Every finding on record at Aventura at Pembrooke

Based on review of clinical records, and staff and resident interview, it was determined that the facility failed to accurately and comprehensively assess and provide ordered wound treatment for one of six residents reviewed (Resident 1).Findings include: Review of Resident 1's admission MDS dated [DATE], revealed that Resident 1 was admitted to the facility from the hospital on August 4, 2026, with a diagnosis of acute kidney injury (a sudden and rapid loss of kidney function) on chronic kidney disease (a gradual, long-term loss of kidney function where the kidneys become damaged and can no longer filter waste and extra fluid from the blood effectively). Resident 1 is cognitively intact. Review of the hospital Discharge summary dated [DATE], revealed a wound on the left lower leg. Review of the facility's admission skin assessment on August 4, 2026, revealed: Skin issue #1 Abdomen - generalized. General bruising related to injection medications and IV placements .Skin issue note: 2 open areas to lower left ankle. Review of the TAR (treatment administration record) record revealed a treatment for the left leg initiated on August 5, 2026. Review of nursing progress notes from August 10, 2026, revealed: While assisting CNA (certified nursing assistant) with returning resident to bed and incontinent care; resident began to complain of pain and a bed sore reportedly obtained after admission per resident. Upon inspection, this nurse observed a dime sized opening to resident intergluteal cleft (the groove between the buttocks just below the sacrum - the triangular bone at the base of the spine). Resident reported staff have been putting a patch to area but that it was becoming increasingly painful and felt as if it were increasing in size and depth per resident. MD (doctor) Made aware, resident own POA (power of attorney), wound tx (treatment) initiated and POC (plan of care) continues. Review of the wound care provider visit report dated August 11, 2026, revealed a pressure injury to the coccyx (the triangular bone at the base of the spine) measuring 1.3 cm x 1 cm x 0.2 cm. The wound was staged as a stage 3 pressure injury (a wound that reaches to the fat layer under the skin). The order for treatment was, Cleanse wound with normal saline (a solution of salt and water that has the same concentration as human blood); apply medihoney (A dressing that aids healing in in acute and chronic wounds); cover wound with clean, dry dressing; change daily and PRN (as needed). Review of the TAR revealed no order for this treatment was entered and no treatment was signed off for this wound. Review of an IDT (interdisciplinary team) note dated August 11, 2026, revealed: IDT met to review 8/10/2026 skin issue to gluteal cleft. Resident bed mobility severely limited. New intervention to provide bed rails as recommended. Review of physician progress note dated August 13, 2026, revealed: has open area of coccyx. Review of the wound care provider visit report dated August 18, 2026, revealed: Pressure injury to coccyx unhealed measuring 1.5 cm x 1.5 cm x 0.1 cm. The stage was documented as: Unstageable Pressure Injury (a wound where tissue covers the wound bed, preventing the clinician from accurately determining the stage of the wound), Obscured full-thickness skin and tissue loss. Treatment was unchanged from the previous week. Review of the TAR revealed that no order for this treatment was entered, and no treatment was signed off for this wound. Review of a nursing progress note dated August 14, 2026, revealed: Head to toe assessment completed 8/13/26. No new skin issues or deviations noted at this time. Resident denies any physical pain or discomfort at this time. Review of the wound care provider visit report dated August 25, 2026, revealed: Coccyx pressure injury, unhealed measuring 3 cm x 1.5 cm x 0.1 cm. The treatment was updated to reflect the following: Santyl (a wound treatment used to remove dead tissue to promote healing) - nickel thick, apply medihoney if no santyl; cover with clean dry dressing. Change daily and PRN. Review of the TAR revealed that the order was entered in the electronic health record and scheduled to start on August 27, 2026. Review of a nursing progress note dated August 26, 2026, revealed: Resident was seen by the wound care team yesterday for follow-up. Today a new recommendation was received to continue to follow-up with the updated wound treatment plan. The resident is self-responsible party was made aware of the new treatment recommendation. The primary care physician was also notified and agreed with the recommendation. The treatment team will continue to implement the wound care treatment as ordered. Interview with Resident 1 on August 27, 2026, at approximately 11:30 a.m. revealed that Resident 1 was concerned about the bed sore on my bottom. Resident 1 stated, The only time they do the dressing right is when the wound nurse comes to do it. Interview with the DON, (Director of Nursing) on August 27, 2026, at approximately 2:45 p.m. confirmed that orders for the wound treatment had not been entered for two weeks and there was no documented evidence that Resident 1's sacral wound was provided with treatment between August 11 and August 27, 2026.28 Pa. Code 211.5(f) Clinical records28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on interview and record review, the facility failed to provide and/or obtain informed consents for psychotropic medications for three of five residents reviewed for unnecessary medications (Resident 3, Resident 9, and Resident 154).Findings include: Review of Resident 3's medical diagnoses revealed diagnosis that include Chronic Diastolic (congestive) Heart Failure (excessive body/lung fluid caused by weakened heart muscle), Dementia (irreversible, progressive, degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations), Psychosis (abnormal condition of the mind that results in difficulties telling what is real and what is not real) not due to a substance or known physiological condition, and Major Depressive Disorder. Review of Resident 3's physician orders revealed an order dated January 31, 2026, for Quetiapine Fumarate (an antipsychotic medication) Tablet 25 milligrams (mg) give 1 tablet by mouth one time a day related to unspecified psychosis not due to a substance or known physiological condition. Review of Resident 3's records revealed no Informed Consent Form (document that explains risks and benefits of taking antipsychotic medications). Review of Resident 9's physician orders revealed a prescription dated February 24, 2026, for Paroxetine HCl 20 mg to be administered in the morning for depression. Further review of Resident 9's physician orders revealed a prescription dated February 24, 2026, for Divalproex Sodium 125 mg to be administered two times a day for bipolar. Review of Resident's 9 clinical record failed to reveal informed consent. Review of Resident 154's physician orders revealed a prescription for Ativan 0.5mg twice a day for anxiety, dated July 25, 2026. Further review of Resident 154's clinical records failed to reveal evidence that informed consent had been obtained from Resident 154's responsible party. Interview with NHA (Nursing Home Administrator) and DON (Director of Nursing) on Julu 29, 2026 at approximately 4:00 p.m. confirmed the facility did not obtain informed consent. The DON stated that informed consent forms were not being completed by the previous administration and was now part of the facility's current Quality Assurance and Performance Improvement (QAPI) plan. 28 Pa. Code 211.12(d)(5) Nursing Services

Based upon observation and interview, it was determined that the facility failed to ensure appropriate storage of dry goods, maintain appropriate concentration of sanitizing solutions, and maintain safe conditions within the facility's freezer. Observation of the facility's kitchen on July 26, 2026, at 9:35 a.m., reveals a buildup of ice accumulation on the PVC strip curtains at the entrance of the walk-in freezer. Further observation of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., finds containers of powder thickener and flour open to air. Observation during a tour of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., finds a bucket of liquid without a detectable level of sanitizer when tested with a pH strip, containing a cloth to wipe down tray delivery carts. Interview with the Nursing Home Administrator on July 29, 2026, at approximately 3:30 p.m. confirms the above findings. 28 Pa. Code 211.6(f) Dietary Services

Based on interview and record review, the facility failed to maintain medication administration records that were accurate and complete for eight of eight residents reviewed (Residents 2, 5, 7, 10, 11, 15, 26, and 39).Findings include:Review of the following MARs (medication administration records) revealed:For Resident 2, 30 out of 31 orders were not signed out on July 25, 2026.For Resident 5, 21 out of 26 orders were not signed out on July 25, 2026.For Resident 7, 36 out of 37 orders were not signed out on July 25, 2026.For Resident 10, 19 out of 29 orders were not signed out on July 25, 2026.For Resident 11, 18 out of 23 orders were not signed out on July 25, 2026.For Resident 15, 16 out of 16 orders were not signed out on July 25, 2026.For Resident 26, 22 out of 25 orders were not signed out on July 25, 2026.For Resident 39, 22 out of 23 orders were not signed out on July 25, 2026.Interview with Resident 26 on July 28, 2026, at approximately 9:30 a.m. revealed that Resident 26 recalled receiving medications on July 25, 2026.Interview with the NHA (Nursing Home Administrator) on July 29, 2026 at approximately 2:00 p.m. revealed that they had contacted the nurse who was assigned to that hallway on July 25, 2026, and the nurse affirmed that the medications had been administered, but the nurse reported feeling overwhelmed and did not document most of the medications. The NHA surveyed cognitively intact residents on the unit regarding whether they recall receiving medications on that day and they responded that they had.The medication administration was not documented accurately and completely.These findings were affirmed with the NHA and DON (Director of Nursing) on July 29, 2026, at approximately 4:00 p.m.28 Pa. Code 211.59(f)(x) Medical Records28 Pa. Code 211.10(c) Resident care policies28 Pa Code 211.12 (d)(1)(5) Nursing Services

Based upon observation and interview, it was determined that the facility failed to prevent accumulations of fruits flies in the kitchen. Observation during a tour of the facility's kitchen on July 29, 2026, at approximately 2:00 p.m., reveals several fruit flies observed throughout the kitchen. Fruit flies were observed inside and around open containers of powder thickener and flour. Interview with Nursing Home Administrator confirms the above findings. 28 Pa. Code 211.6(f) Dietary Services

Based on observations, resident and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for three out of three floors (First, Second and Third floor). Findings include: Observations made of resident rooms on the third floor on July 26, 2026, at 9:25 a.m. revealed clogged bathroom sinks in rooms 312, 315, 316, 321, 322, 326, 327, and 328. room [ROOM NUMBER]'s sink had standing brown water with brown substances floating in the water. The toilets in room [ROOM NUMBER] and 313 had a brown substance on the seat and the bowl. Observations made of resident rooms on the third floor July 27, 2026, at 9:19 a.m. revealed bathroom sinks remained clogged in rooms 312, 315, 316, 321, 322, 326, 327, and 328. room [ROOM NUMBER]'s sink still had standing brown water with brown substances floating in the water. The toilets in room [ROOM NUMBER] and 313 still had a brown substance on the seat and the bowl. Interview conducted with the Corporate Regional Director (CRD) on July 27, 2026, at 9:40 a.m., when the above was presented and the sink and toilet in room [ROOM NUMBER] were observed, the CRD confirmed the sink was clogged and the toilet was not clean. Observation of the bathroom sink in room [ROOM NUMBER] on July 28, 2026, at approximately 9:45 a.m. revealed standing water in the sink. Observation of the in-room sink in room [ROOM NUMBER] on July 28, 2026, at approximately 9:50 a.m. revealed that the basin drained very slowly when the basin after being filled with water. This observation was shared with the LPN (Licensed Practice Nurse) Unit Manager (E3) on July 28, 2026, at approximately 10:00 a.m. Observation of resident room [ROOM NUMBER] on July 29, 2026, at 11:30am revealed a feeding tube pole crusted with brown stains and under resident bed visible trash and dust. Licensed nurse Employee 6 on July 29, 2026, at approximately 11:35am confirmed the above observations. Observation of the bathroom sink in room [ROOM NUMBER] on July 28, 2026, at approximately 10:50 a.m. revealed standing water in the sink. Observation of room [ROOM NUMBER] on July 28, 2026, at approximately 10:35 am revealed standing water on the floor at the foot of unoccupied resident bed. Further observation made with Licensed nurse Employee 6 on July 28, 2026, at approximately 10:40am revealed, placed under the air conditioner unit in room [ROOM NUMBER], a gray basin overflowing with water.

Based on record review, the facility failed to ensure PRN (pro-re nata or as needed) orders for psychotropic medications are limited to 14 days for one out of two residents reviewed for unnecessary medications (Resident 154).Findings include: Review of Resident 3's medical diagnoses revealed diagnosis that include Chronic Diastolic (congestive) Heart Failure, Dementia, Anxiety Disorder, Psychosis not due to a substance or known physiological condition, and Major Depressive Disorder. Review of Resident 3's physician orders revealed an order dated January 31, 2026, for Quetiapine Fumarate (an antipsychotic medication) Tablet 25 milligrams (mg) give 1 tablet by mouth one time a day related to unspecified psychosis not due to a substance or known physiological condition. Review of Resident 3's physician orders revealed an order dated November 28, 2023, for Escitalopram Oxalate (an antipsychotic medication) oral tablet 20 mg (Generic for Lexapro) give 20 mg by mouth one time a day related to Major Depressive Disorder. Review of Resident 3's Medication Management Reviews (MRR) revealed a recommendation dated September 25, 2025, noting the resident's order for Lexapro 20 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form. Review of Resident 3's MRR dated March 31, 2026, noted the resident's order Lexapro 20 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form. Further review of Resident 3's MRR dated July 24, 2026, noted a recommendation that the resident's order for Quetiapine 25 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form. The above findings were presented to the Nursing Home Administrator on July 29, 2026, at 3:35 p.m. Review of Resident 154's current physician orders revealed: Ativan 0.5MG; give 1 tablet as needed for anxiety twice daily, dated July 25, 2026. Further review of the MAR (medication administration record) failed to reveal an end date for the order. This finding was reviewed with the NHA on July 29, 2026, at approximately 3:00 p.m. 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for four out of thirteen residents reviewed. (Resident 13, Resident 64, Resident 82 and Resident 123) Findings include: Review of Resident 13's clinical record revealed resident was transferred to the hospital on May 3, 2026, and admitted with a diagnosis of an ileus (medical condition where the intestines temporarily stop normal muscle contractions, preventing food, gas, and waste from moving forward). Further review of Resident 13's clinical record reveals that Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 13's transfer and admission to the hospital. Review of Resident 13's clinical record revealed that resident was transferred to the hospital on June 5, 2026, for evaluation. Further review of Resident 13's clinical record reveals that Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 13's transfer and admission to the hospital. Interview with the Nursing Home Administrator on July 29, 2026, at approximately 3:30pm confirmed the above the findings. Review of Resident 64's clinical record revealed Resident 64 was transferred to the hospital on June 6, 2026, due to sepsis (serious medical condition that occurs when your body has an extreme reaction to an infection, leading to widespread inflammation). Further review of Resident 64's clinical record revealed Resident 64 was readmitted to the facility on [DATE]. Review of Resident 64's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 64's transfer and admission to the hospital. Further review of Resident 82's clinical record reveals that Resident 82 was readmitted to the facility on [DATE]. Review of Resident 82's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 82's transfer and admission to the hospital. Review of Resident 123's clinical record revealed that resident was transferred to the hospital on June 2, 2026, and admitted with a diagnosis of pneumonia (an infection that inflames the air sacs in one or both lungs). Further review of Resident 123's clinical record reveals that Resident 123 was readmitted to the facility on [DATE]. Review of Resident 123's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 123's transfer and admission to the hospital. Review of Resident 82's clinical record revealed that resident was transferred to the hospital on June 15, 2026, for evaluation and treatment. Interview with the Nursing Home Administrator on July 29, 2026, at approximately 3:30pm confirmed the above the findings. 28 Pa. Code 211.5(b) Medical Records

