Every finding on record at Aventura at Prospect

Based on observation and interview with residents, it was determined that the facility failed to maintain an effective pest control management program for one of three units observed (first floor unit).Findings include: Review of facility policy on Pest Control dated April 1, 2026, revealed that Under section POLICY STATEMENT: the facility shall maintain an effective pest control program. Under section POLICY IMPLEMENTATION AND IMPLEMENTATION: 1 the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Observations on August 26, 2026, at 8:28AM in floor-floor pantry, in the cabinet under the pantry counter, revealed clutter which included a mix of personal items such as an insulated bag, a cup, a thermos, and an open plastic bag. Further observations revealed a live roach running inside the cabinet. Interviews with several residents revealed they observed cockroaches in their rooms. Interview with the Nursing Home Administrator, Employee E1, revealed that she will have the pantry cabinets cleaned out. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of facility investigation/documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure that resident essential equipment was maintained in a safe operating condition for one of eight resident wheelchairs observed (Resident R1).Findings include: Review of facility policy on Assistive Devices and Equipment dated February 2021, revealed that under section POLICY STATEMENT: Our facility maintains and supervises the use of assisted devices and equipment for residents. under section policy interpretation and implementation #4 the following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. #C. Devise condition - devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of but not limited to bipolar disorder (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), and sleep disorder. Review of Resident R1's Minimum Data Set (MDS - federally required resident assessment completed at a specific interval) dated May 17, 2026, revealed that C0500. BIMS (Brief Interview for Mental Status Score) Summary Score was coded as 15, suggesting that Resident R1 was cognitively intact. Review of Resident R1's progress note dated August 12, 2026, revealed Resident R1 rolled oob (out of bed) to right side onto floor while sleeping and sustained a laceration to L (left) lower extremity. Per the progress note, Resident R1 may have banged leg on wheelchair that was at bedside. Review of the facility investigation regarding Resident R1's fall revealed that the incident occurred on August 12, 2026, at 1:00 a.m. Review of statement by licensed nurse, Employee E4, dated August 12, 2026, revealed that prior to the event (fall), Resident R1's wheelchair was on the right side of the bed near the bottom of bed. Further review of statement by Employee E4 revealed, Resident R1 stated he/she was sleeping and fell out of bed. Review of statement by licensed nurse, Employee E3, dated August 12, 2026, under section Environmental factors that may have contributed to the event- revealed that after fall, Resident R1's leg came in contact with wheelchair. Review of Post Event Staff Interview completed by Licensed nurse, Employee E3 dated August 12, 2026, revealed that under question: Were there any other environmental factors (et floor, faulty equipment, etc.) that may have contributed to the event?, was answered Resident R1 wheelchair at bed side. Under question In your own words, what do you think caused this event, was answered wheelchair at bedside contribute to laceration on LLE (left lower extremity). Observation on August 26, 2026, at 8:48AM revealed that Resident R1 was in bed, awake, and dressing to Resident R1's right lower extremity. Further, a wheelchair was observed to the right of Resident R1's bed, facing towards the head of the bed. Further observation revealed that the right metal brake handle of the wheelchair did not have a rubber covering leaving the metal handle exposed. Interview on August 26, 2026, at 8:48AM with Resident R1 revealed that he/she was sleeping and did not remember rolling out of bed. Resident R1 woke up when face hit the floor. Further Resident R1 revealed that his/her wheelchair was on the right side of her bed facing towards the head of the bed. Further Resident R1 revealed that she/he must have rolled towards the right side of the bed and hit his/her left leg on the wheelchair. Further interview with Resident R1 revealed that at the time of the incident, the handle of her wheelchair did not have a rubber cover. Follow-up observation of Resident R1's wheelchair conducted on August 26, 2026, at 9:33AM with the Director of Rehab Employee E5 revealed that the right break handle of Resident R1's wheelchair did not have a protective rubber cap exposing the metal brake. Interview with Employee E5 conducted at the time of the observation confirmed that resident Iwan's [NAME] brake handles did not have a protective rubber cap. Employee E5 stated it should have a protective rubber cap and that she will immediately replace the missing rubber cap. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on review of policy, review of facility documentation, review of clinical record, and interview with staff, it was determined that facility failed to ensure a resident was free from misappropriation of resident property and/or exploitation for one of three residents reviewed (Resident R3).Findings include: Review of facility policy 'Prevention of Misappropriation and Exploitation of Resident Property,' indicates that the facility shall protect each resident's property, funds, personal information, credit cards, bank cards, and financial resources from misappropriation, exploitation, unauthorized use, coercion, manipulation, or theft. The facility prohibits misappropriation of resident property and exploitation of residents by any employee, contracted staff member, volunteer, visitor, resident, or other individual. Further review of policy states that the purchase must be for the residents personal use or benefit only and the original receipt and any change, unused funds, or remaining balance information shall be returned to the resident immediately and documented. The transaction shall be reviewed for accuracy, and documentation shall be maintained in accordance with facility policy. Review of Resident R3 clinical record revealed the resident is awake, alert and oriented to person place and time (x 3), with medical history of vertebra fractures, sleep disorder, embolism and thrombosis (formulation of blood clots), diabetes (when the body cannot properly regulate blood sugar cause high blood sugar levels), neuromuscular bladder dysfunction (loss of bladder control), anemia (deficiency of healthy red blood cells), and falls. Review of information submitted to the state survey agency on July 8, 2026, revealed on July 6, 2026, Resident R3 reported accusations of Receptionist, Employee E3, stealing his/her money. Review of facility documentation revealed a typed interview with Resident R3 dated July 6, 2026. When asked what happened with the credit card, Resident R3 reported I asked the receptionist [Employee E3] to buy me cigarettes from across the street. She came back with the cigarettes but something this morning told me check my online banking. When I did, I saw an ATM transaction for 80$. Well $82.99. I assume the $2.99 the ATM fee. Per the documented interview, Resident R3 admitted to giving the receptionist the PIN number for the credit card in case she needed it to make the purchase of cigarettes. Resident R3 stated that the Front Desk Receptionist, Employee