Every finding on record at Aventura at Creekside

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure residents who lacked the ability to make medical decisions had an identified authorized representative and failed to ensure documentation of advance directives or evidence the resident was offered information regarding the right to formulate an advance directive. The facility failed to ensure medical treatment decisions were made by an appropriate legally authorized decision maker for three of 19 residents reviewed (Residents 13, 27, and 51).Findings included: A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (chronic autoimmune disorder where the immune system mistakenly attacks joint linings, causing pain, inflammation, swelling, and potential deformity) and bipolar disorder (chronic mental health condition characterized by alternating periods of depression and elevated mood). A review of Resident 13's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 20, 2023, revealed that Resident 13 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of the most recent quarterly MDS dated [DATE], revealed Resident 13 remained severely cognitively impaired with a BIMS score of 3. A review of the clinical record revealed medical decisions were documented as approved and signed by Resident 13, including consents for psychotropic medications (medications that affect mood, perception, or behavior), consent for nutritional supplements, and a vaccination refusal signed November 13, 2025, despite documentation indicating the resident lacked the ability to independently make medical decisions. Resident 13's clinical record revealed a Physician Orders for Life-Sustaining Treatment (POLST, a medical order indicating a person's preferences for life-sustaining treatment, it is not intended to replace an advance health care directive document or other medical orders. The POLST process and health care decision-making work best when the person has appointed a health care agent to speak for them when they become unable to speak for themselves. A health care agent can only be appointed through an advanced health care directive or a health care power of attorney,) was completed September 14, 2023. The POLST indicated do not attempt resuscitation (allow natural death), comfort measures, use of antibiotics if life prolonging, and a trial period of artificial hydration and nutrition by feeding tube. The POLST documented review with the resident despite evidence of severe cognitive impairment and lacked documentation of an advance directive (written instruction, such as a living will or medical power of attorney, that identifies a person authorized to make health care decisions if the individual becomes unable to make decisions independently) or documentation the resident was offered information regarding the right to formulate an advance directive. Resident 13's clinical record revealed a Pennsylvania Physician Orders for Life-Sustaining Treatment (POLST- The POLST is not intended to replace an advance health care directive document or other medical orders. The POLST process and health care decision-making work best when the person has appointed a health care agent to speak for them when they become unable to speak for themselves. A health care agent can only be appointed through an advanced health care directive or a health care power of attorney), but no documented evidence of an Advance Directive written instruction, such as a living will or medical power of attorney, that identifies a person authorized to make health care decisions if the individual becomes unable to make decisions independently or if the facility asked the resident if he would like information to formulate an advanced directive. During an interview on April 2, 2026, at 1:00 PM, the Assistant Director of Nursing indicated when Resident 13 requires medical decisions, the physician or administrator is involved in decision making due to the resident's inability to make decisions independently. During an interview on April 2, 2026, at 2:20 PM, the Social Services Director indicated the facility had not initiated court appointment of a representative for Resident 13 despite his ongoing medical issues, and need for decision making. Interview with the Nursing Home Administrator (NHA) on April 2, 2026, at 1:25PM, denied that the NHA was making medical decisions for the resident. Interview with the facility appointment Dietician on April 2, 2026, at 2:00PM revealed she only speaks with the physician regarding medical decisions related to Resident 13's condition, and the physician is the one who makes the medical decisions for the resident since he is unable to make decisions himself. Documentation provided by the facility on April 3, 2026, at 9:00 AM revealed the facility initiated the process of obtaining a court-appointed representative for Resident 13 on April 2, 2026. A review of Resident 27's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and schizophrenia (a chronic, severe brain disorder that causes psychosis, hallucinations, and delusions. A review of Resident 27's quarterly MDS dated [DATE], revealed Resident 27 was severely cognitively impaired with a BIMS score of 7. A review of the clinical record revealed no documentation identifying a legally authorized representative for medical decision making. A review of the clinical record revealed ongoing medical treatment decisions, including use of psychotropic medications and completion of a POLST dated November 5, 2025, signed by the resident despite documentation of severe cognitive impairment. The POLST indicated preferences for attempted resuscitation, full treatment, use of antibiotics, and refusal of artificial tube feeding. The POLST lacked physician signature and reflected signatures of the incapable resident and Social Services Director. During an interview on April 2, 2026, at 2:00 PM, the Nursing Home Administrator indicated the facility informs Resident 27 of medical decisions despite documentation of cognitive impairment. Documentation provided April 3, 2026, at 9:00 AM revealed the facility initiated the process of obtaining a court-appointed representative for Resident 27 on April 2, 2026. A review of Resident 51's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities (a developmental condition characterized by significant limitations in intellectual functioning (learning, reasoning, problem-solving), and depression(a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment, affecting how one thinks, feels, and act). A review of the quarterly MDS dated [DATE], revealed a BIMS score of 4, indicating severe cognitive impairment. A review of resident 51's clinical record revealed ongoing medical decision making, including vaccination consents and psychotropic medication authorizations, completed by the resident despite documented inability to make medical decisions independently. A review of a POLST uploaded to Resident 51's clinical record on April 17, 2023, revealed the form was signed by the resident (printed name) but not signed or dated by the physician. The POLST indicated preferences for attempted resuscitation, full treatment, use of antibiotics, and artificial hydration if life prolonging. The form lacked documentation identifying who the treatment decisions were reviewed with, despite the presence of a designated section for this information. During an interview on April 3, 2026, at 9:00 AM, the Nursing Home Administrator indicated the facility had not identified an individual authorized to make medical decisions for Resident 51. Documentation provided revealed the facility initiated the process of obtaining a court-appointed representative April 2, 2026. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a)(b) Resident rights.

Based on review of facility policy, Resident Council meeting minutes, grievance documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility failed to ensure ongoing communication and timely follow-up regarding issues presented by eight of eight residents attending a Resident Council group meeting (Residents 8, 14, 22, 33, 35, 54, 55, and 68).Findings include: A review of the facility policy titled Grievance Policy, last reviewed September 25, 2025, indicated residents, families, and their representatives have the right to voice grievances regarding care and treatment, staff behavior, or other concerns related to their stay. The policy indicated the designated grievance official is responsible for following up on concerns and grievances reported by residents or resident representatives. A review of a grievance dated January 9, 2026, submitted by Resident CR1 revealed concerns regarding extended call bell response times on January 8, 2026. Documentation indicated staff assigned to the shift were interviewed and the facility determined the call bell was answered timely based on staff interviews. Documentation indicated staff received re-education regarding call bell response expectations and call bell response audits were initiated. The grievance was documented by the facility as resolved. A resident group meeting conducted on April 3, 2026, at 11:30 AM with eight cognitively intact residents (Residents 8, 14, 22, 33, 35, 54, 55, and 68) revealed all residents in attendance reported continued concerns regarding call bell response times. Residents indicated they believed call bell response times remained inconsistent. Residents further indicated concerns regarding call bell response times had been discussed during Resident Council meetings held in January, February, and March 2026; however, the meeting minutes did not reflect documentation of these concerns. A review of documentation provided by the facility revealed call bell audit results that did not identify extended response times. The facility was unable to provide documented evidence residents were re-interviewed following implementation of corrective actions to determine whether residents perceived improvement in call bell response times. The facility was unable to provide documented evidence demonstrating communication to the Resident Council regarding actions taken to address concerns or the outcomes of the concerns raised related to call bell response times. During an interview conducted April 3, 2026, at 9:10 AM, the Nursing Home Administrator was unable to provide documented evidence demonstrating resident satisfaction with actions taken in response to grievances or concerns raised through Resident Council meetings. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observations and staff interview, it was determined the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment, including resident care equipment, for two of 19 residents reviewed (Residents 9 and 28).Findings include: Observations in Resident 9's room on April 1, 2026, at 11:00 AM and 1:30 PM revealed dried tube feeding residue in multiple locations within the resident's room. Specifically, dried nutritional formula (liquid nutrition administered through a feeding tube when a resident cannot eat by mouth) was observed on the base of the resident's tube feeding pole, on the fall mat positioned on the floor to the right side of the bed, and on the privacy curtain located to the right side of the bed. Observations conducted on April 1, 2026, at 1:00 PM revealed Resident 28's Broda chair (a specialized, highly adjustable medical chair used to assist with positioning, pressure injury prevention, and mobility for individuals with complex care needs) was positioned in the resident's room unoccupied and was not maintained in a clean condition. The chair was observed to contain multiple pieces of debris on the seat and footrest. The cushion contained stains from an unknown substance. Multiple strands of hair were observed adhered to the Dycem (a non-slip material used to prevent sliding and improve positioning stability) located on the chair surface. Crumbs were observed throughout the seating area of the chair. During an interview conducted on April 2, 2026, at 2:20 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) reviewed the above findings that the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment and resident care equipment, consistent with maintaining a safe, comfortable, and homelike environment for residents. 28 Pa code 201.18 (b)(1) Management.

Based on clinical record review, policy review, resident observation, and staff interviews, it was determined the facility failed to identify the use of a physical restraint and failed to implement facility policy regarding the use of restraints for one of 19 residents reviewed (Resident 10).Findings include: Clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a neurological disorder that begins in early childhood and permanently affects muscle coordination, body movement, and posture). A review of Resident 10's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 1, 2026, revealed that Resident 10 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 15 reflects normal cognitive abilities). A review of the facility policy titled Use of Restraints, last reviewed September 25, 2025, revealed that restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully. When the use of a restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. A restraint is defined as a device or equipment is attached or adjacent to the individual's body that an individual cannot remove, which restricts freedom of movement. Restraints may only be used if the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention. The policy documented that prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve symptoms. Restraints shall only be used after obtaining the written order of a physician and after obtaining consent from the resident and / or resident representative. Care plans will reflect the use of restraints and interventions implemented to systematically eliminate the need for restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident/resident representative. The policy indicated that once a restraint is initiated, the resident is observed at least every 30 minutes by nursing personnel, and the resident's condition documented in the clinical record. The opportunity for motion and exercise will be provided for a period of not less than 10 minutes during every 2 hours the restraint is applied. Documentation regarding the restraint shall include full documentation of the episode leading to the use of physical restraint, a detailed description of the medical symptoms, how the restraint benefits the resident, the type of restraint, the length of effectiveness, observations, range of motion (movement of joints to maintain flexibility and prevent stiffness) provided, and repositioning efforts. The use of the restraint shall be reviewed regularly (at least quarterly) to evaluate for restraint reduction, less restrictive methods of restraints, or total restraint elimination. The care plan should reflect the measures taken to reduce or eliminate the need for restraints. A review of the care plan dated November 16, 2011, revealed Resident 10 was at risk for falls and included interventions of a wheelchair with a buckle belt for positioning. The care plan also indicated the use of a wheelchair with a cut-out cushion (a specialized cushion designed to relieve pressure on the tailbone), Dycem (a non-skid material used to prevent sliding of items such as cushions), and leg rests (supports used to position the legs while seated in a wheelchair) for transportation. The care plan directed staff to release the buckle belt every two hours. An observation conducted on April 1, 2026, at 1:15 PM revealed Resident 10 was seated in a wheelchair at the nurses' station with a belt secured across the waist using a buckle attached to the wheelchair. Resident 10 was unable to verbalize the purpose of the belt and did not demonstrate movement of the upper extremities (arms, hands, wrists, or trunk) during the observation. A review of Resident 10's physician orders revealed an order originally dated March 1, 2013, for a high-back wheelchair with foam seat cushion and buckle belt. The order also indicated that when Resident 10 leaves the facility with family, a collapsible wheelchair is required. The presence of the buckle belt in physician orders since 2013 indicates the device has been in use for an extended period of time. On December 5, 2025, the order was revised to include a wheelchair with pressure-relieving cushion and buckle belt for positioning (intended to assist with maintaining body alignment while seated). The order was most recently reviewed by the physician on January 9, 2026. Despite long-term use of the buckle belt, the clinical record lacked documentation demonstrating the interdisciplinary team (a group of healthcare professionals such as nursing, therapy, and medical providers who collaborate to plan and evaluate care) evaluated whether the device met the definition of a restraint (a device attached to or placed next to the resident's body that the resident cannot remove and which restricts freedom of movement), whether the device was clinically necessary to treat a medical symptom (a physical or clinical condition that requires treatment), or whether the buckle belt represented the least restrictive intervention for positioning. The clinical record lacked documentation demonstrating periodic reassessment of the continued need for the device, attempts to reduce the use of the device, or evaluation of alternative positioning interventions. During an interview conducted on April 1, 2026, at 2:20 PM, the Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA) stated the buckle belt was used to reduce the risk of falls and to maintain Resident 10's safety while seated in the wheelchair. The ADON and NHA acknowledged Resident 10 was unable to remove the device independently and confirmed the buckle belt restricted Resident 10's movement. A device the resident cannot remove that restricts freedom of movement meets the definition of a physical restraint. The stated purpose of fall prevention does not represent a medical symptom that justifies restraint use without evidence that less restrictive interventions were attempted and determined ineffective. The clinical record lacked documentation demonstrating the interdisciplinary team evaluated whether the buckle belt was necessary for positioning, whether less restrictive positioning interventions were attempted, or whether the use of the buckle belt was clinically justified based on an assessed medical symptom. The clinical record failed to demonstrate interdisciplinary team and resident or resident representative involvement in the decision-making process regarding the use of the buckle belt. The clinical record lacked documentation demonstrating the buckle belt was assessed as the least restrictive intervention or that alternative interventions were attempted and determined ineffective prior to use. The clinical record failed to include documentation of informed consent (permission granted by the resident or representative after receiving sufficient information to make a decision) for the use of the buckle belt as a restraint. The clinical record also lacked documentation of ongoing monitoring of the resident's condition and safety while the restraint was in place, including documentation of routine observations, release of the device, provision of range of motion (movement of joints to maintain flexibility and prevent stiffness), or evidence the restraint was used for the least amount of time necessary. During an interview on April 3, 2026, at 9:15 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated the facility had not identified the wheelchair buckle belt as a restraint. The facility was unable to provide documentation demonstrating the restraint policy was implemented, including interdisciplinary team assessment, identification of a medical symptom, informed consent, care plan interventions to reduce or eliminate restraint use, or ongoing monitoring of Resident 10 while the buckle belt was in use. The facility failed to demonstrate ongoing interdisciplinary team reassessment of a device that had been in place since at least 2013 and failed to ensure the use of the least restrictive intervention to meet Resident 10's assessed needs. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing service. 28 Pa. Code 211.8(c.1)(1)(2)(3)(i)(ii)(d)(e) Use of Restraints.

