CPR (cardiopulmonary resuscitation), to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 14 of 41 licensed nurses (Registered Nurse (RN) Employees E3, E4, E5, E6, and E7 and Licensed Practical Nurse (LPN) Employees E8, E9, E10, E11, E12, E13, E14, E15, and E16).Findings Include: Review of the facility, CPR (cardiopulmonary resuscitation) Policy dated [DATE], indicated To ensure timely and appropriate initiations of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. On [DATE], at approximately 11:00 a.m. the facility provided a list of 41currently employed licensed nurses. On [DATE], the facility provided copies of the facility's licensed nurse's CPR certification cards. CPR certification cards were not available for review for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8, E9, E10, E11, E12, E13, E14, E15, and E16. During an interview on [DATE], at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that facility nursing personnel maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for 14 of 41 licensed nurses. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and observation, it was determined that the facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. (Resident R23)Findings include: Clinical record review revealed that Resident R23 had diagnoses that included dementia, anxiety, and osteoarthritis. The Minimum Data Set assessment (MDS) dated [DATE], indicated that the resident had mild cognitive impairment, and required assistance with dressing. Review of the current care plan revealed that Resident R23 had a self-care performance deficit related to dementia and that staff were to assist the resident with dressing. Observation on 8/4/2026, at 10:15 a.m., revealed Resident R23 was sitting on the bed naked in full view of anyone walking by in the hallway. The resident was being assisted with dressing by Certified Nurse Assistant (CNA) employee E1. During an interview on 8/4/26., at 10:25 a.m., CNA Employee E1 stated I forgot to pull the curtain after I brought the resident back from the bathroom. During an interview on 8/4/26, at 10:25 a.m., Executive Director Employee E2 confirmed the above findings and that the facility failed to provide care and services to maintain a resident's dignity for Resident R23. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on the review of facility policy and facility documents, observations and resident and staff interviews, it was determined that the facility failed to make certain grievance forms can be filed anonymously in one of four locations where grievance information is available. (Willow Unit). Findings include: A review of the facility policy Grievances last reviewed 3/1/26, indicated Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously. During an observation on 8/4/26 at 8:04 a.m., revealed the grievance policy/procedure was not posted at location on [NAME] Unit. Grievance forms available at grievance box location did not contain wording that a grievance form can be filed anonymously. During an interview on 8/6/26, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility grievance policy and procedure failed to provide information on the residents' right to file a grievance anonymously. 28 Pa. Code 201.29(a)Resident rights

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 resident's assigned nursing unit unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for one of fourteen residents who were documented as elopement risks (Resident R1). Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The duties and responsibilities of the Administrator include performing a variety of tasks associated with creating a fulfilling resident experience, including resident care coordination, teammate oversight, and regulatory reporting and compliance for the Skilled Nursing area of the Community. Included in the list of responsibilities were: Supervise all department heads to ensure the community is operating according to standards and in compliance with regulatory guidelines. lnvestigate complaints, document findings, and review with ED; reports to regulatory agencies, where applicable. Organize information/data to identify/explain major trends, problems and causes.Compare and combine information to identify underlying issues. Generate actions to achieve long-range goals. Ensure documentation of care and services provided is accurate and timely. Review of the facility-provided Director of Nursing (DON) job description indicated, The Director of Nursing will plan, organize, develop, and direct the overall operation of the Nursing Services department. Included in the list of responsibilities were: Facilitates the coordination of nursing services and other departments to maintain quality care for residents. Recognizes and responds to changes in residents' conditions and documents observations, interventions, and outcomes. Oversees staffing to ensure appropriate resident care and ensure the applicable state licensure and certification standards are met. Reviews, monitors, intervenes, thoroughly investigates and reports incidents, complaints, and grievances made by residents, families, visiting individuals, agencies, teammates, and other departments. Based on findings identified in this report, the facility failed to prevent and protect residents from exiting the resident's assigned nursing unit unsupervised. 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 8/6/26, at approximately 3:30 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 resident's assigned nursing unit unsupervised. This failure created an Immediate Jeopardy situation for one of fourteen 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 review of facility documents, clinical records, and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of eight residents (Resident R84).Findings include: Review of the facility, Charting and Documentation dated 3/1/26, indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the clinical record revealed Resident R84 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of hemiplegia (paralysis on one side of the body), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R84's behavior monitoring for April through July 2026 revealed:April: No wandering documented, no documentation completed for 4/12/26, evening shift.May: Exit-seeking behavior documented on 5/21/26, evening shift.June: Exit-seeking and wandering behaviors documented on 6/21/26, evening shift.July: Exit-seeking behavior documented on 7/14/26, agitation, exit-seeking, frustration, and threatening others documented on 7/20/26, evening shift. Review of a new physician's order created 4/12/26, at 3:46 p.m. indicated for Resident R84 to have a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door) placed. Review of Resident R84's progress notes failed to any progress notes created on 4/12/26. Review of a progress note dated 4/13/26, at 2:37 p.m. indicated, Had a long discussion with residents' brother regarding her wander guard. Answered all of his questions and explained that our main goal is just to keep her safe. He was satisfied with our conversation and all questions were answered. Review of a physician progress note dated 4/13/26, at 4:27 p.m. indicated, Attending Attestation Note. [Resident R84] was seen today for fu (follow-up), mandatory 60 days recap visit. I did oversee /supervise fellow and later interviewed and examined [Resident R84] personally. Dw RN (Discussed with registered nurse) staff who updated me on her current course. I discussed the case with the fellow and agree with findings in her note and agree with her assessment and plan that we discussed and developed together. Review of a physician progress note dated 4/13/26, at 4:41 p.m. indicated, Yesterday (4/12/26) she was found wandering around outside on the curb and now has a wander guard on. Review of a progress noted dated 6/15/26, at 12:12 p.m. repeated the above statement that Resident R84 was found outside. During an interview on 8/4/26, at approximately 2:30 p.m. the Nursing Home Administrator stated that the progress note from 4/13/26, at 4:41 p.m. was written by a medical fellow, and was inaccurate, and Resident R84 was not found outside on the curb. Review of a progress note dated 8/4/26, at 4:15 p.m. indicated, IDT F/U (interdisciplinary team follow-up) from 4/12/26, 1641 (4:41 p.m.), physician progress note stating, yesterday found wandering around outside on the curb. Investigation into this statement was completed in April, which included obtaining statements from staff members. The staff member who reportedly stated the resident was outside near curb was able to clearly state the resident was near the Hickory unit doorway and not outside of the facility. Documentation in the physician progress note was entered mistakenly, based on word of mouth staffing statements, and was completed by a fellow; a learning practitioner, training to become a physician. Fellow interviewed and stated she believes a staff member mentioned this information to her, but she was unable to specifically recall who, as this occurred several months ago. Investigation concluded, identifying no elopement occurred. Reviewed incorrect documentation with provider. Provider verbalized he is going to immediately correct the documentation R/T (related to) issue and reported he will complete education with involved staff member. During an interview on 8/6/26, at approximately 3:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that medical records on each resident are complete and accurately documented for one of eight residents. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization (Resident R9, R58, R62, and R98). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed. Review of facility Bed Hold and Returns dated 3/1/26, indicated, All residents/representatives are provided written information regarding the facility bed-hold policies which address holding or reserving a resident's bed during periods of absence, hospitalization and/or therapeutic leave. Residents are provided written information about these policies at least twice:Well in advance of any transfer (e.g., in the admission packet)At the time of transfer. If the transfer was an emergency, within 24 hours. Review of the clinical record indicated Resident R9 was readmitted to the facility on [DATE]. Review of Resident R9's minimum data set (MDS, periodic assessment of resident care needs) dated 5/11/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cirrhosis (chronic damage leading to scarring and failure) of the liver and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns indicated Resident R9 had severe cognitive impairment. Review of a progress note dated 5/23/26, at 2:00 p.m. indicated that Resident R9 was transferred to the hospital due to abdominal pain. Further review of Resident R9's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of the clinical record indicated Resident R58 was readmitted to the facility on [DATE]. Review of Resident R58's MDS dated [DATE], included diagnoses of high blood pressure, chronic kidney disease (gradual loss of kidney function), and dementia. Review of Section C: Cognitive Patterns indicated Resident R9 had severe cognitive impairment. Review of a progress note dated 4/15/26, at 2:43 p.m. indicated that Resident R58 was transferred to the hospital due to coughing up blood. Further review of Resident R58's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of the clinical record indicated Resident R62 was readmitted to the facility on [DATE]. Review of Resident R62's MDS dated [DATE], included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat)atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), diabetes, and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R9 had severe cognitive impairment. Review of a progress note dated 7/1/26, at 3:41 p.m. indicated that Resident R62 was transferred to the hospital due to increased altered mental status and elevated blood pressure. Further review of Resident R62's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. Review of the clinical record indicated Resident R98 was readmitted to the facility on [DATE]. Review of Resident R98's MDS dated [DATE], included diagnoses of anxiety, depression, and dementia. Review of Section C: Cognitive Patterns indicated Resident R9 had severe cognitive impairment. Review of a progress note dated 7/1/26, at 3:41 p.m. indicated that Resident R98 was transferred and admitted to the hospital due to a urinary tract infection and pneumonia. Further review of Resident R98's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident or Resident Representative upon transfer. During an interview on 8/6/26, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that residents with Medicaid as a payer source were not provided bed-hold information upon transfer to the hospital. During an interview on 6/8/26, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of facility policy, observations, and staff interview, it was determined that the facility failed to make sure that medications were properly stored and/or disposed of in one of four medication rooms (Hickory Unit).Findings include: Review of the facility policy Storage of Medications dated 3/26/25, indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. During an observation and interview with the Director of Nursing and Nurse Manager RN Employee E1of the Hickory nursing unit on 1/21/26, at approximately 9:30 a.m. the following was observed in an unsecured drawer with in and unsecured office: -(1) Diclofenac gel for Resident R1, current resident, medication was discontinued on 4/10/25.-(27) Vitamin D3 tablets for Resident R200, discharged on 7/17/25.-(15) Vitamin D3 tablets for Resident R200, discharged on 7/17/25.-(21) Vitamin C tablets for Resident R200, discharged on 7/17/25.-(25) Vitamin D3 tablets for Resident R201, discharged on 7/25/25.-(1) Vitamin D2 tablet for Resident R202, discharged on 8/4/25.-(28) Pantoprazole tablets for Resident R202, discharged on 8/4/25.-(1) Hydrocortisone cream tube for Resident R203, discharged on 8/19/25.-(22) Omeprazole tablets for Resident R204, discharged on 8/22/25.-(30) Senna tablets for Resident R205, discharged on 9/22/25.-(7) Cepacol lozenges for Resident R206, discharged on 10/14/25.-(27) Tylenol tablets for Resident R207, discharged on 10/18/25.-(22) Vitamin D3 tablets for Resident R1, current resident, medication was discontinued on 11/25/25.-(1) Silvadene tube.-(1) Aquaphor tube.-(1) Medihoney tube.-(10) Lidocaine 5% patches.-(4) Lidocaine 4% patches. During an interview on 1/21/25, at approximate 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make sure that medications were properly stored and/or disposed. 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy services.28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations and staff interview, it determined the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. Findings include: Review of a facility policy Food Preparation and Service dated 3/26/25, indicated that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. Bare hand contact with food is prohibited. Gloves are to be worn when handling food directly and changed between tasks. During an observation on 6/23/25, from 10:48 a.m., through 11:28 a.m., the following was identified: Dietary Aide Employee E13 had three racks/trays of bowls leaning over food items on the steam table while food was being plated. Dietary Aide Employee E14 had gloves on touching the outer surfaces of bags of buns, removing a bun, plating it then with same gloved hands picking up lettuce and tomatoes and placing it on the burger, was also turning around opening packages of buns and cheese then returning and placing them on burgers with no glove change and/or hand washing between tasks. During an interview on 6/23/25, at 11:28 a.m., Interim Dietary Manager Employee E15 confirmed that the facility failed to maintain sanitary conditions to prevent the potential for cross contamination during lunch time tray line. 28 Pa. Code: 211.6 (c)(f) Dietary services.