Based on record review, the facility failed to accurately assess a Resident's health status for one of eight residents reviewed (Resident 39). Findings include: Review of Resident 39's admission MDS (Minimum Data Set - mandatory assessment of a resident's physical condition and care needs) dated July 2, 2026, revealed Resident 39 was admitted on [DATE]. Review of Section M of the MDS labelled Skin Conditions revealed no pressure ulcers present on admission/entry. Review of Resident 39's TAR (treatment administration record) revealed the following order dated June 26, 2026: Wound Care every 12 hours for Wound Care Sacrum (triangular shaped bone at the base of the spine), cleanse w/ NSS (normal saline solution), pat dry, apply Venelex ointment (a prescription dressing used to treat chronic skin wounds) followed by oil emulsion gauze (a non-stick gauze dressing). Cover with foam dressing (an absorbent, cushioned adhesive dressing). Review of the admission skin assessment dated [DATE], revealed Resident 39's skin was intact. Review of Section N of the MDS labelled Medications revealed that the facility coded 1 in item N0300 Record the number of days that injections of any type were received during the last 7 days since admission. Review of Resident 39's MAR (medication administration record) revealed the following order dated June 27, 2026: Heparin (a medication to prevent blood clots) Sodium Injection Solution 5000 Unit/ML (milliliter). Inject 1ML subcutaneously (under the skin) every 8 hours for DVT (blood clot) prophylaxis (prevention). Review Resident 39's June 2026 MAR revealed the order was signed out as administered on June 27, 2026, June 28, 2026, June 29, 2026, and June 30, 2026. Review of Resident 39's July 2026 MAR revealed the order was signed out as administered on July 1, 2026, and July 2, 2026. These findings were shared with the NHA (Nursing Home Administrator) on July 29, 2026, at approximately 3:00 p.m. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide quality care for three of 28 residents reviewed (Resident 8, Resident 28, and Resident 82).Findings include: Review of Resident 8's clinical record revealed diagnoses including acute congestive heart failure (CHF) (excessive body/lung fluid caused by a weakened heart muscle) and chronic kidney disease (medical condition referring to damage to the kidney due to chronic high blood pressure). Review of Resident 8's physician's orders dated July 17, 2026, and discontinued July 18, 2026, revealed an order for daily weights every day shift for health monitoring (CHF). Notify MD (medical doctor) if 4 lb (pounds) or greater weight gain. Review of Resident 8's clinical record revealed recorded weights of 259.2 pounds on July 14, 2026, and 326.4 pounds on July 17, 2026. Further review of Resident 8 clinical record and facility records revealed no evidence that the physician had been notified as per order. Interview with Employee E5 on July 29, 2026, at approximately 1:20pm confirmed the above findings. Resident 28 has medical diagnoses that include Dementia, Joint Disorder, Osteoarthritis, and Lower Back Pain. Review of Resident 28's care plan revealed a focus revised June 22, 2026, for Resident 28 having potential for falls related to impaired balance during transitions and medications. Review of Resident 28's progress notes revealed a note dated June 20, 2026, documenting the resident was lowered to the floor after attempting to transfer from his/her wheelchair without assistance, causing their wheelchair to tip up. Further review of Resident 28's progress notes revealed a noted dated June 22, 2026, documenting the Interdisciplinary Team discussing Resident 28's post fall lowered to floor. Physical therapy and request for anti-tippers (a safety device attached to the rear of a wheelchair to prevent it from tipping backward) were recommended. Observations of Resident 28's wheelchair on July 29, 2026, at 10:07 a.m., revealed the resident had one anti-tipper on the left side of his/her wheelchair. During interview conducted with Occupational Therapist, Employee E8, on July 29, 2025, at 11:52 a.m., E8 confirmed the resident only had one anti-tipper and confirmed there should be two. Employee E8 stated another one would be ordered. Resident 82 has a medical history significant for end stage renal disease (occurs when kidneys lose 85% to 90% of their function and can no longer remove wastes and extra fluid), peripheral vascular disease (a blood circulation disorder that narrows, blocks, or spasms blood vessels outside the heart and brain), congestive heart failure (a condition where the heart muscle does not pump blood well, causing blood and fluid to back up), and an open wound of the left foot. Review of Resident 82's orders reveals a physician order dated November 20, 2025, for heel boots (pressure relieving foot guard) to be worn every shift for skin prevention. Review of Resident 82's progress notes on July 22, 2026, at 10:54 p.m., reveals that Resident 82, returned from her doctors appointment with the wound doctors . Resident is to continue to use the heel boot to the left heel at all times. Observation of Resident 82 on July 28, 2026, at 9:46 a.m., finds the resident in her bed without a heel boot in place. Further observation of Resident 82 on July 29, 2026, at 9:17 a.m., finds the resident at dialysis without a heel boot in place. Interview with facility employee, E9, on July 29, 2026, at 11:57 a.m., reveals that Resident 82 frequently refuses to wear the heel boots as ordered and that refusals are documented in the resident's electronic health record. Review of Resident 82's clinical record does not reveal documentation of refusals to have heel boots placed on July 28, 2026, or July 29, 2026. Interview the Nursing Home Administrator on July 29, 2026, at approximately 3:30 p.m. confirmed the above findings.

Based on observation, interview, and record review, the facility failed to prevent the risk of accident by leaving patient medication unattended at the bedside for one out of eight residents reviewed (Resident 46).Findings include:Observation of Resident 46's room on July 28, 2026, at approximately 9:50 a.m., revealed a plastic medication cup containing two pills sitting on the bedside table belonging to Resident 46. Resident 46 was not observed in the room.Interview with the LPN Unit Manager (E3) on July 28, 2026, at approximately 10:00 a.m. confirmed that the medication belonged to Resident 46, Resident 46 was at an appointment, and Resident 46 did not have a physician's order to self-administer medications.Review of Resident 46's active physician orders for July 2026 revealed that Resident 46 did not have orders to self-administer medication.Interview with the NHA (Nursing Home Administrator) revealed that the medications found in the cup were Sevelamer Carbonate Oral Tablet, 800 MG and Cinacalcet HCl Oral Tablet 30 MG. 28 Pa. Code 211.10(d) Resident Care Policies28 Pa. Code 212. 12 (d)(1)(5) Nursing Services

Based upon clinical record review and interviews, it was determined that the facility failed to ensure that medication irregularities were appropriately acted upon by a physician for one of five residents reviewed (Resident 3).Findings include:Review of Resident 3's medical diagnoses revealed diagnosis that include Chronic Diastolic (congestive) Heart Failure, Dementia, Anxiety Disorder, Psychosis not due to a substance or known physiological condition, and Major Depressive Disorder.Review of Resident 3's physician orders revealed an order dated January 31, 2026, for Quetiapine Fumarate (an antipsychotic medication) Tablet 25 milligrams (mg) give 1 tablet by mouth one time a day related to unspecified psychosis not due to a substance or known physiological condition. Review of Resident 3's physician orders revealed an order dated November 28, 2023, for Escitalopram Oxalate (an antipsychotic medication) oral tablet 20 mg (Generic for Lexapro) give 20 mg by mouth one time a day related to Major Depressive Disorder. Review of Resident 3's physician orders revealed an order dated October 5, 2023, for Melatonin oral tablet 5 mg, give by mouth at bedtime for insomnia. Review of Resident 3's physician orders revealed an order dated April 21, 2022, for Sudafed 12 hr tablet extended release give one tablet by mouth every 12 hrs. as needed for cough and congestion.Review of Resident 3's Medication Management Reviews (MRR) revealed a recommendation dated September 25, 2025, noting the resident's order for Lexapro 20 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form.Review of Resident 3's MRR dated February 25, 2026, revealed a recommendation to discontinue the resident's Sudafed as needed order due to non-usage. No physician response or signature was observed on the form.Review of Resident 3's MRR dated March 31, 2026, noted the resident's order Lexapro 20 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form.Review of Resident 3's MRR dated April 26, 2026, revealed a recommendation that the resident's order for Melatonin 5 mg was due for annual assessment. No physician response or signature was observed on the form.Further review of Resident 3's MRR dated July 24, 2026, noted a recommendation that the resident's order for Quetiapine 25 mg was due for assessment in accordance with CMS guidelines for psychopharmacologic medication regarding a gradual dose reduction (GDR). No physician response or signature was observed on the form.The above findings were presented to the Nursing Home Administrator on July 29, 2026 at 3:35 p.m.

Based on observation and record review, the facility failed to ensure that transmission-based precautions were adhered to for two of 27 residents reviewed (Resident 7 and Resident 72). Findings include: Facility policy titled Isolation-Categories of Transmission Based Precautions documents when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance and on the front of the chart so that personnel and visitors are aware of the need for and type of precaution. CDC (The Centers for Disease Control) recommendations for contact precautions (an infection prevention technique used for patients with known or suspected infections that represent an increased risk for contact transmission), dated April 3, 2024, recommends that staff wear gowns and gloves for all interactions that may involve contact with the patient or the patient's environment. Observation of room [ROOM NUMBER] on July 28, 2026, at approximately 9:30 a.m. revealed a contact precaution sign outside the room and a nurse (E4), who was not wearing any personal protective equipment, administering medication to Resident 7. Review of Resident 7's care plan revealed that Resident 7 was placed on contact precautions due to an infection, effective July 27, 2026. Resident 72 has medical diagnoses that include Obstructive and Reflex Uropathy (blockage in the urinary tract that impedes urine flow). Review of Resident 72's physician orders revealed an order dated November 26, 2025, for a foley catheter (a flexible tube inserted into the bladder to drain urine) to straight drainage as needed related to Obstructive and Reflux Uropathy. Further review of Resident 72's physician orders revealed an order dated November 25, 2026, for Enhanced Barrier Precautions (EBP) every shift for foley catheter. Resident 72's Medication Administration Reports for June and July 2026, documents EBP are in place. Observations made of Resident 72's room on July 26, 2026, at 10:45 a.m., July 27, 2026, at 9:19 a.m., and July 29, 2026, at 11:17 a.m., revealed no EBP sign on the resident's door or in the resident's room. The above information was discussed with the Nursing Home Administrator on July 29, 2026, at 3:30 p.m. 28 Pa. Code 211.10(c) Resident care policies

Based on observations and resident and staff interviews it was determined that the facility failed to provide hydration for residents on three of three floors. (1st, 2nd, and 3rd floors)Finding include:Observations made of resident rooms on March 26, 2026, revealed most rooms on the 1st, 2nd, and 3rd floors either had no cups with water for hydration or the water in the cups was warm. The cups were not dated; there was no way to determine when the water was provided to the resident.During interviews Resident 1, Resident 2, Resident 3, and Resident 4, stated fresh water is not provided every shift and sometimes not every day. Observations were made of ice machines on each unit indicating ice was available for residents.Observations were made throughout the dayshift. Residents were not provided with fresh water and/or ice during the day shift.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 26, 2025, at 3:10 p.m., when the above information was presented, the DON stated residents are provided with fresh water during every shift. 28 Pa. Code 211.12(d)(1)(5) Nursing Services28 Pa Code: 211.10(c) Resident care policies

Based on observations, facility documentation review, as well as staff and resident interviews it was determined the facility failed to ensure water temperatures were maintained at a safe level in resident care areas for three of three units in the facility resulting in immediate jeopardy to the residents. (1st, 2nd and 3rd floors)Findings Include: Observation of the staff and visitor bathroom on the ground floor on December 23, 2025, at approximately 11:15 a.m. revealed while the surveyor was washing their hands the water was observed to be very hot, steaming, and left red mark covering approximately 50% of both hands after four seconds of exposure to the water. Nursing Home Administrator (NHA) and Maintenance Director were contacted, the surveyors accompanied the Nursing Home Administrator and the Maintenance Director while water temperatures were recorded on all units of the facility with the following water temperature results of December 23, 2025, at 11:20 a.m.: room [ROOM NUMBER]- water temperature registered 132 degrees Fahrenheit (F)room [ROOM NUMBER]- 127 degrees [NAME] 100- 126 degrees [NAME] 100- 126 degrees F1st floor shower room- 116 degrees [NAME] 119- 127 degrees [NAME] 125- 127 degrees F2nd floor shower room sink 115 degrees [NAME] 221- 118 degrees [NAME] 317- 131.2 degrees [NAME] 323- 127.6 degrees [NAME] 315- 132.9 degrees F3rd floor shower room sink- 115.7 degrees F Interview conducted with the Maintenance Director on December 23, 2025, at 11:45 a.m. revealed the facility was unaware of the water temperatures registering the high temperatures. The Maintenance Director revealed maintenance staff monitor the temperature of the water coming out of the mixing valve to the units every day and random room checks are performed on the units once a week. The Maintenance Director was asked to provide verification of the temperature readings through documentation logs when temperatures were monitored but staff were unable to provide any temperature logs, and it was unknown when the last time water temperatures were recorded for the monitoring of the facility water temperatures. Interview conducted on December 23, 2025, at 11:45 a.m. with nursing Employees E4 and E5 revealed they check the water temperature by running it first on their wrist to make sure it is not too hot then place the resident into the water and ask them if it is comfortable for them. Observations of the shower room on the first and third floor failed to reveal working thermometers in the shower rooms and observations of all three floors failed to reveal a log/recording of water temperatures prior to providing residents with showers. Interview with the Nursing Home Administrator on December 23, 2025, at 11:50 a.m. revealed the facility has no policies and procedures for monitoring the water temperatures and no policies and procedures for how staff should ensure a safe water temperature prior to providing care to a resident. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator on December 23, 2025, at 12:05 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the facility. On December 23, 2025, at 2:39 p.m. an acceptable action plan was approved which included the following interventions: Implemented immediately upon identification of IJ- Maintenance responded onsite.- Hot water was turned off at 1:30 p.m. on 12/23/2025.- All resident-accessible sinks and shower rooms with hot water temperatures were audited. Any exceeding 110 F (Fahrenheit) were immediately addressed.- Nursing staff provided direct supervision and assistance with all bathing and hygiene needs as needed.- Education was initiated to all staff regarding water temperatures and safety requirements.- Skin assessments on all residents were initiated.- Hot water temperatures are in the process of being re-tested using a calibrated thermometer at all resident accessible sinks and shower rooms on all nursing floors.- Any affected outlets will be returned to resident use only after verification and documentation of compliant temperatures.Protective MeasuresFollowing implementation of immediate interventions, residents were not exposed to unsafe hot water temperatures. All bathing and showering occurred only at outlets verified to be within the acceptable temperature range, with staff supervision provided as indicated.- The facility implemented a hot water temperature monitoring process requiring:o Daily random water temperature checks in resident rooms, shower rooms, and common areas for 7 days.o Then weekly water temperature checks in resident rooms and shower rooms and common areas for 4 weeks.o Then ongoing monthly water temperature checks in resident rooms and shower rooms and common areas.o Use of a thermometer, not hand tested.o Documentation on a Water Temperature Monitoring Log.- The facility clearly defined the requirement to include:o Maximum allowable temperature of 110 Fo Monitoring frequencyo Immediate corrective action for out-of-range temperatures- Facility staff education was initiated and to be provided to staff prior to start of their shift:o Acceptable hot water temperature ranges, with maximum water temperature not to exceed 110 Fo Proper use of thermometers to accurately measure water temperature (thermometers will be located at each nursing station, every shower room, and the receptionist desk)o Prohibition of hand-testing water temperature due to risk of injury and inaccuracy.o Immediate reporting of any water temperatures found to be outside the acceptable range to administrative staff and/or Maintenance Director for prompt corrective action. Interview with the Nursing Home Administrator on December 24, 2025, at 11:30 a.m. revealed the water system repairs had not been completed by the plumber and second plumber will be coming to the facility by 1:00 p.m. same day. The hot water in the facility remained turned off, and the staff were still providing residents with bed baths using disposable washcloths. There were no temperature audits or logs completed by staff due to the water still being turned off throughout the facility. Observation conducted on December 26, 2025, at 9:15 a.m. of the ground floor bathroom, the same bathroom where the hot water issue was originally identified revealed the water was hot to touch, steaming, and left a red mark on the surveyor's hand. Licensed Nursing Employee E6 indicated the Nursing Home Administrator (NHA) and Director of Nursing (DON) were not present in the facility and was asked to get maintenance director who surveyor was unable to located. Observation of the shower rooms on the first, second, third floor revealed the water was cold to touch. Interview with three Nursing Employees E7, E8, and E9 on December 26, 2025, at 9:45 a.m. revealed two of the three said they were giving the residents bed baths with disposable washcloths but Nursing Employee E9 stated they were using hot water in basins to give the residents bed baths. Telephone Interview with the NHA on December 26, 2025, at approximately 10:00 a.m. revealed a plumber had come to the facility the previous night and was still unable to correct the water problem and might have turned the hot water on the lobby bathroom and forgot to turn it back off. There was no monitoring of water temperatures because they thought the hot water was turned off throughout the facility. Interview conducted with Licensed Nursing Employees E10 on December 27, 2025, at 8:30 a.m. revealed, they didn't tell me anything about the showers, I'm agency. Talk to the aides, they should know. Interview with Licensed Nursing Employee E11 on December 27, 2025, at 8:35 a.m. stated I don't know what you're talking about, I'm agency. They called me here last minute. The NHA, DON, and Maintenance director were not observed to be present in the building. Telephone interview conducted with the DON on December 27, 2025, at 9:30 a.m. confirmed he was not at the facility nor was the NHA or Maintenance Director. When asked for temperature verification via logs for temperature monitoring of the water or education provided to the staff, the DON revealed the NHA has the information but was unavailable until after 6:00 p.m. Observations conducted on December 28, 2025, of resident rooms and shower rooms as well as review of facility temperature logs, review of facility staff education documentation, and interviews conducted with 15 nursing and ancillary staff confirmed the above stated action plan was implemented and immediate jeopardy was lifted on December 28, 2025, at 11:50 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services