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen three employees out of five to ensure they were eligible for employment in a long term nursing care facility. (Employees 1, 2, and 3).Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility on September 25, 2025, revealed the requirement for screening potential employees to determine their appropriateness in working with individuals with specific conditions and needs; including obtaining references from previous and current employers. Review of employee personnel files revealed the following: Employee 1 (Licensed Practical Nurse): Hired on February 26, 2026. The application listed previous employers, but there was no documentation showing the facility had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Registered Nurse): Hired on February 20, 2026. The application listed previous employers, but there was no documentation showing the facility had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 3 (Licensed Practical Nurse): Hired on March 9, 2026. The application listed previous employers, but there was no documentation showing the facility had contacted any former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Interview with the Nursing Home Administrator (NHA) on April 2, 2026, at 1:15 PM was unable to provide evidence that previous employers were contacted for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for three out of five new hires. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.19 (1) Personnel records.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set (MDS) for three of 19 residents reviewed (Resident 10, Resident 11, and Resident 23).Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the MDS dated [DATE], requires the assessment accurately reflects the resident's status. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 10 was admitted to the facility May 18, 2011, with diagnoses that included cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination). The annual Minimum Data Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 1, 2026, Section P (section addressing restraints and alarms) indicated Resident 10 does not use a restraint when in a chair, including a trunk restraint, or limb restraint. An observation on April 1, 2026, at 1:15 PM revealed Resident 10 was seated in his wheelchair, at the nurses' station. Resident 10 was observed to have a belt that was attached to the wheelchair; the belt included a buckle and was secured in the front of Resident 10's waistline. Resident 10 was not able to verbalize what the purpose of the belt with a buckle was and could not demonstrate any movement in his upper extremities (including arms, hands, wrists, or trunk) at the time of the observation. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 1, 2026, at 2:20 PM confirmed Resident 10 was not able to release the belt, and the intent of the belt was for Resident 10's safety. The DON and NHA further elaborated that due to Resident 10's underlying medical condition and the potential for unexpected loss of control over muscle movement consistent with his admission diagnosis, the belt's purpose is for safety. The DON and NHA acknowledged the belt is attached to the wheelchair, secured Resident 10 in the wheelchair, and limited Resident 10's movements. The DON and NHA did not consider the use of the buckle belt as a restraint. A clinical record review revealed Resident 11 was admitted to the facility July 26, 2022, with diagnoses that included chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs which results in swelling and irritation, inside the airways that limit airflow into and out of the lungs). The quarterly MDS dated [DATE], Section J (section related to health conditions, including fall history) documented Resident 11 experienced no falls since admission/ readmission or prior assessment. Upon clinical review, Resident 11 experienced falls on November 16, 2025, January 4, 2026, and January 14, 2026. The three falls were not reflected on the quarterly MDS dated [DATE]. A clinical record review revealed Resident 23 was admitted to the facility on [DATE], with diagnoses that included dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (condition characterized by cognitive decline and affects memory, thinking, behavior, and the ability to perform activities of daily living such as bathing, dressing, walking, and eating). The quarterly MDS dated [DATE], Section J (section related to health conditions, including fall history) documented Resident 23 experienced no falls since admission/ readmission or prior assessment. Upon clinical record review, Resident 23 experienced a fall on November 24, 2026. The fall on November 24, 2026, was not reflected on the quarterly MDS dated [DATE]. The above information reflecting the MDS coding for Resident 10, Resident 11, and Resident 23 was reviewed with Employee 4 Licensed Practical Nurse, MDS Coordinator on April 3, 2026 at 11:15 AM. Employee 4 LPN acknowledged the MDS did not accurately reflect the health conditions for the three residents. The information was communicated to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 3, 2026, at 2:15 PM. 28 Pa. Code 211.5(f)(ix) Medical records. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to ensure the comprehensive person-centered care plan was implemented consistently and accurately reflected resident-centered measures to meet each resident's assessed needs for two of 19 residents reviewed (Residents 10 and 11). Findings include: A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed September 25, 2025, revealed a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs are developed and implemented for each resident. The policy further revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A clinical record review revealed Resident 10 was admitted to the facility May 18, 2011, with diagnoses that included cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination). A review of Resident 10's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 1, 2026, revealed that Resident 10 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 15 reflects normal cognitive abilities). A review of Resident 10's comprehensive care plan, initiated November 16, 2011, revealed the resident required assistance with activities of daily living (routine personal care tasks such as transferring, bathing, dressing, toileting, and eating), including transfers. The care plan indicated Resident 10 required the assistance of two staff members for transfers, with the intervention initiated May 19, 2021. The care plan indicated as of November 8, 2024, Resident 10 required a Hoyer lift (a mechanical lifting device used to safely transfer individuals with limited mobility between surfaces such as bed and wheelchair) for all transfers. The care plan included two different transfer methods (assistance of two staff members and use of a Hoyer lift) without clear direction regarding which intervention was to be implemented. Lack of clear direction in the comprehensive care plan has the potential to result in staff performing transfers using an inappropriate method, which may compromise Resident 10's safety and physical well-being. A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a progressive lung disease that causes airflow blockage and difficulty breathing). A review of Resident 11's quarterly MDS dated [DATE], revealed Resident 11 was cognitively intact with a BIMS score of 11 (a score of 11 indicates moderate cognitive impairment requiring additional support with memory and decision-making). Review of Resident 11's comprehensive care plan, initiated August 3, 2022, revealed the resident was identified as at risk for falls related to weakness and arthritis (joint inflammation causing pain and limited mobility). Fall prevention interventions included placement of Dycem (a non-slip material designed to stabilize objects and prevent sliding) above and below the wheelchair cushion to reduce movement and improve positioning safety. An observation conducted on April 2, 2026, at 1:15 PM revealed Resident 11's wheelchair contained a blue piece of Dycem positioned on top of the wheelchair cushion. Observation of the wheelchair cushion revealed Dycem was not present below the cushion as indicated in the comprehensive care plan. The facility failed to implement the fall prevention intervention as written in the resident-centered comprehensive care plan, which has the potential to increase risk for falls and injury. An interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 3, 2026, at 2:20 PM. The above findings were reviewed related to the facility's failure to ensure the comprehensive person-centered care plan accurately reflected resident needs and was implemented consistently for Resident 10 related to transfers and Resident 11 related to fall prevention interventions. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on clinical record review, review of personnel records, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and demonstrated competency for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for one of 19 residents reviewed (Resident 5).Findings include: A review of Pennsylvania Code Title 49, Professional and Vocational Standards, Department of State, State Board of Nursing, S21.145 Functions of the Licensed Practical Nurse (LPN) indicates the LPN functions as a member of the health care team and administers medications and therapeutic treatments in accordance with established standards of safe nursing practice. Section 21.145(b) IV therapy curriculum requirements indicate an LPN may perform IV therapy functions only when the LPN has completed the required education and training and possesses the knowledge, skill, and ability to perform the procedure safely, and only under appropriate direction and supervision of a licensed professional nurse or other authorized health care provider. Permitted IV therapy functions include administration of IV medications and fluids, monitoring of the IV site, maintenance of IV access devices, and recognition and reporting of adverse reactions. Clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included surgical site infection (infection occurring at the location of a surgical procedure). The clinical record revealed Resident 5 had a PICC line (peripherally inserted central catheter, a long flexible tube inserted into a vein in the arm and advanced into a large vein near the heart to allow long-term administration of intravenous medications). A review of physician orders revealed an order dated March 20, 2026, for Meropenem (an antibiotic medication used to treat serious bacterial infections) 1 gram intravenously every eight hours via PICC line for treatment of the surgical site infection through April 11, 2026. Review of the electronic Medication Administration Record (eMAR, an electronic system used to document medication administration in the clinical record) revealed Employee 5, Licensed Practical Nurse (LPN), documented administration of Meropenem 1 gram intravenously via PICC line on March 21, 2026. The eMAR further revealed Employee 6, Licensed Practical Nurse (LPN), documented administration of Meropenem 1 gram intravenously via PICC line on March 29, 2026. The facility failed to produce evidence that Employee 5 or Employee 6 completed IV therapy education and training consistent with the requirements of Pennsylvania Code Title 49 S21.145(b). The facility was unable to provide documentation of competency validation (process used to confirm staff have demonstrated the ability to safely perform a clinical skill), supervision documentation, or evidence of training specific to administration of IV medications through a PICC line. During an interview conducted on April 2, 2026, at 11:50 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility was unable to provide documentation demonstrating Employees 5 and 6 completed the required IV therapy education or competency validation necessary to administer IV medications through a PICC line. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses accurately administered medication in accordance with physician orders for one of 19 residents reviewed (Resident 20). Findings include: A review of the facility policy titled Administering Medications last reviewed by the facility on September 25, 2025, revealed that medications are administered as prescribed in a safe, timely manner. Medications are administered in accordance with prescriber orders, and information is verified prior to administering medication including vital signs (measurements of basic body functions such as blood pressure, pulse, temperature, and breathing), are verified prior to administering medications when parameters are ordered. A review of the clinical record revealed Resident 20 was admitted to the facility on [DATE], with diagnoses to include hyperkalemia (high levels of potassium in the blood which can affect heart and muscle function). A review of Resident 20's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 10, 2026, revealed that Resident 20 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of the physician's order dated May 5, 2025, directed staff to administer Midodrine HCl (medication used to treat low blood pressure) 5 milligrams (mg) orally three times a day for orthostatic hypotension (a sudden drop in blood pressure occurring within 3 minutes of standing or shifting to an upright position which may cause dizziness or fainting). The physician's order specified to hold (not give) the medication if the systolic blood pressure (top number in a blood pressure reading, representing pressure when the heart contracts) was greater than 145 millimeters of mercury (mm/Hg) and the diastolic blood pressure (bottom number in a blood pressure reading, representing pressure when the heart rests between beats) was greater than 95 mm/Hg. A review of the September 2025 Medication Administration Record (MAR) (a legal document used to record when medications are given) revealed Midodrine was administered 11 times without documentation of a blood pressure reading prior to administration, as required by the physician's order, on the following dates and times: September 5, 2025, at 12:00 PMSeptember 5, 2025, at 4:00 PMSeptember 6, 2025, at 08:00 AMSeptember 6, 2025, at 12:00 PMSeptember 6, 2025, at 4:00 PMSeptember 7, 2025, at 08:00 AMSeptember 7, 2025, at 12:00 PMSeptember 7, 2025, at 04:00 PMSeptember 8, 2025, at 08:00 AMSeptember 8, 2025, at 04:00 PMSeptember 9, 2025, at 08:00 AM Administration of Midodrine without obtaining the required blood pressure reading prevented nursing staff from determining whether the medication was safe to administer according to the physician's ordered parameters. A review of the February 2026 MAR revealed Midodrine was not administered four times when the medication should have been given according to the physician's order. Documentation indicated the medication was held because the systolic blood pressure exceeded 145 mm/Hg; however, the diastolic blood pressure did not exceed 95 mm/Hg as required by the order. The physician's order required that both the systolic blood pressure exceed 145 mm/Hg and the diastolic blood pressure exceed 95 mm/Hg in order to hold the medication. The following blood pressure readings were documented at the time the medication was held: February 5, 2026, at 12:00 PM for a blood pressure reading of 148/90 mm/HgFebruary 12, 2026, at 04:00 PM for a blood pressure reading of 152/62 mm/HgFebruary 13, 2026, at 05:00 AM for a blood pressure reading of 158/76 mm/HgFebruary 24, 2026, at 08:00 AM for a blood pressure reading of 161/84 mm/HgThese findings demonstrated nursing staff did not follow the physician's order because the medication was administered without required clinical information (blood pressure readings) and was also withheld when the ordered criteria to hold the medication were not met. The above findings were reviewed with the Director of Nursing on April 3, 2026, at 7:48 AM. The Director of Nursing acknowledged the medication was administered without obtaining required blood pressure readings and was withheld when the physician-ordered parameters to hold the medication were not met. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure pain management was provided according to physician orders, including implementation of ordered parameters and nonpharmacological interventions, for one of 19 residents reviewed (Resident 1). Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following: An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician. Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions. A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of a facility policy titled Pain Management and Assessment last reviewed by the facility on September 25, 2025, revealed the facility staff will implement the medication regimen as ordered. The policy revealed it is the staff responsibility to administer the medication as ordered, monitor, and document the resident's response to the medication. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including heart failure (a chronic, serious condition where the heart cannot pump enough blood to meet the body's needs, often caused by coronary artery disease, high blood pressure, or weak heart muscles) and muscle weakness. A physician order dated January 9, 2026, revealed Resident 1 was prescribed Tramadol 50 milligrams (mg) (an opioid pain medication used to treat moderate to moderately severe pain) to be administered by mouth every 12 hours as needed for severe pain rated 8-10. A pain scale is a standardized tool used to measure pain intensity, typically ranging from 0 to 10, where 0 indicates no pain, 1-3 indicates mild pain, 4-7 indicates moderate pain, and 8-10 indicates severe pain. A review of the January 2026 Medication Administration Record (MAR) revealed staff administered Tramadol 50 mg 16 times. Of the 16 administrations, 3 doses were administered outside physician ordered parameters for severe pain rated 8-10: January 20, 2026, at 3:49 PM, administered for pain scale rating of 3 (mild pain)January 22, 2026, at 5:07 PM, administered for pain scale rating of 0 (no pain)January 27, 2026, at 7:13 PM, administered for pain scale rating of 0 (no pain) A review of the February 2026 MAR revealed staff administered Tramadol 50 mg 13 times. Of the 13 administrations, 1 dose was administered outside physician ordered parameters: February 22, 2026, at 11:07 AM, administered for pain scale rating of 3 (mild pain) A review of the clinical record revealed the physician order was revised on February 25, 2026, to Tramadol 50 mg, administer one tablet every 6 hours as needed for moderate shoulder pain, with nonpharmacological interventions attempted prior to administration of the medication. Nonpharmacological interventions are treatments that do not involve medications and may include repositioning, application of heat or cold, massage, relaxation techniques, distraction, or other comfort measures. A review of the clinical record revealed the following administrations occurred without documentation of nonpharmacological interventions attempted prior to administration as ordered: February 25, 2026, at 7:38 PMFebruary 26, 2026, at 1:40 AM A review of the March 2026 MAR revealed staff administered Tramadol 50 mg 88 times. Of the 88 administrations, 16 doses were administered outside physician ordered parameters: March 1, 2026, at 03:40AM, the medication was administered for a pain scale of 8.March 1, 2026, at 10:41PM, the medication was administered for a pain scale of 8.March 2, 2026, at 05:25AM, the medication was administered for a pain scale of 3.March 6, 2026, at 7:42PM, the medication was administered for a pain scale of 8.March 8, 2026, 11:29AM, the medication was administered for a pain scale of 8.March 13, 2026, 7:04PM, the medication was administered for a pain scale of 0.March 15, 2026, 08:33PM, the medication was administered for a pain scale of 8.March 20, 2026, 7:20PM, the medication was administered for a pain scale of 8.March 21, 2026, at 11:00AM, the medication was administered for a pain scale of 8.March 21, 2026, at 8:45PM, the medication was administered for a pain scale of 8.March 23, 2026, at 05:58AM, the medication was administered for a pain scale of 8.March 26, 2026, at 7:52PM, the medication was administered for a pain scale of 8.March 27, 2026, at 7:40PM, the medication was administered for a pain scale of 8.March 29, 2026, at 1:19AM, the medication was administered for a pain scale of 8.March 29, 2026, at 7:46PM, the medication was administered for a pain scale of 8.Match 30, 2026, at 05:06AM, the medication was administered for a pain scale of 0. An interview with the Director of Nursing on April 3, 2026, at 11:00 AM included review of the above findings which revealed the facility failed to ensure staff administered opioid pain medication according to physician orders, including adherence to ordered pain scale parameters and implementation of ordered nonpharmacological interventions prior to medication administration. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure the attending physician acted upon and documented a clinical rationale regarding consultant pharmacist identified medication regimen irregularities for one of 19 residents reviewed (Resident 4). Findings include: A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (a mental health condition that causes significant changes in mood, energy, and ability to function, including episodes of depression and mania, which is a period of abnormally elevated mood or irritability). A review of the November 2025 consultant pharmacist Medication Regimen Review (MRR) (a monthly evaluation of a resident's medications conducted by a licensed pharmacist to identify potential medication concerns such as unnecessary medications, excessive doses, or risk of side effects) revealed the pharmacist identified the resident's order for Mirtazapine 15 mg (an antidepressant medication used to treat depression and certain mood symptoms) and recommended consideration of a gradual dose reduction (GDR) (a step-by-step lowering of a medication dose to determine whether the medication is still necessary or whether symptoms can be managed with a lower dose or without the medication). Review of the November 2025 MRR revealed documentation from the facility's contracted psychiatric services Nurse Practitioner indicated the resident previously failed a gradual dose reduction of Seroquel (an antipsychotic medication used to treat mood and behavioral symptoms) and the resident was considered stable on the current medication regimen. However, the clinical record lacked documentation that the attending physician reviewed the pharmacist's recommendation regarding Mirtazapine or provided clinical rationale explaining why a gradual dose reduction was not attempted or was clinically contraindicated (not recommended due to potential harm). A review of the clinical record failed to reveal documentation from the attending physician addressing the pharmacist's identified irregularity, including the reason for continuing the current dose of Mirtazapine without a gradual dose reduction. During an interview conducted on April 3, 2026, at approximately 1:00 PM, the Assistant Director of Nursing (ADON) stated the facility had experienced an ongoing issue obtaining documentation from the attending physician in response to consultant pharmacist recommendations. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a resident's drug regimen was free from the use of an unnecessary antibiotic for one of 19 residents reviewed (Resident 8).Findings Include:A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive condition involving decline in memory, thinking ability, and reasoning beyond normal aging) and muscle weakness. A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on September 25, 2025, indicated antibiotics are prescribed only when there is sufficient clinical evidence of an active infection. The policy further indicated prescribers are expected to provide complete antibiotic orders including the medication name, dose, duration of treatment, and the clinical indication (medical reason) for use. The facility utilized the McGeer's Criteria Checklist to determine the need for initiation of antibiotics. McGeer's Criteria is defined as an evidence-based surveillance tool used in long-term care facilities to identify when clinical signs and symptoms are present that support the presence of an infection and justify antibiotic treatment. A review of a physician order dated January 20, 2026, revealed an order for Ceftriaxone (a broad-spectrum antibiotic used to treat bacterial infections) 1 gram injection to be administered intramuscularly (into the muscle) at bedtime for three days for a urinary tract infection (UTI, an infection involving the bladder, urethra, or kidneys).A review of Resident 8's clinical record revealed a McGeer's Criteria Checklist dated January 17, 2026. The checklist documented Resident 8 did not exhibit symptoms consistent with a urinary tract infection, including absence of fever (elevated body temperature), leukocytosis (increased white blood cells indicating possible infection), acute mental status change (sudden confusion or altered thinking), or acute functional decline (sudden worsening in ability to perform usual activities). Despite the absence of required clinical criteria, the checklist indicated the UTI criteria had been met. A review of a urinalysis with culture report (a laboratory test used to detect the presence of bacteria and identify the most effective antibiotic treatment) dated January 21, 2026, at 8:42 AM revealed the presence of Escherichia coli (E. coli, a common bacterium from the intestinal tract that can cause urinary tract infections). The culture report further revealed the identified bacteria was resistant (not effectively treated) to Ceftriaxone, indicating the antibiotic ordered was not an appropriate treatment for the identified organism. The clinical record did not contain documentation of clinical signs or symptoms consistent with infection prior to the initiation of the antibiotic. The facility failed to ensure Resident 8's drug regimen was free from unnecessary antibiotics by initiating Ceftriaxone without sufficient clinical indication supported by McGeer's Criteria and without evidence the medication would be effective based on culture results. During an interview on April 3, 2026, the Director of Nursing reviewed the above findings related to the facility's failure to ensure Resident 8 was free from the use of an unnecessary antibiotic. 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa Code 211.10 (c) Resident care policies.