E3, gave the card back but did not give a receipt. Resident R3 also reported he/she did not give permission to use the debit card at an ATM and only gave permission to use the card to purchase cigarettes. The purchase of the cigarettes was also noted to be a separate charge from the $80 ATM withdrawal. Review of facility documentation revealed a statement dated July 7, 2026, by Resident R3, states on Sunday, July 5, 2026, around 6:15 pm I gave front desk receptionist (Employee E3) my debit card to go to the gas station to get two packs of cigarettes for me. I offered her something, but she stated she didn't want anything, but in the midst of conversation she told me she gets off at 8:00 p.m. so meet her in the hallway. I came out by 8:00 p.m. and I've seen her coming up the hill. She gave me two packs of cigarettes. She also told me she won't be back to work until Wednesday . I didn't think she was going to steal anything because she made me think she was trustworthy, but she took $80 out of my bank account without my permission, and I looked at my statements online Monday morning, and I had to report it . Further review of facility documentation revealed resident/family concern form completed on July 6, 2026, by Resident R3 with the following concern: needed cigarettes asked the front desk staff to go to the store. Resident did say E3 went at 8:02 pm; R3 did give pin. E3 came back at 8:11 pm - 8:17 pm with the cigarettes. When resident checked bank account saw an atm withdrawal for $80. Further review of grievance form revealed that R3 confirmed that he/she did not receive receipt from Receptionist, Employee E3. Further review of facility provided documentation revealed the facility returned Resident R3's funds in the amount of $82.99 was completed on July 6, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of facility policy, interviews with residents, and facility record review it was determined that the facility did not ensure an effective pest control program was maintained so that the facility is free of pests and rodents for two of two nursing floors reviewed. (First floor and Second floor) Findings Include: Review of pest control policy titled, Pest Control dated April 1, 2022 states, Policy Statement-The facility shall maintain an effective pest control program. Further review of the policy revealed, Policy Interpretation and Implementation 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents Interview held with six awake, alert, and oriented resident on March 18, 2026 at 1:30 p.m. During resident council four of the residents reported having mice and roaches in their room at times. (Residents R12, R41. R101). Resident R12 reported that the mice problem has gotten worse over time. Resident R12 reports that the bottom drawer of her dresser has several wholes in it from mice chewing through to the point the drawer in unusable. Resident R12 states that the mice are seen both in the bedroom and in the hallways. Resident R12 resident on the first floor. Resident R41 reported mice coming in and out of the room through a whole on the left side of the toilet. The resident reports that he often sees roaches at night especially in the bathroom. Resident R41 resides on the first floor. Resident R101 reported mice at night in her room. Resident R101 resides on the second floor. A tour was taken of the second-floor nursing unit of the facility on March 19, 2026 at 10:00 a.m. with the Director of Maintenance Employee E6. A tour of the second floor was taken to clarify if a void had been repaired for room [ROOM NUMBER]. The void under the air conditioning unit was noted as filled. Next to the air conditioning unit there was a roach trap with one dead roach and one roach actively dying in the trap. A tour was taken of the first-floor nursing unit of the facility on March 19, 2026 at 10:10 a.m. The tour revealed room [ROOM NUMBER] the bathroom wall on the left-hand side of the toilet has the baseboard peeling and a void in the corner that was not filled in. Further observation of the bathroom revealed approximately ten baby roaches in a trap behind the toilet. Review of the facility pest control reports from March 12, 2026 states, Inspected and treated the kitchen, lobby, lounges, soiled utility room, laundry room, employee break room, and nurse's stations for general pest control. Inspected and treated hallways areas of 1-north for mice activity seen. Observed open voids in hallway baseboard heaters surrounding rooms [ROOM NUMBERS]. Technician dusted, baited and sealed open voids. Replenished bait stations seen in rooms [ROOM NUMBERS] for positive bait acceptance, staff verbally reported seen mice going into both rooms. To improve tracking and accuracy, the use of logbooks is encouraged on 1- North. Placed [NAME] stations at 1-north nursing station. No reports were noted in logbooks. Spoke with administrator Review of 1-north pest control log revealed on March 18, 2026 there were mice noted in room [ROOM NUMBER]. Review of 1-north pest control log revealed on February 13, 2026 there were mice and dropping noted in room [ROOM NUMBER].Review of 1-north pest control log revealed on February 2, 2026 there was a rat noted to come from under the radiator in room [ROOM NUMBER]. During an interview on March 17, 2026, at 11:08 a.m. in room [ROOM NUMBER] with alert and oriented Resident R148, the resident complained of mice in his/her room. Observations revealed there was a hole located on the wall directly opposite the A-bed in room [ROOM NUMBER]. The hole measured approximately 3 inches wide and 8 inches in length.Continued observations in room [ROOM NUMBER] revealed the resident from bed 116-A had a line of snacks along the wall, placed directly on the floor. Snacks were identified as bags of chips and pretzels that were open to air and not in airtight, sealed containers.Observations on March 17, 2026, at 11:20 a.m. revealed two left-over (and half eaten) resident breakfast trays were placed directly on top of the ice machine in the 1-North Nursing Unit Pantry. Food was observed to be left out on the tray as well.Observations confirmed by nurse aide, Employee E17, on March 17, 2026, at 11:25 a.m. 28 Pa. Code 201.18(a)(b)(1) Management28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to ensure food was served for palatable taste and temperature. Findings Include: Review of the facility's undated Test Tray Evaluation form revealed the acceptable delivery temperature of the starch and vegetable should be 135-165 degrees Fahrenheit. A test tray was conducted during the lunch time meal service on March 18, 2026, at 12:25 p.m. with the Food Service, Employee E18, and the Nursing Home Administrator, Employee E1. The test tray consisted of three pureed food items that was supposed to be pureed mac and cheese, mashed potato, and mixed vegetables. Temperatures and tastings revealed the food temperature resulted below standards at 110 degrees Fahrenheit and had a bland, unfamiliar taste. The pureed vegetables tasted more like pureed meat. Nursing Home Administrator, Employee E1, also tasted the food and agreed with surveyor's findings of the test tray. 28 PA Code 201.18(b)(3) Management