Based on the review of job descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure the safety of residents due to hot water temperatures. This failure resulted in an Immediate Jeopardy situation.Findings Include: Review of the job description for the Nursing Home Administrator (NHA) states position purpose: Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Further review of the NHA position description revealed the Essential Function: Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations. Review of the job description for the Director of Nursing (DON) states Position Purpose: Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. The findings in this report identified the facility failed to maintain the safety of the residents from hot water temperatures by ensuring that there was a system in place to monitor the water temperatures and that staff were ensuring the water was a safe temperature prior to providing care to the residents. Refer to F689 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management

Based on clinical records review, and staff interview, it was determined that the facility failed to follow the medication ordered by the physician for one of three residents reviewed (Resident CL1). Findings include:A review of Resident CL1's diagnosis list includes Anemia (low red blood cell count) and chronic kidney disease (progressive condition where kidneys gradually lose their ability to filter waste and fluids from the blood). The resident was admitted to the facility on [DATE].Clinical records review revealed Resident CL1 was sent to the hospital for a blood transfusion on October 14,2025, and October 16, 2025, for a low Hemoglobin level (an iron-rich protein that carries oxygen from the lungs to the body's tissue and organs).A review of the Physician's order, dated November 24, 2025, revealed an order for Aranesp (A medication used to treat anemia) 200 mcg/ml, inject 200 mcg intramuscularly (injection of a substance into a muscle) one time a day every Thursday.A review of Resident CL1's November and December 2025 Medication Administration Record (MAR) revealed that the Aranesp was not administered to the resident on the following dates: November 27, 2025, December 4, 2025, and December 11, 2025.Nursing progress notes dated November 27, 2025, at 11:34 a.m., revealed Aranesp medication awaiting from pharmacy.Nursing progress notes dated December 4, 2025, at 11:24 a.m., Aranesp medication Awaiting from pharmacy, pharmacy called needs to be approved due to high cost, DON (Director of Nursing) was made aware.Nursing progress notes dated December 11, 2025, at 11:24 a.m., revealed Aranesp medication awaiting from pharmacy.An interview was conducted with the DON on December 24, 2025, at 1:00 p.m. The DON reported that they were notified of the medication needing approval due to its cost. The DON reported giving approval via phone to the pharmacy on December 5, 2025, for the medication to be sent, but was unable to provide the name of the person they spoke to and was unable to provide documented evidence that the approval was made. The DON also confirmed that a follow-up was not made on December 11, 2025, when the medication was not sent by the pharmacy.Clinical records review failed to reveal that the physician was notified of the missed Aranesp dosage. The resident was discharged home on December 17, 2025.The facility failed to ensure physician's medication order to treat Resident CL1's Anemia was followed.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/25, 11/3/202528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25, 11/3/25

Based on observations and staff interview it was determined the facility failed to label and date oxygen and suction tubing for two of two residents reviewed (Resident 1 and 2). Findings Include: Observations of Residents 1 and 2 on December 23, 2025 at 9:45 a.m. revealed both residents had a tracheostomy (a surgical procedure creating an opening (stoma) in the neck into the windpipe (trachea) to provide a direct airway for breathing, often using a tube, used for blockages, long-term ventilation, or secretion clearance) with a trach collar (a soft strap that secures a tracheostomy tube in place around the neck, preventing it from moving or dislodging, while also providing a way to deliver humidified oxygen or manage airflow directly to the airway opening) in place. Further observations revealed that both residents had suctioning set up at their bedside. Observations of the tubing for the oxygen and the suctioning and for the disposable canister for the suctioning revealed there was no date last indicating when it should have been changed. Interview with the DON on December 23, 2025 at 10:30 a.m. revealed that the tubing should be dated with the date it was last changed. 28 Pa code: 211.12(d)(1)(3)(5) Nursing services

Based on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to ensure laboratory tests for Urinalysis (A set of tests that looks at the appearance of the urine and checks for blood cells, proteins, and other substances in it) ordered by the physician were timely followed (Resident CL1). Findings include:A review of the facility's policy titled Lab and Diagnostic Test Results-Clinical Protocol, undated, revealed that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the test requisitions and arrange for tests.A review of Resident CL1's Physician order dated October 13, 2025, revealed an order for Urinalysis, culture, and sensitivity one time only for frequency, irritation related to acute kidney failure.A review of the October 2025 Treatment Administration Record (TAR) revealed that the order for the urinalysis was done on October 13, 2025.A review of the laboratory report dated October 14, 2025, revealed Specimen received, unlabeled.Clinical records review failed to reveal that the urinalysis test was completed. The record revealed that no follow-up was done, and the resident's urine was not collected for re-testing since the initial urine was not tested due to improper labeling. The records also revealed that the physicians were not notified of the missed urine test until October 20, 2025. A new order to collect urine for urinalysis with culture and sensitivity was made on October 20, 2025.A review of the laboratory report dated October 21, 2025, revealed Resident CL1's urine was positive for an organism Klebsiella Pneumoniae ESBL, with a colony count of above 100,000 (indicating an active infection).The physician ordered Augmentin (antibiotic) 875 mg 1 tablet twice daily for seven days for Urinary tract infection (UTI).An interview with the Director of Nursing was conducted on December 23, 2025. The DON confirmed that Resident CL1's urine was not tested by the laboratory due to improper labeling. The DON also confirmed that follow-up with the urine test was not done until October 20, 2025.The facility failed to ensure Resident CL1's urine test order was timely followed, which resulted to delay in treatment on the resident's urinary tract infection.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/25, 11/3/202528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25, 11/3/25

Based on facility policy review, observations and staff interviews it was determined the facility failed to provide PPE and signage for residents who require enhanced barrier precautions for four resident rooms and one resident (115, 108, 104, 102, and Resident 2)Findings Include: Review of facility policy titled Infection Prevention and Control, effective February 24, 2025, revealed Use EPB (enhance barrier precautions) for residents with wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism).post notice outside the resident room when on EBP. Observations of rooms 102, 104, 108, and 115 on December 23, 2025, at 9:45 a.m. revealed hanging from each door was a storage system with PPE (Personal Protective Equipment) Sucha as gowns, gloves and mask. Further observations revealed there were no signs on the door to post notice of the need for the PPE. Observation of Resident 2 on December 23, 2025 at 9:50 a.m. revealed the resident had a Tracheostomy (a surgical procedure that creates a new airway by making a hole (stoma) in the neck directly into the windpipe (trachea) to help with breathing) and tube feeding (provides liquid food, fluids, and medicine directly into the GI tract via a soft tube when someone can't eat or swallow safely). Further observations revealed there was no PPE in the room and there was no sign for EBP. These findings were relayed to the Nursing Home Administrator and the Director of Nursing on December 23, 2025, at 2:45 p.m. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on observation, clinical record reviews, and staff interviews, it was determined the facility failed to follow a physician's order for two of five residents reviewed (Residents R1 and R2). Failure to follow Resident R2's wound care orders resulted in actual harm with deterioration of the wounds as evidenced by increased size.Findings include:Review of Resident R2's diagnosis list includes Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time), Peripheral Venous Insufficiency (condition that occurs when the veins in the legs do not function properly, leading to poor blood flow back to the heart), and non-pressure chronic ulcer (wound) of the right leg.Review of Resident R2's active care plan revealed actual skin integrity impairment related to immobility, chronic progressive disease, and history of bilateral extremity venous ulcers: Sacral- Stage 4 Pressure Ulcer ( Full-thickness skin and tissue loss); left medial thigh MASD (Moisture-Associated Skin Damage- skin condition caused by prolonged exposure to moisture, leading to inflammation, irritation, and potential skin breakdown); right medial thigh venous ulcer. Intervention includes treatment as ordered.Review of Resident R2's physician order dated August 23, 2025, revealed wound instructions of cleanse area to the left lower leg with normal saline solution apply Medihoney (dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns) cover with abdominal dressing (large absorbent bandage) and Kling (gauze wrap).Review of Resident R2's physician order dated October 10, 2025, revealed wound instructions of Hydrogel gel (used to maintain a moist wound) apply to right medial (middle) lower leg topically one time a day after cleansing with normal saline solution (sterile salt water), then cover with abdominal dressing and Kling.Review of Resident R2's wound physician consult dated October 28, 2025, revealed right leg venous ulcer's measurement of 1.5 x 1.0 cm (centimeters) with partial thickness and moderate serosanguinous (mixture of clear fluid and blood) drainage. Wound progress was documented as deteriorating. A new treatment of Medihoney daily was ordered. Left leg MASD had a measurement of 3.0 x 2.5 cm, with partial thickness and moderate serosanguinous drainage. Wound progress was documented as deteriorating, remained on Medihoney treatment daily.Review of Resident R2's October 2025, Treatment Administration Record (TAR), revealed Hydrogel treatment for the right leg was discontinued on October 29, 2025. Further review of resident's TAR revealed the Medihoney treatment recommended by the wound physician on October 28, 2025, was not transcribed to the TAR. Review of Resident R2's clinical records revealed Resident R2's right leg venous ulcer was not treated from October 30, 2025, until November 2, 2025. Review of the same TAR revealed Resident 2's left leg MASD was treated on October 30, October 31, November 1, November 2, and November 3, 2025.Observation conducted on November 3, 2025, at 11:35 a.m., in the presence of licensed nurses Employees E8 and E9 revealed Resident R2 was lying in bed, both legs had a wound dressing that was observed loose. The right leg dressing did not have a date written on the dressing, but the left leg dressing had a date of 10/29/25.Interview conducted with licensed nurse, Employee E9 on November 3, 2025, at 11:40 a.m. revealed Employee E9 was Resident R2's nurse. Employee E9 confirmed they documented Resident R2's wound treatments were done around 9:30 to 10:00 a.m., while completing resident's behavior documents. Employee E9 confirmed wound treatments to bilateral legs had not been performed for the day despite documenting, the treatment was completed. Employee E9 confirmed documenting the wound treatment to the left leg was done on October 30, October 31, and November 1, 2025. When asked if treatment to the left leg was done on the previously mentioned dates as wound dressing indicated a date of 10/29/25, Employee E9 was unable to provide an answer. Observation of the wounds was conducted in the presence of the Direct of Nursing (DON) on November 3, 2025, at 12:15 p.m. Right and left leg wounds were measured by the DON and revealed the following: Right leg venous ulcer had a measurement of 9.5 x 7.5 cm and left leg MASD wound had a measurement of 8.5 x 2.5 cm. Surrounding area of both wounds were reddened. Interview conducted with the DON on November 3, 2025, at 3:00 p.m., confirmed Resident's R2's bilateral leg wound treatment was not administered from October 30, 2025, until November 2, 2025.The facility failed to ensure wound treatment order for Resident R2's right leg venous ulcer and left leg MASD was followed which resulted in actual harm with further deterioration of both wounds as evidenced by increased in size.Review of Resident R1's clinical records revealed resident was readmitted to the facility on [DATE], with diagnosis of wound infection. Review of the physician's order dated September 30, 2025, revealed the following: Ertapenem Sodium (Antibiotic) one gram intravenously (administered into a vein) one time a day for infected sacral (lower middle back) wounds for eight days: and Daptomycin Solution (antibiotic) 500-0.9 mg/50ml% use 445 mg intravenously one time a day for infected sacral wounds for eight days.Review of Resident R1's October 2025, Medication Administration Records (MAR) revealed medications Ertapenem and Daptomycin were not administered to Resident R1 on October 5 and 6, 2025.Review of Resident R1's nursing progress note dated October 5, 2925, at 12:00 and 12:02 a.m., revealed that Resident R1 did not have IV (intravenous) access and is a hard stick (difficult in finding peripheral vein), will put in an order for IV access via company.Review of Resident R1's nursing progress note dated October 6, 2025, at 10:34 and 10:35 a.m., revealed IV not in the arm.Review of Resident R1's nursing progress note dated October 6, 2025, at 12:15 p.m., revealed resident without an IV access, physician was notified and ordered to place new midline (IV).Review of Resident R1's clinical record revealed that although the physician was notified of the missing IV access, there was no documented evidence the physician was notified of the missed doses of Ertapenem and Daptomycin for October 5, and 6, 2025.Review of Resident R1's clinical record revealed that the resident only received a total of six doses of both the Ertapenem and Daptomycin instead of the ordered eight doses. Interview with the DON (Director of Nursing) confirmed Resident R1 did not receive the ordered eight doses of both Ertapenem and Daptomycin medications. The facility failed to ensure Resident R1's medication order to treat his/her wound infection was followed as ordered.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Based on clinical record review, observation, staff and resident interviews, it was determined the facility failed to provide adequate supervision during resident care resulting in actual harm to Resident R1 who sustained a fall and an Acute Subarachnoid Hemorrhage (life-threatening condition where bleeding occurs in the space between the brain and the membrane that covers the brain) for one of five residents reviewed (Resident R1).Findings include:Clinical record review revealed Resident R1 had a diagnosis of Paraplegia (loss of motor or sensory functions in the lower half of the body) post spinal injury.Review of Resident R1's Annual Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated May 9, 2025, revealed the resident was determined to be cognitively intact. The same MDS assessment revealed Resident R1 had an impairment on both sides of the upper and lower extremities.Further review revealed Resident R1 was dependent on staff for the following activities: shower/bathing, upper and lower extremity dressing, personal hygiene, toileting, transferring, and rolling left to right.Review of the MDS dated [DATE], revealed Resident R1 required extensive with two-person assistance for bed mobility and toileting.Review of the Quarterly MDS dated [DATE], revealed Resident R1 remained with impairment on both sides of upper and lower extremities and remained dependent on staff assistance with shower/bathing, upper and lower extremity dressing, personal hygiene, toileting, transferring, and rolling left to right.Review of Resident R1's care plan failed to reveal information regarding Resident R1 requiring extensive/dependent with two-person assistance with bed mobility as documented on MDS assessments.Interview was conducted with the LNAC (License Nurse Assessment Coordinator) Employee E3 on November 3, 2025, at 3:40 p.m., and confirmed Resident R1's requiring two-person assistance with bed mobility was not reflected in the resident's care plan. When asked for an explanation, Employee E3 responded, I don't have an answer.Review of Resident R1's nursing progress note dated September 11, 2025, at 9:59 a.m., revealed resident was observed lying in a supine position on the floor on next to [his/her] bed, blood was observed under resident's back and left arm, and the resident reported hitting [his/her] head. The physician was in-house and assessed the resident and ordered them to be transfer to the hospital for evaluation. (Not direct quote).Review of Resident R1's nursing progress note dated September 11, 2025, at 2:44 p.m., revealed a follow-up call made to the hospital, the resident was admitted to the ICU (Intensive Care Unit) with a diagnosis of Subarachnoid Hemorrhage.Review of the facility's investigation, revealed unlicensed Employee E4's statement dated September 11, 2025, indicated I was changing (Resident R1's) sheets when the left side of the mattress lifted up and tilted, causing the resident to roll off the bed.Additional review of facility investigation revealed a statement by Employee E4, taken by the DON (Director of Nursing) on September 16, 2025, revealed Employee E4 was on the left side of the resident's bed and turned the resident on their right side towards the door to wash their back. The aide also stated that they were changing the resident's bottom sheet while the resident was turned over, the mattress lifted, and the resident fell on the floor.Interview conducted with Resident R1 on November 3, 2025, at 2:00 p.m. revealed when questioned regarding the incident, the Resident responded, That is what I want to know, how did I fall? The resident was unable to articulate what caused the fall but confirmed there was only one staff member providing care during the incident. When asked if they can turn on their side, the resident responded, I cannot roll. Further interview with Resident R1 revealed that there are usually two staff providing care, but sometimes only one. The resident stated, I should probably need two staff because I cannot roll.Interview was conducted with Nursing Assistant (NA), Employee E5 on November 3, 2025, at 3:00 p.m. Employee E5 reported that they had been caring for the resident for a few years. Employee E5 reported that Resident R1 requires two-person assistance with bed mobility. Employee E5 stated, (Resident R1) cannot do anything.Interview conducted with licensed nurse Employee E6 on November 3, 2025, at 3:05 p.m. Employee E6 reported not being on the unit consistently but had been caring for Resident R1 when assigned to work on the unit. Employee E6 reported Resident R1 required two-person assistance with bed mobility. Employee E6 further stated, (Resident R1) cannot do anything, they're dependent.Interview conducted with NA Employee E7 on November 3, 2025, at 3:05 p.m. Employee E7 indicated they were on the unit consistently and had been caring for Resident R1. Employee E7 confirmed Resident R1 required two-person assistance with bed mobility. Employee E7 stated, (Resident R1) cannot do anything, even with eating, they need help.Interview conducted with the NHA (Nursing Home Administrator) on November 3, 2025, at 3:00 p.m. The NHA reported Employee E4 was an agency staff.The above findings were conveyed to the NHA and DON on November 3, 2025, at 4:30 p.m.The facility failed to ensure Resident R1 was provided with adequate supervision while providing care. This failure resulted in a fall, causing actual harm, requiring hospitalization, and ICU monitoring for diagnosis of Acute Subarachnoid Hemorrhage. 28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 8/25/2528 Pa. Code 211.12(d)(1)(5) Nursing ServicesPreviously cited 8/25/25

Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure residents were free from abuse when staff failed to implement supervisory measures allowing Resident CL3 to physically assault and cause significant injuries to the head and upper extremities of Resident CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of CL2's clinical record revealed 5 day Medicare MDS (Minimum Data Set -periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) of 10 out of 15. The score indicates Resident CL2 had moderate cognitive impairment. Review of CL2's clinical record revealed diagnoses including but not limited to following: Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and muscle weakness; Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of CL3's clinical record revealed hospital documention prior to admission on [DATE] to facility which indicated under History of Present illness; .Presents to the ED (Emergency Department) with subsequent 302 petition (involuntary psychiatric admission petition) filed by wife through VCC for agitated and aggressive behavior, threatening purportedly to kill himself and his wife brandishing a knife in furtherance thereof, who subsequently to being brought to the ED by police, having little recollection of events prompting his presentation Review of Resident CL3's clinical record revealed a Quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) score of 03 out of 15 which reflectsa severe cognitive impairment. Review of CL3's clinical record progress note dated [DATE] (14:,d+[DATE]:26 p.m.) revealed, Residents daughter brought butter knife from residents room and asked that the kitchen not put knives on the residents tray because he was trying to cut himself with it. Resident was assessed and no bruising or skin tears noted. Kitchen staff also called and made aware that resident is not to have plastic or metal knives on his tray. Resident will be placed on Q1hr checks. Review of CL3's clinical record revealed a Psychiatric Evaluation and Consult document dated [DATE], which under section titled Impression and Plan, Staff reports he was collecting knives in his drawer so now he is not receiving knives on his tray. Review of CL3's clinical record revealed the resident was on safety checks every one hour, which was initiated on [DATE]. The last documented evidence of Q (every) hour supervision check was completed on [DATE]. Review of Resident CL3's [DATE] MAR (Medication Administration Record) and TAR (Treatment Administration Record) revealed an intervention of checking Q (every) shift for safety, No knives plastic or metal on meal trays was discontinued as of [DATE]. Review of Resident CL3 clinical record revealed an eMAR (Medication Administration Record) Progress note dated [DATE] revealed resident came out to med nurse swinging his cane. Review of Resident CL3's clinical record revealed a social work progress note date [DATE], revealing, SW (social worker) contacted spouse and notified (spouse) that [Resident] is displaying aggressive behaviors and we are transferring him to [psychiatric facility] in DE (Delaware) to be evaluated. Clinic record of Resident CL3 revealed resident was transferred to a psychiatric facility for treatment on [DATE] and returned to the facility on [DATE]. Review of Resident CL3's clinical record including psychiatric hospital admission summary dated [DATE] which revealed under History of Present Illness; the patient was getting agitated, aggressive, threatening other residents with the cane. Review of clinical record of Resident CL3 including care plan goals and interventions failed to reveal goal(s) to address resident's physical aggression or interventions for aggression, knife hoarding, or threatening behavior using a walking cane. Review of clinical record of Resident CL3 revealed progress note dated [DATE], which indicated, Nursing staff responded to room following roommate yelling for help. Resident found to be hitting his roommate. Resident was removed from the room. Police notified; Residents wife now present in agreement for Resident to get psych help. MD (Medical Doctor) notified, 911 was called. Resident send to [local hospital] ER (emergency room ) for evaluation. Review of facility documentation including witness statement by staff member revealed heard screaming from room [ROOM NUMBER]. Help, immediately went to open the room door because his roommate closed it. I saw him standing over his roommate in the wheelchair, he was (hitting) him with the (cane) and punching him. He was covered with blood. Immediately called the nurse. Review of witness statement by LPN revealed, Around 1730, I was called to the room [ROOM NUMBER] by the CNA (certified nurse aide). On entry to the room [ROOM NUMBER]A was noted standing over (resident) 301B yelling 'where is my wife. Resident in 301B was sitting in his wheelchair, face covered in blood with multiple hematomas to the left, right, and top of head. (Resident) 301A (AKA CL3) continued to be aggressive constantly repeating, 'I hate him because he did something to my wife. Review of CL3's care plans failed to reveal 1 hour supervision checks. The care plan interventions did not include prohibiting resident to have knives as a result of an incident on [DATE], when resident was reportedly cutting self with meal knife. The care plan interventions failed to address behavior specific interventions including attempting to hit staff member with walking cane. Residents CL2 and CL3 were shared a room at the end of hallway, 113 feet 4 inches from the nursing station, and direct supervision. Review of hospital emergency room documentation for Resident CL2 under Reason for Visit (chief complaint) indicated, Head injury and Assault victim. Further review of hospital record revealed under ED Provider Note section the following; [AGE] year old male with past medical history of dementia brought to ED (emergency Department) after assault. Patient was assaulted by his demented roommate. Patient was struck multiple times by a cane. Patient has extensive facial trauma (contusions) with facial lacerations. Significant bruising to bilateral upper extremities. Additional review of hospital record revealed under Summary of hospitalization the following notation under subsection Hospital Course. who presented from NH (Nursing Home) with SOB (Shortness of breath) and found to be in acute heart failure after he was assaulted by his roommate at his nursing home. Pt (Patient) found to be Hypoxia (oxygen deficiency in arterial blood) upon admission, put on oxygen up to 8L (liters) as his renal function continued to worsen with diuretic usage to help his acute heart failure flare. Further review of hospital record revealed Resident CL2 expired at the hospital on February 3, 2023. Review of Resident CL2's clinical record revealed attending physician discharge summary revealed, under Final Diagnosis the notation of head trauma - hit by another resident. An Immediate Jeopardy situation was identified on [DATE], at 6:10 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator and corporate compliance nurse, Employee E3 at 6:41 p.m. on [DATE], regarding the facility's failure to ensure the residents were free from abuse by providing supervision for Resident CL3 who has a history of violent behavior. The facility submitted and completed an immediate action plan which included whole house audit to determine residents with behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents and education regarding abuse/neglect. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, care plans, and abuse/neglect were reviewed and updated as deemed necessary. Random audits of resident behaviors and nursing interviews with five staff per week (x4 weeks then x2 months) were conducted and will continue till completed. The action plan was accepted on [DATE], at 8:51 p.m. On [DATE], a review of audits, documentation of completed employee education, and interviews with 38 and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on [DATE], at 4:54 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. Review conducted of the clinical records affected by the abusive inaction caused by insufficient supervision which alllowed Resident CL3 to physically abuse Resident CL2 but also had the potential to cause significant harm, physical pain, or mental/emotional anguish. 483.13 Resident behavior and facility practices [DATE] edition 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure to initiate or implement adequate supervisory measures for Resident CL3 to prevent life threatening injuries to CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of CL2's clinical record revealed 5 day Medicare MDS (Minimum Data Set -periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) of 10 out of 15. The score indicates Resident CL2 had moderate cognitive impairment. Review of CL2's clinical record revealed diagnoses including but not limited to following: Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and muscle weakness; Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of CL3's clinical record revealed hospital documention prior to admission on [DATE] to facility which indicated under History of Present illness; .Presents to the ED (Emergency Department) with subsequent 302 petition (involuntary psychiatric admission petition) filed by wife through VCC for agitated and aggressive behavior, threatening purportedly to kill himself and his wife brandishing a knife in furtherance thereof, who subsequently to being brought to the ED by police, having little recollection of events prompting his presentation Review of Resident CL3's clinical record revealed a Quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) score of 03 out of 15 which reflectsa severe cognitive impairment. Review of CL3's clinical record revealed a progress note dated [DATE] (14:,d+[DATE]:26 p.m.) revealed, Residents daughter brought butter knife from residents room and asked that the kitchen not put knives on the residents tray because he was trying to cut himself with it. Resident was assessed and no bruising or skin tears noted. Kitchen staff also called and made aware that resident is not to have plastic or metal knives on his tray. Resident will be placed on Q1hr checks. Review of CL3's clinical record revealed a Psychiatric Evaluation and Consult document dated [DATE], which under section titled Impression and Plan, Staff reports he was collecting knives in his drawer so now he is not receiving knives on his tray. Review of CL3's clinical record revealed the resident was on safety checks every one hour, which was initiated on [DATE]. The last documented evidence of Q (every) hour supervision check was completed on [DATE]. Review of Resident CL3 clinical record revealed an eMAR (Medication Administration Record) Progress note dated [DATE] revealed resident came out to med nurse swinging his cane. Review of Resident CL3's [DATE] MAR (Medication Administration Record) and TAR (Treatment Administration Record) revealed an intervention of checking Q (every) shift for safety, No knives plastic or metal on meal trays was discontinued as of [DATE]. Review of Resident CL3's clinical record revealed a social work progress note date [DATE], revealing, SW (social worker) contacted spouse and notified (spouse) that [Resident] is displaying aggressive behaviors and we are transferring him to [psychiatric facility] in DE (Delaware) to be evaluated. Clinic record of Resident CL3 revealed resident was transferred to a psychiatric facility for treatment on [DATE] and returned to the facility on [DATE]. Review of Resident CL3's clinical record including psychiatric hospital admission summary dated [DATE] which revealed under History of Present Illness; the patient was getting agitated, aggressive, threatening other residents with the cane. Review of Clinical record of Resident CL3 revealed progress note dated [DATE], which indicated, Nursing staff responded to room following roommate yelling for help. Resident found to be hitting his roommate. Resident was removed from the room. Police notified; Residents wife now present in agreement for Resident to get psych help. MD (Medical Doctor) notified, 911 was called. Resident send to [local hospital] ER (emergency room )for evaluation. Review of facility documentation including witness statement by non licensed Employee E5 revealed heard screaming from room [ROOM NUMBER]. Help, immediately went to open the room door because his roommate closed it. I saw him standing over his roommate in the wheelchair, he was (hitting) him with the (cane) and punching him. He was covered with blood. Immediately called the nurse. Review of witness statement by Licensed Employee E4 revealed, Around 1730, I was called to the room [ROOM NUMBER] by the CNA (certified nurse aide). On entry to the room [ROOM NUMBER]A was noted standing over (resident) 301B yelling 'where is my wife. Resident in 301B was sitting in his wheelchair, face covered in blood with multiple hematomas to the left, right, and top of head. (Resident) 301A (AKA CL3) continued to be aggressive constantly repeating, 'I hate him because he did something to my wife. Review of CL3's care plans failed to reveal 1 hour supervision checks. The care plan interventions did not include prohibiting resident to have knives as a result of an incident on [DATE], when resident was reportedly cutting self with meal knife. The care plan interventions failed to address behavior specific interventions including attempting to hit staff member with walking cane. Residents CL2 and CL3 were shared a room at the end of hallway, 113 feet 4 inches from the nursing station, and direct supervision. Review of CL2's hospital emergency room documentation under Reason for Visit (chief complaint) indicated, Head injury and Assault victim. Further review of hospital record revealed under ED Provider Note section the following; [AGE] year old male with past medical history of dementia brought to ED (emergency Department) after assault. Patient was assaulted by his demented roommate. Patient was struck multiple times by a cane. Patient has extensive facial trauma (contusions) with facial lacerations. Significant bruising to bilateral upper extremities. Additional review of hospital record revealed under Summary of hospitalization the following notation under subsection Hospital Course. who presented from NH (Nursing Home) with SOB (Shortness of breath) and found to be in acute heart failure after he was assaulted by his roommate at his nursing home. Pt (Patient) found to be Hypoxia (oxygen deficiency in arterial blood) upon admission, put on oxygen up to 8L (liters) as his renal function continued to worsen with diuretic usage to help his acute heart failure flare. Further review of hospital record revealed Resident CL2 expired at the hospital on February 3, 2023. An Immediate Jeopardy situation was identified on [DATE], at 6:10 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, and the Executive Director at 6:41 p.m. on [DATE], regarding the facility's failure to ensure the residents were free from neglect when licensed staff failed to provide supervision for a resident with a history of violent and aggressive behavior. The facility submitted and completed an immediate action plan which included whole house audit to determine residents with behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents and education regarding abuse/neglect. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, care plans, and abuse/neglect were reviewed and updated as deemed necessary. Random audits of resident behaviors and nursing interviews with five staff per week (x4 weeks then x2 months) were conducted and will continue till completed. The action plan was accepted on [DATE], at 8:51 p.m. On [DATE], a review of audits, documentation of completed employee education, and interviews with 38 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on [DATE], at 4:54 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE], [DATE] 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa code 211.10 (c) Resident care policies Previously cited [DATE], [DATE], [DATE] 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services

Based upon observation, interview, and clinical record review it was determined the facility failed to monitor for signs/symptoms of [CONDITION(S)] such as weight gain in a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of Resident 30's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 30's Weight Summary revealed Resident 30's weight was 299 pounds on August 2, 2022. Further review of Resident 30's Weight Summary revealed Resident 30's weight was 317.5 pounds on September 12, 2022. Review of Resident 30's clinical record revealed Resident 30 was sent to an acute care facility on September 19, 2022 after complaining of shortness of breath at the facility. Review of Resident 30's acute care facility discharge record dated September 25, 2022 revealed Resident 30 was admitted to the acute care facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 30 on October 12, 2022 at approximately 10:00 a.m. revealed Resident 30 to have bilateral (both sides) leg [CONDITION(S)] (swelling). Resident 30 was also receiving oxygen at the time of the observation. Review of Resident 30's clinical record failed to reveal evidence that Resident 30's physician was notified of Resident 30's significant weight gain on October 12, 2022. Further review of the clinical record failed to reveal any interventions in place to address the weight gain or monitor symptoms of [CONDITION(S)]. Review of Resident 30's care plan failed to reveal evidence that a baseline care plan for [CONDITION(S)] was initiated. Interview with the Director of Nursing on October 14, 2022 revealed that Resident 30's physician was not notified of Resident 30's significant weight gain, no evidence of CHF signs or symptom monitoring and no interventions were put into place at the time the weight gain was identified. The facility failed to monitor for signs and/or symptoms of [CONDITION(S)] including weight gain nor notify the physician of the significant weight gain. The facility failed to put interventions into place at the time of the identification of the weight gain on September 12, 2022 which ultimately resulted in actual harm to Resident 30 of hospitalization for [CONDITION(S)]. Review of Resident 119's progress notes revealed a nursing entry dated October 10, 2022 at 3:38 p.m. stating resident reported that coffee spilled on his hand this weekend. Resident has 2 blister on L [left] Hand (palm). Wound on middle of palm is open. NP [Nurse Practitioner] notified. TX [treatment] ordered and completed. Review of Resident 119's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 119's clinical record failed to reveal any wound care orders for Resident 119's wound (burn) from October 10, 2022 when the wound was identified through October 12, 2022. Observation of Resident 119 on October 12, 2022 at 10:14 a.m. revealed the resident has a bandage on his left hand that was dated October 10, 11 A.M. Interview with Resident 119 at the time of the observation revealed the bandage needed to be changed. Interview with Licensed Nursing Employee E7 on October 12, 2022 at 10:20 a.m. confirmed the bandage on resident 119's left hand was not changed on October 11, 2022 as ordered and that was the original bandage she had placed on the wound on October 11, 2022 at 11 a.m. Review of Resident 119's clinical record revealed there was no documented evidence the dressing had been changed since it's discovery on October 11, 2022. Interview with the Director of Nursing and Licensed Nursing Employee E3 on October 14, 2022 at 9:45 a.m. confirmed Resident 119 did not have wound care provide to a burn on the left had as ordered by the physician. 28 Pa. Code 201.18(b)(1)(2) Management Previously cited 4/27/2022 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 7/29/2020, 9/24/2021, 2/1/2022, 4/27/2022, 8/4/2022