Based on observation, a review of select facility policy, and staff interviews it was determined that the facility failed to ensure the kitchen was maintained in a manner to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms. This failure created an increased potential for foodborne illness and placed 80 out of 80 residents in a situation of Immediate Jeopardy to their health and safety. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The Food and Drug Administration (FDA) requires commercial food service establishments to clean and sanitize all equipment and utensils that come into contact with food using an effective two-step process: cleaning (removal of debris) and sanitizing (elimination of microorganisms). According to Ecolab Inc., a global company specializing in water hygiene and infection prevention solutions for industries that require strict safety and sanitation standards such as health care, long term care, food service, food processing, hospitality and manufacturing indicate that cockroaches are known vectors for pathogens such as Salmonella (bacteria that can contaminate food, water, and surfaces and cause salmonellosis, resulting in diarrhea, fever, and abdominal cramps when ingested., E. coli (Escherichia coli ,bacteria commonly found in the intestines of humans and animals; some strains produce toxins that can cause severe gastrointestinal illness, including diarrhea and, in some cases, kidney complications) and Staphylococcus (bacteria often found on human skin and in nasal passages; certain strains, such as Staphylococcus aureus, can cause food poisoning, skin infections, or more serious illnesses when introduced into the body, which can lead to serious foodborne illnesses in residents). Cockroaches pick up these bacteria on their bodies and legs when moving through contaminated areas and can transfer them to food, utensils, and preparation surfaces. This contamination creates a significant risk for the spread of disease A review of the facility's Pest Control Policy last updated July 18, 2025, indicated the facility will maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Contracted outside pest control services are provided. Windows are always screened. Only approved FDA and EPA' insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. A tour of the kitchen on August 25, 2025, at 8:20 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness. The exit door in the kitchen leading to the outside was propped open with a rock. An interview with Employee 1, a dietary aide, confirmed this observation and stated the door should not be propped open. Observation of the janitor's closet located next to the exit door revealed a mop directly on the floor and a cracked light shield containing debris. The perimeter area of the floors throughout the kitchen had a buildup of dirt and debris. The floor area under the dishwasher was soiled, and a three-foot length of stainless-steel plating located behind the dishwasher was pulling away from the wall, leaving a gap along the top edge of the dishwasher area located behind the garbage disposal. Further interview with Employee 1 at this time revealed that he does sometimes see water bugs in the dishwasher area. Observation of the floor in the food preparation and tray line service area revealed a dead cockroach on the floor. Interview with the Food Service Director (FSD) on August 25, 2025, at 9:00 a.m. confirmed that cockroaches were identified in the kitchen one month ago and that the nursing home administrator (NHA) was made aware. Further observation of the kitchen with the FSD on August 25, 2025, at 9:15 a.m. revealed several live cockroaches under the dishwasher. Interview with the NHA on August 25, 2025, at 9:30 a.m. confirmed the facility did have a contract with a pest management company and that on July 21, 2025, in response to seeing cockroaches in the kitchen, the facility requested pest control services increase from monthly visits to every two weeks. However, other than increasing visits with the pest management company, there was no documented evidence the facility addressed the concern of cockroaches in the kitchen between visits, increased sanitation, or evaluated food storage and distribution practices. The NHA confirmed that food and nutrition services were to be maintained in a sanitary manner and free of pests. Review of the Commercial Services Agreement for pest management dated July 21, 2025, revealed the facility requested to increase pest control services from monthly to every two weeks and signed a new contract on that date. Review of the Pest Control Report dated July 21, 2025, indicated heavy treatment was placed in the kitchen for roaches. Review of the next Pest Control Report dated August 18, 2025, 28 days after the previous treatment, indicated that roach gel (slow-acting poison-laced bait placed in areas where roaches hide that attracts and kills cockroaches), and growth regulators (substances that prevent immature cockroaches from reaching their full pest potential) were placed in the kitchen for roach activity.Further interview with the Administrator on August 25, 2025, at 9:45 AM confirmed the pest control company did not provide a service the week of August 4, 2025, as per the facility contract for service every two weeks. When questioned if there had been any reports made to him about cockroaches being present on residents' meal trays, the Administrator confirmed that staff had reported an incident to him on August 19, 2025, that a dead cockroach was on Resident 1's refused breakfast tray. Review of the clinical record confirmed that the resident did refuse breakfast on that day as he often does refuse breakfast per personal preference. The facility failed to provide any documented evidence the facility staff was monitoring for the presence of roaches in the kitchen or had put any increased sanitation measures or environmental measures (identifying gaps, repairing wall cracks, ensuring doors are closed) in place to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation. Immediate Jeopardy was identified and called on August 25, 2025, at 10:50 AM and the Immediate Jeopardy template was provided to the Nursing Home Administrator regarding the facilities failure to maintain the kitchen so that food was stored, prepared, distributed and served under sanitary conditions. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms and resulted in failure to maintain proper sanitary conditions in the kitchen thereby placing all residents at risk for foodborne illness. Evaluation of the facility's records determined that Immediate Jeopardy was initially identified on July 21, 2025, when the pest control company documented the need for heavy pest control treatment in the kitchen. In response, the facility submitted an immediate corrective action plan at 2:45 PM on August 25, 2025. The plan directed the kitchen to begin using paper supply and disposable products for all meal service. Staff were assigned to monitor each meal while the tray line was active to ensure that no insects or cockroaches were observed. Facility leadership notified all residents, families, and the medical director regarding the situation and the actions being taken. Pest control services were activated for immediate treatment of the source areas. Full sanitation of the kitchen, including all equipment and floors, was completed, and all exposed food and single-use items were discarded. The three-compartment sink was designated for use as needed, and staff were instructed to complete sanitation treatments in the kitchen after each meal. The kitchen was placed under continuous monitoring throughout the day and night by the Food Service Director or the registered nurse supervisor. Audits were scheduled to be completed hourly for three days, then daily for seven days, and weekly for four weeks. On August 26, 2025, at 11:00 a.m., the licensed pest control inspector conducted a thorough inspection of the kitchen and identified cockroach activity around walls and behind appliances, including the entire kitchen area. Recommendations included fogging treatment, four-foot door sweep installation to the kitchen exit door and sealing around the floor pipe opening under the sink. Dietary staff were educated on the facility's Pest Control and Kitchen Sanitation Policies and Protocols. All residents were to be assessed for any gastrointestinal symptoms related to food. An Ad Hoc QAPI (meeting within a nursing home to address a specific quality issue) was held to address the issue and develop ongoing preventive measures. The facility initiated daily audits and weekly inspections and treatments by both the maintenance director and the licensed pest control vendor. A fogging treatment was recommended by the pest control company and scheduled for August 27, 2025, at 7:00 PM. Staff in-service training on food safety and pest prevention was scheduled for completion by the staff educator on August 27, 2025. Final environmental measures, including sealing cracks, installing a door sweep, and repairing baseboards, were assigned a completion deadline of August 30, 2025. The Immediate Jeopardy was lifted on August 28, 2025, at 10:00 a.m. after verification the facility had implemented a comprehensive corrective action plan that immediately addressed the risk of serious harm to residents. Cross Refer F92528 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1)(2.1)(3) Management. 28 Pa. Code 211.6 (f) Dietary Services. 28 Pa Code 211.10 (a)(b)(c)(d) Resident care policies

Based on a review of facility policy, observations of the food and nutrition services department, interviews with facility staff, and review of pest control records, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects/pests, specifically cockroaches.Findings include: A review of the facility's Pest Control Policy last updated July 18, 2025, indicated the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of insects and rodents. Contracted outside pest control services are provided. Windows are always screened. Only approved FDA and EPA' insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. During observation of the kitchen on August 25, 2025, at 8:20 AM interview with Employee 1 (dietary aide) revealed that at times he does see water bugs in the dishwasher area. At that same time, a dead cockroach was observed on the floor in the food preparation/tray line area. Interview with the food service director (FSD) on August 25, 2025, at approximately 9:00 AM confirmed cockroaches had been seen in the kitchen and that the administrator was informed approximately one month ago. Despite this increase in pest control, further observation with the FSD on August 25, 2025, at 9:15 AM revealed several live cockroaches under the dishwasher. Review of the facility's Commercial Services Agreement dated July 21, 2025, confirmed the increased service schedule, and the pest control report for that date documented heavy treatment for roaches. However, the next pest control report was dated August 18, 2025 which was 28 days later, rather than every two weeks as requested indicated that roach gel (slow-acting poison-laced bait placed in areas where roaches hide that attracts and kills cockroaches) and growth regulators (prevent immature cockroaches from reaching their full pest potential) were placed in the kitchen for roach activity. Interview with the nursing home administrator (NHA) on August 25, 2025, at approximately 9:30 AM confirmed that the facility did have a contract with a pest management company. The administrator confirmed that on July 21, 2025, in response to seeing cockroaches in the kitchen the facility requested the pest control services increase from monthly visits to every two weeks. During an interview with the nursing home administrator (NHA) on August 25, 2025, at approximately 9:45 AM confirmed the pest control company did not provide a service the week of August 4, 2025, as per the facility contract for service every two weeks. Interview with the maintenance director on August 25, 2025, at approximately 10:00 AM failed to provide any documented evidence the facility was monitoring for cockroaches, documenting finding, and identifying possible areas where the cockroaches could be entering and hiding (dark, warm, and moist areas near food sources such as under appliances, under the dishwasher, and within cracks and crevices) as per facility policy. On August 26, 2025, at 11:00 AM a licensed pest control inspector visited the facility for a thorough inspection of the kitchen. The inspection revealed cockroach activity around walls and behind appliances and under the dishwasher. The problem areas included the walls around the kitchen and the entire kitchen. Recommendations included a fogging treatment, four foot door sweep installation to the kitchen exit door, and to seal around the opening of pipe in floor under the sink. Interview with the nursing home administrator (NHA) on August 26, 2025, at approximately 12:30 PM confirmed that the facility failed to show evidence of an effective pest control program. The NHA confirmed it is the facility's responsibility to maintain an effective pest control program to ensure the facility is free of pests including cockroaches.Cross Refer F812 28 Pa. Code 201.18 (e)(1)(2.1) Management 28 Pa Code 211.20 (a)(b)(c)(d) Resident care policies

Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports and interviews with staff and residents it was determined the facility failed to ensure that one resident (Resident 49) out of 19 residents sampled was free from physical abuse perpetrated by a facility staff member This failure to prevent, identify, and respond appropriately to physical abuse placed Resident 49 and all other residents in the facility at risk for further harm, resulting in Immediate Jeopardy.Findings include: A review of a facility policy entitled Abuse Policy, last reviewed July 8, 2024, revealed it is the policy of the facility that acts of physical, verbal, phycological and financial abuse directed against residents are absolutely prohibited. Eash resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Further under the section titled Protection, stated that residents will be protected from harm during the investigation of allegations of abuse. A review of Resident 49's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). A Quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 20, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 2 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). A review of facility investigative documentation dated July 4, 2025, at 7:45 PM documented that Employee 1 (Nurse Aide) reported to Employee 2 (Registered Nurse Supervisor) that Employee 3 (Nurse Aide) had physically abused Resident 49 while providing care. Employee 1 alleged that Employee 3 roughly pushed the resident's head back while the resident was in a mechanical lift (Hoyer lift) during a transfer. After the transfer, Employee 3 allegedly grabbed the resident's hands and pinned them to her chest to prevent the resident from pulling at her own clothing. The resident was assessed and found to have two areas of discoloration on her left hand. Employee 3 was removed from the unit, escorted out of the facility and placed on administrative leave. A written witness statement from Employee 1 dated July 4, 2025, confirmed Employee 1 and Employee 3 were providing care to Resident 49. According to Employee 1, while the resident was in the Hoyer lift her head was close to the bar on the lift, and Employee 3 pushed the residents head back roughly to keep her head from hitting the bar. Further stating that Employee 3 pinned the resident's hands to her chest to keep the resident from grabbing her clothing while yelling in the resident's face. A review of a written witness statement from Employee 4 NA also dated July 4, 2025, revealed she entered Resident 49's room to retrieve the Hoyer lift and observed Employee 3 push the resident's head roughly. She stated that Employee 3 appeared frustrated, grabbed a brief from the resident's hand, and threw it across the room. She also witnessed Employee 3 pin the resident's hands to her chest to prevent her from grabbing her clothing. Further investigation conducted onsite on July 29, 2025, revealed that an earlier incident involving potential staff-to-resident abuse occurred on July 4, 2025, prior to the confirmed physical abuse of Resident 49. During an interview conducted with Employee 1 (Nurse Aide) at approximately 12:30 p.m., Employee 1 disclosed to the survey team that prior to providing care to Resident 49, on July 4, 2025, she and Employee 3 (Nurse Aide) had also provided care to another resident (Resident 8). Employee 1 stated that Resident 8 had been attempting to pull up her pants during care and that Employee 3 had responded by roughly grabbing Resident 8's hand. Employee 1 described Employee 3's actions as aggressive and concerning. Employee 1 further stated that immediately after completing care for Resident 8 and just prior to beginning care for Resident 49, she approached Employee 2 (the RN Supervisor on duty at the time) to express concern about Employee 3's conduct. Employee 1 stated that because other staff were present at the time, she and Employee 2 were unable to complete their discussion about the incident involving Resident 8. However, she stated she asked Employee 2 to come observe the care being provided to Resident 49 due to her concerns about the way Employee 3 had treated Resident 8. Employee 1 stated that Employee 2 responded by saying she needed a minute, and did not accompany them. Employee 1 then proceeded to assist Employee 3 with providing care to Resident 49 without any supervisory oversight. An in-person interview with Employee 2, conducted at approximately 12:45 p.m. the same day, revealed that she denied receiving any report or concern from Employee 1 regarding Employee 3's treatment of Resident 8 prior to the incident involving Resident 49. Employee 2 confirmed that she was made aware of the allegations concerning Resident 49 during or after care was provided, at which time she removed Employee 3 from the unit and placed her on administrative leave. When questioned about the prior interaction with Employee 1, Employee 2 was unable to recall or explain the conversation Employee 1 described as occurring between the two staff members prior to the incident involving Resident 49. Despite Employee 2 stating she was not aware of the concerns Employee 1 had with Employee 3's treatment of Resident 8, a second interview with Employee 1 conducted on July 29, 2025 at approximately 2:00PM confirmed she told Employee 2 she had concerns with Employee 3's treatment of Resident 8 prior to Employee 1 and Employee 3 caring for Resident 49, indicating a window for intervention from Employee 2 prior to the abuse involving Resident 49. It was determined on July 29, 2025, and confirmed through further review on July 30, 2025, that the allegation of potential physical abuse of Resident 8 by Employee 3 was not investigated by the facility and was not reported to the State Survey Agency. The facility failed to initiate a formal inquiry into the allegation and failed to protect other residents from a staff member. During an interview with the Director of Nursing on July 30, 2025 at approximately 1:00 p.m., a request was made for an investigation into allegations of abuse that Employee 3 NA had been rough with Resident 8 on July 4, 2025, while providing care. The DON was unable to provide an investigation into this allegation, however she did provide two witness statements. Including a written witness statement completed by Employee 1, NA, on July 4, 2025, that indicated while providing care to Resident 8 with Employee 3, NA, she had roughly grabbed the resident's hand to stop her from grabbing her own pants. Employee 1 NA stated that she felt uncomfortable with the way Employee 3 NA had treated the resident indicating it was aggressive. The facility failed to ensure that residents were protected from physical abuse by facility staff. Employee 2, the RN Supervisor on duty, was made aware of concerns regarding Employee 3's behavior prior to Employee 3 providing care to Resident 49. Despite this, the facility failed to remove Employee 3 from her assignment, and she continued to provide direct care, during which time she physically abused Resident 49. The facility did not take timely and appropriate steps to prevent the abuse, thereby placing Resident 49 and all other residents at risk for serious harm. The failure to recognize, report, and intervene in response to a clear concern of potential abuse resulted in Immediate Jeopardy. Immediate Jeopardy was identified on July 30, 2025, at 10:38 a.m., and the Immediate Jeopardy template was provided to the Nursing Home Administrator. It was determined that Immediate Jeopardy had begun on July 4, 2025, when Employee 3 physically harmed Resident 49, as evidenced by the observed areas of discoloration on the resident's left hand. In response to the Immediate Jeopardy findings, the facility submitted an immediate action plan on July 30, 2025, which included the following corrective measures:1. Employee 3 was suspended from duty on July 4, 2025, and remained off duty pending the outcome of the internal investigation.2. Resident 49 was assessed for injury by a licensed nursing staff, and the attending physician and responsible party were notified of the incident.3. All residents who received care from Employee 3 on July 4, 2025, received full-body audits to assess for signs of injury.4. Cognitively capable residents were interviewed to determine whether they had concerns or fears about any staff members. Cognitively impaired residents were observed for non-verbal signs of distress or potential abuse.5. Notifications were made on July 4, 2025, to Older Adult Protective Services, local law enforcement, and the Area Agency on Aging. A report was submitted to the Department of Health on July 5, 2025.6. From July 5 through July 7, 2025, all facility staff were reeducated on the facility's abuse policy and procedure, with emphasis on the immediate removal of alleged perpetrators from resident care areas and prompt notification of facility leadership. Special attention was given to RN Supervisors' responsibilities in these situations.7. The Director of Nursing reviewed the facility's risk mitigation policy on July 5, 2025.8. The interdisciplinary team was instructed to continue reviewing resident documentation for behavioral indicators or other signs suggestive of abuse and to respond promptly to any identified concerns.9. Social Services initiated follow-up visits with affected residents beginning on July 7, 2025, to assess emotional well-being and monitor for signs of psychological distress.10. Beginning July 7, 2025, the Nursing Home Administrator initiated daily audits of all abuse allegations, which were reviewed for one month to ensure reporting compliance and investigation timeliness.11. An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was convened on July 10, 2025. The meeting included abuse reporting education presented by the Nursing Home Administrator and Director of Nursing.12. Risk mitigation education was provided to all licensed nursing staff on July 29 and July 30, 2025, with documented completion. Immediate Jeopardy was determined to be removed on July 30, 2025, at 3:30 p.m., following onsite verification by the survey team that the corrective actions had been fully implemented and that the likelihood of serious harm had been removed. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 211.12(c)(d)(5) Nursing Services.

Based on observation, review of select facility policies, and staff interviews, it was determined that the facility failed to store, prepare, and serve food under sanitary conditions to prevent potential contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.Findings included: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of facility policies entitled Environment and Food Storage last reviewed by the facility on July 17, 2025, indicated all preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code (a model that assists food control jurisdictions at all levels of government by providing them with a scientifically sound technical and legal basis for regulating the retail and food service segment of the industry (restaurants and grocery stores and institutions such as nursing homes). All food items will be stored 6-inches above the floor and 18-inches below the sprinkler units. An initial tour of the dietary department, conducted on July 29, 2025, at 9:03 AM with the facility's consultant Certified Dietary Manager (CDM), revealed unsanitary conditions with the potential to contaminate food and increase the risk of foodborne illness. Upon entry into the dietary department, dirty breakfast meal carts containing soiled resident trays were stored in close proximity to food preparation areas, clean utensils, and clean cooking equipment. Observations of the ceiling tiles and light fixtures above the dishwashing machine revealed brown discoloration, splattered residue, and visible dirt and debris within the light covers throughout the kitchen area. Observations of the juice station revealed the thickened juice dispenser contained a gelatinous substance inside the nozzle and was sticky to the touch. The consultant CDM reported that the juice station equipment cleaning was done weekly. Further observations of the dietary department revealed that the inside of the dry storage area revealed wire racks stored directly on the floor, debris under shelving, and an accumulation of dirt and debris behind the door. During an interview with the Nursing Home Administrator (NHA) on July 30, 2025, at 2:30 PM, the above observations were reviewed. The NHA acknowledged that the facility's dietary department is required to be maintained in a clean and sanitary condition. 28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (Lilac Hall).Findings include: Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility July 17,2025, indicated that multi-use medication vials/bottles that have been opened or accessed (e.g. seal broken) are to be labeled with the date they were opened to ensure proper tracking for expiration purposes. An observation of the medication cart located on Lilac hall unit on July 30, 2025, at 8:22 AM, in the presence of Employee 8 (Licensed Practical Nurse) of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Degludec (a long acting insulin medication used to lower blood sugar) and one (1) multi-dose pens of Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated when initially opened. Further observation revealed one (1) multi-dose insulin pen of Insulin Aspart (a rapid acting insulin used to lower blood sugar) with a date on the sticker of the pen indicating the pen was opened July 1, 2025. Review of manufacturer safety information revealed the multi-dose pen of Insulin Aspart is to be discarded 28 days after opening indicating the dated pen should have been discarded on July 28, 2025. An interview with Employee 8 (LPN) on July 30,2025, at 8:24 AM, confirmed all three (3) multi dose insulin pens one (1) Insulin Aspart, one (1) Insulin Glargine and one (1) Insulin Degludec were opened, available for resident use, currently being used for administration, and not dated when initially opened with one pen of insulin Aspart being used past the expiration date. Interview with the Director of Nursing (DON) on July 31, 2025, at approximately 11:00 AM, confirmed the facility policy reflects it is the expectation of the staff to adhere to acceptable storage and labeling practice for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with physician's orders for three of 20 residents reviewed (Residents 13, 79, and 85).Findings include: A review of the facility policy titled Oxygen Administration, last reviewed by the facility on July 17, 2025, revealed it is the facility's policy to provide oxygen therapy to residents upon order of the physician. The policy indicated it is the responsibility of the licensed nurse to initiate and monitor the administration of oxygen per physician's orders. Oxygen therapy is a medical treatment in which supplemental oxygen is administered to a resident to maintain adequate oxygen levels in the blood. Oxygen is typically delivered by a nasal cannula, which is a lightweight tube that splits into two prongs placed into the nostrils. The flow rate, measured in liters per minute (LPM), is determined by the physician based on the resident's medical needs. Deviations from prescribed flow rates can result in insufficient oxygen delivery or, in some cases, excessive oxygen administration, both of which can adversely affect health. A clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia (a condition in which the lungs are unable to adequately exchange oxygen, leading to persistently low blood oxygen levels). Further clinical record review revealed Resident 13 had a physician's order placed on May 22, 2025, for supplemental oxygen via nasal cannula at 4 liters per minute (LPM). An observation on July 29, 2025, at 8:15AM revealed Resident 13 was awake and sitting upright in her chair with nasal cannula tubing connected to an oxygen concentrator via an oxygen concentrator with the liter flow set at 0 liters per minute (LPM). During an interview on July 29, 2025, at 8:18 AM, the Director of Nursing (DON) confirmed that Resident 13 should have been receiving continuous oxygen at 4 LPM as ordered and stated she would immediately adjust the concentrator and check the resident's vital signs. A clinical record review revealed Resident 85 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD a progressive lung disease that causes airflow blockage and breathing-related problems). A physician's order dated July 19, 2025, directed supplemental oxygen via nasal cannula at 3 LPM continuously.An observation on July 30, 2025, at 8:30 AM revealed Resident 85 was awake and lying in bed with nasal cannula tubing connected to an oxygen concentrator; however, the flowmeter was set at 2.5 liters per minute (LPM). During an interview at 8:35 AM, Employee 8 Licensed Practical nurse (LPN) confirmed the setting was incorrect and stated it would be adjusted to the prescribed 3 LPM immediately.A clinical record review revealed Resident 79 was admitted to the facility on [DATE], with a diagnosis to include chronic obstructive pulmonary disease. A physician's order dated November 30,2023 revealed the resident was prescribed supplemental oxygen via nasal cannula to be applied at 3 liters per minute (LPM) continuously. An observation on July 29, 2025, at 09:00AM revealed resident 79 was awake and sitting upright in her chair with supplemental oxygen in place via nasal cannula tubing connected to an oxygen concentrator with the liter flow set at 2 liters per minute (LPM). An interview with the resident at this time revealed the resident did not feel oxygen coming from the cannula but denied experiencing distress. An interview on July 29, 2025, at 9:05 AM, the DON confirmed Resident 79 should have been receiving 3 LPM and stated she would adjust the concentrator and check the resident's vital signs. The facility failed to follow their policy in accordance with physician orders for three resident's receiving supplemental oxygen. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, staff interviews, and review of the facility's abuse prohibition policy, it was determined that the facility failed to ensure allegations of abuse were reported to the State Survey Agency within 24 hours of the incident and failed to submit completed investigation findings within five (5) working days, for two of four abuse allegations reviewed (Residents 8 and 9).Findings include: A review of the facility policy entitled Abuse Policy, last reviewed July 17, 2025, revealed it is the policy of the facility that acts of physical, verbal, psychological, and financial abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property. Under the section titled Investigation and Reporting, the policy states the Administrator, Director of Nursing (DON), or designee shall notify the Department of Health Event Reporting System and will notify the Adult Protective Services Area Agency on Aging within 24 hours of an alleged incident. A report of abuse will be submitted within five (5) working days to the Department of Health. The Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse and neglect and is required to report instances of suspected or actual abuse or neglect occurring within the facility. Abuse coordinators are the Administrator and the DON/designee of the facility, who shall coordinate all investigations ensuring resident safety and report findings to regulatory agencies as required. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/DON immediately and initiate gathering requested information. An investigation must be conducted by the Administrator or designee immediately and no later than twenty-four (24) hours after the knowledge of the alleged incident. The Administrator, DON, or designee shall notify the Department of Health via the Event Reporting System electronically, or by phone in the event the electronic system is unavailable. Upon receiving an incident or suspected incident of resident abuse, the Administrator/DON/designee will conduct an investigation and report all alleged violations timely, thoroughly, and objectively, with corresponding reports submitted within five (5) working days to the appropriate agency. A review of Resident 8's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). A review of a Quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 6, 2025, revealed the resident was severely cognitively impaired with a BIMs score of 2 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). During an interview with Employee 1 nurse aide (NA) on July 29, 2025, at approximately 12:30 p.m., she disclosed an incident involving Employee 3 (NA) and Resident 8 that had occurred on July 4, 2025. Employee 1(NA) reported that while assisting Resident 8 with care, Employee 3 (NA) roughly grabbed the resident's hand to stop her from pulling at her pants. Employee 1(NA) stated she immediately shared her concerns with Employee 2 Registered Nurse (RN) that the act was aggressive and inappropriate. This disclosure during the survey interview was the first time surveyors became aware of the alleged incident. Upon follow-up with the DON at 1:00 p.m. on July 29, 2025, it was confirmed that the facility had not reported this allegation of physical abuse to the State Survey Agency within 24 hours of the event. A review of a written witness statement completed by Employee 1(NA) on July 4, 2025, documented that Employee 3 (NA) had roughly grabbed Resident 8's hand during care, and that Employee 1(NA) felt uncomfortable with the interaction, describing it as aggressive. Further review determined that the facility did not submit a complete investigation to the State Survey Agency within five (5) working days of the incident, as required by policy. The DON confirmed during an interview on July 29, 2025, at 11:25 a.m., that neither the timely reporting requirement nor the investigation submission requirement had been met. Resident 9 was admitted [DATE], with diagnoses including Parkinson's disease (a progressive neurological disorder affecting movement), aphasia (difficulty communicating), and epilepsy (a seizure disorder). An annual MDS dated [DATE], documented a BIMS score of 3, indicating severe cognitive impairment. A review of Resident CR1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included stage 3 chronic kidney disease (CKD) refers to permanent damage to the kidneys that occurs gradually over time) and [NAME] Syndrome (is a rare genetic disorder caused by a loss of function of specific genes and begins in childhood. Individuals affected become constantly hungry, which often leads to obesity and type 2 diabetes and may cause mild to moderate intellectual impairment and behavioral problems). Review of Resident CR1's admission MDS assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. On July 22, 2025, Resident CR1, the roommate of Resident 9, filed a grievance with Employee 9, Director of Social Services, alleging that on the night of July 20, 2025, Employee 10, a nurse aide, entered the room and repeatedly used profanity toward Resident 9, telling him to get the ‘F' in bed when he attempted to use the bathroom. On July 26, 2025, Resident 9's responsible party also filed a grievance alleging repeated verbal abuse. The DON initiated an investigation on July 22, 2025, identified Employee 10 nurse aide, as the alleged perpetrator, and did not make contact with Employee 10 nurse aide until July 25, 2025. The DON confirmed on July 31, 2025, at 11:33 a.m., that this verbal abuse allegation was not reported to the State Survey Agency within 24 hours and the completed investigation was not submitted within five (5) working days. Through the survey ending July 31, 2025, the facility did not provide documentation demonstrating that allegations of abuse involving Residents 8 and 9 were reported within the required 24-hour period or that completed investigation results were submitted within five (5) working days. 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(c) Resident Rights. 28 Pa. Code 211.10(d) Resident care policies.