Based on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to ensure that food was served in accordance with the planned menus for one of four days observed (lunch meal 3/18/2026).Findings Include: Review of the facility menu revealed the lunch meal offered on March 18, 2026, was listed as tomato soup, grilled American cheese sandwich, mixed vegetables, crackers, chilled peaches, and a beverage. There was no alternate lunch item listed on the main menu; however, the facility had an always available menu with daily food items available at lunch and dinner. The undated always available food menu consisted of cottage cheese, fresh fruit, chicken salad sandwich, grilled cheese sandwich, hot dog, turkey hoagie, and cheeseburger. Review of diet type report dated March 18, 2026, revealed Resident R46 and R26 had physician orders for nectar thick liquids. Review of facility production sheets for the lunchtime meal service on 3/18/2026 revealed nectar thick, tomato soup (6 ounces) was included. Review of the facility production sheets for the lunchtime meal service on 3/18/2026 revealed the serving instructions for the pureed mac and cheese was intended to be served with a #6 scoop (serving utensil equivalent to 8 ounces) and the pureed mixed vegetable to be served with a #8 scoop (equivalent to 4 ounces). Observations on March 18, 2026, at 12:00 p.m. in the main kitchen revealed tray line was started for the lunchtime meal. Observations revealed the cook plating resident trays was using a #16 scoop (equivalent to 2 ounces) to plate the mac and cheese and mixed vegetables. Further observations revealed pureed diets were also being given mashed potatoes, which was not part of the planned meal. Further observations on March 18, 2026, at 12:00 p.m. in the main kitchen revealed only one type of soup (observed thin consistency) was prepared for the residents. During an interview on March 18, 2026, at 12:08 p.m. surveyor asked the Food Service Director, Employee E18, if residents prescribed thickened liquids received a thickened soup. The Food Service Director, Employee E18, was unsure. Observations on March 18, 2026, at 12:25 p.m. on the second-floor nursing unit during the lunchtime meal service revealed no crackers were on the resident meal trays to go along with the grilled cheese and tomato soups per the planned menu. Interview on March 18, 2026, at 12:25 p.m. with the Food Service Director, Employee E18, confirmed crackers were unavailable for the lunch time meal. Continued observations on March 18, 2026, at 12:37 p.m. during the lunchtime meal service on the second-floor nursing unit revealed Resident 27's diet ticket specified double protein portions with food items listed as tomato soup, grilled cheese sandwich, mixed vegetables, and crackers. Observations revealed Resident R27 received grilled cheese and a piece of meatloaf. The Food Service Director, Employee E18, confirmed meatloaf was not on the menu and was unsure why it was being served. Interview on March 18, 2026, with licensed nurse, Employee E19, revealed Resident R46 was not offered tomato soup for lunch. Observations and interview on March 18, 2026, at 12:45 p.m. revealed Resident R26 was not offered tomato soup. Resident R26 informed surveyor he/she enjoys tomato soup and would have eaten it. Review of Resident R10's clinical records revealed resident was admitted to the facility on [DATE], with diagnosis of End stage renal failure, Osteomyelitis of left femur (infection of the bone). Review of Resident R10's MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 12, 2026, revealed that resident has a BIMS (Brief interview for Mental Status) score of 15, indicating resident is cognitively intact. Interview with Resident R10 on March 16, 2026, at 12:00p.m. revealed always available menu is limited and they don't always have an alternative, so I just don't eat. Review of Resident R11's clinical records revealed resident was admitted to the facility on [DATE], with diagnosis of fracture of fourth throacic vertebrae (back fracture), fracture of left patella (left knee fracture). Review of Resident R11's MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 26, 2026, revealed that resident has a BIMS (Brief interview for Mental Status) score of 15, indicating resident is cognitively intact. Interview with Resident R11 on March 16, 2026 at 12:30 p.m. revealed the always available menu is a joke, they keep reducing what is actually available and if you don't like what they are serving for a meal then they send you a hot dog. That is your only option you can have a hotdog or a hamburger. Most the time I just don't eat because it is terrible and I have no other choice. 28 Pa Cde 201.18(b)(1)(3) Management

Based on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units) Findings Include: Review of the facility policy titled, Resident's Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation dated November 25, 2024 states, Policy- It is the policy of the facility to ensure that all residents rights are upheld and that residents are free from abuse, neglect, misappropriation of their property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy applies to all any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants and others currently are potentially working for the facility. A tour of the facility was taken with the facility Director of Social Services Employee E5 on March 18, 2026 at 12:10 p.m. for required notices and postings in the facility. Employee E5 stated she was new and has worked in the facility for two weeks. The Director of Social Services was unsure of where the posting were located for the State Survey Agency. A tour was taken of all nursing units and common areas and State Survey Agency phone number, contact information, and information regarding reporting was not able to be located. An interview with the Nursing Home Administrator on March 19, 2026 at 2:00 p.m. confirmed the required postings were not up and may have been taken down at some point during painting. It was determined that the facility did not ensure required postings including Name, Addresses, and telephone number for the State Survey Agency were posted in prominent places throughout the facility including a statement that the resident may file a complaint with the State Survey Agency in relation to resident abuse, neglect, exploitation, misappropriation of resident property. 28 Pa. Code: 201.18(a)(e)(1) Management 28 Pa. Code: 201.18(b)(1) Management

Based on review of facility policy and facility provided documentation, and staff interview, it was determined that the facility did not ensure to maintain an effective antibiotic stewardship program that includes a system to effectively monitor antibiotic usage for 11 of 11 months of antibiotic stewardship program data reviewed (May 2026 through March 2026)Findings include:According to Patient Safety Authority (PSA), Act 52 of 2007 revised the MCARE Act to require nursing homes to report healthcare associated infections (HAI's) to PSA. Specifically, the act states that the occurrences of a healthcare-associated infection in a healthcare facility shall be deemed a serious event as defined in section 302. HAI's infections are deemed serious events and are submitted into PA PSRS for tracking, analysis, and statewide patient safety improvement. Main infection types reported in nursing homes include skin and soft tissue infections, urinary tract infections, respiratory tract infections, gastrointestinal infections as well as illnesses related to influenza. Review of facility's policy 'Infection Prevention and Control Program,' revised December 2025, revealed no evidence that facility acquired infections were reported to Pennsylvania Patient Safety Authority (PSA) through the Pennsylvania Patient Safety Reporting System (PA PSRS)(act-52). Review of facility policy 'Antibiotic Stewardship,' revised December 2016, revealed no evidence that facility acquired infections were reported to Pennsylvania Patient Safety Authority (PSA) through the Pennsylvania Patient Safety Reporting System (PA PSRS)(act-52). Upon request from Director of Nursing/Infection preventionist, employee E2, on Thursday, March 19, 2026, at 3:00 pm - facility was unable to provide evidence of compliance with Act 52 as required by law. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility's policy, interview with staff, and review of facility provided documentation, it was determined that facility did not ensure to maintain an effective antibiotic stewardship program that includes ongoing tracking, analysis, and reporting of antibiotic use for 11 of 11 months reviewed (May 2025 through March 2026)Findings include: Review of facility policy 'Antibiotic stewardship,' revised December 2016, indicates its purpose is to monitor the use of antibiotics in residents. Review of facility policy 'Infection Prevention and Control Program,' revised December 2025, indicates that the infection prevention program (IPC) provides the framework through which the infection preventionist and the facility can: educate staff and ensure adherence to evidence-based infection prevention and control practices; identify infections and standardized definitions; identify significant pathogens using laboratory culture and sensitivity testing; monitor for outbreaks; ensure the appropriate use of antibiotics; adhere to mandatory reporting requirements. Further review of facility policy 'Infection Prevention and Control Program,' revised December 2025, indicates that culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities, and antibiotic usage is evaluated and practitioners are provided with feedback as needed. Further review of facility policy 'Infection Prevention and Control Program,' revised December 2025, under 'Surveillance,' indicates that outcome surveillance collects data that indicates the presence of infections, communicable diseases, and antibiotic usage among residents and compares the data to standard definitions and criteria. Examples of data that can be used in outcome surveillance include: monitoring resident(s) with fever or other signs or symptoms of potential infection; laboratory cultures or other diagnostic test results consistent with potential infections to detect clusters, trends, or susceptibility patterns; antibiotic orders . Review of facility provided documentation 'Infection Surveillance Report,' dated May 20, 2025 - March 19, 2026, revealed no evidence of implemented interventions to optimize antibiotic use - excluding review of antibiotic prescriptions for appropriateness, setting protocols for empiric therapy, de-escalation based on culture results and avoiding unnecessary antibiotics for viral infections. Further review of 'Infection Surveillance Report,' during infection prevention and control program review on March 19, 2026, at 10:00 am, revealed no evidence of tracking, monitoring or staff education upon request. Further review of 'Infection Surveillance Report, revealed no evidence of analysis and feedback for months of May 2025 through March 2026. Findings confirmed with facility's Director of Nursing/Infection preventionist, Employee E2, on Thursday, March 19, 2026, at 3:00 pm. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based upon observation, interviews with resident and staff, and review of clinical records and facility policy it was determined the facility failed to ensure rehabilitative nursing care was provided to two of 31 resident records reviewed (Resident R1 and Resident R7). Findings include: Review of the facility policy titled Restorative Nursing Services, dated July 2017, states Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation- 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission during the course of stay or when discharged from rehabilitation care. 3. Restorative goals and objectives are individualized and resident- centered and are outlined in the resident's plan of care. Review of Resident R1's clinical records revealed the resident was admitted to the facility on [DATE] and was diagnosed with pulmonary hypertension (high blood pressure in the arteries of the lungs, which can strain the heart and lead to serious complications. Review of Resident R1's physical therapy Discharge summary, dated [DATE], discharge recommendations include Supine and seated HEP (home exercise program). Restorative program established/ trained. Other restorative program- the resident is to be out of bed to chair via hoyer lift 1 to 3 times per week to encourage socialization and to increase sitting tolerance and preform wheelchair mobility. Review of Resident R1's nursing tasks revealed no documented evidence that recommendations were implemented. Review of Resident R1's comprehensive care plan revealed no documented evidence of care plan implemented for restorative nursing program. Interview with Employee E2, Director of Nursing on March 18, 2026, at 2:21p.m. revealed they recommend restorative nursing, but it is not well documented. Further interview confirmed no care plan implemented and no documented evidence that Physical therapy recommendations were completed. Eeview of Resident R7's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 24, 2026, revealed the resident was rarely/never understood and had a diagnosis of functional quadriplegia (inability to use all four extremities). Review of Resident R7's comprehensive care plan dated February 20, 2025, revealed the resident had limited physical mobility related to neurological deficits. Intervention dated July 17, 2025, specified to provide skilled physical/occupational therapy services as indicated. Review of Resident R7's nursing Kardex (system for recording and referencing essential patient information to guide daily nursing care) revealed a task labeled NURSING REHAB to assist Resident R7 with passive range of motion (ROM) daily to his/her bilateral upper and lower extremities with morning and evening care. Review of documentation for the amount of minutes spent providing passive range of motion for Resident R7 from February 18, 2026, through March 19, 2026, revealed it was marked as not applicable on 39 occasions. Continued review of Resident R7's clinical record revealed no supporting evidence as to why passive range of motion was not provided or why it was marked as not applicable. 28 Pa Code 211.12(d)(1)(3) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to conduct a complete and thorough investigation to rule out neglect for one of 31 residents reviewed (Resident R24).Findings Include: Review of facility policy Residents Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation effective/revised 2025 revealed it is the policy of the facility to ensure that all resident's rights are upheld and that residents are free from abuse, neglect, misappropriate of their property, and exploitation. Continued review of facility policy Residents Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation revealed in response to allegations of abuse or neglect the facility will ensure that alleged violations are thoroughly investigated. Review of Resident R24's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 9, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (imbalance in a person's energy/nutrient intake), hemiplegia (paralysis that affects one side of the body) affecting left-side, contracture of right hand, and homonymous bilateral field defects (visual impairments affecting the same side of the visual field in both eyes). Continued review of Resident R24's MDS dated [DATE], revealed the resident was independent for rolling left and right and was assessed as cognitively intact. Review of Resident R24's care plan dated May 27, 2025, revealed