Based on review of the facility policy, observations, clinical record review, review of facility document and staff interviews, it was determined that the facility failed to provide an environment free from potential accident hazards due to uncovered electrical plugs, accessible potential hazardous materials, foods and sharps that had potential to cause injury and actual removal of a elopement bracelet for one resident (Resident R225) on one of four nursing units( Memory Care Unit). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 3/26/25, with a previous review date of 3/1/24, indicated that all accidents or incidents involving residents occuring on the premises shall be investigated and reported. the investigation shall be initiated promptly and documented on the Report of Incident/Accident Form. During an observation of the Secured Memory Care Nursing Unit on 6/23/25, from 11:26 a.m., through 11:48 a.m., the following was identified: Three plug outlets in the right wing hallway had no covers with exposed wiring. An unsecured room identified as the Activity Room had shelving/drawer units with five unsecured drawers four of which had packages of wipes, two pretzels, clips, hand sanitizer packs and sugar packs, paper files which the sharp file holder metal bar fell off, within the drawer also was a roll of tape, paperclips and binding clips and other unidentifiable items. The cabinet contained two electrical extension cords and a coiled wire for an unidentified item. During the observation, Resident R97 was in the hall attempting to wheel his wheelchair throughout the hallway. During an interview on 6/23/25, at 11:33 a.m., Registered Nurse Employee E11 confirmed that the facility failed to provide an environment free from potential accident hazards. During a clinical record review Resident R225 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, insomnia and kidney disease. Resident R225 was identified as requiring placement on the memory care secured unit. Review of a physician order dated 6/14/25, indicated placement of a wanderguard bracelet and placement checked each shift for security. Review of a progress noted dated 6/18/25, at 1:34 p.m., indicated Resident R225 had cut off the wanderguard bracelet with nail clippers and the nurse had taken the clippers and replaced the bracelet. During an interview on 6/24/25, at 2:50 p.m., the Nursing Home Administrator(NHA) and Director of Nursing stated that the incident was put the information on a Incident Statement Form by the nurse however, the incident investigation did not take place. The NHA confirmed that the facility failed to provide an environment free from potential accidents hazards. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to report an allegation of neglect to the State Agency for one of four residents (Resident R325). Finding include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 3/26/25, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 3/26/25, indicated if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman, resident's representative, adult protective services, law enforcement officials, resident's attending physician and the facility medical director. Review of Resident R325's admission record indicated the resident was admitted on [DATE] , with diagnoses that included high blood pressure, diabetes (blood sugar too high or too low), muscle weakness and cognitive communication deficit (difficulties in communication due to impairments in cognitive processes like attention, memory, and problem-solving, rather than primary speech or language disorders). Review of Resident R325's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/13/25, indicated the diagnoses remained current. Review of Resident R325's progress note dated 6/15/25. indicated that Registered Nurse (RN) Employee E8 came to RN Employee E9 stating that the resident wanted to speak with the supervisor on duty. Upon entering the resident's room, resident was sitting in the wheelchair watching TV. When asked, how may I help you, resident stated that the certified nursing aide (CNA) Employee E10 was abusing an old lady. This RN Employee E8 asked resident to explain what had happened, the resident explained that the CNA Employee E10 told her to use the wheelchair to go to the bathroom instead of walking, which the resident didn't want to do, then the CNA Employee E10 pushed my chair hard and on purpose. Resident stated she wanted something done about this immediately and in writing. Resident R325 requested for this CNA Employee E10 not to be assigned to her or come in her room again. Director of Nursing (DON) and Nursing Home Administrator (NHA) were made aware of situation. RN Employee E8 was made aware that going forward there will have to be two aides going into her room to provide care. Review of documentation provided to the State Agency from 6/1/25, to 6/22/25, did not include Resident R325's incident of abuse. During an interview on 6/24/25, at 2:50 p.m. the Director of Nursing confirmed the facility failed to report an allegation of abuse to the State Agency for one of four residents (Resident R325). 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 clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for one of five residents (Resident R71). Findings include: Review of facility policy Resident Assessments reviewed 4/1/24 and 3/26/25, indicated a comprehensive assessment of every resident ' s needs is made at intervals designated by OBRA and PPS requirements. A comprehensive assessment includes completion of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs), completion of the care area assessment (CAA) process, and development of the comprehensive care plan. Review of the clinical record indicated that Resident R71 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and repeated falls. Review of a physician order dated 7/12/24, indicated Resident R71 was admitted to hospice services. Review of the MDS dated [DATE], indicated the diagnoses remain current. Further review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, O0110 K1 Hospice Care failed to indicate Resident R71 was receiving hospice care at the facility. Review of the MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, O0110 K1 Hospice Care indicated Resident R71 was not receiving hospice care at the facility. During an interview on 2/14/25, at 12:05 p.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E7 confirmed the facility failed to complete an accurate assessment for Resident R58.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of three residents (Resident R57). Findings include: Review of facility's policy Care Plans, Comprehensive Person-Centered dated 3/26/25, indicated the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record face sheet revealed that Resident R57 was admitted to the facility on [DATE], with a diagnosis of dementia. Review of the comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/14/24, indicated Resident R57 had a diagnosis of dementia. Review of Resident R57's care plan dated 5/22/25, failed to reveal a care plan with goals and interventions for dementia. During an interview on 6/26/25, at 12:30 p.m. the Director of Nursing confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Resident R57. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for three of nine residents reviewed (Residents R58, R64, and R111). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Obtaining a Fingerstick Glucose Level reviewed 4/1/24 and 3/26/25, indicated the documentation after the procedure should contain all assessment data obtained during the procedure. Document the blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages), etc. Review of the facility policy Change in Resident ' s Condition or Status reviewed 4/1/24 and 3/26/25, indicated the nurse will notify the resident ' s attending physician or physician on call when there has been a need to alter the resident ' s medical treatment significantly. A significant change of condition is a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. Review of the care plan Charting and Documentation reviewed 4/1/24 and 3/26/25, indicated the following information is to be documented in the resident medical record: (a) Objective observations; and (d) Change ' s in resident ' s condition. Documentation of procedures and treatments will include care-specific details, including the assessment data and/or unusual findings obtained by the procedure and notification of family, physician, or other staff, if indicated. Review of the facility policy Care Plans, Comprehensive Person-Centered reviewed 4/1/24 and 3/26/25, states a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. When possible, interventions address underlying source(s) of the problem area(s), not just symptoms or triggers. The facility was unable to provide a policy regarding care of the diabetic resident. Review of the clinical record revealed Resident R58 was admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), diabetes, and aphasia (an impairment in a person's ability to comprehend or formulate language because of dysfunction in specific brain regions). Review of Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/28/25, indicated the diagnoses remain current. Review of Resident R58 physician ' s order revealed the following orders: - On 12/31/24, Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) insulin per sliding scale with meals; For blood sugar 331 and greater, give six units then call MD (doctor). Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 5/6/25, at 5:58 p.m. the CBG was noted to be 413. Recheck CBG at 5:59 p.m. was noted to be 413. - On 5/9/25, at 5:50 p.m. the CBG was noted to be 393. Recheck CBG at 6:28 p.m. was noted to be 393. - On 5/12/25, at 7:58 p.m. the CBG was noted to be 397. Recheck CBC at 7:59 p.m. was noted to be 397. - On 5/18/25, at 6:08 p.m. the CBG was noted to be 359. Recheck CBG at 6:14 p.m. was noted to be 359. - On 5/26/25, at 5:52 p.m. the CBG was noted to be 354. Recheck CBG at 5:52 p.m. was noted to be 354. - On 5/27/25, at 8:47 a.m. the CBG was noted to be 350. - On 6/1/25, at 6:52 p.m. the CBG was noted to be 438. Recheck CBG at 6:54 p.m. was noted to be 438. - On 6/6/25, at 5:37 p.m. the CBG was noted to be 438. Recheck CBG at 6:54 p.m. was noted to be 438. - On 6/17/25, at 7:36 a.m. the CBG was noted to be 368. - On 6/23/25, at 6:28 p.m. the CBG was noted to be 349. Recheck CBG at 6:31 p.m. was noted to be 349 Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. Review of a clinical record indicated Resident R64 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and lymphedema (accumulation of protein-rich fluid that's usually drained through the body's lymphatic system, most commonly affects the arms and legs). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R64 physician ' s orders revealed the following orders: - On 7/16/24, Humalog insulin per sliding scale. For blood sugar 331 and greater, cover with 7 units and call MD for further orders. Review of Resident 64's eMAR revealed that the resident's CBG's were as follows: - On 3/26/25, at 11:43 a.m. the CBG was noted to be 334. - On 4/16/25, at 12:41 p.m. the CBG was noted to be 350. - On 5/28/25, at 7:57 a.m. the CBG was noted to be 374. - On 5/29/25, at 8:33 a.m. the CBG was noted to be 375. - On 6/1/25, at 6:58 p.m. the CBG was noted to be 367. Review of the care plan dated 6/17/24, indicated the following interventions: - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. - Monitor/document/report PRN (as needed) any psychosocial problem areas - Monitor/document/report PRN compliance with diet and document any problems. - Monitor/document/report PRN any sign/symptoms of infection to any open area. Review of the care plan revised on 6/5/25, failed to reveal a person-centered care plan with interventions specific to Resident R64. Review of Resident R64's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R111 was admitted to the facility on [DATE], with diagnoses that included diabetes, aphasia (an impairment in a person's ability to comprehend or formulate language because of dysfunction in specific brain regions), and dysphagia (difficulty swallowing). Review of Resident R111 physician ' s order revealed the following orders: - On 4/3/25 through 5/8/25, Humalog insulin per sliding scale. If blood sugar is 341 and greater, give six units and call MD. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 4/4/25, at 12:37 p.m. the CBG was noted to be 408. Recheck CBG at 12:49 p.m. was noted to be 408. - On 5/3/25, at 5:43 p.m. the CBG was noted to be 434. Recheck CBG at 5:43 p.m. was noted to be 434. Review of the care plan dated 1/30/24, indicated the following interventions: - Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. - Monitor/document/report PRN (as needed) any psychosocial problem areas - Monitor/document/report PRN compliance with diet and document any problems. - Monitor/document/report PRN any sign/symptoms of infection to any open area. Review of the care plan revised on 4/4/25, failed to reveal a person-centered care plan with interventions specific to Resident R111. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed date. During an interview on 6/25/25, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E1 stated it depends on the resident ' s order for when to notify the doctor. If the blood sugar was below 70, they would provide juice or snack depending on their signs and symptoms. If the blood sugar was greater that 300, they would give the resident water, the ordered insulin, and assess the resident to see if signs and symptoms were present, they would notify the doctor. They stated they would document in the eMAR and progress notes. During an interview on 6/25/25, at 10:05 a.m. Registered Nurse (RN) Employee E2 stated for blood sugar less than 70, they would call the doctor and give a snack or juice. If the blood sugar was over 330, they would give the ordered insulin, call the doctor, check the resident ' s vital signs. They would document in the eMAR and a progress note. During an interview on 6/25/25, at 10:08 a.m. RN Employee E3 stated if the blood sugar was less that 70 or over 400, they would notify the doctor. If the blood sugar was less than 70, they would provide a snack or juice and recheck the blood sugar in 15 minutes. If the blood sugar was over 400, they would check the resident ' s vital signs, assess the resident for any signs and/or symptoms, and call the doctor. They would document in the eMAR and progress notes. During an interview on 6/25/25, at 10:10 a.m. LPN Employee E4 stated if the resident ' s blood sugar was less than 60, they would provide a snack or juice and call the doctor if the blood sugar did not During an interview on 6/25/25, at 10:15 a.m. RN Employee E5 stated they would check the doctor ' s orders to check when to notify the doctor. If the blood sugar was less than 70, they would assess the resident for signs and symptoms and provide a snack or juice. For blood sugar over 140, they would monitor the resident. They would document in the eMAR and progress notes. During an interview on 6/26/25, at 10:00 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R58, R64, and R111. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on review of facility policies, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of an indwelling urinary catheter as required for two of four residents (Resident R51 and R331). Findings include: Review of the facility policy Indwelling (Foley) Catheter Removal dated 3/26/25, indicated documentation in the medical record should consist of the following: date and time the procedure was performed, name and title of the individual who performed the procedure, all assessment data (urine amount, color, clarity, etc.) obtained during procedure, time and amount of first void after catheter removal, how the resident tolerated the procedure, if resident refused the procedure, reason and interventions taken, signature and title of person recording data. Review of the facility policy Output, Measuring and Recording dated 3/26/25, indicated this procedure is to accurately determine the amount of urine that a resident excretes in a 24 hour period. Review of the facility policy Urinary Continence and Incontinence-Assessment and Management dated 3/26/25, indicated the staff and practitioner will appropriately screen for, and manage individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatments to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Indwelling urinary catheters will be used sparingly, for appropriate indications only. Identification and management of urinary tract infections will follow relevant clinical guidelines. Antibiotics will be used appropriately. Review of Resident R51's medical record indicated admission to the facility on 6/2/25, with diagnoses that include history of falling, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), urinary tract infection, and obstructive and reflux uropathy (two distinct conditions of the urinary tract where one causes a blockage allowing for normal flow and the other causing urine in the bladder to the back up into the kidneys). Review of Resident R51's Minimum Data Set (MDS-a periodic assessment of care needs) dated 6/9/25, indicates the diagnoses are current. Review of Resident R331's medical record indicated admission to the facility on 6/9/25, with diagnoses that include history of falling, obstructive and reflux uropathy, urinary tract infection, and cognitive communication deficit (difficulties in communication due to impairments in cognitive processes like attention, memory, and problem-solving, rather than primary speech or language disorders). Review of Resident R331's MDS dated [DATE], indicates the diagnoses are current. Review of Resident R331's clinical record indicated the foley catheter was to be discontinued on 6/23/25, review of the record revealed that bladder scans were ordered every shift for 72 hours with resident to receive a straight catheter (temporary catheter used once to empty the bladder and then removed immediately) for residual of greater than 450 milliliters. Review of Resident R331's clinical record indicated the resident was not offered attempts to toilet more frequently per policy for post removal of catheter, incontinent without measurement (resident also had order to push fluid of 250 milliliters every 2 hours while awake), and no documentation of staff's assistance in resident's continence/incontinence per policy. Review of Resident R331's clinical record indicated resident had to have foley replaced on 6/24/25, due to inability to empty bladder completely. Observation on 6/23/25 at approximately 1:30 p.m. Resident R51 was noted up in wheelchair with foley bag hanging on side of wheelchair with no dignity bag for privacy. Resident R331 was noted to be in bed with foley bag hanging on side of bed with no dignity bag for privacy. Observation on 6/25/25 at 12:40 p.m., noted Resident R51 sitting in wheelchair with foley hanging on walker with dignity bag next to it. Resident R331 was noted in bed with foley hanging on side of bed with no dignity bag in place. Interview with Nurse Aide (NA) Employee E12 on 6/25/25 at 12:40 p.m. confirmed the catheter drainage bag facing entrance door on the walker and bed frame were not covered with a dignity bag for privacy as required. Interview with Director of Nursing (DON) on 6/26/25, at 10:15 a.m. confirmed the facility failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R51 and R331) with an indwelling urinary catheter. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(a)(c)(d)(1)(2)(5) Nursing services.