Based on a review of clinical records, the facility's abuse prohibition policy and information provided by the facility it was determined the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action and submit the results of the completed investigation to the State Survey Agency within five working days of the incident as evidenced by two of 4 residents reviewed (Resident 9 and 8).Findings include: A review of the facility's Abuse Policy that was last reviewed by the facility on July 17, 2025, indicated the Administrator/designee was responsible for operationalizing all policies and procedures that prohibit abuse and neglect and are required to report instances of suspected or actual abuse or neglect occurring within the facility. Abuse coordinators are the Administrator and the Director of Nursing (DON)/designee of the facility. They shall coordinate all investigations ensuring resident safety, and report the findings to the regulatory agencies, as required. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/DON immediately and initiate gathering requested information. An investigation MUST be directed by the Administrator or designee immediately and no later than twenty-four (24) hours of knowledge of the alleged incident The Administrator, DON, or designee shall notify the Department of Health, via the Event Reporting System electronically, or by phone in the event of the electronic system being unavailable. Further review of the facility's abuse policy indicated that upon receiving an incident or suspected incident of resident abuse, the Administrator/DON/designee will conduct an investigation to include, but not limited to the following: complete designated report form for investigation or abuse, interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident; interview the resident's attending physician and review the resident's clinical record; interview staff members (on all shifts) having contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, or visitors; interview other residents to which the accused employee provided care or services; and review all circumstances surrounding the incident. The Administrator/DON is responsible to receive and investigate all alleged violations timely, thoroughly, and objectively. A review of Resident 8's clinical record revealed admission on [DATE], with diagnoses including unspecified dementia (a progressive loss of intellectual function affecting memory, reasoning, and behavior). A review of a Quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 6, 2025, revealed the resident was severely cognitively impaired with a BIMs score of 2 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). During an interview with Employee 1, a Nurse Aide (NA), on July 29, 2025, at approximately 12:30 p.m., stated there was an incident with Employee 3, NA, and Resident 8 on July 4, 2025. Employee 1 stated that Employee 3 had grabbed Resident 8's hand roughly to stop her from grabbing her pants while they were providing care to the resident. Employee 1 stated she went to Employee 2, the Registered Nurse (RN), with concerns that Employee 3, NA, had roughly grabbed Resident 8's hand while they were providing care. A review of a written witness statement completed by Employee 1, NA, on July 4, 2025, indicated that while providing care to Resident 8 with Employee 3, NA, she had roughly grabbed the resident's hand to stop her from grabbing her own pants. Employee 1 NA stated that she felt uncomfortable with the way Employee 3 NA had treated the resident indicating it was aggressive. There was no documented evidence of a complete investigation as required by the facility's abuse policy. Missing elements included completion of the investigation form, interviews with all staff on the shift having contact with the resident, notification to the physician and responsible party, and interviews with other residents cared for by the alleged perpetrator. During an interview on July 31, 2025, at approximately 12:00 p.m., the DON confirmed no documentation existed showing the facility had conducted an investigation consistent with the abuse policy. A review of Resident CR1's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included stage 3 chronic kidney disease (CKD) refers to permanent damage to the kidneys that occurs gradually over time) and [NAME] Syndrome (a rare genetic disorder caused by a loss of function of specific genes and begins in childhood. Individuals affected become constantly hungry, which often leads to obesity and type 2 diabetes and may cause mild to moderate intellectual impairment and behavioral problems). Review of Resident CR1's admission MDS (Minimum Data Set a federally mandated standardized assessment process conducted periodically to plan resident care) assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score (Brief Interview for Mental Status a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 15, which indicated the resident was cognitively intact. A review of Resident 9's clinical record revealed admission to the facility on April 4, 2024, with diagnoses that included Parkinson's disease (a disease primarily of the central nervous system, affecting both motor and non-motor systems with symptoms developing gradually and non-motor issues become more prevalent as the disease progresses), aphasia (difficulty communicating), and epilepsy (seizure disorder). Review of Resident 9's annual MDS assessment dated [DATE], section C Cognitive Patterns revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. A review of a grievance report dated July 22, 2025, submitted by Resident CR1 to the Director of Social Services (Employee 9), reported that on the night of July 20, 2025, Resident 9 attempted to get out of bed to use the bathroom several times, and Employee 10, NA, entered the room and repeatedly swore at him, telling him to get the F in bed. CR1 reported the incident was upsetting to hear. A review of a grievance report dated July 26, 2025, from Resident 9's responsible party (RP) with Employee 9, Director of Social Services, reported being told of the same incident by CR1, describing repeated verbal abuse by Employee 10 due to the bed alarm sounding. The DON initiated an investigation on July 22, 2025, and identified Employee 10 as the alleged perpetrator. Documentation reflected attempted telephone contact with Employee 10 on July 23, 2025, but no evidence of completed investigative steps as outlined in the abuse policy. The only interview conducted was with Resident 4, the roommate of CR1 and Resident 9 at the time. No signed witness statements or interviews with other residents or staff were completed. A grievance response dated July 25, 2025, documented that Employee 10 was educated regarding inappropriate language and residents' rights and that disciplinary action was discussed. Employee 9 met with CR1 to explain the resolution. On July 30, 2025, at approximately 11:00 a.m., the DON and Nursing Home Administrator confirmed they did not consider the incident abuse and did not complete a full investigation. On July 31, 2025, at approximately 12:30 p.m., the DON was unable to provide any evidence that a thorough investigation was completed consistent with the abuse policy. 28 Pa. Code 201.14 (c) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies.