the resident had limited physical mobility related to stroke. Review of Resident R24's clinical record revealed a nursing note dated January 26, 2026, that revealed Resident R24 sustained an unwitnessed fall at 5:45 a.m. Resident R24 rolled out of bed, after reaching for his/her cell phone, and landed hard on the left hip and abdomen. Resident R24 expressed a pain scale of 10 out of 10 and requested to go to the emergency room for evaluation. Review of the incident report dated January 26, 2026, revealed per the nursing description, Resident R24 fell out of bed when reaching for his/her cell phone. Per the incident report, call light was within reach and there were no known predisposing environmental, psychological, or situation factors. Continued review of facility documentation revealed witness statements were obtained from the Registered Nurse Supervisor, Employee E21, two licensed nurses (LPN), Employee E22 and E23, and two nurse aides, Employee E24, and E25. Review of facility documentation revealed no documented evidence the facility obtained a written or signed statement from Resident R24 or his/her roommate, identified Resident R107. During an interview on March 19, 2026, at 11:53 a.m. with Resident R24, the resident reported when he/she fell on January 26, 2026, staff did not respond right away. Resident R24 indicated his/her roommate Resident R107 had to ring the call bell to alert staff that Resident R24 had fallen out of bed. Resident R24 further reported no bed rails were on at the time of the fall. Subsequent interview on March 19, 2026, at 12:00 p.m. with Resident R107 confirmed that he/she needed to call for assistance from nursing staff to alert them Resident R24 was on the floor. Interview on March 19, 2026, at 12:45 p.m. with the Director of Nursing, Employee E2, confirmed written/signed statements were not obtained from Resident R24 or R107 regarding the recall of incidents related to the fall on January 26, 2026. Refer to F689. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to provide assistance devices necessary to prevent an avoidable accident for one of 31 residents reviewed (Resident R24).Findings Include: Review of Resident R24's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 9, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (imbalance in a person's energy/nutrient intake), hemiplegia (paralysis that affects one side of the body) affecting left-side, contracture of right hand, and homonymous bilateral field defects (visual impairments affecting the same side of the visual field in both eyes). Continued review of Resident R24's MDS dated [DATE], revealed the resident was assessed as cognitively intact. Per Resident R24's physical therapy treatment notes dated January 24, 2026, indicated Resident R24 required partial/moderate assistance for bed mobility (rolling left and right). Skilled interventions focused on training in log rolling techniques to increase independence in bed mobility tasks, including instruction in use of handrails. Review of Resident R24's clinical record revealed a nursing note dated January 26, 2026, that revealed Resident R24 sustained an unwitnessed fall at 5:45 a.m. Resident R24 rolled out of bed, after reaching for his/her cell phone, and landed hard on the left hip and abdomen. Resident R24 expressed a pain scale of 10 out of 10 and requested to go to the emergency room for evaluation. Review of the incident report dated January 26, 2026, revealed per the nursing description, Resident R24 fell out of bed when reaching for his/her cell phone. Per the incident report, call light was within reach and there were no known predisposing environmental, psychological, or situation factors. Interview on March 19, 2026, at 11:53 a.m. with Resident R24, the resident reported no handrails were on the bed at the time of the fall. Interview on March 19, 2026, at 12:15 p.m. with the Director of Rehabilitation, Employee E16, revealed Resident R24 was on therapy caseload at the time of the fall and required assistance for bed mobility. Further interview on March 19, 2026, at 2:10 p.m. with the Director of Rehabilitation, Employee E16, confirmed Resident R24 should have had bed handrails (device for patients to have something to grab, for increased stability) on his/her bed at the time of the fall to assist with bed mobility. Interview on March 19, 2026, at 12:45 p.m. with the Director of Nursing, Employee E2, confirmed Resident R24 did not have bed handrails on at the time of the fall. Per the Director of Nursing, Employee E2, bed rails were applied after the fall. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to develop a person-centered comprehensive care plan related to restraints and restorative nursing program for two of 30 residents reviewed (Resident R1 and R13).Findings include: Review of facility policy, Care Plan - Comprehensive Person Centered dated revised March 2022, revealed that care plans include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 1, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including pulmonary hypertension(type of high blood pressure that affects the arteries in the lungs) and acute and chronic respiratory failure (condition in which blood doesn't have enough oxygen or too much carbon dioxide). Review of Resident R1's Physical therapy Discharge summary, dated [DATE], revealed discharge recommendations including restorative program indicating Established/ trained, other restorative program (the patient is to be OOB (out of bed) in chair via hoyer lift 1-3xs per week to encourage socialization and to increase sitting tolerance and perform wheelchair mobility. Review of Resident R1's comprehensive care plan revealed no care plan in place for restorative nursing program. Interview with Employee E2, Director of Nursing on March 19, 2026 at 1:45 p.m. confirmed no care plan in place in place for Resident R1 for restorative nursing program. Review of Resident R13's Quarterly MDS (Minimum Data Set- a mandatory periodic resident assessment tool) dated February 5, 2026, revealed that the resident was admitted to the facility on [DATE], and had diagnosis including Quadriplegia (paralysis of all 4 limbs) and acute and chronic respiratory failure. Review of Resident R13's Physician orders, dated January 9, 2026, Bilateral hand mitts to prevent dislodgement of trach, release mitts every 2 hours and check skin integrity. Review of Resident R13's comprehensive care plan revealed no care plan in place for restraints. Interview with Employee E3, Director of Nursing on March 19, 2026 at 1:45 p.m. confirmed no care plan in place for resident R13 for restraints. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, interview with resident and staff, and review of policy and clinical record, it was determined that facility did not ensure that resident received necessary assistance with activities of daily living, related to bathing, grooming and personal hygiene for one of 31 residents reviewed (Resident R86)Findings include: Review of facility policy 'Resident's Right to Freedom from Abuse, Neglect, Misappropriation of Resident Property and Exploitation,' revised in 2025, defines Neglect as the failure of a facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to meet a resident's basic needs such as food, water, hygiene, and essential medical care. Review of Resident R86's clinical record revealed medical history of hemiplegia and hemiparesis (weakness and paralysis) affecting right dominant side, unsheltered homelessness, post traumatic stress disorder, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood), urogenital candidiasis, adrenocortical insufficiency, retention of urine, high blood pressure, psychoactive substance abuse. Review of Resident R86's Minimum Data Set (MDS)/Resident Assessment and Care Screening, completed on March 5, 2026, revealed Brief Interview for Mental Status (BIMS) score of 15. Review of job description for nurse aide, employee E13, received and acknowledged on April 20, 2023, revealed that essential duties and responsibilities require staff to assist residents with daily bath, dressing, grooming, dental care . Review of Resident R86's Functional Abilities assessment, completed on March 4, 2026, revealed Resident R86 was independent to complete shower/bath task and independent for tub/shower transfer. Observations of Resident R86 on Wednesday, March 18, 2026, during day shift, in room [ROOM NUMBER]-C, unit Two North, revealed disheveled appearance with visible flakes from dandruff on clothing. During interview with Resident R86 on March 18, 2026, at 11:30 am. the resident revealed that (he/she) was not aware of location of common shower room on the unit, has not been offered a shower and does not know which days are (his/her) scheduled shower days. Resident R86 further stated that (he/she) has been using sink in (his/her) room for hygiene care. Review of Resident R86's clinical record revealed documentation by nurse aide, Employee E13, indicating Resident R86 completed shower task on morning of Wednesday, March 18, 2026, at 8:54 am. Interview with nurse aide, employee E13, on Wednesday, March 18, 2026, at 11:40 am, confirmed the shower/bath was falsely documented as completed. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff and residents it was determined that the facility failed to ensure adequate monitoring and timely reassessment to maintain acceptable parameters of nutrition status for 3 of 9 residents reviewed for nutrition (Resident R1, R87, and R11).Findings Include: Review of facility policy titled, Weight Policy with a revision date on July 2025 states, Policy- It is the policy of this facility to weigh each resident on admission, weekly for four weeks, then monthly thereafter, unless otherwise ordered by the physician/interdisciplinary team. The facility will utilize consistent procedures for monitoring weights to prevent unnecessary weight loss/gain in our residents. Any resident displaying a significant change in weight of greater than or equal to 5%, gain or loss in one month will be reported to the Registered Dietitian and reweighed. Review of undated facility documentation Clinical Dietitian Job Description revealed the Registered Dietitian will develop individualized nutrition care plans based on assessments and use of clinical judgement. The Registered Dietitian has a responsibility to conducted nutrition focused physical exams as needed. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 1, 2026, revealed the resident was admitted to the facility on [DATE], and had diagnoses of diabetes mellitus (the body's inability to use and distribute blood sugars resulting in high or low sugars) and malnutrition (lack of intake of nutrition that leads to altered body composition and body cell mass leading to diminished physical and mental function). Continued review of Resident R1's MDS dated [DATE], revealed the resident lost weight of 5% or more in the last month, or 10% or more in the last 6 months, and was not on a physician prescribed weight loss regimen. Review of Resident R1's comprehensive care plan dated September 24, 2025, revealed the resident may be at risk for malnutrition related to diabetes and wounds. Goals specified that Resident R1 would maintain current body weight (with no defined weight) within 5 pounds. Review of Resident R1's documented weight history revealed Resident R1 began to trigger for a significant weight loss on January 14, 2026, sustaining a weight loss of 20 pounds from January 2, 2026. Review of Resident R1's documented weight history revealed Resident R1 continued to lose a total of 12 more pounds, with a documented weight of 237 pounds on January 20, 2026. Continued review of Resident R1's weight history revealed the downward weight trend continued to 234 pounds on February 18, 2026. Review of Resident R1's clinical record revealed a nutrition weight note dated February 20, 2026, that the resident triggered for a 6.4% weight loss over one month. Interventions included weekly weights and to monitor weights for trends. Resident R1 was noted to be at potential risk for malnutrition. Further review of Resident R1's clinical record revealed he/she triggered for a significant weight loss again on February 26, 2026, with a documented weight of 207 pounds (reflected a 27-pound weight loss from 2/18/26). Review of Resident R1's clinical record revealed the ongoing significant weight loss was not addressed by the Registered Dietitian until March 12, 2026. Review of nutrition weight/wound note dated March 12, 2026, revealed Resident R1 may be at risk/potential risk for malnutrition however there is no formal documented assessment/outcome to determine if Resident R1 met the criteria for malnutrition. Review of Resident R11's clinical records revealed resident was admitted to the facility on [DATE], with diagnosis of fracture of fourth thoracic vertebrae (back fracture), fracture of left patella (left knee fracture). Review of Resident R11's MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 26, 2026, revealed that resident has a BIMS (Brief interview for Mental Status) score of 15, indicating resident is cognitively intact. Review of Resident R11's clinical record revealed on February 4, 2026 resident weighed 161.0 lbs (pounds). On March 3, 2026 resident weighed 153.5 lbs. Indicating a weight loss of 7.5 lbs in 1 month. Further review of Resident R11's clinical record revealed no documented evidence of nutritional assessment related to significant weight change. Interview with Employee E7, Registered dietician, confirmed no nutritional assessment completed. Review of facility policy titled weight policy, undated, revealed any resident displaying a significant change in weight of greater than or equal to 5%, gain or loss in one month will be reported to the Registered Dietitian and reweighed. Review of Resident R11's clinical records revealed resident was admitted to the facility on [DATE], with diagnosis of fracture of fourth thoracic vertebrae (back fracture), fracture of left patella (left knee fracture). Review of Resident R11's MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated February 26, 2026, revealed that resident has a BIMS (Brief interview for Mental Status) score of 15, indicating resident is cognitively intact. Review of Resident R11's clinical record revealed on February 4, 2026 resident weighed 161.0 lbs (pounds). On March 3, 2026 resident weighed 153.5 lbs. Indicating a weight loss of 7.5 lbs in 1 month. Further review of Resident R11's clinical record revealed no documented evidence of nutritional assessment related to significant weight change. Interview with Employee E7, Registered dietician, confirmed no nutritional assessment completed. 28 Pa. Code 210(c)(d) Resident care policies