Based upon review of facility policies, medication instructions, employee file, clinical records, facility investigation, resident and staff interview, it was determined that the facility failed to ensure that residents were free from significant medication errors, which resulted in actual harm with the resident experiencing a [CONDITION(S)] and an unresponsive episode requiring hospitalization for one of nine sampled residents (Resident R1). Findings include: The facility Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Admission policy dated 8/8/12, and last reviewed on the 3/23/22, indicated that the referring facility provides all necessary documentation to ensure a safe hand-off for a new admission. Prior to admission, the facility will receive physician's discharge orders from acute care facility, recent history and physical, discharge summary, and medication administration record. Review of Medication insert instructions titled [MEDICATION(S)] provided by the facility dated 5/2019, indicated the medication side effects include dizziness, confusion, shortness of breath, very slow heart beats, and diarrhea. Many drugs can affect [MEDICATION(S)] including other heart medications. Review of Registered Nurse (RN) Supervisor Employee E3's personnel file indicated employee was hired on 10/28/19. RN Supervisor Employee E3's job description indicated to ensure all orders are correctly transcribed and to complete admissions and discharges. Review of Resident R1's admission record indicated resident was originally admitted on [DATE], readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's admission MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 3/2/22, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R1's care plan dated 3/3/22, indicated that resident was at risk for elevated blood pressure, blood pressure will remain within acceptable limits and will have no complaints of headache or dizziness for 90 days, and to administer antihypertensive medications as ordered. Review of Resident R1's nurses notes dated 4/18/22, indicated resident was observed having shortness of breath after leaving the bathroom. Resident R1's blood pressure was 126/63, pulse was 37-40, and radial pulse 44. Staff were ordered to send him to the hospital for cardiac evaluation. Review of Resident R1's hospital discharge summary dated 4/22/22, indicated resident was admitted to the hospital on 4/18/22 due to [CONDITION(S)] (slow heart rate). The discharge summary included to begin and end the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Start [MEDICATION(S)] 200mg one time a day Start [MEDICATION(S)] 6.25mg two times a day Start [MEDICATION(S)] 80 mg two times a day Stop [MEDICATION(S)] 50mg two times a day Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's nurse notes dated 4/22/22, indicated resident was readmitted to the facility with new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications reviewed and resident was resting comfortably with wound vacuum attached. Review of Resident R1's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 200mg once on 4/23/22 and once on 4/24/22 [MEDICATION(S)] 6.25mg twice on 4/23/22 and once on 4/24/22 [MEDICATION(S)] 80 mg twice on 4/23/22 and once on 4/24/22 [MEDICATION(S)] 50mg twice on 4/23/22 and once on 4/24/22 Review of Resident R1's nurse note dated 4/24/22, indicated that resident had loose bowel movement, ten minutes later family witnessed [CONDITION(S)] activity and loss of consciousness. Resident R1 appeared grayish in color. Resident R1 then had nausea and vomiting and appeared lethargic upon assessment. Glucose level read 81. Order to send to the emergency room . The facility investigation dated 4/24/22, found the 4/22/22 order for [MEDICATION(S)] still active. The order was not discontinued until 4/24/22. The facility re-education documentation dated 4/24/22, indicated Registered Nurse (RN) Supervisor Employee E3 was re-educated on discontinuing medication orders when a resident is out to the hospital for 24 hours. Review of Resident R1's emergency department note dated 4/24/22, indicated that resident's medication list from the facility listed [MEDICATION(S)] 50mg, in addition to [MEDICATION(S)] 80 mg twice daily, [MEDICATION(S)] 200mg daily, [MEDICATION(S)] 6.25mg twice a day. Resident R1 explained to emergency room personnel that on the afternoon of 4/24/22, had diarrhea and abdominal cramping, then developed nausea and vomiting, followed by [CONDITION(S)] (feeling faint) and seizures. Resident stated that consciousness lost and has no [CONDITION(S)] history. Review of facility submitted documentation dated 4/24/22, indicated that Resident R1 experienced nausea, vomiting, and a loss of consciousness. Resident's blood pressure was 80/50 and heart rate in the low 70 range. Resident R1 was sent to the emergency room . Upon investigation, it was discovered that resident was still receiving blood pressure medications in error. Registered Nurse (RN) Supervisor Employee E3 submitted a statement on 4/25/22, that indicated she must have overlooked the discharge medication order for the [MEDICATION(S)] and failed to discharge the order. Review of Resident R1's Certified Registered Nurse Practitioner (CRNP) note dated 5/2/22, indicated that Resident R1 was hospitalized following an episode where resident lost consciousness, slumped over in a chair, within 20 seconds of shaking. Prior to this episode, resident did have diarrhea, had a vomiting episode in the evening. Resident R1 had been recently hospitalized and had some changes made to heart medications. New life vests (vests that stimulates the heart with electronic shock) is on just in case his heart stops. During an interview on 5/16/22, at 10:51 a.m. Registered Nurse (RN) Supervisor Employee E1 stated that Resident R1 was out to the hospital prior to this incident with low blood pressure and [CONDITION(S)]. On 4/24/22, Resident R1's every other heart beat was irregular and she was concerned there had been a medication error and was having [CONDITION(S)] activity. Resident R1 had loss of consciousness. On 4/24/22, was previously outside with wife. Then came back in lethargic, eyes rolling in back of head and vomiting. Resident R1 never passed out before. Resident was in and out of irregular heart beating and was sent to hospital. During an interview on 5/16/22, at 11:19 a.m. the Director of Nursing (DON) stated that no other residents had issues with medications being placed in the system incorrectly, there was not an audit done on medication entry, and re-education was provided to Registered Nurse (RN) Supervisor Employee E3. During an interview on 5/16/22, at 11:48 a.m. Resident R1 stated that he was sent from the hospital sent with new blood pressure medications. During this incident on 4/24/22, he was getting new medications with old ones and then went out to the hospital again. External heart vest is in place as a precaution. During an interview on 5/16/22, at 11:59 a.m. Certified Registered Nurse Practitioner (CRNP) Employee E2 stated that taking [MEDICATION(S)] and [MEDICATION(S)] together may cause blood pressure to drop. She stated that taking these medications together may have placed Resident R1 in mortal danger and could technically be a life threatening event. She stated that when Resident R1 came back from the hospital on 4/18/22, [MEDICATION(S)] stayed on the orders and it should have been discontinued. When residents are discharged to the hospital, nurses are to discharge all medications. Resident R1 now has a heart vest as a precaution. During an interview on 5/16/22, at 1:02 p.m. Registered Nurse (RN) Supervisor Employee E3 stated that she did not discontinue the [MEDICATION(S)]. During an interview on 5/18/22, at 12:38 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that Resident R1 was free from significant medication errors, which resulted in actual harm with the resident experiencing a [CONDITION(S)] and an unresponsive episode requiring hospitalization . 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1) Nursing Services. 28 Pa. code 211.12(d)(5) Nursing Services. 28 Pa. Code 211.9(a)(1) Pharmacy services.

Based on review of facility policy, resident clinical records, observations, hospital records, email correspondence, and staff interviews, it was determined the facility failed to provide an environment free from potential or actual accidents and hazards, failed to investigate and implement safety measures to prevent potential accidental medication use by a cognitively impaired resident (Resident R60). The facility failed to provide sufficient staff supervision of residents and effective safety measures, including use of a Wanderguard system (an electronic alarm system designed to prevent memory impaired individuals from elopement), and failed to prevent the elopement of 3 of 14 residents (Resident R97, R206 and R52) with Wanderguard bracelets, resulting in physical harm to 1 resident (Resident R97). This failure placed residents at high risk for elopement and injury and resulted in Immediate Jeopardy. Findings include: Review of the facility policy titled 2.0 Accidents and Incidents last reviewed May 2021, states All accidents and incidents involving residents will be reported and investigated for root cause, process improvement and necessary corrective actions to promote quality assurance. The purpose is to promote a safe environment for all residents, report occurrences appropriately and review and analyze for preventative measures. Review of the facility policy titled 2.10 Elopement Prevention last reviewed 2/3/21, states UPMC Senior Communities Skilled Nursing Facilities properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement. The admitting nurse will perform an initial evaluation to identify behaviors and collect history. A care plan will be developed that reflects the potential for elopement and preventative measures, if relevant, including but not limited to 1.1 Interdisciplinary care team planning, 1.2 Activities diversion, 1.3 Staff monitoring plan a staff monitoring plan, 1.4 Family involvement and suggestions for prevention, 1.5 Application of personal signaling device (Wanderguard), if indicated, 1.6 Update photos for identification. Additionally, upon admission, readmission, quarterly and as necessary, nurses will complete a Wandering Risk Evaluation. Review of the facility policy titled 11.10 Wanderguard/Watchmate Testing and Maintenance last reviewed on 2/3/21, states UPMC Senior Communities provides a safe environment for all residents. The facility will properly test the Wanderguard or Watchmate equipment used to prevent resident elopement. Process: Follow the manufacturer's instructions for testing and maintenance; Test bracelet prior to being applied to resident; Test bracelet monthly; Maintain log of testing. Review of the facility policy Accidents and Incidents dated 2/3/21, indicated all incidents and accidents involving residents will be reported and investigated for root cause, process improvement, and necessary corrective actions to promote quality assurance. The resident is assessed by an RN and the nurse completes an incident report, the MD and family is notified, and the care plan is updated noting follow up needed, and measures to prevent future incidents. Review of Resident R97's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interfere with everyday activities), cognitive communication deficit (difficulty in thinking and language use), major depressive disorder (depressed mood and long term loss of pleasure or interest in life), muscle weakness, other lack of coordination, [CONDITION(S)] ([CONDITION(S)]-[MEDICATION(S)] of airways causing difficulty or discomfort in breathing), diabetes mellitus (a chronic condition which affects how your body turns food into energy), chronic kidney disease (a disease that prevents kidneys from filtering waste and excess fluid from the blood), [CONDITION(S)] (loss of tissue causing bones to become brittle and fragile), and pacemaker (an artificial device to stimulate the heart muscle). Review of Resident R97's current physician orders dated August 2021, included medications of [MEDICATION(S)] (antidepressant for major depressive disorder), [MEDICATION(S)] (antidepressant for major depressive disorder), [MEDICATION(S)] (for bone loss/[CONDITION(S)]), [MEDICATION(S)] (pain mediation), [MEDICATION(S)] (to prevent and treat blood clots), Med Pass (a dietary supplement), and a Wanderguard (an electronic alarm system designed