Based upon clinical record review of a closed record, it was determined that the facility failed to administer pain medication as ordered by the physician resulting in a hospitalization for pain and causing actual harm to one of one resident reviewed (Resident 278). Findings include: Review of Resident 278's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 278's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 278's clinical progress notes dated October 6, 2022, revealed Resident had complaints of pain. Further review of the October 6, 2022 progress note revealed resident complained of pain in back and rib cage area. Medicated as ordered. Review of Resident 278's clinical progress note dated October 9, 2022 revealed Acetaminophen 650 mg [medication used to treat mild to moderate pain] administered c/o [complaints of] back pain. Review of Resident 278's clinical progress notes dated October 9, 2022 revealed Pt [patient] continues to cry out in pain. [MEDICATION(S)] is on order from pharmacy and has yet to arrive. Nursing supervisory notified. Pt. to be sent to hospital for evaluation. Resident 278 was admitted to the hospital for uncontrollable pain. Review of Resident 278's October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 278's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 278's clinical record failed to reveal evidence that the pain medication ([MEDICATION(S)]) was administered between October 5, 2022 and on October 9, 2022 during which time, Resident 278 was sent to the hospital for complaints of intractable pain. Clinical record review revealed that resident no longer resides in the facility, therefore an interview could not be conducted with resident 278. Interview with the Director of Nursing on October 14, 2022 at 10:00 a.m. confirmed that Resident 278 did not receive the [MEDICATION(S)] pain medication as ordered by the physician to treat resident's moderate/severe pain, due to the medication being unavailable for five days. The facility failed to administer pain medication as ordered by the physician for pain resulting in a hospitalization for Resident 278 for pain causing actual harm. Pa. 28 Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 7/29/2020, 9/24/2021. 2/1/2022, 4/27/2022, 8/4/2022

Based on observations, clinical record reviews, facility documentation, policy and procedures, staff and resident interviews, it was determined that the facility failed to implement sufficient monitoring interventions, supervision, and effective safety measures to prevent elopement (unauthorized leave from a safe area) of a resident assessed with history of elopement and exit seeking behavior. This failure placed residents at the facility in an Immediate Jeopardy situation for one of nine residents reviewed who were identified as at risk for elopement (Resident R1). Findings include: Review of the facility's policy titled Elopement/Missing Resident, revised in April 2022, revealed Residents exhibiting exit-seeking behaviors should be placed under close supervision and offered activities to distract residents. Close supervision can be discontinued once behavior had subsided. Review of the facility's policy titled Elopement Risk Evaluation, undated revealed, Evaluation: Interventions will be developed and implemented by the Interdisciplinary Care Plan Team. Interventions for elopement risk will be care planned. All staff will be aware of any resident deemed to be at risk for elopement. Identification: The care plan and resident profile will indicate resident is at risk for elopement. Alarm Checks: Alarm placement will be checked every shift by nursing staff and the function of the wander guard will be checked daily by nursing staff. Review of progress note dated April 6, 2022, at 9:46 p.m., revealed Resident R1 was admitted to the facility for long-term placement. The same note revealed resident had a diagnosis of Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life) with a behavior problem and a history of brain tumor. Review of Resident R1's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 13, 2022; revealed resident had severe cognitive impairment. Review of progress note dated April 6, 2022, at 10:55 p.m., revealed resident was a new admission to the facility and 3rd floor dementia unit, continually chasing exit doors and elevator with all belongings packed and wanted to go home, wander guard in place to the right wrist. Review of Resident R1's Elopement Risk completed on April 7, 2022, revealed the resident was cognitively impaired, independently mobile, demonstrated exit-seeking behavior, and had a history of elopement. The resident was determined at risk for elopement. Review of Resident R1's active care plan revealed that the elopement care plan was not developed until April 11, 2022; subsequent to elopement on April 10, 2022. Review of the progress notes dated April 10, 2022, revealed that at 10:15 p.m., a police officer came to nursing unit, to report, Resident R1 was found across the street near a diner at 9:35 p.m. The resident was transported to a local hospital for evaluation. Review of the progress notes dated April 11, 2022, at 12:07 a.m., revealed that [Resident R1's] family was made aware of the hospitalization after the resident was found by the police officer eloping out of the building. Review of facility investigative documentation, including Employee E9 statement revealed Resident R1 was seen by the elevator on April 10, 2022, at 7:35 p.m., and was told to go back to his/her room. As per the statement, the resident went back to his/her room and the employee continued to do his/her job. Review of the facility investigative documentation, including Employee E10 statement which revealed resident was observed walking up and down the hallway after dinner. As per statement, the resident was last seen by the nursing station approximately 8:00-8:30 p.m. The statement did not indicate if staff were near to provide supervision for resident. Review of information dated April 10, 2022 submitted by the facility revealed that on April 10, 2022, at 9:22 p.m., the resident left the building by following a staff member through the door and down the stairwell at approximately 9:20 p.m. The staff member was unaware that the resident followed her/him through the door. The resident was located at approximately 10:00 p.m. and was taken to the hospital for evaluation. The resident returned to the facility with no injuries and was placed on 1:1 supervision. Review of Resident R1's progress notes failed to reveal that the resident was provided close supervision or activities to divert attention when the resident exhibited exit-seeking behavior on April 10, 2022. Interview with Resident R1 attempted on April 26, 2022, at 9:30 a.m., but due to severe cognitive impairment was only able to provide name but no details regarding the elopement of April 10, 2022. Interview conducted with the Nursing Home Administrator (NHA) on April 26, 2022, at 10:45 a.m., revealed; per facility investigation, Employee E3 used the third-floor (secure dementia unit) stairwell exit door (located in front of the nursing station) to leave the unit. Per the NHA, without knowing that Resident R1 was following, Employee E3 entered the key code to exit the door and left in a hurry. Resident R1 was able to prevent the door from closing by holding onto it then left the unit. The NHA reported that the investigation/information was based on the recordings from the hallway monitor/camera. The NHA informed the surveyor that the recording was no longer available for viewing. The NHA narrated as per investigation, Resident R1 used the stairs from the third floor to the first floor and then exited on the first-floor north side exit door leading to the side of the building where ambulance park. As per the NHA, the first floor north side exit door should have alarmed when opened but the facility investigation revealed no information if the door alarmed when the resident exited on the night of April 10, 2022. An interview with licensed nurse Employee E3 was conducted on April 26, 2022, at 11:00 a.m., revealing that she/he was the nursing supervisor on the day of the incident and was unable to recall her/his whereabouts. The staff stated, I was all over the building. Employee E3 was unaware of being followed by a resident and unable to recall going out of the third floor exit door between 8:30 p.m. and 9:30 p.m. Employee E3 confirmed that no exit door alarm sounded during the night. Employee E3 reported that she/he did not go out of the building during the shift. Employee E3 reported that a police officer came to the facility around 10:00 p.m. and informed them that the resident was found by the diner (located across a four lane highway in front of the facility building) and was brought to the hospital for evaluation. Review of Resident R1's clinical record failed to reveal documented evidence of Resident R1's wanderguard being checked for placement every shift and functionality daily until the evening of April 13, 2022. Observation conducted on April 26, 2022, at 10:20 a.m., revealed third-floor stairwell exit door's alarm was working. The exit door was located across from the elevator and the nursing station. There were two flights of stairs to reach the first-floor north side exit door. Further observation revealed that the exit door is estimated to be approximately 400-500 feet distance to the diner where Resident R1 was found wandering on April 10, 2022. Additional observation revealed a busy four-lane highway Resident R1 crossed to reach the area adjacent to the diner. Observation on April 26, 2022, at 10:35 a.m., in the presence of the Nursing Home Administrator failed to reveal a working door alarm to the first floor north side exit door. NHA confirmed that the door should have alarmed every time it was opened, with or without a wander guard. The NHA reported that maintenance was working on it. Additional observation conducted on April 26, 2022, at 11:05 a.m., in the presence of the Maintenance Director, Employee E4 revealed absence of alarm when the the first-floor north side exit door was opened. Employee E4 reported that one of the maintenance staff turned off the door alarm due to a building construction delivery. Employee E4 used a key to turn on the alarm but still did not alarm when opened. Interview with Employee E5 on April 6, 2022, at 11:15 a.m. revealed that the north side exit door alarm was turned off at 8:00 a.m., he/she reported that Employee E4 was notified that the door alarm was turned off. Additional observation conducted on April 26, 2022, at 12:00 p.m. in the presence of licensed nurse Employee E6; revealed first-floor exit door on the north side did not alarm when opened. Employee E6 confirmed that the exit door should alarm when opened. Further observation conducted on April 26, 2022, at 12:30 p.m., with Employee E4 revealed that the exit door of the first floor, north side alarm sounded when opened. The exit door alarm was observed loud throughout the first floor unit. Interview with Employee E6, directly after alarm initiated, confirmed hearing the exit door alarm. Interview conducted on April 26, 2022, at 12:45 p.m with Employee E7 confirmed that he/she worked on April 10, 2022, during the 3-11 shift on the first-floor unit. Employee E7 confirmed that no exit door alarm sounded during the evening shift. Interview with the Nursing Home Administrator on April 26, 2022, at 12:54 p.m., confirmed the exit doors should never be off for any substantial time, and if turned off administration (NHA/DON) should be notified to implement safety measures. Interview with the Nursing Home Administrator and Employee E4 conducted on April 26, 202; confirmed being notified of the turned-off door alarm on the first-floor north side. NHA confirmed safety measures for elopment risk residents were not implemented while the door alarm was turned off. Employee E4 reported that all exit door alarms were checked weekly for functioning, but the documentation provided only indicated the doors were inspected monthly. Review of facility documentation titled Monthly Doors and Exit Sign Inspection Form dated April 4, March 12, February 7, and January 7, 2022, revealed no documented evidence that exit door alarms were checked for functioning. Interview with Assistant Director of Nursing, Employee E8 on April 26, 2022, at 12:45 p.m., confirmed that the exit doors inspection form provided to the surveyor does not include information/evidence that exit door alarms were checked on a monthly basis. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on April 26, 2022, at 1:00 p.m. Resident R1 was assessed with a history of elopement and exhibited exit seeking behaviors and the facility failed to develop a plan of care timely, implement appropriate supervision and interventions, and provide effective safety measures to prevent Resident R1 from leaving a safe area, climbing down two flights of stairs, walking out of the building at nighttime and crossing a busy four-lane highway with the potential to experience negative outcomes. An Immediate Jeopardy (IJ) situation was identified to the Nursing Home Administrator (NHA) on April 26, 2022, at 4:18 p.m., and the IJ template was provided to the NHA, related to Resident R1's elopement out of the building. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to ensure implementation of all supervision and safety measures to prevent elopement for residents in the facility and an immediate action plan was requested. On April 27, 2022, at 8:28 p.m. an acceptable immediate action plan was approved which included the following interventions: Resident R1 orders were checked for accuracy and the wander guard was checked for function. Resident R1's care plan was updated to reflect his status as an elopement risk, which includes wander guard placement and intervention of 1:1 supervision. The first-floor side door was checked by maintenance direction and is functioning properly. The third floor wanderguard alarm box near the stairwell was checked by the maintenance director and is functioning properly. All residents will be assessed and for those deemed to be an elopement risk, orders will be reviewed and corrected if needed. All wander guards were checked for residents assessed as an elopement risk and determined to function properly. All residents assessed to be at risk for wandering will have their care plans reviewed for appropriateness and accuracy. Care plans will be audited by DON/designee weekly x 4 week, then monthly x 2 months. Audit results to be reviewed at month QA meeting. Exit doors on all floors were checked by the maintenance director and are functioning properly. Wander guard boxes on all floors were checked by the maintenance director and are functioning properly. All wander guards were checked, they are in place as ordered and are functioning properly. Elopement policy and procedure reviewed and updated. Facility staff, as well as agency staff, will be educated (before the change of shift) with emphasis on assuring doors close properly behind them and reporting system issues to management immediately. Staff will be in-serviced on elopement binders on each floor to review before the start of the shift and where binders are located. Maintenance staff was re-educated to check all exit doors for proper locking and alarm function if placed and to report any issues to management immediately. The maintenance staff was re-educated to check all wander guard boxes for proper functioning and to report any issues and manage immediately. The maintenance staff were educated that if any door is alarmed being taken out of service for maintenance or deliveries the administrator and nursing are to be made aware before turning it off. Department of Health to be notified if necessary. Residents assessed as a wandering risk will be audited by DON/designee daily x 30, then weekly x 2 months for documentation that wander guard is in place and functioning, and report to the QA committee monthly. Maintenance director/designee will check wander guard boxes, exit doors and alarms, if placed, on all floors 5x/week for 3 months and report to QA committee monthly. On April 27, 2022, at 8:30 a.m., a Department of Health surveyor entered the facility to verify the immediate action plan implemented. At 10:00 a.m., all alarms on the exit doors in the building were observed functioning except for the east and west exit doors on the third-floor locked dementia nursing unit. As per the NHA, maintenance was working on a call bell system on the second floor which could have possibly affected the door alarms. Staff were stationed in front of each exit door, all residents whereabouts were verified every 15 mins. The third-floor unit exit doors alarm was fixed and observed functioning at 1:45 p.m. Through observations, staff interviews, facility documentation, and audits, it was confirmed that the facility's immediate action plan was implemented, and Immediate Jeopardy was lifted on April 27, 2022, at 3:28 p.m. 28 Pa. Code 211.5(f) Clinical records Previously cited 2/1/22, 9/24/21, 7/29/20 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 2/1/22, 9/24/21, 7/29/20 28 Pa code 211.10 (c) Resident care policies Previously cited 2/1/22, 9/24/21, 7/29/20 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services

Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure a pressure wound was monitored, and assessed timely to prevent infection, resulting in actual harm to Resident R1 with a deterioration to the resident's sacral pressure ulcer, requiring transfer, admission to the of hospital and a [DIAGNOSES REDACTED]. Findings include: Review of facility policy titled Nursing Policy and Procedure Skin and Wound Care dated (MONTH) 2019 revealed, under section Documentation, Number 3: Wound rounds will be completed weekly, by nurse practitioner from Wound Healing Solutions and Aventura at Pembrooke Wound Team Nurse. Further review of facility policy revealed under section labeled Documentation Number 5 of that Progress reports will be completed weekly and maintained in the chart and Number 7 Treatments will be re-evaluated every two weeks for effectiveness and changed if necessary. Review of Resident R1's clinical record revealed resident [DIAGNOSES REDACTED]. Review of Resident R1's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated (MONTH) 19, 2019, identified the resident with a BIMS (Brief Interview of Mental Status) of 10 out of 15 indicating moderate cognitive deficits. Further review of the MDS revealed the resident required extensive assistance with two staff members for bed mobility, dressing, bathing, and eating but was totally depended on staff for transfers and toilet use. Continued review of the quarterly MDS revealed that the resident had no ambulation abilities and limited upper and lower body range of motion. The resident was identified as always incontinent of bowel and with a urinary catheter in place. The assessment indicated under Section M- Skin Conditions that the resident was at risk of developing pressure ulcers. Review of Resident R1's care plan initiated on (MONTH) 16, (YEAR), identified the resident had potential for further skin breakdown related to mobility deficit, contracture to left hand fingers. Resident R1's care plan identifying Resident has a sacral ulcer with noted interventions to Turn and reposition and weekly wound evaluations and the use of an air mattress. Review of Resident R1's clinical record revealed that (MONTH) (YEAR) wound assessments were conducted on (MONTH) 2; (MONTH) 9; and then on (MONTH) 28, (YEAR). Continued review of (MONTH) (YEAR) wound documentation failed to reveal wound assessments conducted for the weeks of (MONTH) 11-17 and 18-24, (YEAR). Review of Resident R1's wound assessments revealed only one wound assessment was conducted on (MONTH) 14, (YEAR) indicating wound size of length 1.5 cm (centimeters), width 1.5 cm and depth 2.5 cm and only one assessment was conducted on (MONTH) 24, 2019 indicating the wound had increased in size to length 2.5 cm, width 2 cm and depth 2 cm. The facility failed to conduct weekly pressure ulcer assessments to Resident R1's sacral pressure ulcer as indicated in the facility policy during the months of (MONTH) and (MONTH) (YEAR). Continued review of Resident R1's wound assessments conducted by the facility revealed that on (MONTH) 27, 2019 the resident's Stage IV sacral wound measured 2.5 cm x 3.0 cm x 4.0 cm. The sacral pressure ulcer wound increased in measurements on (MONTH) 2, 2019 to 6.0 cm x 5.0 cm x 6.0 cm with Sanguinous-(red/bloody) Exudate (fluid emitted through a wound). Further review of Resident R1's wound assessments revealed on (MONTH) 9, 2019 the wound size increased to 7.5 cm x 5.5 cm x 4.5 cm and red/bloody sanguinous with large exudate. On (MONTH) 16, 2019 wound measurements were 5.0 cm x 8.0 cm x 6.0 cm with undermining and Exudate amount large. Review of (MONTH) 2019 Treatment Administration Records revealed that it was not until (MONTH) 9, 2019 that the treatment to the resident's Sacral Stage IV pressure ulcer was change to cleanse sacral wound with saline solution and pack with calcium alginate, cover with border gauze and cover with dry dressing every dressing. Review of Resident R1's clinical record failed to reveal the physician and/or nurse practitioner from the wound specialist clinic was notified of worsening of the resident's sacral wound when it was noted on (MONTH) 2, 2019. Continue review of Resident R1's clinical record revealed that it was not until (MONTH) 23, 2019 that the wound Certified Registered Nurse Practitioner (CRNP) assessed the resident's sacral pressure ulcer. Review of Resident R1's interdisciplinary notes revealed a nursing note dated (MONTH) 23, 2019 indicating Resident seen by wound CRNP for wound to sacrum. Wound has declined. Increase in size, depth to bone. Wound bed with granulation tissue and slough, heavy purulent drainage. CRNP recommends hospitalization for IV (intravenous) ABT (antibiotic) and surgery . MD (physician) aware and agreeable to sending resident to hospital. MD aware, orders received to send to (hospital) for eval and treat. Review of Resident R1's emergency room documentation dated (MONTH) 23, 2019 revealed [DIAGNOSES REDACTED]. Further review revealed in the emergency department notes resident history of The wound nurse came to facility today to check and change the wound dressings, and recommended resident be sent in right away due to worsening and foul drainage. Continued review of emergency department notes revealed under section titled physical exam indicated, Cavernous massive sacral decubitus wound, to the deep fascia over sacral bone, with feculent (containing dirt, sediment, or waste matter) versus exudative BROWN foul smelling material copiously pouring from wound with macerated and [DIAGNOSES REDACTED]tous (injury or irritation causing dilatation of the blood capillaries) skin changes. Interview on (MONTH) 9, 2019 at approximately 10:31 a.m. with the Director of Nursing confirmed that the facility failed to properly monitor or assess the resident's sacral pressure wound. The facility failed to assess Resident R1's sacral pressure ulcer weekly, failed to notify the physician and/or CRNP timely of the deterioration of the resident's pressure ulcer resulting in actual harm to Resident R1 with deterioration of a sacral pressure ulcer, requiring transfer and admission to the hospital and a [DIAGNOSES REDACTED]. 28 Pa. Code 211.5(f) Clinical Records Previously cited on 9/27/18, 6/08/18, and 4/12/18 28 Pa Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3) Nursing Services Previously cited on 4/9/19, 12/14/18, 9/27/18, and 6/8/18 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited on 4/9/19, 12/14/18, 9/27/18, 6/8/18, and 4/2/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident was protected from physical abuse from another resident for one of five residents reviewed (Resident R2) which resulted in Resident R2 sustaining a laceration of the scalp requiring sutures. Findings include: Review of clinical record of Resident CL1 revealed an admitted [DATE], with diagnoses, including but not limited to, urinary tract infection, change in mental status (a disruption in how your brain works that causes a change in behavior. This change can happen suddenly or over days), dementia (a group of symptoms caused by disorders that affect the brain), and [MEDICAL CONDITION] (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). Review of hospital documentation revealed Resident CL1 was admitted to the hospital on July 7, 2017, for worsening dementia and aggressive behaviors. Further review of the hospital records revealed a psychiatrist note dated July 12, 2017, which noted that when the resident arrived he was agitated and assaultive to staff, and was being placed in four point restraints (when both hands and both feet are restraints to prevent a resident from hurting himself or others). Review of Resident CL1's plan of care initiated August 14, 2017, identified the resident with wandering, physical abusive behavior, altercation with other resident and rejection of care related to [DIAGNOSES REDACTED]. Further review of Resident CL1's clinical record revealed a nursing note for August 11, 2017, at 1:57 p.m. that stated while participating in activities in the dining room, Resident CL1 accused another resident (unknown resident) of stealing his paper and began cursing at the other resident throwing a paper at him. Resident CL1 then walked around the table and came towards the resident, balled fist up in resident's face and Resident CL1 hit the other resident in the chest. Further review of Resident CL1's clinical record revealed a nursing note dated August 12, 2017, that reported another man (unknown resident) was yelling for help and stated that Resident CL1 had just assaulted him, hitting him a few times after verbally calling him names for staring at him in the doorway. Further review of Resident CL1's clinical record revealed a nursing note on August 15, 2017, at 4:55 a.m. that stated the resident was physically abusive to other resident and staff. On August 15, 2017, at 10:07 a.m. the nursing note indicated that the resident was, very violent with staff, picking up books to throw at the unit manager and swing with balled fist at nurse. Resident has been kicking at staff, is acting aggressive and demented, neurotic this morning. On August 17, 2017, at 10:04 p.m. nursing noted that the resident had two separate physical altercations and the resident required 1:1 supervision for the remainder of the shift. Further review of Resident CL1's clinical record revealed a behavior note dated August 19, 2017, at 1:53 p.m. that revealed the resident was physically aggressive toward staff and physically attacked nursing staff by punching and kicking. The resident was redirected. Resident tried to assault staff and other resident's. Resident was counseled and then did come back . and apologized, he said, I am sorry for hitting you. Resident is very quick and unpredictable, in an instance he will strike and come charging at others. Further review of Resident CL1's clinical record revealed a nursing note dated August 19, 2017, 9:00 p.m. that revealed the, resident had physically assaulted another resident who ran to the nurse's station for help. During this time the assaulted resident (Resident R2) was being placed behind the nurses' station for protection. This is when the resident was trying to come behind the nurses' station desk after the resident. The nursing note also stated, the resident was punching and charging the nurse trying to get to the assaulted resident. He wrapped his leg around the nurses leg causing them both to fall and he landed on his right side . Resident c/o (complained) of right leg pain. Resident was sent out to the ER (emergency room ) for evaluation and treatment of [REDACTED]. Review of Resident R2's clinical record revealed diagnoses, including but not limited to, [MEDICAL CONDITION] (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), [MEDICAL CONDITION] (a severe brain disorder in which people interpret reality abnormally), shortness of breath and major [MEDICAL CONDITION] (a mental disorder characterized by at least two weeks of low mood that is present across most situations. It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause). Review of the Quarterly Minimum Data Set assessment (MDS- a periodic review of resident needs) dated August 14, 2017, revealed a score of 15 out of 15 (cognitively intact no impairment) on the Brief Interview of Mental Status (BIMS- interview to determine resident's cognitive level). Review of Resident R2's clinical record revealed a nursing note for August 11, 2017, that indicated Resident R2 came to the nursing station stating that another resident (Resident CL1) came into her room and threw her to the ground and was punching her. Further review of the clinical record revealed on August 12, 2017, bruising was noted on the resident's right upper arm measuring 4 cm (centimeter) x 1.5 cm and 5 cm x 1.5 cm. Further review of Resident R2's clinical record revealed a nursing note for August 17, 2017, stated that Resident R2 reported that Resident CL1 entered the resident's room and began to climb into her bed. Resident stated that she asked Resident CL1 to leave upon which he grabbed her and pushed her to the ground, yelling, Get out of my way! Resident R2 stated that she fell to the floor and landed on her buttocks. The resident did not sustain any injuries. Further review of Resident R2's nursing note dated August 19, 2017, at 11:45 a.m. revealed that the resident was sent to the local hospital for evaluation and treatment for [REDACTED]. On August 20, 2017 at 2:20 a.m. nursing note indicated that the resident returned from the hospital with [DIAGNOSES REDACTED]. The resident was treated with four staples and three sutures. An interview was conducted with the Director of Nursing on October 16, 2017, at approximately 11:15 a.m. and confirmed the aggressive behavior of Resident CL1 towards Resident R2 on August 19, 2017, which resulted in Resident R2 sustaining an injury to the head. The Director of Nursing stated that Resident CL1 was not on one to one supervision at the time that Resident CL1 exhibited aggressive behavior to Resident R2. The facility failed to ensure that Resident R2 was protected from physical abuse from Resident CL1 on three separate ocassions which resulted in Resident R2 sustaining a laceration of the scalp, transfer to the hospital and requiring sutures. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 05/31/17, 03/27/17, 11/04/16 28 Pa. Code 201.18(b)(1) Management Previously cited 03/27/17, 11/04/16 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(b)(3) Management Previously cited 05/31/17, 03/27/17, 11/04/16 28 Pa. Code 201.18(e)(1) Management Previously cited 05/31/17, 03/27/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 03/27/17, 11/04/16 28 Pa. Code 211.12(c) Nursing services Previously cited 11/04/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 08/30/17, 05/31/17, 03/27/17, 11/04/16

Based on review of clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to provide proper supervision to Resident O8 which resulted in actual harm by the resident falling and sustaining a orbital blowout fracture and tripod fracture, as well as fractures of the maxillary sinus wall and nose, and sutures to the top of the forehead, nose, and left cheek; failed to provide the proper interventions to prevent a fall and injury to Resident CL2 which resulted in actual harm to Resident CL2 sustaining fractures to the right hip, right shoulder and right upper arm; and failed to ensure that interventions to prevent falls were implemented (Resident C5) for three of 24 residents reviewed (Resident C5, Resident O8, Resident CL2). Findings include: Review of Resident O8's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident O8's care plan stated that the resident was identified as a high fall risk and required supervision in the bathroom. Review of Resident O8's May 4, 2016, quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs) revealed that the resident required a one person assist with extensive assist (resident involved in activity, and staff provide weight-bearing support) for transfers and personal hygiene and extensive assistance with toileting with one person physical assist. Review of Resident O8's interdisciplinary note dated May 24, 2016, at 7:16 p.m. revealed the resident was found on the floor, face down with walker underneath her in the bathroom. The resident was assisted to standing then to wheelchair where laceration to forehead was cleansed and 911 (emergency medical services) called. The resident was transported by the emergency medical services to the local hospital. Review of the hospital discharge summary dated May 27, 2016, revealed that the resident was diagnosed with [REDACTED]. Further review of Resident O8's clinical record revealed an admission nursing note dated May 27, 2016, that indicated the resident was readmitted with 14 sutures to the top of the forehead, three sutures on the bridge of her nose, and eight sutures to the left cheek. Review of the facility's investigation into the fall sustained by Resident O8 on May 24, 2016, revealed that the resident was seated on the toilet with a nursing assistant in attendance due to previous falls. The resident alerted the nursing assistant that she was having a bowel movement. At this time, the nursing assistant stepped outside of the bathroom to reach for gloves outside the door when the resident stood up and fell forward onto the floor. Review of statement obtained by the facility of the nursing assistant who cared for Resident O8 at the time of the fall incident revealed that the nursing assistant last saw the resident at 5:00 p.m. before the incident occurred and at 5:05 p.m. became aware of the injury sustained by the resident. An interview with the Director of Nursing on November 3, 2016, at approximately 11:00 a.m. confirmed that on May 24, 2016, Resident O8 fell when the nursing assistant left the resident unattended while on the commode, which resulted in a fall and the resident striking her head and face. The facility failed to ensure that Resident O8 was provided with proper supervision while in the bathroom which ultimately resulted in the resident sustaining a fall and actual harm of a left orbital blowout fracture and tripod fracture, fractures of the left maxillary sinus wall and left nasal bone fracture (nose), as well as 14 sutures to the top of the forehead, three sutures on the bridge of her nose, and eight sutures to the left cheek. Review of Resident CL2's demographic sheet revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].) and dementia (an irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). Review of Resident CL2's admission Minimum Data Set assessment revealed that the resident scored a seven out of 15 on the Brief Interview for Mental Status (BIMS - structured cognitive test used to determine a resident's cognitive status) which indicated that the resident had severely impaired cognitive status. Review of Resident CL2's care plan revealed a care plan for the potential for falls. An intervention initiated on May 3, 2016, was to ambulate with contact guard (steadying during the performance of a task). Further review of the care plan revealed an intervention initiated on April 29, 2016, for an assist of one with ambulation. Review of Resident CL2's interdisciplinary notes revealed a nursing entry on May 29, 2016, at 4:12 a.m. stating that the nurse was receiving a call from another resident's family when she heard a loud sound coming from the hallway and when she arrived to the hallway, with another nurse, they observed Resident CL2 lying on her right side between room 317 and room 319 with her walker beside her. Upon assessment the resident was noted with pain to both lower and upper extremities. Before the fall, the resident was noted walking/ambulating in the hall with the resident in 319A, and giving her walker to the resident in room 319A. Resident CL2 was re-directed at that point and her rolling walker was given back to her. She was reminded by the nursing staff to ambulate with the walker at all times. Further review of Resident CL2's interdisciplinary notes revealed a nursing entry on May 28, 2016, at 11:13 a.m. which revealed an X-ray of the right shoulder, right humerus (long bone of the upper arm), lumbar spine (five vertebrae between the rib cage and the pelvis), and right hip due to a fall. Results received showed an acute right pubic (hip bone) and acute humeral neck fracture (shoulder) and impacted (a break in continuity of bone) right humerus fracture (upper arm). An interview with Licensed Nursing Staff, Employee E12, on November 4, 2016, at 12:00 p.m. revealed that the resident was care planned to be ambulated with a contact guard and an assist of one with ambulation and the care plan was not followed when the resident fell on [DATE]. The facility failed to provide the proper interventions to prevent a fall and injury to Resident CL2 by not providing proper interventions of contact guard and ambulation with the assistance of one when the resident was found in the hallway with another resident prior to the fall of May 28, 2016 resulting in actual harm to Resident CL2. Review of Resident C5's annual MDS dated [DATE], revealed [DIAGNOSES REDACTED]. Further review of Resident C5's annual MDS revealed that the resident required the assistance of one with transfers and ambulation. Review of Resident C5's care plan revealed a plan of care for the prevention of falls, which included a bed alarm (a devise that alarms when the resident attempts to get out of bed by self) while the resident was lying in bed as one of the interventions to prevent falls. Observation made on November 1, 2016, at 4:45 p.m. of Resident C5 revealed the resident to be lying in bed and the bed alarm was turned off. Observation of Resident C5 in bed on November 2, 2016, at 10:00 a.m. revealed Resident C5 lying in bed and the bed alarm was turned off. An interview conducted with Licensed Nursing Staff, Employee E11, at the time of the observation confirmed that the bed alarm was turned off and should be turned on while Resident C5 was lying in the bed. The facility failed to ensure a functional bed alarm device for Resident C5. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/03/14, 02/12/15, 07/06/15, 10/13/15 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 11/03/14, 02/12/15, 03/10/15, 07/06/15, 10/13/15, 03/08/16 28 Pa. Code 201.18 (b)(1) Management Previously cited 11/03/14, 02/12/15, 07/16/15, 10/13/15, 11/23/15, 03/08/16, 10/05/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/03/14, 12/03/14, 02/12/15, 07/06/15, 10/13/15, 12/04/15, 03/08/16, 10/05/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/03/14, 12/03/14, 02/12/15, 10/13/15, 12/04/15, 03/08/16, 10/05/16