Based on observations, review of clinical record and review of policy, as well as interview with staff, it was determined that facility did not ensure the accurate administration of psychotropic medication by administering a medication at a dose different from that prescribed for one of three residents observed (Resident R50)Findings include: Review of Resident R50's clinical record revealed medical history of bipolar disorder (condition in which a person has period of depression and periods of being extremely happy), schizoaffective disorder, drug induced parkinsonism (progressive disease of the central nervous system), generalized anxiety disorder, psychosis, drug induced subacute dyskinesis (involuntary, abnormal movements that develop days to weeks after starting or changing a medication; commonly caused by antipsychotics such as haloperidol/risperidone, antiemetics or antidepressants), recurrent depressive disorders, schizophrenia (mental disease characterized by loss of reality contact). Review of psychiatric progress note, completed on March 5, 2026, by Nurse practitioner (Employee E14), revealed that Resident R50 with a history of schizophrenia or schizoaffective disorder, treated with Lamotrigine and Invega Sustenna, is experiencing acute worsening of psychosis. Over recent days, (she/he) has shown escalating agitation, aggression, paranoia, and refusal of care, including verbal outbursts and inability to be redirected. During evaluation, (she/he) displayed disorganized behavior, poor reality testing, and persistent delusions, making cooperation with care impossible. These symptoms are considered breakthrough psychosis, possibly related to inconsistent medication adherence despite a recent injection. Due to the immediate safety risk to herself and others, urgent medication intervention is needed, and her granddaughter agreed to start Haloperidol. Review of Resident R50's physician orders revealed an order was placed on March 13, 2026 for Haloperidol with adjusted decreased dose of 0.25 milligrams (mg) and Ingrezza with dose increase to 60 mg. Haloperidol (first-generation (typical) antipsychotic medication used to treat severe mental health and behavioral conditions); Ingrezza (medication used to treat Tardive Dyskinesia, a condition that causes repetitive, uncontrollable body movements-often after long-term use of antipsychotic drugs). Both medications were still pending confirmation on March 18, 2026. Observations of medication administration with Licensed nurse employee E15, on March 18, 2026, at 9:52 am, revealed Resident R50 received 40 mg of Ingrezza instead of 60 mg. Interview with Unit manager, Employee E8, on Thursday, March 19, 2026 at 12:30 pm, confirmed that both orders for Haloperidol and Ingrezza, were not timely confirmed, resulting in administering lower dose of Ingrezza than prescribed. Review of Resident R50's electronic medication administration record (e-MAR), revealed that Ingrezza 60 mg was not administered for dates March 13, 2026 through March 17, 2026. Further review of e-MAR revealed Resident R50 did not receive Haloperidol 0.25 mg on dates of March 13, 2026, evening shift, through March 17, 2026. Review of nursing note dated March 18, 2026, at 10:31 am, revealed provider orders: Haloperidol reduced from 0.5 mg twice daily to 0.25 mg twice daily due to tremors; Ingrezza increased to 60 mg daily. Give 40 mg today per NP, then start 60 mg daily once the medication arrives from the pharmacy. Further review of nursing notes dated March 18, 2026, at 10:35 am, revealed that new medication order is not yet available; pharmacy will deliver. Provider is aware. It is acceptable to give Ingrezza 40 mg temporarily until the 60 mg dose becomes available. Responsible party has been notified. Findings confirmed with facility's director of nursing, employee E2, on March 19, 2026 at 3:00 pm. 28 Pa Code 211.9(a)(1) Pharmacy services 28 PA Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of facility documentation, clinical record review, and interviews with staff, it was determined that the facility failed to provide copies of medical records as requested in a timely manner and reasonable cost for one of one resident reviewed for medical record request (Resident R162). Findings include: Review of facility policy titled Release of Information revised November 2009, revealed The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative (sponsor). A resident may obtain photocopies of his or her records by providing the facility with at least forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services. Review of facility documentation revealed medical record request dated October 13, 2025, request including HIPAA (Health insurance portability and accountability act) compliant authorization form signed by Resident R162's Power of Attorney. Review of Resident R162's medical record request invoice dated October 23, 2025, revealed Medical record copies for Resident R162 (1,424 pages) cost total $732.08. Interview with the Director of Medical Records, Employee E12, on March 19, 2026, at 12:35 p.m. revealed records were requested and I processed the request and sent an invoice to the son for the records, and he told me that he would not pay for them. I explained to him that if he wanted them, he would have to pay for them because that is our facility's policy. Review facility documentation revealed medical record request dated January 3, 2026, stated Please be advised that our office has retained . to retrieve any and all records, pursuant to an authorization, on our behalf, request including HIPAA (Health insurance portability and accountability act) compliant authorization form signed by Resident R162's Power of Attorney. Review of facility documentation revealed email with recipient of Director of Medical Records, Employee E12, dated February 9, 2026, Please provide our client with his medical records without further delay or we will have no choice but to notify the Department of Health, U.S. Department of Health and Human Services, and Pennsylvania Health and Human Services and any and all other regulatory agencies of your refusal to provide medical records. Review of facility documentation revealed email response from Director of Medical Records, Employee E12, dated February 10, 2026, revealed I was off yesterday so I will be getting the records ready for [Resident R162] to pick up this week. I will contact him when they are ready. Interview with Director of Medical Records, Employee E12, on March 19, 2026, at 12:35 p.m. revealed [Resident 162's] son picked up the paper copy of records on February 17, 2026. Review of facility documentation revealed email with recipient of Employee E12, dated February 22, 2026, revealed please note that our client requested electronic version of his records via the [electronic form] Instead, he was given a paper copy that was missing multiple important parts of the chart. Below are the records that were missing for the production. Please note that this can easily be solved by simply providing a pdf copy of the PCC (point click care) chart with hyperlinks. My office can assist in sending a link to drop them in if needed. I am really hoping we can get these missing records as soon as possible. Review of facility documentation revealed email response from Director of Medical Records, Employee E12, dated February 25, 2026, revealed Sorry about that, I will get them to you as soon as I can. Review of facility documentation revealed email with recipient of Employee E12, dated March 2, 2026, revealed just following up on below. Thank you. Review of facility documentation revealed email response from Director of Medical Records, Employee E12, dated March 3, 2026, revealed I am still working on the records. I have the MDS (Minimum data set- assessment of resident care needs) and 9 more months of the CNA's (nursing aides) flow sheets to do. The records will be completed by the end of the week and I will scan them to you. Review of facility documentation revealed email with recipient of Director of Medical Records, Employee E12, dated March 10, 2026, revealed sorry to stalk you just want to make sure you didn't scan to me and I missed it. Interview with Employee E12, on March 19, 2026, at 12:35 p.m. revealed I have been printed and scanning things as fast as I can. I do not know how to send the chart electronically; I was never taught that way. Interview with Employee E1, Nursing Home Administrator on March 19, 2026, at 2:00 p.m. confirmed that medical records can be send through a link electronically and confirmed findings that Resident R162 records were not released upon request in a timely manner or for a reasonable cost. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.29(a) Resident rights