Based on a review of clinical records, investigative reports, staff interviews, and facility documentation, it was determined the facility failed to consistently ensure adequate supervision, staff training, and implementation of appropriate individualized interventions to prevent accidents for three residents (Residents 1, 2, and 3) out of 10 sampled resulting in harm including skin ters, lacerations and a head injury requiring staples. Findings include: A review of clinical records revealed that Resident 1 was admitted to the facility on [DATE] with diagnosis to include Picks Disease (condition that affects the brain leading to inappropriate behavior and language difficulties), psychotic disorder with hallucinations (a mental health condition that may include hearing things, false beliefs based on reality, and difficulty sustaining activities), and muscle atrophy (loss of muscle tissue, resulting in decreased strength) and a history of falling. A Quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 3, 2025, revealed that the resident was cognitively impaired with a BIMS score of 0 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment) and required assistance for activities of daily living. A review of a Morse Fall Score (MFS is a rapid and simple method of assessing a patient ' s likelihood of falling) dated February 10, 2025, indicated Resident 1 was at high risk for falls. A review of the resident's plan of care initially dated June 6, 2024, last revised March 6, 2025, revealed that the resident was at risk for falls related to agitation, instability, and muscle weakness. Further it was indicated the resident required assistance of 1 with transfers, bed bolsters to define the edge of the bed and staff to keep the resident's environment clutter free. Despite these documented risks and interventions, the resident experienced multiple falls with injuries. Nursing documentation dated December 9, 2024, at 4:30 AM revealed the resident had fallen from the bed and was found on the floor. The resident was noted to be restless and incontinent of a large amount of urine. The bed alarm was in place but failed to sound. Nursing documentation dated February 10, 2025, at 9:34 PM revealed the resident had another fall from bed with no injury noted. The resident was placed on 15-minute checks as an intervention to prevent future falls. A facility investigation report dated March 16, 2025, at 12:52 AM documented that Employee 1 (Nurse Aide) approached the doorway of Resident 1's room and observed the resident to be restless and climbing out of bed. The employee reported leaving the room to request assistance in getting the resident into her chair. While the resident was left unsupervised, she rolled out of bed and struck her head on the corner of the nightstand located at the head of the bed. The resident sustained a laceration to the left side of her head above the temple (the flattened area on either side of the head, situated between the forehead and ear, and behind the eye), measuring 2 cm x 2 cm x 1 cm, and was actively bleeding. Resident 1 was documented as requiring extensive assistance with both transfers and bed mobility. Following the fall, neuro checks and vital signs were initiated, the physician was notified, and the resident was transferred to the hospital for evaluation and treatment. A witness statement from Employee 1, dated March 15, 2025, corroborated the above events, stating that she had passed by Resident 1's room and observed the resident slightly moving in bed. She acknowledged the resident was restless and that she turned away to get help. When she returned, the resident was found on the floor with the bed alarm sounding, and blood was visible on the corner of the dresser. A review of a witness statement dated March 15, 2025, no time indicated, revealed Employee 5 agency LPN (licensed practical nurse) revealed that Employee 1 had come out of Resident 1's room to ask for assistance because the resident was attempting to crawl out of bed. Employee 5 stated that before assistance could be rendered, a bang was heard, and the resident was found on the floor. A review of hospital documentation dated March 16, 2025, revealed that Resident 1 was evaluated in the emergency department following the fall. The resident was diagnosed with a 2 cm x 2 cm x 1 cm laceration to her left eyebrow area, which required closure with five sutures. A CT scan (computed tomography head scan uses X-rays to develop a 3D image of the skull, brain, and other related areas) of the head was performed, revealing a thin subdural hematoma (brain bleed). A nursing progress note dated March 16, 2025, at 9:03 AM documented that Resident 1 returned to the facility with five sutures and bruising to the left temple. In response to family concerns, a sign was placed on the wall where the nightstand had been located, stating that no furniture should be placed at the head of the bed. A review of the resident's plan of care for fall risk revealed that a new intervention was added on March 18, 2025, which included the removal of the nightstand from the resident's room per family request. In an interview conducted on April 3, 2025, at 1:30 PM, the Director of Nursing (DON) confirmed that prior to the fall on March 16, 2025, the nightstand had been moved to the foot of the bed at the family's request. However, during a routine deep cleaning, the nightstand was inadvertently returned to the head of the bed. During the fall, Resident 1 struck her head on the nightstand, resulting in a laceration and subdural hematoma. The DON also acknowledged that Employee 1 should not have left the resident unattended, especially given the resident's restlessness, history of falls, and need for extensive assistance. The facility failed to provide appropriate supervision by leaving the room when Resident 1 was agitated and trying to climb out of bed resulting in the resident failing from bed causing the resident to sustain a laceration requiring sutures and a brain bleed. A review of manufacturer's instructions for the use of a Broda chair, dated February 2022, included, chair assessments, positioning adjustments, and mobilization handling must be performed by professionals who have been trained for this purpose. Before using the chair, caregivers must have received adequate training from the chair manufacturing company or a trained third party. Recommended instructions for the use of the chair to include, to tilt the chair forward for the resident to stand and transfer out of the chair and for a more upright position while eating. Improper uses of the chair to include, transferring/transporting the resident without using the tilt function. A review of a facility investigation report dated March 21, 2025, at 9:26 AM revealed that Resident 1 fell from her Broda chair (reclining wheelchairs that offers tilt, recline and leg rest adjustments) while being transported from the dining room to the activity room by Employee 2 (Activity Aide). At the time of transport, the Broda chair was in the upright position, which is intended for eating and not for safe transport, a reclined position is utilized for transport. During the incident, the resident sustained two lacerations, measuring 3 cm x 1 cm and 2 cm x 1 cm, along with a raised area and a hematoma (a localized collection of blood) to the right side of her forehead. The attending physician, who was on site, assessed the resident, and the responsible party declined hospital transfer. A witness statement dated March 21, 2025, at 9:00 AM, from Employee 2, documented that while she was pushing Resident 1 in the Broda chair, the resident began rocking forward. As the employee attempted to stop the chair, the resident leaned forward and fell out, resulting in injury. During an interview conducted on April 3, 2025, at approximately 2:30 PM, Employee 2 stated she had recently started working at the facility and had not received training on the use or adjustment of the Broda wheelchair. She explained that she was responsible for transporting residents from the dining room to the activity room but did not adjust the chair into the reclined position prior to transport on March 21, 2025. Employee 2 was unaware the upright position was not appropriate for transport. In an interview with Employee 3 (Activities Director) on April 3, 2025, at approximately 10:00 AM, it was confirmed that Employee 2 was new and on orientation at the time of the incident. Employee 3 further stated that Employee #2 had not been trained on the proper positioning and handling of the Broda chair during transport. In a separate interview with Employee #4 (Activities Aide) on April 3, 2025, at approximately 12:30 PM, the staff member explained that activity aides were expected to assist with transporting residents but were not permitted to adjust or reposition specialized chairs such as the Broda chair, either before or after transport. In an interview with the Nursing Home Administrator (NHA) conducted on April 3, 2025, at approximately 1:00 PM, the NHA acknowledged the facility had not provided training to staff on the proper use and positioning of the Broda chair. A clinical record review revealed Resident 3 was admitted to the facility on [DATE] with diagnosis to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and atrial fibrillation (an irregular heartbeat). A quarterly MDS assessment dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 4. A review of the resident's care plan, initiated on April 10, 2024, identified the resident as being at risk for falls related to declining functional status. Interventions included assistance of one staff member for transfers. However, the care plan did not define the level of assistance required for bed mobility or toileting, despite the resident's increasing physical and cognitive decline. The resident was also noted to be resistive to care, with the only documented intervention being to leave and re-approach after five to ten minutes if care was refused. There was no care card or [NAME] (a list of instructions for nurse aide staff to ensure the provision of care provided is accurate) in use January 29, 2025, to guide nurse aide staff on the number of staff required or the method of assistance needed for bed mobility or toileting tasks. The following incidents involving Resident 3 were identified. January 29, 2025, at 8:37 AM: A facility investigative report and nursing documentation indicated the resident was found on the floor with a 2 cm x 2 cm abrasion to the center of his lower back. The physician was notified, and a treatment plan was obtained. There was no indication of a witnessed fall, or documented interventions reviewed or revised following this incident. February 6, 2025, at 7:15 PM: facility investigative documentation and nursing documentation noted the resident fell from the bed during provision of care. A 0.3 cm x 0.4 cm skin tear was observed on his left heel. A review of Employee 9's NA witness statement dated February 6, 2025, at 7:15 PM, indicated the employee was in the middle of changing Resident 3 in bed when he became agitated and rolled out of the bed onto the floor. Employee 9 stated she yelled out for help. A review of a witness statement from Employee 8 (LPN) dated February 6, 2025, at 7: 15 PM stated that Employee 9 had informed her the resident had fallen while being changed. It was indicated that the resident rolled over too far and fell onto the floor. There was no documentation indicating that two staff were present, nor was there evidence the care plan had been updated to address agitation during care or to require additional staff during bed mobility. A review of a facility investigative documentation and nursing documentation dated March 8, 2025, at 8:00 PM, indicated the resident was again found on the floor after having previously been in bed. No injuries were noted, and the physician was contacted. A new intervention to apply nonskid strips on the floor to the right side of the bed was implemented. A review of a facility investigative documentation and nursing documentation dated April 2, 2025, at 1:45 AM revealed Resident 3 was found in bed with active bleeding. Assessment revealed a 1.5 cm x 1.5 cm V-shaped laceration on the back of his head and a 10 cm laceration to his lower right arm. The resident reported he had fallen out of bed and then put himself back in bed. Given the resident's use of anticoagulation medication, the physician was notified, and the resident was sent to the hospital. Facility investigation determined the resident had turned off the bed alarm, contributing to the fall. A new intervention to add a magnetic alarm box was implemented after this event to alert staff of unsafe transfers or falls. A review of nursing documentation dated April 2, 2025, at 2:04 AM revealed the resident was transported to the hospital for evaluation and treatment. Nursing documentation dated April 2, 2025, at 6:11 AM revealed hospital staff reported a CT of the head showed negative results, but the resident required two staples to the back of the head and treatment for the arm laceration. The resident returned to the facility at approximately 10:40AM. Despite multiple incidents and injuries, there was no documented evidence that the facility implemented effective and individualized interventions to prevent the recurrence of falls. The care plan was not updated to reflect changes in the resident's fall patterns, behavioral triggers, or the need for increased staff assistance during personal care tasks. In an interview with the Nursing Home Administrator (NHA) on April 3, 2025, at 3:00 PM, the NHA confirmed the facility failed to implement effective interventions to address and prevent repeated falls for Resident 3. The NHA acknowledged that despite known behavioral risks and multiple incidents, the care plan and staff guidance had not been adequately revised or communicated. A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include chronic obstructive pulmonary disease (COPD a progressive lung disease causing difficulty with breathing). A quarterly MDS assessment dated [DATE], revealed the resident to be cognitively intact with a BIMS score of 14 (13 to 15 indicates cognitively intact), required staff assistance for activities of daily living and utilized a wheelchair for mobility. A wander risk assessment dated [DATE], identified the resident to be at moderate risk for wandering, and the resident was provided a Wander guard (an electronic device that alerts staff when a resident approaches an exit). However, a subsequent assessment dated [DATE], indicated a low risk for wandering, and the physician's order documented that the Wander guard was discontinued the same day. The resident's care plan for potential elopement related to exit-seeking behavior, initiated on April 24, 2024, included interventions such as frequent location checks, reorientation as needed, providing diversionary activities, and use of a Wander guard. However, following the March 10 assessment, the Wander guard was removed, and other interventions remained in place. A facility investigation report and nursing documentation dated March 21, 2025, at 2:39 PM, documented that the facility received a telephone call at approximately 2:48 PM from an unidentified passerby reporting a resident outside the facility alone. Staff responded and found Resident 2 in the parking area at the edge of facility property near the parking lot. A review of surveillance footage revealed the resident had exited the resident care area into the lobby at 2:32 PM and left the building through two sets of front doors by 2:39 PM. The footage showed the resident wheeling himself through the parking lot and toward the sidewalk before the resident was safely returned inside at approximately 2:50 PM with no injury noted. A review of Employee 6's (NA) witness statement dated March 21, 2025, at 3:05 PM, revealed the employee stated she was coming back from an appointment when she saw Resident 2 rolling himself away from the building. The employee indicated she called the facility to notify someone he was outside and two staff came outside to get him. A review of Employee 7's NA witness statement dated March 21, 2025, at 2:45 PM, indicated she received a phone call from a man reporting that a resident was wheeling himself through the bushes. She and a nurse (identity unconfirmed) went outside and observed Resident #2. When asked, the resident reportedly stated he was going for a walk. The facility could not provide a witness statement from the second staff member who retrieved the resident, nor was the nurse identified by name. A review of facility documentation revealed the resident wanted to go outside for a walk and was looking for Ivette. Interventions put into place after the incident were to place a Wander guard (a wearable device used in healthcare settings, particularly for memory care or senior living facilities, to help prevent residents from wandering or eloping) on the resident and to initiate every 15-minute checks. In an interview conducted April 3, 2025, at approximately 1:00 PM, the Nursing Home Administrator (NHA) explained that at the time of the incident, the designated front desk receptionist was not on duty. Per facility protocol, the Activity Director (Employee 3) was assigned to monitor the front lobby when the receptionist is unavailable. The NHA confirmed that the lobby doors are typically locked between 4:00 PM and 8:00 AM, with keypad access, but they remain open during daytime hours. He further stated the receptionist normally remains at the desk during her meal breaks. In a follow-up interview with Employee 3 (Activity Director) on April 3, 2025, at 1:30 PM, the employee stated she had been assigned to cover the front desk that day, in addition to her regular duties. She noted that on March 21, 2025, she left the building at approximately 12:30 PM to purchase supplies for a special activity and returned around 1:30 PM. From 1:45 PM to 2:30 PM, she was in the activity room setting up and conducting the event. She then took her break from 2:30 PM to 2:50 PM, during which the front lobby was left unattended. Upon returning, she saw staff bringing Resident 2 back into the building. A review of facility records showed that following the incident, elopement/wander risk assessments were completed on all residents on March 21, 2025, as part of a facility-wide review. In an interview on April 3, 2025, at 3:00 PM, the Director of Nursing (DON) and the NHA confirmed the lobby had been unattended at the time of the incident and acknowledged this contributed to the resident's ability to exit the building. While they acknowledged the lapse in supervision, they emphasized the resident remained on facility property, did not enter the public roadway, and was returned safely without injury. They indicated although the resident was outside briefly, the facility responded promptly, and the resident experienced no physical harm. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

APPEAL FILED Based on a review of clinical records and staff interviews it was determined that the facility failed to implement sufficient measures to prevent development and worsening of pressure ulcer/injury (injury occurs as a result of intense and/or prolonged pressure) for one resident out of 1 sampled resident (Resident 52). Findings included: A review of the clinical record revealed Resident 52 had diagnoses, which included [MEDICAL CONDITION] ( a progressive disease that destroys memory and other important mental functions), [MEDICAL CONDITION] (loss of ability to understand or express speech, caused by brain damage), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left and right hand. A quarterly Minimum Data Set assessment ( MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated (MONTH) 11, 2019, revealed that the resident was severely cognitively impaired and never/rarely made decisions. The resident required extensive assistance with activities of daily living, has functional limitation of range of motion of upper and lower extremities and was identified as at risk for development of pressure ulcers. A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated (MONTH) 16, 2019, revealed the resident received a score of 8, indicating that the resident was at very high risk for pressure sore development. A review of the resident's care plan initiated on (MONTH) 10, 2019, and revised (MONTH) 2019, revealed that the resident had contractures of bilateral hands and the goal was that the resident will tolerate a splints (palm rolls) without signs and symptoms of skin breakdown thru next review. Interventions planned included that staff were to assess the resident for pain, assess resident's skin and circulation under the device and the use of a positioning device, palm rolls to bilateral hands daily, which staff were to remove for hygiene and skin checks every shift. A review of the clinical record revealed an interdisciplinary progress note dated (MONTH) 24, 2019, at 12:13 p.m. indicated that physical therapy staff notified Employee 2, a licensed practical nurse, that the resident had new pressure areas on bilateral thumbs. Upon nursing assessment the resident's left thumb presented with purulent (discharging pus) drainage and an odor along with [MEDICAL CONDITION] (swelling) present in both thumbs. The physician was made aware and prescribed an antibiotic (a drug used to treat bacterial infections ([MEDICATION NAME] 875-125 milligrams (mg) twice daily for 10 days)). Review of a Pressure Ulcer Investigation dated (MONTH) 24, 2019, indicated the resident has a history of pressure areas and this was a reoccurrence. The facility's investigation noted that the palm rolls were in place at the time the pressure areas were identified. There was no indication of the size or stage of the two pressure areas identified at this time. Review of facility pressure ulcer records dated (MONTH) 28, 2019, completed by Employee 3, Assistant Director of Nursing, Registered Nurse, revealed that the pressure area on the resident's right thumb was a Stage IV pressure ulcer (full thickness skin and tissue loss) with measurements of 2 centimeters (cm) x 1 cm x 0.2 cm and the pressure area on the resident's left thumb was a a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon purple discoloration due to damage of underlying soft tissue) with measurements of 2 cm x 1.5 cm x 0 cm. A review of VOHRA wound physician (specialty wound care physician) documentation dated (MONTH) 28, 2019, revealed that the resident had a Stage IV pressure wound of the right first finger measuring 2 cm x 1 cm x 0.2 cm with light serous exudate (a mass of cells and fluid that has seeped out of a blood vessel, especially in inflammation) and an unstageable deep tissue injury of the left first finger measuring 2 cm x 1.5 cm x 0 cm. A review of the resident's Treatment Administration Record (TAR) from the time period of (MONTH) 1, 2019, through (MONTH) 30, 2019, revealed that staff had not consistently implemented the planned intervention (palm rolls and skin and circulation under device) to bilateral hands as ordered. There was no documented nursing entry during the shift prior to therapy's discovery of the Stage IV and Deep tissue injury identified on the resident's bilateral thumbs on (MONTH) 24, 2019. There was no documented evidence that nursing staff had consistently been applying the palm rolls as ordered. According to the resident's care plan nursing staff was to assess the resident's skin and circulation under the device when used and during hygiene and skin checks every shift. However, nursing documentation failed to identify changes or declines in the resident's skin integrity prior to therapy identifying the bilateral pressure areas on the resident's hands. Interview with the Director of Nursing on (MONTH) 23, 2019, at approximately 10:30 a.m. confirmed that the staff are required to document the completion/provision of the planned interventions/preventative devices on the TAR. The DON confirmed there was no documentation of skin condition and circulation under the palm rolls the shift prior (June 23, 2019 7 p.m.-7 a.m.) therapy discovering the pressure sore and verified that the facility was unable to demonstrate that the planned interventions were consistently implemented to prevent the development of the bilateral thumb pressure injuries. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services previously cited 7/27/18, 1/30/19, 3/7/19, 4/2/19 28 Pa. Code 211.5(f) Clinical Records. previously cited 7/27/18, 3/7/19, 4/2/19