Based on observations, resident and staff interviews, facility documentation and investigation reports, it was determined that the facility failed to provide an environment that remained free of accident hazards related to resident access to water at temperatures exceeding 110 degrees Fahrenheit for three of three nursing floors (first floor, second floor and third floor), thereby placing the health and safety of the residents in Immediate Jeopardy. The facility also failed to properly supervise one of 24 residents (Resident I3) with a history of entering a non-resident area and failed to provide an escort to accompany a resident to a cardiac study for one of 24 residents reviewed (Resident F1). Findings include: Observations during the initial tour of the first floor on October 6, 2015 at approximately 12:30 a.m., revealed hot water temperatures in the sinks located in the resident rooms as follows: 115.3 degrees Fahrenheit in Room 122, 114.5 degrees Fahrenheit in Room 126, 118.3 degrees Fahrenheit in Room 115, and 119.6 degrees Fahrenheit in Room 104. Observations during the initial tour of the second floor on October 6, 2015 at approximately 12:15 p.m., accompanied by Licensed Nurse, Employee E3, revealed the following hot water temperatures in resident sinks: 120 degrees Fahrenheit in Room 200; 118 degrees Fahrenheit in Room 205; 118 degrees Fahrenheit in Room 206; 120 degrees Fahrenheit in Room 210; 118 degrees Fahrenheit in Room 214; and 115 degrees Fahrenheit in the central bathing room. Observations during the initial tour of the third floor on October 6, 2015, at approximately 12:25 p.m. revealed the following hot water temperatures in resident sinks: 116.6 degrees Fahrenheit in Room 311; 120.2 degrees Fahrenheit in Room 312; and 119.0 degrees Fahrenheit in Room 314. The high water temperatures were reported to the facility Maintenance Director on October 6, 2015 at approximately 1:30 p.m. Interview with the Maintenance Director, at this same time, indicated that the high water temperatures tested by surveyors had been reported by the nursing staff and that a maintenance worker had gone to adjust the mixing valve. Observation of hot water temperatures on the second floor on October 6, 2015 at approximately 1:35 p.m., accompanied by the facility Maintenance Director, revealed temperatures ranging from 104.4 degrees Fahrenheit to 116.8 degrees Fahrenheit and a temperature of 99.5 degrees Fahrenheit in the central bath room. Observations of the thermometer while the Maintenance Director was taking the water temperatures revealed fluctuations from high to low before finally settling on a temperature. Interview with Maintenance Worker, Employee E4, at approximately 1:50 p.m., revealed that after being told by the nursing staff that there was a problem with the water temperatures, he went down to adjust the water temperature. Upon further interview, Employee E4 revealed that before adjusting the temperature, he did not check the temperature of the mixing valve as he, just went by the report of the nurses. Employee E4 further revealed that he and another maintenance worker were the staff that maintained the water temperature logs and that water temperatures had been fluctuating for at least a couple of months. Additionally, Employee E4 confirmed that he had not checked the calibration on the thermometer used for monitoring water temperatures for approximately a year. Review of water temperature logs from August 2015 and September 2015 revealed that water temperatures were taken at the mixing valve first, then in the therapy room, the central bathing rooms and one resident room from each floor, with the majority of temperatures taken from 7:15 a.m. to 8:30 a.m. Additional review indicated that on August 16, August 18, August 25, August 27 through September 1, 2015, no water temperatures were recorded on the water logs for resident rooms. Further review revealed that the maintenance staff did not take water temperatures on the weekends from August 22, 2015 through October 4, 2015. Additionally, on the following dates the water temperatures recorded at the mixing valve were lower than the water temperatures recorded in the therapy room and resident areas: August 19 - 21, 2015; August 26 - 29, 2015; August 31, 2015; September 29, 2015 and October 6, 2015. Further review indicated that there was no temperature recorded for the mixing valve on September 4, 2015. Interview with the Nursing Home Administrator on October 6, 2015 at approximately 3:00 p.m., revealed that the nursing staff were responsible for taking the water temperatures on the weekends. Review of the documentation of these temperatures for the aforementioned weekends, revealed that the only temperatures taken were those taken before the residents' showers. There was no record of temperatures taken at the sinks in any of the residents' rooms. Interview with the Regional Maintenance Director on October 7, 2015 starting at 11:10 a.m., revealed that it was known for two to three months that the existing mixing valve was not the correct one for the facility building size and that there was a problem with fluctuating temperatures. The Regional Maintenance Director further indicated that he had met with the company who installed the mixing valve a few months ago and was told that there was nothing wrong with the mixing valve itself, but that the only way to adjust the temperature of the mixing valve was to open 30 faucets all at the same time which was not practical. He further indicated that yesterday when the maintenance staff went down to adjust the mixing valve, it was not done correctly. Additionally, he confirmed that even though there was knowledge of a problem, no changes were made to the way that hot water temperatures were being monitored or the frequency with which they were taken. Furthermore, he could not explain how it was possible that the temperature of the mixing valve was recorded on several occasions as being lower than the temperatures recorded in the therapy room and residents' rooms, and confirmed that someone should have been looking/monitoring for this discrepancy. Immediate Jeopardy was identified to the Nursing Home Adminsitrator on October 6, 2015 at 2:50 p.m. for failing to assure that hot water temperatures did not exceed 110 degrees Fahrenheit, and for failing to ensure that the mixing valve at the boiler was the appropriate valve for the size for the facility, which placed the health and safety of residents in immediate jeopardy. An action plan was requested on October 6, 2015 at 2:50 p.m., to immediately put a system in place to ensure that hot water temperatures were at safe temperatures of not exceeding 110 degrees Fahrenheit. The facility submitted the following plan of action on October 6, 2015, which included the temperature at the holding tank adjusted to 110 degrees Fahrenheit, the nursing staff was to utilize thermometers to ensure that water in the basin used for bathing did not exceed 110 degrees Fahrenheit and the mixing valve and parts needed for replacement/repair were to be located for immediate installation by the outside plumbing company. Hourly water temperatures were obtained by the maintenance staff on every unit at four random room locations and all shower rooms from 8:00 a.m. to 8:30 p.m. The hourly check included temperatures leaving the boiler at the mixing valve. Education was initiated to all licensed and non-licensed nursing staff regarding safe and appropriate water temperatures. The facility implemented an acceptable action plan and the Immediate Jeopardy was removed on October 7, 2015 at 2:50 p.m. Observations of the 2nd Floor Unit in the facility on October 6, 2015 at 2:30 p.m., revealed that when a person enters the unit from the elevators, the nursing station was positioned to the right of the elevators which directly faces a set of large double doors that allow entrance to a non-resident area. The double doors were directly in line of sight from the nursing station, and two medication carts were positioned on the opposite side of the nursing station. Any staff member who was at the nursing station and/or near the two medication carts had direct vision of the double doors. Observation of the double doors revealed that to exit through the double doors into the non-resident area, a code must be entered in the code pad, which was located on the right wall prior to the double doors. This code was used to release the alarm locking mechanism. Immediately entering the double doors into the non-resident side with Licensed Nurse, Employee E10, multiple resident wheelchairs were being stored in the corridor when not in use. To the left was the door to the staff break room/lounge. Upon entering the staff lounge, there were a few vending machines to the left and a few tables and chairs for the staff to sit in the middle of the room. Walking through the staff lounge, there was no evident area that was not visible from the door leading into the staff lounge. Exiting the staff lounge, and turning left, there was an exit door down the corridor past the resident equipment that was not in use, and the door lead to the outside of the building and steps were observed leading to ground level. During observation, Employee E10 stated that the door was equipped with an alarm if it was opened. To the left of the exit door was a short corridor with a door at the end of the corridor which led, according to Employee E10, to the main housekeeping closet that contained supplies. Employee E10 stated that to the right of the housekeeping door was a door to that lead to where the maintenance department kept all their supplies. Walking back down the corridor towards the double doors that lead to the resident area of the 2nd Floor Nursing Unit, there was a green lighted button on the right side of the wall. Employee E10 stated that the green button was how to enter back into the resident area simply by pushing it. Employee E10 pushed the green button releasing the alarm system locking mechanism of the double doors, which allowed entrance back into the 2nd North Unit. Observation of the 2nd Floor Nursing Station on October 6, 7, 8, 9 and 13, 2015 at various times on the 7-3 tour of duty (day shift) revealed that there was a unit clerk stationed at the desk for most of the time. Nursing staff were consistently present at the nursing station, which was a very high traffic area for staff and residents with some of the staff sitting and doing charting, making phone calls or interacting with each other, and some residents who sat around the nursing station area. It was also noted that there were many staff members going in and out of the double doors, utilizing the code pad to enter the non-resident area. Review of Resident I3's electronic medical record revealed an original admitted [DATE] with a readmitted [DATE]. Resident I3 was admitted with [DIAGNOSES REDACTED]. Review of Resident I3's 5 day quarterly admission Minimum Data Set assessment (MDS-a periodic assessment of the residents physical and cognitive functioning) indicated it was completed on June 7, 2015, following a readmission to the facility from the hospital after a left ankle tendon release surgery (surgical procedure that involves cutting through or disconnecting a tendon to allow for a greater range of movement). The MDS indicated that the resident needed extensive assistance with bed mobility, transfers, dressing, toileting and hygiene needs. It also indicated that the resident's mode of ambulation was by wheelchair. Review of Resident I3's nursing note dated August 30, 2015 revealed that the resident left the 2nd Floor North area through the secure doors on August 30, 2015. The clinical nursing note on August 30, 2015 at 4:02 p.m., stated, this nurse was informed by co- nurse that resident was observed coming through double doors from employee break room area. Resident had attempted to go through the double doors earlier shift she was redirected not to go through the doors, that area is for employees only. When asked, resident was able to verbalize knowledge of code. Review of the resident's current plan of care revealed that there were no interventions developed after the August 30, 2015 incident to ensure the safety and supervision of Resident I3. A clinical nursing progress note dated September 12, 2015, stated, About 1:20 p.m. this nurse was informed by co-nurse that the resident went through the double doors, both nurses went back there but resident was nowhere to be found. Supervisor made aware of resident disappearance. Nurses searched the whole building but could not find resident. About 2:40 p.m. this nurse saw resident coming through the door back of employee break room, leaving the 2 North area. When this nurse asked the resident regarding her whereabouts, the resident stated, Shhh, keep your mouth shut. Resident was escorted to her room and supervisor was notified. Review of August 30, 2015 through September 12, 2015, nursing notes indicated that the resident was being monitored for elopement, but did not indicate how the facility and staff were providing supervision to the resident in order to prevent the resident from entering the non-resident area off of the 2nd floor of the facility. Review of Resident I3's current plan of care revealed that on September 14, 2015, (2 days after the second incident of the resident entering a non-resident area) the resident's plan of care was revised to include that at times, the resident went through the double doors to the north side of the building. Further review of the interventions included in the care plan revealed that there were no interventions developed to direct the nursing staff in the supervision of Resident I3 in order to ensure the resident safety. Interview with Employee E10 at the time of the tour on October 6, 2015, revealed that she was aware that Resident I3 exited from the resident area two times, but stated that she was not present at the facility on those days. Employee E10 confirmed that the resident followed a staff member through the doors into the non-resident area when the staff member was going to the break room. She stated that the management of the facility changed the code to the entry pad after on the the first incident that the resident left the unit, but that the resident again went through the doors a couple of weeks after the first incident. She stated that both the incidents occurred on the 7-3 tour of duty (day shift). Interview with Resident I3 on October 6, 2015 at 3:00 p.m., revealed that the resident had a brace on her left arm which extended onto her left hand which limited mobility of the left hand and arm. The resident stated that she was not ambulatory and had limited function in her left arm and legs. The resident further indicated that she propelled her wheelchair primarily with her right hand/arm. Resident I3 acknowledged that she went into the non-resident area of the second floor and stated that she followed a staff member who entered the area after releasing the doors by placing the code into the code pad. Resident I3 stated that she wheeled herself into the non-resident area through the doors to use the vending machines. She stated that the facility management was upset with her for going into the non-resident area and told her that staff would assist her in buying something in the vending machines. She stated that to get back into the resident area, she hit the green button on the wall and wheeled herself back onto the nursing unit. Interview with the Nursing Home Administrator (NHA) on October 8, 2015 at approximately 10:30 a.m., revealed that she was not aware of the first incident of the resident entering the non-resident area on August 30, 2015. When the surveyor requested the investigation reports for both incidents, the NHA produced one investigation report for the incident that occurred on August 30, 2015, but no investigation report was provided for the incident that occurred on September 12, 2105. The NHA stated that an in-house investigation was completed for the incident that occurred on August 30, 2015, and the team decided to change the code on the access pad after the incident on that day (August 30, 2015) and on September 12, 2015, they decided to change the code every seven days. The Nursing Home Administrator stated that there was no formal policy or procedure written for this change, but education to the staff was completed on September 14, 2015. Review of the education roster provided by the NHA revealed that no education was completed on providing supervision to residents living the nursing unit and assessing the non-resident area off of the 2nd floor or the changing of access codes with the housekeeping or maintenance staff; the staff who pass through the double doors during the day shift (7-3 tour of duty) because their supply rooms are located in the non-resident area. It was also noted that the Nursing Home Administrator could not answer whether other interventions were implemented to prevent further exit seeking behavior from Resident I3 because the resident admitted to the staff that after the first elopement she had the code to the access pad. The Nursing Home Administrator confirmed that the resident was missing for one hour during the second incident of September 12, 2015 while staff conducted a search for the resident within the building and on the 2nd floor non-resident area, but the staff did not find the resident in that area. Review of Resident F1's [DIAGNOSES REDACTED]. Review of Resident F1's quarterly Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS- assessment to determine a resident cognitive ability) score of four, which indicates severe cognitive impairment. Review of Resident F1's current care plan revealed a focus of, problematic manner in which resident acts, characterized by ineffective coping; demands attention related to: yelling repeatedly and demanding attention while staff is caring for others. Review of Resident F1's physician's orders [REDACTED]. Review of the nursing progress notes revealed that this resident returned from the hospital after having the echocardiogram completed on October 6, 2015 at 4:32 p.m. On October 9, 2015 at 9:00 a.m. an interview with the Nursing Home Administrator revealed that they had received a call from the hospital where the echocardiogram was being done, indicating that Resident F1 had no escort that accompanied the resident to the appointment and confirmed that the nursing care facility should have sent an escort with this resident due to the resident's behaviors. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 07/06/15, 02/12/15, 11/03/14 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 07/6/15, 3/10/15, 02/12/15, 11/03/14, 04/07/14, 10/22/13 28 Pa. Code 201.18(b)(1) Management. Previously cited 07/06/15, 02/12/15, 11/03/14, 04/07/14, 10/22/13 28 Pa. Code 201.18(e)(1) Management. Previously cited 02/12/15, 11/03/14, 04/07/14, 10/22/13 28 Pa. Code 201.18(b)(3) Management. Previously cited 02/12/15, 11/03/14, 04/07/14, 10/22/13 28 Pa. Code 201.20(a)(c) Staff development. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 03/10/15, 04/07/14 28 Pa. Code 211.10(d) Resident care policies. Previously cited 07/6/15, 02/12/15, 12/03/14, 11/03/14, 04/07/14, 10/22/13 28 Pa. Code 211.12(c) Nursing services. Previously cited 07/06/15, 02/12/15, 12/03/14, 11/03/14, 04/07/14, 10/22/13