to prevent memory impaired individuals from elopement). Review of Resident R97's Quarterly Review MDS (Minimum Data Set - a periodic assessment of resident care needs) dated 6/22/21, indicated Section C: Cognitive Patterns recorded a BIMS score (Brief Interview for Mental Status - a mandatory interviewing tool to screen cognition to determine if interventions are needed) of 02 out of 15 indicating severe cognitive impairment; Section E Behaviors, subsection E900 Wandering, coded 0 indicating the behavior was not exhibited; Section G Functional Status, subsection G0110 Activities of Daily Living Assistance, C. - Walk in Room coded 8 for the activity did not occur, D. - Walk in Corridor coded 8 for activity did not occur, E. - Locomotion On Unit coded 3 for extensive assistance and 2 for one person physical assist, F. - Locomotion Off Unit coded 3 for extensive assistance and 2 for one person physical assist; Section P Restraints and Alarms, subsection P0200 Alarms, E. Wander/elopement alarm coded 2 for used daily. Resident R97's care plan dated 3/16/21, identified elopement risk as a problem with interventions to include check placement of Wanderguard each shift, assess elopement risk each quarter, gentle physical redirection, look for immediate cause of wandering and respond to physical and emotional needs, encourage resident to express needs and feelings, assess for signs of illness causing confusion, provide resident with feelings of control and offer choices, family to provide personal and familiar items from home, staff are not to argue, confront, or attempt to reason and smile and listen to resident, anticipate elimination needs, provide structured and/or diversionary activities, be aware of resident's location throughout the shift, check security battery for functioning, and note location of security bracelet. Resident R97's care plan dated 3/16/21, identified fall risk as a problem with interventions to include proper footwear, areas free of obstructions, reminders to use ambulation and transfer assist devices, and restorative nursing programs. Review of Resident R97's progress admission note dated 1/10/20, indicated prior residence was a personal care home on the facility campus. Review of an email from the Personal Care Home Administrator dated 8/12/21, indicated Resident R97 was discharged from personal care due to general decline and the personal care home could no longer safely meet the resident's needs. Review of Elopement Risk Assessments for Resident R97 indicated the following: 12/30/19 (admission)- Resident is not ambulatory or self-mobile in a wheelchair. 1/23/20 - Resident is ambulatory or self-mobile in a wheelchair, is cognitively impaired with poor decision-making skills, is opening doors to the outside and/or elopement, is making statements that they are leaving or seeking to find someone/thing, displays behaviors, body language, etc. indicating elopement may be forthcoming. Recommendation included Wanderguard for safety. 3/31/20 - Resident is ambulatory or self-mobile in a wheelchair, resident is alert but non-compliant with facility protocols regarding leaving the unit, has a history of wandering, is opening doors to the outside and/or elopement. Recommendations included a Secured Unit and Wanderguard for safety. 6/1/20 - Resident is ambulatory or self-mobile in a wheelchair, is cognitively impaired with poor decision-making skills, is alert but non-compliant with facility protocols regarding leaving the unit, has a history of wandering, is opening doors to the outside and/or elopement, is making statements that they are leaving or seeking to find someone/thing. Staff are aware of wander risk. Recommendation include Wanderguard for safety. 6/28/20 - Resident is ambulatory or self-mobile in a wheelchair, is cognitively impaired with poor decision-making skills, is alert but non-compliant with facility protocols regarding leaving the unit, has a history of wandering, is opening doors to the outside and/or elopement. Recommendations include Secured Unit and Wanderguard for safety. 10/4/20 - Resident is ambulatory or self-mobile in a wheelchair, is alert but non-compliant with facility protocols regarding leaving the unit, has a history of wandering, is making statements that they are leaving or seeking to find someone/thing. Recommendations include Secured Unit and Wanderguard for safety. 12/22/20 - Resident is not ambulatory or self-mobile in a wheelchair. Recommendation include Secured Unit. 3/22/21 - Resident has attempted to leave a residence or other place, resident is cognitively impaired with poor decision-making skills, resident has a history of elopement, resident has verbalized intent to leave facility. Intervention include Elopement Deterrent Device Implemented. Review of Resident R97's face sheet indicated the resident's original room location was on the Evergreen Unit (unsecured unit). Review of Resident R97's progress note dated 4/20/21, documented the resident was moved to the Hickory Unit (unsecured unit). Review of Resident R97's progress note dated 4/22/21, documented no wanderguard on resident not needed. Review of Resident R97's Treatment Administration Record for August 2021, documented Wanderguard placement checks were ordered 3/2/21, with no assigned administration times, and function checks were ordered on 3/2/21, with no assigned administration times and discontinued on 4/22/21. Review of Resident R97's progress note dated 5/17/21, indicated the resident was transferred from the Hickory Unit to the Evergreen Unit ( unsecured unit). Review of resident R97's progress note dated 5/20/21, documented the resident propelled self to back elevator attempting to leave. Wanderguard placed to right wrist. Review of Resident R97's Treatment Administration Record for August 2021, documented Wanderguard placement checks for each shift was ordered 7/19/21, and Wanderguard daily function testing was ordered 7/19/21. Review of Resident R97's progress note dated 7/17/21, at 6:42 p.m. indicated Around 6:00 p.m. Security alerted nurse station that resident was found lying on the ground by a visitor across the street in front of the Personal Care Facility. Staff of the Personal Care Facility states Resident R97 got out of building 5. Resident was witnessed by staff that [resident] hit a pothole and fell on the ground. Resident was wearing 2 wander guards, 1 on [resident's] R (right) foot and 1 attached to [resident's] chair. Wander guards functioning. Resident alert with confusion, [resident] had skin tear to [resident's] L (left) forehead and L (left) hand was bleeding. Ambulance was called and brought [resident] to hospital for further evaluation. Family and physician notified of incident. Review of Resident R97's progress note dated 7/17/21, at 7:36 p.m. indicated the resident acquired a head injury-bleeding skin tear to left forehead and left hand resulting from fall. Resident alert but shows altered mental state. Incident reported to daughter and physician. Review of documentation submitted by the facility on 7/17/21, at 5:30 p.m. indicated the resident eloped from the facility in an attempt to get back to [NAME] personal care home, the resident's prior residence.Staff were immediately interviewed and educated about Wanderguard system, and the importance of not clearing a Wanderguard without visualization of the resident. Wanderguard system checked to ensure proper function, all residents with Wanderguard checked to ensure proper placement and function of Wanderguard. Review of an email dated 7/19/21, at 5:43 a.m. from Security Employee E15 of video review of the elopement states I reviewed the camera, from what I can tell from the camera's, I am thinking the resident used the back elevator and took it down to level 1 and then exited through the doors in the breezeway out to the courtyard then a visitor wheeled [resident] over to the 5-1 entrance, [resident] then on [resident] own went down to the sidewalk towards the [NAME] and then you could see [resident] go down road towards the 7-1 parking lot and that was it. Review of Resident R97's progress note dated 7/18/21, at 3:56 a.m. indicated called hospital and resident is admitted to MICU (Hospital Intensive care Unit). Resident obtained C3 (cervical) fracture. Review of the hospital emergency room report dated 7/17/21, documented Resident R97 had injuries of a left frontal scalp hematoma (blood filled swelling), acute facial bone fractures, acute type II [NAME] type fracture of the odontoid (upper neck fracture), nondisplaced fracture of the left lamina papyracea (roof of nose bone plate), and attenuated enhancement of the distal V2 and V3 segments of the right vertebral artery (damage to arteries that supply blood to the brain and spine). Review of information submitted by the facility on 7/17/21, at 5:30 p.m. indicated the resident eloped from the facility in an attempt to get back to [NAME] personal care home, Resident R97's prior residence. Staff were immediately interviewed and educated about Wanderguard system, and the importance of not clearing a Wanderguard without visualization of the resident. Wanderguard system checked to ensure proper function, all residents with Wanderguard checked to ensure proper placement and function of Wanderguard. Review of email dated 7/20/21, at 5:16 p.m. from the Administrator to Security Employee E16 indicated the employee was questioned if the Wanderguard was cleared or silenced for that resident prior to the incident. Response from Employee E16 indicated the employee did not recall clearing or silencing a Wanderguard alarm at that time. Review of Resident R97's progress note dated 7/21/21, at 7:10 p.m. indicated Resident readmitted to facility with Diagnosis of C2 Cervical (neck) and Nasal Bone Fracture (non-surgical) resulting from accidental fall from wheelchair. Resident had soft cervical collar in place and to be worn at all times. Has limited mobility given multiple fx acquired. Scattered abrasions and bruises noted to L forehead, arms and BLE (bi-lateral extremities). During an interview on 8/12/21, at 9:30 a.m. Nursing Assistant (NA) Employee E19 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 10:35 a.m. Evergreen Unit Secretary Employee E18 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 10:40 a.m. NA Employee E21 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 10:45 a.m. Registered Nurse (RN) Employee E30 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 11:00 a.m. NA Employee E17 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 11:16 a.m. Housekeeping Employee E23 confirmed they were not aware on how to determine if the Wanderguard system was operational and did not receive recent training on the system or resident safety if the system failed. During an interview on 8/12/21, at 12:30 p.m. the Administrator confirmed the facility failed to provide sufficient staff supervision and effective safety measures, including use of a Wanderguard system, to prevent elopement of Resident R97, resulting in physical harm to the resident. Review of Resident R206's closed clinical record conducted on 8/18/21, indicated the resident was admitted to the facility on [DATE], with diagnoses that included surgery for a left dislocated hip prosthesis, history of [CONDITION(S)] (an acute disturbance of the mind characterized by restlessness, illusions, and incoherence of thought and speech), and agitation. Review of Resident R206's MDS indicated the diagnoses remained current. Review of Resident R206's elopement evaluation dated 1/26/21, indicated the resident was not cognitively impaired, did not have poor decision making, and was compliant with facility protocols, and was not an elopement risk. A review of a physician progress note dated 1/27/21, indicated Resident R206 was in wrist restraints was yelling and kicking in bed. The documentation indicated that Resident R206 had increased [CONDITION(S)] due to narcotics. Review of a progress note dated 1/27/21, indicated Resident R206 was upset with being in the facility and stated this was not the right place for [resident]. Resident R206 expressed to daughter that I shouldn't be here. Review of Resident R206's care plan dated 2/3/21, documented wandering behaviors. Review of Resident R206's progress note dated 2/7/21, indicated at approximately 7:00 p.m. Resident R206 was found outside of building #6 with walker. Resident was confused, combative and would not come back into Hickory unit where the resident resided. A Wanderguard bracelet was placed