Based on review of clinical records and staff and resident interviews it was revealed that the facility failed to implement sufficient measures necessary to protect residents from sexual harassment and abuse for one of four residents reviewed (Resident 57). Findings include: A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on (MONTH) 27, (YEAR), with diagnoses, which included unspecified [MEDICAL CONDITION] (mental disorder that affects the brain), anxiety (an emotion characterized as an unpleasant state of turmoil), recurrent [MEDICAL CONDITION] (persistent feelings of sadness), nicotine dependence and [MEDICAL CONDITION]. A review of the resident's most recent annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 25, 2019, revealed that the resident was independent with ambulation. The Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) revealed that the resident scored a 15, which indicated that he was cognitively intact. A review of the clinical record revealed that Resident CR1 had recently eloped from the facility through the window in his room, on (MONTH) 26, 2019, but was later returned without injury. In response to that elopement, the facility placed the resident on every 15 minute checks. According to an interview conducted on (MONTH) 7, 2019, at 9:37 AM with Employee 4, a Nurse Aide, she stated then when she arrived to work on (MONTH) 20, 2019, at 5:30 AM she stated Employee 5, a Licensed Practical Nurse (LPN), informed her to keep an eye on female resident, Resident 59, who was known to wander around the facility in and out of resident rooms. Employee 4 stated that Resident 59 had been found in Resident CR1's bathroom the prior shift. A review of Resident 59's clinical record revealed that she was cognitively impaired with a BIMS score of 3. The Director of Nursing (DON) was interviewed on (MONTH) 7, 2019, at 10:00 AM regarding Resident 59 being in Resident CR1's bathroom. The DON stated that she was unaware of the situation, until she interviewed staff following a recent sexual incident involving Resident CR1 and another female resident, Resident 57, which had occurred on (MONTH) 23, 2019. Interview with Employee 5, LPN on (MONTH) 7, 2019, at 9:50 AM revealed that on (MONTH) 20, 2019, Resident 59 was wandering and had to be redirected out of Resident CR1's room by a NA (Employee 6). Employee 6 confirmed during an interview on (MONTH) 7, 2019, at 10:15 AM that she had redirected Resident 59 out of Resident CR1's room as stated by Employee 5. According to the facility's documented every 15 minute checks, Resident CR1 was in bed from 12:00 AM until 8:30 AM on (MONTH) 20, 2019. The DON stated during an interview on (MONTH) 7, 2019, at 10:00 AM that Resident CR1's roommate was not interviewed following Resident 59's wandering into their room because his BIMS score was low and he was not reliable. A review of the clinical record of Resident 26, Resident CR1's roommate, revealed that he had BIMS score of 9, which indicated that he is moderately cognitively impaired. The resident was noted to be able to understand others and able to make his needs known. Interview with Resident 26, on (MONTH) 7, 2019, at approximately 2:30 PM revealed that the resident stated that not too long ago my roommate (Resident CR1) was in the bathroom with a lady, she was, you know, kind of slow. Resident 26 stated that he knew that his roommate, Resident CR1 was in the bathroom with someone because he had been trying to get into the bathroom when Resident CR1 and the lady came out. Resident 26 stated that when Resident CR1 came out of the bathroom he threw up his hands and stated I didn't' touch her. The facility was unable to confirm Resident 26's account of this incident and Resident 26 was unable to recall the specific date it had recently occurred when interviewed during the survey ending (MONTH) 7, 2019. A review of the clinical record revealed that Resident 57 was admitted to the facility on (MONTH) 18, 2013, with [DIAGNOSES REDACTED]. The resident was cognitively impaired and her BIMS score was 0. She was unable to understand others and unable to make her needs known. She was dependent on staff for activities of daily living care and required two persons for assistance for most tasks. A review of the 15 minute checks of Resident CR1 revealed that on (MONTH) 23, 2019, between 8:00 AM and 8:15 AM Resident CR1 was in the activity room (green room) and at 8:30 AM he was observed in the hallway. A statement written by Employee 2, a dietary aide, at 8:22 AM (time of written statement) revealed that she walked into the green room and saw Resident CR1 with his hand in his pants playing with himself touching female Resident 57 on her chest area. Employee 2 did not attempt to verbally intervene, redirect, summon other staff while remaining with the residents or separate the residents at that time. However, Employee 2 went to the nurses station and reported her observation to the RN, (Registered Nurse) Employee 3. At approximately 8:30 AM, Employee 1, LPN, stated that she walked into the activity room (green room) and observed Resident CR1 standing along side of Resident 57's Broda chair (a tilt-in-space positioning chair). Resident CR1's hand was observed on his exposed penis and his other had was down Resident 57's blouse touching her breast. Employee 1 asked Resident CR1 what he was doing; he then adjusted his pants and bolted from the green room, his belt was still intact. Employee 1 reported this observation to Employee 3, the RN. Employee 1 stated that when she went to the nurse station to report her observations to Employee 3, Employee 2 was there reporting what she had observed. The facility interviewed Resident CR1 after the incident with Resident 57 and he stated I touched her (grabbing his chest) and I touched here (grabbing his genitals). The resident was immediately placed on continuous one to one direct supervision on (MONTH) 23, 2019, at 8:45 AM. The local area police arrested Resident CR1 at 2:40 PM on (MONTH) 24, 2019, and charged him with indecent assault to a person with mental disability. Resident CR1 was unable to post bail and was housed in the county prison awaiting a preliminary hearing dated (MONTH) 27, 2019. A review of Resident CR1's prior public court records indicated that on (MONTH) 16, (YEAR), he was charged with stalking (engaging in conduct repeatedly causing fear), harassment (to annoy or alarm another person) and open lewdness (an act observed by others which would cause alarm), but was never convicted and the charges were dismissed at that time. The facility was unaware of these prior charges. The facility failed to ensure that Resident 57 was free from sexual abuse perpetrated by Resident CR1. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 1/30/18, 7/27/18 28 Pa. Code 201.18(e)(1) Management Previously cited 1/30/19, 7/27/18, 3/6/18, 8/3/17 28 Pa. Code 201.29(a) Resident Rights Previously cited 8/3/17 28 Pa. Code 201.29(c) Resident Rights 28 Pa. Code 201.29(d) Resident Rights Previously cited 7/27/18 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 1/30/19, 7/27/18, 3/6/18, 11/28/17, 9/20/17, 8/3/17

Based on observations, a review of clinical records and resident incident/accident reports and staff and resident interview, it was determined that the facility failed to provide adequate staff supervision to prevent an elopement by one resident (Resident 1) out of seven residents reviewed. Following this elopement the facility further failed to immediately rectify an unsafe environmental condition and prevent access to tools, which facilitated the resident's ability to elope to prevent another elopement, which placed residents in immediate jeopardy of future unsupervised exits from the facility. Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The facility identified the resident as a smoker and the resident continued to smoke during his stay at the facility. A quarterly Minimum Data Set Assessment (MDS -a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 3, (YEAR), indicated that the resident was cognitively intact and was able to ambulate independently throughout the facility. A review of a facility incident investigation report dated (MONTH) 26, 2019, at 1:00 PM revealed that Resident 2 informed a housekeeper that he saw Resident 1 walking outside the facility in the direction of a local manufacturing plant, which was located immediately adjacent to the front of the facility building. The housekeeper notified the nursing supervisor, Employee 1 (RN). The facility was searched and staff were dispatched to search the grounds in response to Resident 2's report received at 1:00 PM on (MONTH) 26, 2019. According to the facility's report the resident was found and returned to the facility (time the resident was located and returned to the facility was not documented). The resident was found on the property of a high school located approximately 0.7 miles away from the facility. The temperature outside was 33 degrees Fahrenheit as per local area weather. The resident was noted to be wearing a coat when found. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on (MONTH) 30, 2019, at 4:30 PM also failed to identify how long the resident was missing from the facility. Employee 2, LPN (Licensed Practical Nurse) reportedly last observed the resident leaving the dining room at approximately 12:50 PM on (MONTH) 26, 2019. Further review of the facility's incident investigation report dated (MONTH) 26, 2019, revealed that the resident was alert and oriented to person, place and time. The resident is able to ambulate independently throughout the facility (one story building). The report noted that the window in the resident's room was found open and the safety locks (screws surrounded by rubber) removed. Upon interview by the facility staff, when located, the resident confirmed that he had removed the safety locks on the window in his room. The resident stated I wanted to go for a smoke, I was tired of being here and not being able to smoke. Resident 1 was assessed with [REDACTED]. Upon the resident's return to the facility on (MONTH) 26, 2019, (no time noted) the facility assigned 1:1 staff supervision of the resident for 72 hours, then every 15 minute checks. The facility also applied a Wanderguard bracelet (an electronic monitoring device which alarms when a resident (who is wearing the device) gets in close proximity to an alarmed door) to the resident's wrist. (Windows are not part of the facility's Wanderguard electronic monitoring system). The facility further planned to offer [MEDICATION NAME] gum (a smoking cessation gum) to the resident when conditions (weather) are inclement. When the resident would like to smoke, the facility noted we will accommodate his needs to the best of our ability. During an interview on (MONTH) 30, 2019, at 4:00 PM the DON and the NHA stated that the windows in the facility were secured with a screw surrounded by a rubber [MEDICATION NAME] with its surrounding casing placed in the window casement track; these [MEDICATION NAME] were positioned so that the window can only be opened approximately 6 inches from the bottom of the window. The NHA stated that after Resident 1's elopement on (MONTH) 26, 2019, maintenance staff had checked all the windows to ensure that the [MEDICATION NAME] (screws surrounded by rubber) were screwed in place. The NHA further stated that Resident 1 had used the file part of his metal nail clippers to unscrew the screw, remove the [MEDICATION NAME] and fully raise the window open allowing him to exit the building without being seen by staff. The NHA and DON confirmed that multiple residents residing in the facility were in possession of their own metal nail clippers, similar to the type used by Resident 1 to unscrew the window safety lock. The observations conducted during a tour of the facility on (MONTH) 30, 2019, at approximately 4:15 PM of the resident windows, as well as, the windows in the dining rooms and activity rooms revealed that in resident room [ROOM NUMBER], the [MEDICATION NAME] was easily pulled out of the window track, without any tool, allowing the window to be fully raised. In resident room [ROOM NUMBER], the [MEDICATION NAME] was easily manually pulled out of the window on the right side and the [MEDICATION NAME] on the left side of the window was missing. In resident room [ROOM NUMBER], the window [MEDICATION NAME] was easily pulled out manually without tools of any kind. In Resident 1's room, room [ROOM NUMBER], observation revealed that a(NAME)head screw, approximately one inch in length, had been screwed into the track on the left side window. There were no rubber [MEDICATION NAME] on the resident's window and the singular screw had been screwed into the track in a manner in which its recess depth was too low for it to catch the window to prevent it from rising. The surveyor was easily able to open the window at the time of this observation. Resident 1, at surveyor request, was also able to easily open the window, without using a tool of any kind at the time of this observation on (MONTH) 30, 2019, at approximately 4:30 PM. During an interview (MONTH) 30, 2019, at approximately 4:45 PM Resident 1 stated that on (MONTH) 26, 2019, after lunch at approximately 12:30 PM the resident wanted to go outside to smoke. The resident stated that the next facility scheduled smoking period was not until 3:30 PM. The resident explained that he had used his nail clippers to remove the screw in the window track, opened the window, removed the screen and exit the building through the window. The resident stated that he did have his coat on and that it was cold outside that day. The resident further stated that he keeps his nail clippers with him. The resident then removed the clippers from his pants pocket and showed them to the surveyor. Resident 1 further stated that when he got outside he walked down the street where the facility is located then crossed the main road (state route) and entered a mini mart, where he purchased cigarettes and a lighter. He stated that he continued walking towards the local high school. The resident stated that he was walking to another town where his sister lived. Nursing staff from the facility picked him up at the high school and drove him back to the facility. The resident stated that he was out of the facility for about a half hour. Resident 1 relayed that when the weather is bad, they (staff) will not let residents go outside to smoke. During an interview (MONTH) 30, 2019, at approximately 4:55 PM the NHA stated that the window [MEDICATION NAME] (screw surrounded by rubber) had been in place since the facility was opened (1996) and are checked by maintenance monthly. Following Resident 1's elopement and the facility's awareness of the means by which the resident had successfully eloped from the facility on Janaury 26, 2019, the facility failed to immediately check the functionality and placement of window [MEDICATION NAME] to ensure security of the windows in each resident room and common area. The facility further failed to ensure that those residents with metal nail clippers in their possession, including Resident 1, were assessed for continued appropriateness of safe independent use and security of storage. As the result of the facility's failure to promptly act upon the factors, which contributed to Resident 1's elopement, which had yet to be addressed at the time of the survey, Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator on (MONTH) 30, 2019, at 5:00 PM. The facility's corrective action plan included: 1. All windows were inspected for integrity and dry rot. All, are in proper working condition without any dry rot noted. Vinyl track in windows is a covering over wood and intact. 2. Window [MEDICATION NAME] were placed utilizing a star shaped headed screw that requires a specialized bit for removal. Cannot be removed with common objects. [MEDICATION NAME] was placed 37 inches from window sill allowing window to be opened 6 inches. 3. Special star shaped screws were used to secure window front to back and will remain in place until warmer weather. 4. Resident 1 will no longer have nail clippers in his possession. 5. Resident 1 was on a 1:1 observation for 72 hours then placed on a every 15 minute watch until he will be assessed in 30 days for continued elopement risk. Resident 1 currently has a Wanderguard in place. Order was obtained for [MEDICATION NAME] gum for when the resident cannot go outside to smoke because of inclement weather. Prior to incident, this resident was not an elopement risk. Residents reassessed for elopement risk. 6. Residents that utilize nail clippers have been educated on use and proper storage for safety. 7. Staff and residents were made aware of the reason why the windows have been secured. 8. Maintenance will do audits weekly times 2 months and then monthly thereafter to ensure all windows in the residents areas remain secure. Following verification of the implementation of the corrective action plan, a tour of the facility and inspection of all windows the Immediate Jeopardy was lifted at 7:30 PM on (MONTH) 30, 2019. Cross refer F868, F835 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 7/27/18, 8/3/17 28 Pa Code 201.18(e)(1) Management Previously cited 7/27/18, 3/6/18, 8/3/17 28 Pa Code 201.18(e)(3) Management Previously cited 7/27/18, 8/3/17 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 7/27/18, 3/6/18, 8/3/17 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services Previously cited 7/27/18, 3/6/18, 11/28/17, 9/20/17, 8/3/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 7/27/18, 3/6/18, 11/28/17, 8/3/17