Based on observations, clinical record review, resident and staff interviews and review of the facility's policy, it was determined that the facility failed to ensure that the environment in the Physical and Occupational Therapy Room remained free from accident hazards, placing the health and safety of the residents in Immediate Jeopardy. Additionally, the facility failed to ensure that the residents were provided adequate supervision and access to mobility equipment (walker) when in the smoking area and that the smoking materials were secured for resident safety for two of two residents reviewed, resulting in actual harm to one of the two residents (Resident I6). Findings include: Observations on the initial tour of the facility on October 27, 2014, at 6:15 p.m., revealed that the therapy room was unlocked and that residents and their families had unsupervised access to this area. Observations during the environmental tour conducted on October 31, 2014, at approximately 2:00 p.m., revealed that the Physical and Occupational Therapy Department's hydrocollator unit (a unit that contains very hot water, which is used to heat and store hot packs used for therapeutic application for physical therapy treatments) was observed to be unlocked in the Physical and Occupational Therapy Room behind a curtain. Water temperature recordings were listed on a clipboard which hung on the handle of the hydrocollator unit. Water temperature logs were not available from August 2, 2014 through Thursday October 15, 2014. A high water temperature was listed on August 1, 2014, and the temperature listed for Thursday, October 16, 2014, at 6:55 was 171.2 degrees Fahrenheit (none of the temperature readings recorded on the clip board indicated a.m. or p.m.) The next entry was Monday, October 20, 2014, at 2:45 which was 170.1 degrees Fahrenheit. A notation made next to this temperature that stated that the temperature was, "turned down," however, there was no recheck temperature recording noted on October 20, 2014. The temperature recorded on October 21, 2014, at 8:05 measured 167.2 degrees Fahrenheit with the notation, "turned down," written next to the temperature although there was no recheck written. On October 22, 2014, at 7:00 the temperature was measured as 148.5 degrees Fahrenheit with the notation, "turned up," but no recheck was noted. The hydrocollator unit water temperature logs from October 24, 2014, through October 28, 2014, ranged between 161.8 and 164.8 degrees Fahrenheit. On October 29, 2014, at 7:08 the temperature was recorded as 158.9 degrees Fahrenheit and a notation read, "increase temperature." The last temperature recorded was for October 30, 2014 at 11:10 at 160.5 degrees Fahrenheit. The facility policy was requested on October 31, 2014, at 3:00 p.m., and again at 3:30 p.m., relating to the appropriate temperatures for the hydrocollator unit temperature and the frequency of temperature monitoring. A policy was not provided during the survey through November 3, 2014. In addition, there was no written policy provided regarding directing the staff on the reporting and action for inappropriate high and low temperatures. The only temperature direction provided was on a yellow sticky note located on the clip board which stated that the, "ideal," temperature was 160 degrees Fahrenheit and that the temperature should not be higher than 165 degrees Fahrenheit. The Nursing Home Administrator confirmed on October 31, 2014, at 3:00 p.m., that the hydrocollator unit was stored in an area that was not routinely locked when staff were not present including the evenings and weekends and that residents used this area unsupervised at times which posed a safety risk from this unmonitored equipment containing hot water. Additional observations made during the environmental tour on October 31, 2014, at approximately 2:00 p.m., of the Physical and Occupational Therapy Room revealed a small kitchen area used for Occupational Therapy retraining. Further investigation revealed that the stove and the oven were turned off but when the control knobs were tested by the surveyor, the electricity was not locked out to this cooking area. Brownies, that had just been baked, were observed cooling on the top of the stove. A small toaster oven, which could be plugged in, was observed on the counter. Two therapy staff members were observed across the room with their backs to the area and were watching a computer screen. Resident D7 was observed in this area on October 31, 2014, at 2:00 p.m., sitting in a wheelchair with an oxygen canister attached to the back of the wheelchair. The resident stated that the stove could be turned off at the breaker box. The breaker box was noted to be located on the wall to the left of the cooking area. The breaker box was partially open with a key hanging out of the lock. In a drawer to the left of the stove, was a large knife with a blade approximately 10 inches long. The drawer contained hardware for locking, however, the padlock was not able to be located. A serrated "rocker" knife was observed in the sink. Also observed on October 31, 2014, at 2:00 p.m., were two small canisters of oxygen mounted on wheelchairs and stored in the back of the Physical and Occupational Therapy Room. There was no visible signage alerting residents and visitors about oxygen in the therapy room. Signs stating "No Smoking" were not posted at the entrance to the therapy room where oxygen tanks were stored. On the second walk through of the Physical and Occupational Therapy Room at 3:10 pm, on October 31, 2014, revealed that there were two additional oxygen tanks in tank holders, stored behind a curtain in the area of the hydrocollator unit. There were no signs to indicate oxygen storage or to indicate this was a Nonsmoking Area. Immediate Jeopardy was identified to the Nursing Home Administrator on October 31, 2014, at 3:30 p.m., for failing to ensure that the Physical and Occupational Therapy Room was supervised and secure which allowed residents access to hazardous and flammable equipment, placing the safety of these residents in Immediate Jeopardy. An action plan was requested on October 31, 2014, at 3:30 p.m., to immediately put systems in place to ensure that the hydrocollator unit was not accessible to residents and that hazardous utensils (knives), electrical appliances (range, toaster oven) and the circuit breaker box were not accessible for resident's unsupervised use. On Saturday, November 1, 2014, a resident was observed in the therapy room alone between 5:30 p.m., and 6:00 pm. Through conversation he explained that he came to the room to use the arm strengthening machine and at night, it's not busy. On Monday November 3, 2014, at approximately 8:30 a.m., a resident was observed in the Physical and Occupational Therapy Room with an oxygen tank attached to his chair. No other staff were in the therapy area at the time of this observation. The facility submitted and implemented an acceptable plan of action and the Immediate Jeopardy was removed on November 2, 2014, at 6:45 p.m. The facility disconnected and removed the hydrocollator unit, the power to the stove was disconnected, the breaker box was locked and the keys were given to the Director of Maintenance and the Nursing Supervisor and the drawers adjacent to the stove were secured with the use of a padlock. Review of Resident I6's October 2014, physician's orders [REDACTED]. Review of the annual Minimum Date Set assessment (MDS - a periodic assessment of resident status and care needs) completed on August 14, 2014, identified the resident as requiring limited assistance of one person for transferring and ambulation. Review of the nursing documentation dated June 22, 2014, noted that at 10:25 a.m., the resident was in the smoking area outside of the 1 South Nursing Unit when the resident fell out of a "regular chair." The activity staff observed the resident laying on his left side. The resident's walker was found in the foyer area on the 1 South Nursing Unit and not with the resident when he went outside to smoke. Review of the facility's investigation into this incident, revealed that the resident sustained [REDACTED]. The resident also was noted with a skin tear to the top of the right hand measuring 1.0 centimeters long x 0.5 centimeters wide and 0.1 centimeters in circumference. Further review of Resident I6's nursing documentation, revealed that on August 8, 2014, at 11:30 p.m., the resident was found outside in the smoking area and the resident had fallen forward out of a chair. The resident stated to the staff that he was trying to sit down on the chair and it slid out from under him. Review of the facility's investigation into this incident confirmed that the resident was found outside of the facility at the smoking area with blood coming from the side of his head. An interview with the Director of Nursing on October 31, 2014, at 11:30 a.m., confirmed that Resident I6 fell from a regular chair and that the resident, at times, leaves his walker behind. The facility failed to ensure that Resident I6's assistive device (his walker) for ambulation was within his reach to reduce the risk of an accident. Observations conducted on October 30, 2014, at 1:20 p.m., of the smoking area outside of the 1 South Nursing Unit, revealed that there were a total of 5 chairs available for resident use, which included two plastic chairs, one chair without arms, and two stacked chairs. The facility failed to ensure the proper supervision and safety of Resident I6 who was found smoking outside of the facility on June 22, 2014, at 10:25 a.m., and on August 8, 2014, at 11:30 p.m., and sustained lacerations to his head, resulting in actual harm to Resident I6. Review of the facility's smoking policy stated that the facility has been designated as a smoking facility. The facility has a designated outside smoking area for residents to smoke which is located at the rear exit on the 1st floor. The front of the building is off limits for smoking at any time. The smoking area is available from 9:00 a.m. to 9:00 p.m., from April through October and from 9:00 a.m. to 7:00 p.m., November through March. Smoking material is prohibited to be kept in the residents' rooms. All smoking material must be turned in and kept at the nursing station for safety. Observations conducted on Saturday, November 1, 2014, at 6:10 p.m., revealed that Resident C2 was smoking outside, at the front of the facility while seated on his wheelchair. A pack of cigarettes and a lighter were observed in the right cup holder of the wheelchair. There were no facility staff providing supervision to this resident at the time of the observation. Interview conducted with Resident C2 revealed that the resident, stated to the surveyor, that the lighter was given to him by a nursing assistant and that he kept the cigarettes with him until he went to bed, when he gives the smoking materials back to the nursing staff. Interview with the Nursing Supervisor, Employee E5 on November 1, 2014, at 6:25 p.m., confirmed that the residents were not to have smoking materials on their person. An interview with the Regional Director, Employee E6, on November 1, 2014, at 6:45 p.m., revealed that upon investigation of how Resident C2 obtained the smoking materials, it was revealed that the resident was given the smoking materials by family who visited the resident earlier in the day. In a previous interview with the Nursing Home Administrator on October 30, 2014, at 2:30 p.m., it was revealed that the facility had revised the smoking policy but the residents' families were not told of the revision to the smoking policy. The facility failed to ensure that Resident C2 was smoking in the designated smoking area, and that smoking materials were not in the possession of the residents per the facility's policy in order to ensure resident safety. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 09/21/2012. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 09/21/2012, 10/22/2013, 04/07/2014. 28 Pa. Code 201.18(b)(1)(3)Management. Previously cited 09/21/2012, 10/22/2013, 04/07/2014. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/22/2013, 04/07/2014. 28 Pa. Code 201.18(e)(3) Management. 28 Pa. Code 211.10(a)(c) Resident care policies. Previously cited 09/21/2012, 04/07/2014. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 09/21/2012, 10/22/2013, 04/07/2014. 28 Pa Code 211.11(a) Resident care plan. Previously cited 10/22/2013. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/22/2013, 04/07/2014. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(c) Nursing services. Previously cited 10/26/2012, 10/22/2013. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/22/2013, 04/07/2014. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 09/21/2012, 10/26/2012, 10/22/2013, 04/07/2014.

Based on observations, review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to provide the necessary care and services to prevent and/or promote the healing of pressure sores causing actual harm to four of 14 residents with pressure sores. (Residents I77, B19, F52, and J89) Findings include: Review of the facility's " Pressure Ulcer-Prevention and Treatment Policy " dated January 31, 2013, indicated that it was the facility's goal to prevent the development of avoidable pressure ulcers. The policy further stated that routine preventative and daily care would be provided to prevent avoidable pressure ulcers including turning and positioning as well as pressure reduction or relief devices. The policy also indicated that pressure sores that developed would be treated as ordered by the physician and the treatment would be regularly assessed for signs of healing. The physician would be notified of deterioration or failure to improve noted after a two week period for a possible change in treatment to facilitate healing. Review of Resident I77 's [DIAGNOSES REDACTED]. The resident 's annual assessment (assessment of resident status and care needs dated March 13, 2013 indicated that the resident had severe cognitive impairment and was at risk for pressure ulcer development. In addition, the resident required the extensive assistance of two staff members for repositioning in bed. Review of Resident I77's nursing progress notes dated March 11, 2013 revealed an open area was identified on the resident 's sacrum (a triangular-shaped bone at the bottom of the spine). It was described as a skin tear measuring 2 centimeters in length and 1 centimeter wide. On March 12, 2013, the open area was described as a Stage II pressure wound (partial thickness loss of dermis presenting as a red/pink wound bed, clean without any devitalized tissue). Resident I77's nursing progress notes dated March 11,2 013 revealed that [MEDICATION NAME] ointment (an [MEDICATION NAME] and antiseptic ointment for minor cuts and scrapes) was applied daily on March 11 and March 12, 2013. The physician orders [REDACTED]. Resident I77's wound documentation dated March 27, 2013 revealed that the wound measured 2 centimeters by 1 centimeter with a covering of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumbs) Review of the March 29, 2013 physician orders [REDACTED]. Review of Resident I77's wound documentation dated April 10, 2013 indicated that the wound had measureable depth of 0.1 centimeters for the first time. On May 23, 2013 wound documentation, the wound had increased in size and depth measuring 1.7 centimeters by 2 centimeters with a depth of 0.4 centimeters. The wound was described as unstageable (a pressure area that involves full tissue loss in which the wound base can not be visualized because of a covering of dead tissue) due to necrosis (dead tissue) at this time because the wound bed could not be visualized due to necrotic tissue (dead tissue black in color); however, the treatment continued with the March 29, 2013 order for daily Santyl application. Resident I77's wound documentation on June 6, 2013 indicated that the wound was measured as 2 centimeters wide by 2 centimeters long and 1.5 centimeters deep. The wound edges were rolled and inflamed which would impair healing and light drainage was noted. The wound continued to be considered unstageable and the physician orders [REDACTED]. Documentation of Resident I77's wound on June 12, 2013 revealed that the wound now measured 3.2 centimeters by 3 centimeters by 2 centimeters. The wound edges were rolled and inflamed and there was heavy serosanquinous (bloody) drainage. The wound documentation also indicated that tunneling and undermining (an open area underneath the " lip " of the border) was observed under the edge of the wound in three places. From March 13, 2013 until June 12, 2013, a three month period, the facility recorded Resident I77's wound became unstageable due to necrotic (dead) tissue, larger and deeper and developed undermining with heavy serosanquinous (bloody) drainage but did not change the treatment. Review of Resident I77's physician's orders [REDACTED]. This treatment was continued until July 5, 2013 when the Santyl was discontinued and an absorbant dressing was added. Hospice services were started. Resident I77's wound documentation continued to indicate that the wound enlarged and deepened with measurements on August 1, 2013 of 3 centimeters by 3 centimeters by 3 centimeters with moderate drainage and undermining (an open area underneath the " lip " of the border) in two places under the wound margin; however there was no change to the treatment for [REDACTED]. Resident I77's treatment of [REDACTED]. The wound required sharp debridement (surgical removal) on October 11, 2013 of necrotic tissue and muscle. Review of Resident I77's wound documentation indicated that the sacral wound developed in the facility continued to deteriorate over approximately six months and the facility failed to change the treatment timely in consultation with the physician as outlined in the facility Pressure Ulcer Policy resulting in actual harm to Resident I77. Review of Resident B19's annual MDS (Minimum Data Set - an assessment of identified resident status and care needs) dated July 3, 2013, included [DIAGNOSES REDACTED]. (progressive disease of the central nervous system characterized by tremors, muscle weakness, and unsteady gait). Review of Resident B19's care plan revised July 6, 2013, indicated actual/potential risk for skin impairment related to chronic, progressive disease, mobility deficit, and bowel/bladder incontinence. Review of the nursing quarterly skin assessment dated [DATE], revealed the resident was at risk for developing pressure sores and had a pressure ulcer risk score of 9 (a score 10 or higher indicates high risk and requires interventions and a care plan according to the assessment directions). The quarterly MDS assessment (assessment of resident status and care needs) indicated the resident was at risk for developing pressure sores and was totally dependent on staff for bed mobility. No new interventions were put into place in the care plan for the resident totally dependent on staff for bed mobility and with impaired skin integrity (pressure reduction or relief devices as per facility policy). Review of Resident B19's nursing progress note dated October 9, 2013, revealed that a stage II intact circular blister measuring 4 centimeters by 4 centimeters was observed on the left heel. Review of the nursing progress note dated October 11, 2013, indicated that a new order for soft heel boots while in bed was noted and initiated (two days after the development of the pressure sore to the left heel). The facility failed to timely implement a care plan to off-load Resident B19's heels (a pressure reduction device) who was totally dependent on staff for bed mobility and at risk for pressure sore development resulting in development of a stage II left heel blister and actual harm to Resident B19. Review of Resident F52's admission MDS (Minimum data set- assessment of resident status and care needs) dated May 13, 2013, included a [DIAGNOSES REDACTED]. The assessment indicated the resident was at risk for developing a pressure ulcer, was receiving hospice services and required the extensive assistance of two people for bed mobility. Review of Resident F52's nursing progress note and wound evaluation flow sheet dated June 12, 2013, revealed that a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) measuring 3.0 centimenters by 3.5 centimeters noted on the right heel and an order was obtained for skin prep every shift. Review of physician's orders [REDACTED]. Review of Resident F52's wound care specialist's initial evaluation dated October 4, 2013, revealed an unstageable area (a pressure area that involves full tissue loss in which the wound base can not be visualized because of a covering of dead tissue) due to necrosis (dead tissue) measuring 1 centimeter by 1.1 centimeter to the right heel. The wound care specialist's assessment and plan consisted of skin prep every shift, to float heels in bed, and to off load the heels (elevate heels off the bed). Review of physician's orders [REDACTED]. Review of the wound evaluation flow sheet dated October 11, 2013, revealed an unstageable area with slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumbs) and eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges) to the right heel measuring 0.8 centimeters by 1.0 centimeters. Review of Resident F52's nursing progress note dated October 20, 2013, revealed an open area to the right heel measuring 2 centimeters by 1.5 centimeters with moist slough tissue formation. Review of the treatment administration record indicated that there was no treatment to done to the right heel after the completion of the [MEDICATION NAME] on October 12, 2013 until October 21, 2013 when Resident F52 was seen by the wound care specialist. Interviews with licensed nursing staff Employee E7 and E8 on October 22, 2013, at 11:30 a.m. confirmed that there was no treatment being applied to Resident F52's right heel wound from October 12, 2013, until October 21, 2013 resulting in actual harm to Resident F52 whose wound increase in size and opened during the time no treatment was done. Review of Resident J89 's [DIAGNOSES REDACTED]. The nursing admission assessment completed on June 21, 2013 revealed a pressure ulcer risk score of 11 ( a score of 10 or above indicates high risk for pressure sore development). . In addition, the admission MDS (Minimum data set- assessment of resident status and care needs) dated June 28, 2013 indicated that the resident was at risk for developing a pressure sore and also required the extensive assistance of two people to move in bed. Review of Resident J89's nursing progress notes dated July 14, 2013 at 6:44 a.m. revealed that an unstageable wound with a dark scab was observed on the resident 's left heel measuring 3 centimeters by 3 centimeters. Review of the resident's care plan revealed that an intervention to off-load pressure on the resident heels was not initiated until July 15, 2013, one day after the development of the pressure sore. An interview with the Director of Nursing on October 22, 2013 at 9:00 a.m. confirmed that Resident J89'st pressure relieving intervention was not put in place to off load the resident's heels ( a pressure reduction device to maintain heels off the bed) who was totally dependent on staff for bed mobility and at high risk for pressure sore development until after the unstageable pressure ulcer on the left heel was identified on July 14, 2013 resulting in actual harm to Resident J89. 28 Pa Code: 201.14(a) Responsibility of licensee Previously cited 9/21/12 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code: 211.5(f) Clinical records Previously cited 10/26/12, 9/21/12 28 Pa. Code: 211.10(d) Resident care policies Previously cited 9/21/12 28 Pa. Code: 211.11(a) Resident care plan 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(d)(5) Nursing services Previously cited 9/21/12