and Resident R 206 was transferred to the Willow Unit, a locked secured dementia unit. During an interview on 8/18/21, at 9:10 a.m. Registered Nurse Unit Manager Employee E6 confirmed that Resident R206 should have had a Wanderguard bracelet placed to maintain supervision as the resident had wandering behaviors and the Elopement Assessment was not indicative to the resident's needs. Review of the clinical record indicated that Resident R60 was admitted to the facility on [DATE], with diagnoses which included dementia, [CONDITION(S)], [CONDITION(S)]. A Quarterly MDS dated [DATE], indicated the diagnoses remained current. Review of a progress note dated 4/14/21, indicated that Resident R60 had a handful of pills he was explaining to his roommate's wife. The writer of the note, Registered Nurse Employee E7 indicated that she attempted to get the pills from Resident R60 but he became aggressive with his words, when the Nurse Supervisor attempted to get them he again became verbally aggressive, at which time the documentation indicated the staff would wait until he took his pants off for bed and retrieve the pills. During an interview on 8/11/21, at 12:20 p.m. Registered Nurse Employee E4 could not provide an investigation and follow up for the situation, as a follow up note was not documented. The facility failed to identify or investigate the medications being left with a resident with dementia and poor decision-making skills. On 8/12/21, at 6:55 p.m. the Administrator and DON (Director of Nursing) were notified Immediate Jeopardy (a situation in which the provider's non compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) had been identified, an Immediate Jeopardy template was presented, and the facility would need to provide an immediate action plan to ensure the safety of the residents. The facility provided an immediate action plan that was accepted on 8/12/21 at 9:36 p.m. The immediate action plan included: Resident R97 has been moved to Willow the secured dementia unit. Resident's family has been updated regarding the room move and the plan of care has been updated. R30, R76 and R77 have had security bracelets replaced and will be monitored q 30 minutes for placement. R59 had new security bracelet placed and will be checked for function q shift. Resident R97 and all residents with a security bracelet are being re-evaluated to ensure the security bracelet continues to be an appropriate safety intervention. All assessments will be documented in the resident record. The plan of care will be updated as indicated. Any resident at risk for elopement will be moved to the secure dementia unit as indicated for increased supervision. Until then, door monitor will be placed at Redwood's exit due to 4 residents currently residing on that unit with security bracelet. The Nursing Home Administrator and the Director of Nursing or designee will check all residents to ensure their security system bracelet is in place and is functioning immediately and q 30 minutes. All residents will be evaluated for elopement risk every 30 days and interventions will be implemented including use of a security bracelet. All alarmed doors are being evaluated for the length of time the alarm sounds by outside contractor. All doors will be lowered to the lowest time allotment as indicated. All Staff will be educated by the Nursing Home Administrator and/or designee on the frequency of alarm checks, the need to check all areas for residents if a door alarm sounds, the need to alert the nursing supervisor if the alarm sounds so that all residents can be accounted for as indicated. Training will begin immediately with all staff on current shift. Shift supervisor will be trained and educate night shift staff. 100% of staff will be educated within 48 hours. A QA will be completed daily 5 times per week for 2 weeks, three times per week for 2 week, and monthly thereafter. Findings will be reviewed by the QA Committee at the Quarterly meetings. On 8/13/21, at 8:30 a.m. the Department of Health survey team entered the facility to determine if the immediate action plan was implemented. During interviews on 8/13/21, NA (Nursing Assistant) Employees E17, E24, E25, and E26, RN (Registered Nurse) Employee E20, Unit Secretary Employee E5, and Physical Therapist E27 confirmed they did not receive training on the frequency of Wanderguard alarm checks, the need to check all areas for residents if a door alarm sounds, the need to alert the nursing supervisor if the alarm sounds so that all residents can be accounted for as indicated. On 8/14/21, at 11:00 a.m. a Department of Health surveyor entered the facility to determine if the immediate action plan was implemented. During an observation on 8/14/21, at 3:15 p.m. surveyor went to exit the [NAME] Unit (secured unit) and found Resident R52 outside of the unit and in the hallway of the Redwood Unit (unsecured unit). During an interview on 8/14/21, at 3:17 p.m. Resident R52 reported 'hitting a button and the door opened'. The resident reported trying 'to get back in' to the secured unit but 'the door wouldn't open'. The resident reported 'being ready to go home'. Review of Resident R52's clinical record documented the resident was admitted to the facility on [DATE] from a short term hospital. Diagnoses included unspecified dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interfere with everyday activities), restlessness and agitation, chronic kidney disease(a disease that prevents kidneys from filtering waste and excess fluid from the blood), diabetes mellitus (a chronic condition which affects how your body turns food into energy), and polyneuropathy (damage to peripheral nerves which travels from the spinal cord to muscles, skin, internal organs and glands). Review of Resident R52's current physician orders included medications, [MEDICATION(S)] (for improved blood flow to the heart), [MEDICATION(S)] (for diabetes), [MEDICATION(S)] (insulin for diabetes), [MEDICATION(S)] (insulin for diabetes), and Wanderguard (placement three times daily, and function testing once daily). Review of Resident R52's MDS (Minimum Data Set - a federally mandated standardized assessment tool conducted to periodically to plan resident care) dated 3/17/21 documented: Section C Cognitive Patterns recorded a BIMS score (Brief Interview for Mental Status - a mandatory interviewing tool to screen cognition to determine if interventions are needed) of 03 out of 15 indicating severe cognitive impairment; Section E Behaviors, subsection E900 Wandering coded 0 indicating the behavior was not exhibited; Section G Functional status, subsection G0110 Activities of Daily Living Assistance, E. Locomotion on unit coded 1 for supervision, and F. Locomotion off unit coded 1 for supervision; Section P Restraints and Alarms, subsection P0200 Alarms, E. Wanderguard/elopement alarm coded 2 for used daily. Resident R52's care plan dated 3/17/21, identified wandering behaviors as a problem with interventions to include assessing physical needs, ensuring all door alarm/locks are armed to reduce risk of leaving secured area, diversion activities, recording behaviors on tracking form, redirection, and use of Wanderguard. Elopement was identified as a problem, effective 7/20/21, with interventions to include redirection, causes of wandering, encourage resident to express needs and feelings, reassurance, use of security alarm bracelet, and elopement assessments effective 8/16/21. Review of Resident R52's progress notes dated 3/19/21, documented wandering behaviors. Review of Resident R52's progress note dated 6/23/21, documented wandering the hall asking for location of bus stop. Difficult to redirect. Review of Resident R52's progress note dated 7/26/21, documented resident became highly agitated looking for car keys. Attempts to redirect with no success. Pacing around nurse's station stating I need out of here I have to get my car to go to Alabama to see family. Review of Resident R52's progress note dated 7/28/21, documented resident becoming agitated wanting to leave the unit. Standing in front of nurse's station after lunch walking toward door to exit when opened. Redirected immediately. Review of Resident R52's progress note dated 8/2/21, documented resident has continuously throughout the shift been attempting to leave the unit, stating go Home. Redirection without success. Resident stating has to get to work at [NAME] Hospital, go home to see mother and father, and ask nurse why being treated this way and wants to go home. Review of Resident R52's progress note dated 8/12/21, documented Wanderguard placement confirmed and functioning. During an interview on 8/14/21, at 3:20 p.m. RN (Registered Nurse) Employee E28 confirmed letting Resident R52 off the unit as the employee thought the resident was a visitor. During an observation on 8/14/21, at 3:22 p.m. RN (Registered Nurse) Employee E29 and surveyor tested Resident R52's Wanderguard bracelet for placement and functioning. The bracelet and the system was functional. During an interview on 8/14/21, at 5:30 p.m. the DON (Director of Nursing) reported the Wanderguard system disconnected from the server at 2:25 p.m. through 3:57 p.m. and presented an email confirmation from security as verification. On 8/15/21, at 1:00 p.m. a Department of Health surveyor entered the facility to verify the immediate action plan was implemented. Through observations, staff interviews, facility documentation and audits, it was confirmed that the facility's immediate action plan was implemented and Immediate Jeopardy was lifted on 8/15/21, at 4:50 p.m. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, facility clinical records, incident reports, resident interviews, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of five residents reviewed (R36 and R86) resulting in acutal harm to one resident who sustained a disclocation of her right shoulder (R36), requiring transfer to the hospital for admission and treatment and another resident (R86) who sustaied a fractured thighbone of the knee, resulting in increased pain and pain medication (Residents R36 and R86). Findings include: Review of facility policy 1.0 Abuse reviewed on 2/3/21, states The skilled nursing facilities at UPMC Senior Communities prohibit all forms of abuse and strive to provide an environment and culture that treats every resident with dignity and respect while providing person-centered care and services to adults who may lack the capacity to protect themselves. Definitions include 7. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, anguish, or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatments and care, including but not limited to . activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. A review of the clinical record revealed that Resident R36 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (Periodic Assessment of Care Needs) dated 3/6/21, indicated that Resident R36 required extensive assist of two persons for bed mobility. A review of the care plan dated 3/16/21, indicated that Resident R36 required extensive assist of two persons for bed mobility. A review of information the facility reported to the State Agency on 5/21/21, indicated that Resident R36 was transferred to the hospital due to a fall from her bed resulting in a dislocated right shoulder. The report indicated that the fall was the result of a Nursing Assistant (NA) rolling the resident away from the NA while providing care, which resulted in the resident rolling out of the opposite side of the bed, falling to the floor and sustaining the injury. A review of a Incident/Accident Form, dated 5/20/21, indicated that while care was being provided, the resident rolled out of the bed onto the floor. The resident concern of pain of her entire body. The resident was assisted back into bed and continued to voice concerns with pain. A mobile Xray was ordered and determined that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility report form for investigation of alleged neglect, dated 8/12/21, indicated that on 5/20/21, Resident R36 was being provided care by Nursing Assistant (NA) Employee E32. While care was being provided NA Employee E32 neglected to follow the assist status for bed mobility for Resident R36 (assist of two). NA Employee E32 negelcted to position herself on the correct side of the bed while repositioning a resident while providing care. NA Employee E32 was positioned on the opposite side of the bed that that the resident was being rolled from (right side) the residnet