Based on observation, staff interview and review of clinical records and investigations into the development of pressure ulcers (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence {areas where bones are close to the surface} as a result of pressure, or pressure in combination with shear and/or friction) it was determined that the facility failed to timely identify declines in skin integrity and promptly address contributing and/or risk factors and provide necessary care or revise existing interventions, to prevent the development and/or worsening of multiple pressure sores for one resident out of 15 sampled (Resident 7 ). Findings include: A review of the clinical record revealed that Resident 7 had diagnoses, which included [MEDICAL CONDITION] (a nervous system disease that affects the brain and spinal cord), constipation and [MEDICAL CONDITION] bladder (bladder dysfunction caused by neurologic damage) . The resident had a supra pubic catheter (a catheter {thin flexible tube} inserted into the lower abdomen through the skin into the urinary bladder to drain urine) for urine output. The resident was frequently incontinent of bowel, with formed bowel movements every two to three days, according to a review of bowel records. Review of a July 6, 2016, quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) revealed that the resident's BIMS score (Brief Interview for Mental Status -a tool to assess cognitive function) was 8 (8-12 moderately cognitively impaired). The resident required total assistance of two staff for activities of daily living to include bed mobility, transfer and toilet use. The resident had limited mobility of her lower extremities. The resident utilized a suprapubic catheter and was frequently incontinent of bowel. The resident was identified at high risk for developing pressure ulcers and had a MASD (Moisture Associated Skin Damage - a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus. It is proposed that for MASD to occur, another complicating factor is required in addition to mere moisture exposure, such as mechanical factors of friction), the location of which was not verified. Review of the facility's Skin Check forms dated September 6, 2016, revealed that the resident had an active skin condition present, but the form did not describe or explain the appearance of the resident's skin condition. Review of nursing documentation dated September 7, 2016, at 6:31 PM revealed that the resident was found with a reddened discolored open area on the left buttock identified as MASD. The physician was notified at that time and orders were obtained for Hydrogel (highly absorptive wound dressing that maintains the wound in a moist state to promote healing) daily; covered with a dry dressing and re-evaluate in 7 days. On September 10, 2016, the resident's left sacral area (bottom of the spine) was also found to have an MASD area. The physician ordered Santyl ointment ( an enzymatic [MEDICATION NAME] wound cleanser that selectively removes necrotic {dead} tissue without harming healthy {granulation} tissue) daily; covered with a dry dressing daily. Review of nursing documentation dated September 23, 2016, at 2:05 PM revealed that new wounds were identified during wound rounds. A Stage IV pressure area ( full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead) tissue may be present) was identified on the resident's right ischium (curved bone forming the base of each half of the pelvis) measuring 7 cm x 4 cm x 1 cm and a Stage III pressure sore (full thickness skin loss involving damage to, or necrosis (death) of, subcutaneous (below the skin) tissue) to the sacrum measuring 4 cm x 1 cm x .1 cm. The physician prescribed Santyl for both wounds and cover with a dry dressing. The entry noted that the resident had all preventative measures in place: a low air loss mattress in bed and a pressure relieving cushion when out of bed in the chair. The resident had catheter for urinary output and was on an every two hour turn schedule. The plan was to continue with all preventative measures. Review of a facility incident investigation into the resident's multiple pressure areas dated September 23, 2016, at 10:38 AM revealed that during routine wound rounds the resident was noted to have a Stage III pressure area measuring 4.0 centimeters (cm) x 1.0 cm x 1.0 cm depth on the sacrum and a Stage IV pressure area to the right ischium measuring 7.0 cm x 4.0 cm x 1.0 cm depth. These wounds were described as acquired at the facility and the result of pressure. The pressure areas were observed by the facility's wound team, to include the wound care physician, who ordered Santyl daily covered with a dry dressing. There was no documented evidence that the facility had evaluated the adequacy, or verified the consistent implementation, of these planned preventative measures on September 23, 2016, when the resident was identified with new pressure sores, at a Stage III and Stage IV. There was no indication that the facility had ensured that the resident was being turned and repositioned at the frequency necessary to prevent the development or worsening of pressure sores. A review of a Pressure Ulcer Record dated September 23, 2016, revealed that the pressure area on the resident's sacrum was not present upon admission but was acquired at the facility. The Stage III pressure ulcer was identified on September 23, 2016, and the identified risk factors were noted as incontinence and immobility. There was no documented evidence that the facility had revised the resident's pressure ulcer prevention measures to address these specific risk factors after the resident had developed pressure ulcers with the existing preventative interventions in place. Further review of the facility's investigation into the pressure areas dated September 26, 2016, revealed that the wounds increased in size. The sacral wound now measured 6.5 cm x 2.2 cm x 1.0 cm depth and the wound on the right ischium had increased in depth and now measured 6.5 cm x 6.5 cm x 2.0 cm depth. The physician was notified of the decline in the pressure sores and orders were obtained for laboratory blood work for a pre-[MEDICATION NAME] (a protein level used as a marker for malnutrition), which was low at 8.9 mg/ml (norm 18-45) and [MEDICATION NAME] (measures protein stores in the body), which low at 2.3 g/dl (norm 3.8-5.0). The resident was placed on a nutritional supplement twice daily, fortified foods, and liquid protein three time daily for wound healing on September 26, 2016. Further review of the Pressure Ulcer Record dated September 30, 2016, also revealed that the Stage III pressure area on the resident's sacrum had worsened. The Pressure Ulcer Record did not include measurements of the wound on that date. On October 3, 2016, after the development of the Stage III and Stage IV pressure sores, a Clinitron bed (Air Fluidized Therapy beds provide an ideal healing environment for compromised skin by minimizing the forces that cause tissue breakdown: pressure, shear, friction, heat and moisture) was added as an intervention. Additionally, a 1 inch pressure re-distribution cushion when out of bed in the wheel chair. The resident's care plan on October 3, 2016, noted the current approaches of wound consulting with physician; weekly skin assessments, encourage turning and repositioning every 2 hours, incontinence care and use of a draw sheet to lift and turn the resident were added to the resident's care plan Observation of the wound on the resident's sacrum on August 2, 2017, at 10:55 AM revealed that the sacral site was a Stage III with depth (nurse did not perform measurements at the time of this observation). The wound was clean and without drainage. There were multiple reddened areas on the resident's left buttock and on the resident's right buttock areas of dark discolorations were observed. During interview with the charge nurse (Employee 4, LPN ) performing the resident's pressure sore treatment, at this time revealed that the wound care physician had debrided the pressure sore on the resident's sacrum and right ischium multiple times since their discovery during September 2016. Employee 4 stated that the pressure sore on the resident's sacrum continued to be a Stage III, but the pressure sore on the resident's right ischium had healed on February 24, 2017. Interview with the Director of Nursing (DON) on August 2, 2017, at approximately 2:00 PM failed to provide evidence that the facility had timely identified the resident's risk factors for skin breakdown and promptly implemented necessary measures to prevent the development and/or worsening of pressure sores. The DON was unable to provide evidence that the resident's development pressure ulcers were unavoidable. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/14/15 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 3/2/17, 1/3/17, 7/8/16, 2/18/16, 10/14/15, 8/14/15 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited 3/2/17, 7/8/16, 2/18/16, 10/14/15, 8/14/15

Based on a review of clinical records, facility documentation, select facility policy and staff interview, it was determined that the facility failed to timely and effectively monitor fluid intake for a resident experiencing a change in condition, including symptoms which increase hydration needs, and promptly implement necessary supportive interventions to prevent dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will become dehydrated) developed by one of 15 residents reviewed (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR 1 had [DIAGNOSES REDACTED]. Review of a Nutrition Risk Review, (a facility form used for nutritional assessment of residents) dated June 13, 2017, noted that the resident's weight was 145 pounds and the resident's hydration need was 1,800 cc (cubic centimeters) of fluid per day. The resident's appetite at meals, at the time of this assessment was noted as greater than 75%, including 50% to 75% of fortified potatoes and nutrition shakes (nutritional supplementation interventions). A nurse progress note dated June 28, 2017, at 6:19 PM indicated that the resident's appetite was poor at dinner. The staff encouraged the resident to eat and drink, but the resident became combative with any staff assistance. Nursing noted that the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were stable, but the resident's speech was garbled. Nursing notified the physician and the physician directed nursing staff to monitor resident for changes in vital signs and report any significant change in status. A nursing progress note dated June 29, 2017, at 7:02 PM indicated that Resident remains alert, disoriented and confused. Resident not making appropriate responses. Refusing any assistance for staff for meals, appetite and fluid intake remains poor. Vital signs remain stable. Will continue to observe. A nursing progress note dated June 30, 2017, at 7:11 AM revealed that the resident had an elevated temperature of 100 - 101.5 degrees Fahrenheit ( normal temperature is 98.6 degrees Fahrenheit) between 10 PM and 6:30 AM, for which Tylenol 650 mg (milligrams) was administered as ordered by the physician. A nursing progress note dated June 30, 2017, at 2:14 PM noted that the Resident is not taking any substantial amount of food in, refusing liquids like nutrition shakes or even water, some applesauce has been taken with some medication, residents family members present, and son notified of condition. Appetite decrease refusal of food and drink sluggish mentation and change. Physician notified and requested urinalysis and urine culture and sensitivity (lab test to determine the presence of an infection). A nursing progress note dated June 30, 2017, at 3:26 PM indicated that the resident had a fever of 100.3 degrees Fahrenheit during the whole nursing shift and was being monitored. The physician was made aware but no new orders were received. A nursing progress note dated June 30, 2017, 11 PM stated Resident refused fluids totally (no oral intake) so far this shift. Resident voiding without difficulty and incontinent (having no or insufficient voluntary control over urination) of yellow urine, no change in urine smell. A nursing progress note dated July 1, 2017, at 12:11 PM stated Resident combative with staff members. Attempted straight catheterization (insertion of a catheter (flexible plastic tubing) into the bladder to relieve retention of urine) for urine (lab specimen), but was unsuccessful. Resident agitated with this nurse; hitting biting scratching. Fluid intake poor, despite much encouragement. Speech garbled. Physician and son aware of same. Will continue to observe. A nursing progress note dated July 1, 2017, at 9:24 PM stated resident in bed. Refused all medications and fluids. Several attempts made. Will continue to observe. A nursing progress note dated July 3, 2017, 12:30 PM indicated that the nursing placed a call to physician concerning resident refusing meals, fluids and all medications. Made physician aware resident's condition is declining. Increased confusion. Urinalysis and culture was obtained awaiting results. Son made aware of same. A nursing progress note dated July 4, 2017, at 9:17 AM revealed that the resident's urinalysis was positive for a urinary tract infection and the physician's office was notified of the positive urinalysis results. Antibiotic therapy was initiated for the treatment of [REDACTED]. Nursing noted on July 5, 2017, at 2:09 PM that the resident refused lunch and spit our her morning medications. The resident's lab test results dated July 6, 2017, at 7:37 AM revealed a critically elevated sodium blood sodium level (lab study to determine the balance between the sodium and water) level of 164 mmol/L (normal 135-146), an elevated BUN (blood urea nitrogen is a lab test done to see how well your kidneys are working; heart failure, dehydration, or a diet high in protein can also make your BUN level higher) of 67 mg/dl (normal 6-20 mg/dl) and an elevated Creatinine (test that helps determine whether the kidneys are functioning normally) level of 1.5 mg/dl (normal 0.5- 1.0 mg/dl). These lab values are also indicators of hydration status, which may become elevated with dehydration. A nursing progress note dated July 7, 2017, 4:37 PM stated Resident continues antibiotic therapy for urinary tract infection [MEDICAL CONDITION]. Resident's general condition declining. Appetite poor and fluids taken with encouragement. Resident needs much encouragement and assistance with activities of daily living. A nursing progress noted dated July 8, 2017, at 1:41 AM revealed that the resident's vital signs were no longer stable, with decreased blood pressure (90/53 mm/Hg-millimeter of mercury), oxygen saturation levels (amount of oxygen in the blood, usually range from 95 to 100 percent) were 80% on room air and temperature 96.9 degrees Farenheit. The physician was notified of the resident's decline in condition and ordered that the resident be sent to the hospital for treatment. The resident was transferred to the hospital at that time. Review of the resident's Fluid Intake reports (facility records of the resident's fluid intake each day) for the dates beginning June 27, 2017 through July 7, 2017, revealed that on six of 11 days during that time period the resident did not consume at least 50% (900 ccs) of the resident's recommended 1800 cc per day fluid needs. A review of the resident's Meal Intake (facility records of meal consumption) beginning June 27, 2017 through July 7, 2017, revealed that the resident had zero percent meal consumption or (refused all three meals) in a 24-hour period on five out of the 11 days. A review of the resident's Medication Administration Record [REDACTED]. A nursing progress note dated July 8, 2017, 6:25 PM revealed that the resident was admitted to the hospital with [REDACTED]. On August 1, 2017, at 1:00 PM an interview conducted with the registered dietitian, Employee 2, revealed he was not made aware of the resident's decreased oral intake of food and fluids. Employee 4 was unable to demonstrate that the adequacy of Resident CR1's fluid intake had been evaluated and measures implemented or recommended to prevent dehydration. An interview with the Director of Nursing (DON) on August 1, 2017, at 1:30 PM revealed that Employee 2 attended daily report on all residents and should have been aware of the Resident CR1's change in ability to maintain hydration due to her decreased food and fluid intake. The DON confirmed that alternate forms of hydration interventions were not identified or recommended during this 11 day period, to prevent dehydration. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/2/17, 1/18/17, 8/14/15 28 Pa. Code 211.5(g)(h) Clinical records Previously cited 3/2/17, 2/18/16 28 Pa. Code 211.6(d) Dietary services Previously cited 3/2/17, 2/7/17 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 10/14/15 28 Pa. Code 211.12(c)(d)(5) Nursing Services Previously cited 3/2/17, 1/3/17, 7/8/16, 2/18/16, 10/14/15, 8/14/15 28 Pa. Code 211.12(d)(1) Nursing Services Previously cited 3/2/17, 7/8/16, 2/18/16, 10/14/15, 8/14/15