rolled out of the bed (left side) onto the floor During an interview on 8/11/21, at 1:30 p.m. the Registered Nurse Unit Manager Employee E6 confirmed that the facility failed to follow proper procedure during care, which resulted in a fall with serious injury. During a resident council meeting conducted on 8/10/21, at 2:00 p.m. residents on the Redwood Unit reported, while playing Bingo in the dining area on 8/6/21, between 1:30 p.m. and 3:30 p.m., they heard someone yell, Help Help and then heard shrieking screams. The residents reported they later heard from staff that Resident R86 fell out of bed and broke a leg. Resident R86 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R86's MDS (Minimum Data Set - a periodic assessment of resident care needs) dated 7/9/21, documented under Section C-Cognitive Patterns, a BIMS ( Brief Interview for Mental Status - a mandatory interviewing tool to screen cognition to determine if interventions are needed) score of 8 out of 15, indicating moderate cognitive impairment. Section G Functional Status, documented under subsection G0110, B. Transfer coded the resident as total dependence with two + persons physical assist. Subsection G0300, Balance During Transitions and Walking coded the resident as not steady and needing staff assistance. Section GG Functional Abilities and Goals, Subsection GG0170 Mobility documented the resident was dependent in chair/bed-to-chair transfer with the helper does all of the effort, resident does none to complete the activity. Review of provider progress note dated 8/9/21, at 3:12 p.m. from the CRNP (Certified Registered Nurse Practioner) of the primary care physician documented the resident was examined today for follow up on resident's pain. Patient reports [resident] being was recently dropped onto [resident's] knees while being transferred from chair to bed. Resident reports being told to walk to bed and then fell on to [resident's] knees, patient is nonambulatory. Staff has no record of this incident and reports it did not happen or any other trauma. Patient state [resident] has pain in both of [resident] knees but the right is worse then the left and nothing seems to help the pain. The note also documented Resident R86 is non-ambulatory and requires a Hoyer lift (an assistive device that allows transfer between bed/chair by electrical or hydraulic power). An x-ray was ordered for the right knee. Review of the x-ray report dated 8/9/21, at 8:09 p.m. documented findings of an up to 2.7cm (approximately 1) impacted fracture of the distal femoral metaphsysis (fracture of the thigh bone above the knee joint), with up to 1.3cm (approximately 1/2) posterior displacement of the distal fracture moiety (space between the fracture). Review of Resident R86's July MAR (medication administration record) documented the resident received Oxycodone 5mg tablet as needed for pain. On 8/9/21, this medication order was changed to Oxycodone 5mg three times daily for pain. During an interview with Resident R86's daughter on 8/11/21, at 2:45 p.m. it was reported the primary care physician contacted the daughter on 8/9/21, and reported the resident was dropped and suffered a knee injury. The daughter was also told the injury happened over the weekend. The daughter participated in the resident's care plan meeting held on 8/10/21, where the incident was not presented until the daughter ask about not being notified of the injury. During an interview on 8/12/21, Resident R86 reported sitting in the Broda chair at the foot of the bed, facing the window. During the lunch meal two female staff persons came into the room, and the resident asked to be assisted into bed. One nursing assistant grabbed the resident, pulled the resident to stand up, then dragged the resident around the chair toward the bed. The resident reported the other nursing assistant commented '(the resident) can't walk.' The first nursing assistant remarked 'I'll show you how to walk' and the resident was dropped to the floor, injuring the right knee. The resident reported both nursing assistants helped the resident to get up, and rolled the resident onto the bed. The resident stated [I] called out in pain, it was a very frightening situation, and very painful. The resident reported assuming the staff were going to use the Hoyer lift. The resident also reported two days had passed before the knee was x-rayed. The resident also commented 'hearing staff talking about the incident in the hallway. During an interview on 8/16/21, the CRNP from the primary care physician's office confirmed the documentation in the provider progress note dated 8/9/21, at 3:12 p.m. and disclosed the facility did not report the injury to the physician's office. On 8/9/21, the CRNP spoke with the resident about the injury and the resident reported the staff did not use a Hoyer lift. The CRNP reported Resident R86 is clear in thought with periods of confusion. The CRNP reported going to RN Unit Manager Employee E8's office to report the allegation and together they went to Resident R86's room to observe the injury. During an interview on 8/16/21, at 11:50 a.m. Unit Manager RN Employee E8 confirmed the facility failed to prevent an injury that occurred during resident care and resulted in additional increased pain and physical harm to the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 201.18(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(d) Resident care policies. 28 Pa. Code: 211.11(d) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, reports, clinical records, and staff interviews, it was determined that the facility failed to properly maintain leg immobilizer devices which impeded bone healing and resulted in the development of a pressure ulcer and failed to effectively monitor and provide the necessary treatments to prevent worsening of the pressure ulcer resulting in actual harm to one of 4 residents reviewed (Resident R1). Findings include: The facility policy titled, Pressure Ulcer Risk Assessment, reviewed on 6/15/16, indicated that all residents were assessed with [REDACTED]. risk for developing skin breakdown) for predicting pressure ulcer (damage to skin or underlying structures as a result of pressure) risk and that the nurse also reviewed risk factors and conditions that increased the risk of development of pressure ulcers which included impaired or decreased mobility and functional ability due to recent fracture with or without a cast. The facility policy titled, Skin Condition Assessment, reviewed on 6/15/16, indicated that risk factors would be assessed, that treatment and pressure relief strategies would be reviewed, that physician's orders [REDACTED]. The facility policy titled, Interdisciplinary Skin Committee, reviewed on 6/15/16, indicated that the team was comprised of the manager, the charge nurse, the dietitian, the wound care nurse and a representative from rehabilitation, and that the team provided recommendations for treatment and/or prevention strategies. Review of the Profile Face Sheet (a form that identifies resident personal and medical information to health care providers) indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment (MDS-a periodic assessment of care needs) dated 1/20/16, included additional diagnoses; of anxiety disorder (any group of mental conditions that can include panic attacks, extreme stress or fear of things) and depression and noted that the resident had a recent weight loss. Review of the information dated 3/8/16, submitted by the facility indicated that the nurse and several staff persons responded to Resident R1's call for help and found the resident laying on the floor in front of the lift chair (motorized chair that assists the user to a standing position because the entire chair rises from its base). Resident R1 had a hematoma (a collection of blood under the skin) on the right temporal area (the region of the head in front of the ear and over the cheek). Resident R1 was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A review of an X-ray of Resident R1's left foot dated 3/8/16, indicated a traumatic (caused by or relating to an injury) closed displaced (broken bone caused by trauma that does not produce an open wound and/or break in the skin) [MEDICAL CONDITION] (long part of the bone) of the left tibia and fibula (lower leg bones in the ankle region). A review of a consultation note from an orthopedic surgeon (a medical doctor with extensive training in [DIAGNOSES REDACTED]. Resident R1's family opted for the splint as indicated in the consultation. A review of a nursing note dated 3/15/16 at 11:30 p.m., indicated that Resident R1 was readmitted to the facility with a, splint with ace wrap intact on left lower leg. A review of the readmission physician's orders [REDACTED]. A review of the office note from the orthopedic doctor dated 4/4/16, indicated that the splint was removed from Resident R1's left leg and a non-weight bearing air boot (a supportive boot made of an air cushion and encased in a hard plastic shell) was applied. Instructions were that the facility staff, can only open the front of the boot to wash the leg with soap and water, otherwise just not come out of the boot for any reason. The resdient was to have a follow-up in one month. A review of Resident R1's Treatment Administration Record (TAR) for April and May 2016, revealed that the air boot was not added to the TAR and the nursing staff continued to document each shift from 4/4/16 through 5/5/16, that the, left lower leg splint remained on the resident's left leg at all times. A review of the clinical record did not include any documentation that therapy services were consulted to assist the nursing staff with proper care of the air boot. A review of the office note from the orthopedic doctor dated 5/5/16, indicated that Resident R1's family member sent some pictures of the resident's left leg positioning while at the facility and that, Clearly, they (the facility staff) are allowing the foot to rotate in the boot, which is causing incredible torsional stresses (pressure caused by twisting or rotating) on the bone. The note included reference to X-rays taken of the left tibia-fibula on 5/5/16, which showed delay in healing of the fracture. The orthopedic doctor also noted that a KAFO (knee, ankle foot orthosis) brace (long leg brace that locks joint in more appropriate alignment) would be ordered to, protect the leg much better from rotational forces placed by the nursing home and requested that the facility obtain a, left clam shell KAFO (rigid, split brace used for knee, foot orthosis). A review of an orthotic company (specialists in the design, manufacture and application of orthotics) note dated 5/12/16, indicated that the facility notified them about the needed left clam shell for Resident R1 on 5/12/16, which was seven days after it was ordered by the orthopedic surgeon. A review of Resident R1's TAR for May 2016, revealed that the air boot was not added to the TAR and the nursing staff continued to document each shift from 5/5/16 through 5/16/16, that the left lower leg splint remained on the resident's left leg at all times. A review of a nurse note dated 5/16/16 at 9:40 p.m., indicated, Representative from (orthotic company) in to measure (Resident R1) for a clam shell at 4:30 p.m. When (representative) removed the air boot noted sores on heel .notified nurse on duty. Upon examination, 8 x 5.7 cm (centimeter) gray DTI (deep tissue injury-a pressure-related injury to subcutaneous (beneath the skin) tissue under intact skin) .on the left outer heel. 1.6 x 1.1 cm discolored area on the left outer ankle .2.8 x 4.6 cm fluid fill purple DTI on the left outer heel .1.6 x 1.1 cm discolored area on the left lower leg. The representative from the orthotic company reported that the air boot was too tight. The note indicated that the Certified Registered Nurse Practitioner (CRNP) was contacted and the CRNP was, unable to see resident today. CRNP asked staff to keep air boot on loosely and (CRNP) will see resident in AM. A review of Resident R1's clinical record revealed no orders, no physician or CRNP progress notes and no nurses' notes for 5/16/16 or 5/17/16, about the air boot and/or the newly identified areas of skin breakdown on the resident's left leg/foot. A nurses' note dated 5/18/16 at 9:01 a.m., indicated that Resident Family Member RF1 notified the Assistant Director of Nursing (ADON), Employee E1, that the family member made an appointment for Resident R1 to be seen by the orthopedic doctor on 5/19/16 at 1:15 p.m. A review of the office note from the orthopedic doctor dated 5/19/16, indicated that the boot on Resident R1's left leg was, apparently allowed to shift anteriorly, then compressed without anyone following it and that the resident had, abrasions and bruising over the anterior (the top) aspect of the ankle. The orthopedic doctor's note went on to read that, if the boot was placed anteriorly (on the top of the foot) and increased on pressure, this will cause breakdown of the skin over the fibula and the medial (inside of the foot towards the body) area. This would explain the breakdown of the skin. The orthotic company applied the clam shell brace at the doctor's office during this visit on 5/19/16. Resident R1 returned to the facility with orders for wound care and wearing the clam shell brace. A review of the physician's orders [REDACTED]. Clean area with Saf-Clens (a brand of skin cleanser) first. Brace (clam shell) to left leg on AAT (at all times) except during wound care .follow-up six weeks. A review of the May 2016, TAR indicated that the dressing on Resident R1's left leg wound was changed on 5/22/16 and 5/23/16. A review of a nurses' note dated 5/26/16 at 8:11 a.m., indicated that therapy demonstrated the correct placement of the clam shell brace, which was seven days after the initial application of the clam shell brace. A review of the, Skin Assessment Forms dated 5/26/16, completed by the Registered Nurse (RN) Wound Nurse, Employee E2, described the left outer and left inner wounds on Resident R1's left foot as, abrasions from old boot covered with slough (accumulation of necrotic tissue). A review of a nurses' note dated 5/29/16 at 2:38 p.m., indicated the dressing on Resident R1's left leg/foot wounds were changed, that there was a small amount of drainage noted on the old dressing and, No odor from wounds, only odor noted was 'sweaty foot'. A review of the clinical record did not include documentation that the doctor and/or the CRNP was notified about the drainage and odor from Resident R1's left foot. A review of the nurses' notes dated 5/30/16 at 5:13 p.m., and on 5/31/16 at 10:07 p.m., indicated that Resident Family Member RF1 requested that the left leg wounds be left open to air because of the odor. A nurses' note dated 6/2/16 at 7:33 a.m., indicated that the, wounds on Resident R1's left leg had moderate amount of serous sanguineous drainage (composed of serum and blood) and a foul odor. A review of a CRNP note dated 6/2/16, indicated that Resident R1 had an open wound to the left lateral (outer) ankle which was a Stage III pressure ulcer (a wound with full thickness loss of skin involving damage to the subcutaneous tissue) with yellow slough, serous drainage with foul odor and eschar (scab of dead tissue) and a larger wound on the left medial (inner) ankle with large amount of brown slough, foul odor and draining serous purulent (pus) fluid. The CRNP planned to contact the orthopedic doctor to discuss treatment options such as follow-up at a wound clinic or hospital for debridement (removal of injured/dead tissue) and wound care. A review of the physician orders [REDACTED]. A review of the hospital records revealed a note by the orthopedic doctor dated 6/3/16, that indicated that Resident R1 initially presented to the hospital with a left leg fracture and being managed non-operatively and stated, Unfortunately, was then treated at a nursing home, which resulted in displacement of the fracture and pressure necrosis (dead tissue) wounds of the left inside and outside ankle regions. The hospital record indicated that on 6/3/16, Resident R1 had an open reduction and internal fixation (ORIF-surgical repair of a bone fracture) of the left ankle. A review of the hospital records revealed a note by the plastic surgeon dated 6/3/16, that indicated, Unfortunately, the (resident) was at a nursing home receiving treatment and the splint appeared to be too tight and was not managed properly at the nursing facility leading to displacement of the fracture and also pressure necrosis wounds on the medial and lateral (outer) malleolus (ankle bones). The hospital record indicated that on 6/3/16, Resident R1 had surgical debridement of the left medial malleolus and placement of a xenograft (tissue graft) and that the left lateral malleolus would be treated with [MEDICATION NAME] (topical antibacterial cream). During an interview on 6/17/16 at 10:55 a.m., Occupational Therapist (OT) Employee E3 reported that therapists were not involved in any discussions regarding Resident R1's left leg splint and ace wrap, which was on the resident's leg from 3/15/16 through 4/4/16, or the air boot, which was on the resident's leg from 4/4/16 through 5/19/16. Employee E3 reported that on 5/23/16, the therapy department received a referral from nursing regarding proper removal and reapplication of the left clam shell brace and that initial teaching which included direct demonstration was provided to one staff nurse on 5/26/16, and that written instructions for the other nursing staff were available on 5/26/16, which was seven days after the clam shell brace was applied to the resident's leg. During an interview on 6/17/16 at 11:15 a.m., the Director of Nursing (DON) confirmed that nursing staff changed the dressing on Resident R1's left leg/foot on 5/22/16 and on 5/23/16, which was prior to receiving instructions for proper removal and reapplication of the left clam shell brace. During an interview on 6/17/16 at 11:30 a.m., Employee E1 was not able to recall what devices were on Resident R1's left leg, and stated that, I didn't examine it closely and, we (nursing) did not do anything with the (air) boot and was not able to explain how the air boot got over inflated. During an interview on 6/17/16 at 11:45 a.m., with Employee E1 revealed, we (facility) thought the orthopedic doctor was going to get the open clam shell (for Resident R1). We didn't know we had to order it. Although ordered by the orthopedic doctor on 5/5/16, the orthotic company was not contacted by the facility until 5/12/16. During a phone interview on 6/17/16 at 1:10 p.m., the Orthotic Specialist reported that .instructions come with the air boot .the air boot has a built-in air pump and that the only way it (the air boot) got to be over inflated was because some one had to push the air pump to inflate it. During an interview on 6/17/16 at 2:30 p.m., the Director of Nursing (DON) confirmed that Resident R1's clinical record did not include any documentation that the facility did any follow-up with the CRNP, the primary care doctor or the orthopedic doctor, to assure that the newly identified pressure ulcers on the resident's left leg/foot were evaluated and confirmed that it was the resident's family member that initiated an appointment for the orthopedic doctor to evaluate the resident's left leg/foot. During an interview on 6/17/16 at 3:00 p.m., the DON confirmed that the facility failed to properly maintain leg immobilizer devices which impeded the bone healing of Resident R1's left ankle fracture and resulted in the development of pressure ulcers on the resident's left foot and failed to effectively monitor and provide the necessary treatments to prevent worsening of the pressure ulcers resulting in actual harm to Resident R1. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 8/6/15, 12/23/14. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/23/14, 7/11/14. 28 Pa. Code 211.12(c) Nursing services. Previously cited 12/23/14. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/6/15, 12/23/14, 7/11/14. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/23/14.

Based on a facility policy, clinical record review, facility documents, an event report and staff interviews, it was determined that the facility failed to assure that a positioning device was being used appropriately, which resulted in actual harm to one of nine residents reviewed (Resident R1). Findings include: A review of the facility's, "Side Rail" policy dated 6/2/14, indicated that side rails when used for bed mobility/positioning, would be evaluated periodically, for appropriateness and safety, and when the resident can not utilize them as an assist, the side rails would be viewed as a restraint. A review of Resident R1's clinical record indicated that the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an Event Report submitted by the facility to the State Agency, stated, "resident requires frequent repositioning during the night as resident will place legs off the side of the bed." The "SIDE RAIL EVALUATION AND PERIODIC REVIEW" form last completed on 10/07/14, indicated top side rails for assistance with bed mobility and positioning. A physician's recapitulation order dated 11/5/14, indicated Resident R1 had an order for [REDACTED]. A physician's note dated 11/5/14 indicated that resident was unable to reply due to dementia. A review of Resident R1's most recent Minimum Data Set assessment (MDS-a periodic review of a resident's physical and medical capabilities and needs) dated 10/8/14, indicated that the resident was totally dependent for bed mobility and required the assistance of staff (two or more) every time. There was no evidence of a reevaluation of the side rail for restraint use after the MDS assessment indicated the resident was unable to use the side rails as the resident was totally dependent for bed mobility. A review of Resident R1's care plan last reviewed on 10/21/14, did not include documentation for the use of the side rails for turning and positioning or for the use of the side rails as a restraint. Additionally, the resident's care plan indicated hand splint to left hand at all times related to alteration in ADL's related to decreased bed mobility. Resident R1's care plan indicated that the resident wore a left palm guard at all times due to contractures (a shrinkage or shortening, as of muscle or scar tissue, resulting in distortion or deformity) of both hands (as per Occupational Therapy recommendations). The resident was referred to Occupational Therapy for appropriate equipment for contractures of both hands on 1/7/14. The resident wore only one palm guard, on the left hand, after a screening that was completed by Occupational Therapy on 1/7/14, regarding an open wound inside the resident's left palm from the resident's fingernails digging into the skin of the hand. The Occupational Therapist consult stated, "for appropriate equipment for contractures of both hands." A review of the facility event report dated 11/30/14, indicated that Resident R1 was found, "stuck between railing and bed" and that, "No pulse or lung sounds were present. Doctor, family, Hospice, and Coroner were notified." The event report also indicated that the resident was, "unable to utilize a call light for needs." Further review of the event report submitted by the facility indicated that Resident R1 was found between the bed and the side rail approximately one hour after the resident was last checked by a Nursing Assistant (NA). The last side rail evaluation had been completed on 10/7/14, and indicated that the side rail was used for care and repositioning and that the resident had not fallen in six months. The Medical Examiner's preliminary report indicated asphyxiation as the cause of death. During an observation on 12/22/14, at 10:30 a.m., with Registered Nurse, Employee E2, the surveyor and Employee E2 measured 2 inch space between the inner part of the side rail and the outer edge of the mattress which was air inflated, while the side rail was up. An interview with NA, Employee E1, on 12/22/14, at 2:35 p.m., confirmed that Resident R1 was found sitting at the side of bed on the fall mat, on the floor, with the legs extended, chin "stuck" on the bottom part of the side rail, and the back of her head was against the mattress. Employee E1 indicated that, "we always left resident's side rails up." Employee E1 also confirmed that the resident was unable to use a call light related to mental and physical disabilities. 28 Pa Code: 201.14(a) Responsibility of licensee. Previously cited 7/11/14, 8/8/13. 28 Pa Code: 201.18(a)(e)(1) Management. 28 Pa Code: 201.18(b)(1)(3)Management. Previously cited 7/11/14. 28 Pa Code: 211.10(c) Resident care policies. 28 Pa Code: 211.10(d) Resident care policies. Previously cited 7/11/14. 28 Pa Code: 211.11(d) Resident care plan. 28 Pa Code: 211.12(c)(d)(3) Nursing services. 28 Pa Code: 211.12(d)(1)(2)(5) Nursing services. Previously cited 7/11/14.