Based on clinical record review, staff interview and review of facility provided documentation, and review of clinical records, it was determined that facility failed to timely monitor and assess a resident's medical condition for one of eight residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to facility on [DATE], with diagnosis of history of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, acute or chronic diastolic (congestive) heart failure, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, anemia and schizophrenia (mental disease characterized by loss of reality contact). Review of Resident R2's Minimum Data Set (MDS- assessment of resident needs), completed on [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was cognitive intact. Review of Resident R1's clinical record revealed that on Friday, [DATE] at 8:33 pm, the resident was found unresponsive on the floor in (his/her) room. Cardiopulmonary Resuscitation was initiated and continued until EMS arrival at approximately 8:38 pm - at which point EMS (Emergency Medical Staff) personnel relieved staff and continued resuscitation efforts until 9:15 pm, when resident was pronounced deceased by EMS. Review of facility provided statement, completed by Licensed nurse, Employee E11, on [DATE] states the following: This nurse was passing medications when the CNA (nurse aide) came out of residents room said resident fell and is on the floor. This nurse went into residents room and resident was lying on the floor. Checked for pulse was faint, started CPR immediately and told CNA to alert nurse and call a STAT (immediate) code to room. CPR continued by staff until 911 EMS arrived. This nurse last seen resident at approximately 19:45 was sitting in chair in his room. Review of statement completed by licensed nurse, employee E7, who worked over night shift, from Thursday, [DATE], 11:00 pm, through Friday, [DATE], 7:00 am, and who was assigned to care for Resident R1, states the following I worked 11-7 Thursday Oct. 23, 2025. Between the hours of 12A-1A. [Resident R1] approached me in his wheelchair complaining of generalized body aches stated (he/she) had cold symptoms, but (he/she) requested Tylenol which I gave to (him/her) per (his/her) orders. I did not hear any cough/congestion like resident was complaining of but did endorse to 7-3 nurse that [Resident R1] was complaining of cold symptoms. Throughout the shift since (XXXX) is on Q (every) 15 minute checks I did note [Resident R1] sitting up in (his/her) wheelchair on the bathroom randomly throughout the shift (unlike resident). The last time I saw him was around 6:15 am when I brought medication to B and C bed. [Resident R1 was sleeping in his bed in no acute distress. Review of Resident R1's clinical record indicated no documented evidence of Licensed nurse, Employee E7 checked Resident R1's vital signs during shift after the resident expressing experiencing cold symptoms and no evidence of further assessment related to why he was found in bathroom randomly throughout shift. Interview with nurse aide, Employee E6, on [DATE], at 2:37 pm, who was assigned to care for Resident R1 on Friday, [DATE], during day shift, 7:00 am to 3:00 pm revealed that Resident R1 was found with a bucket next to him at 7:10 am and stated that he had nausea and vomiting started at approximately 4:00 am. Further interview with Employee E6 revealed that he informed charge nurse of R1's vomiting - stating it's not his norm, check him immediately. At 10 :00 am [Resident R1] was still vomiting and vomited again after lunch meal service E6 also noted Resident R1 in his room after lunch, undressed, rocking back and forth, stating 'I feel neither hot nor cold ' - at which point, Employee E6 notified charge nurse again. Further review of Resident R1's clinical record revealed only one set of vital signs were taken on Friday, [DATE], at 9:15 am. Review of progress note, completed by facility's director of nursing, dated [DATE], at 11:46 am, stating that [Resident R1] complained of one episode of vomiting this morning, followed by throat pain and chest discomfort. On assessment, he was AAO x 4 (people, place, time and situation), VSS (vital signs). No radiation of pain noted. Call placed to on-call service. (Physician, Employee E10) returned call. TVO (telephone verbal order) received for Pepcid 20mg (milligrams) PO (by mouth) x 1 dose. If pain continues, 9Employee E100 said to send to ER (Emergency Room) for evaluation. Orders read back and confirmed. Nursing made aware. Interview with Physician, Employee E10, on [DATE], at 12:17 pm, revealed that he was contacted on morning of Friday, [DATE], related to Resident R1's one episode of vomiting, burning throat, discomfort sensation in chest. Further review of late entry progress note, dated [DATE], at 3:58 pm, completed by day shift Licensed nurse, Employee E1, who was assigned to care for Resident R1 on Friday, [DATE], states received in nursing report resident was complaining of cold symptoms. Upon entering room, nurse was told resident was in his room vomiting. Nurse assessed resident, obtained VS (vital signs), 97.3, 115/71, 60HR, 20RR, 97% on RA (room air). Nurse notified ADON (Assistant Director of Nursing) of resident status, ADON assessed resident whom notified the MD, new order for Pepcid. Nurse administered medication. Made oncoming nurse aware of resident status for continuing follow up. However, interview with Licensed nurse, Employee E2, on Friday, [DATE] at 11:47 am, who was assigned to care for Resident R1 on Friday, [DATE], during evening shift of 3:00 pm to 11:00 pm, revealed that he was not assigned to care for Resident R1, further stating that he only checked Resident R1's blood glucose. Further interview with Licensed nurse, EmployeeE2 revealed that he did not receive information related Resident R1's status during change of shift report. 28 Pa Code 211.12(d)(1)(5) Nursing services28 Pa Code 211.12(e) nursing services

Review of Resident R2 ' s quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 5, 2025, revealed the resident was rarely/never understood and had diagnoses of hemiplegia or hemiparesis, and functional quadriplegia. Continued review of Resident R2's quarterly MDS dated [DATE], revealed the resident had functional limitation in range of motion impairments on both sides of upper extremity.Review of Section GG0170. Mobility of Resident R2's quarterly MDS dated [DATE], revealed the resident was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff to roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). Review of Resident R2's comprehensive care plan dated August 13, 2021, revealed the resident was at risk for falls related to immobility. Review of intervention dated August 13, 2021, revealed Resident R2 required two-assist for bed mobility.Review of Resident R2's nursing Kardex (a documentation system that helps nurses organize and access key patient information for care planning) revealed a nursing rehab task dated June 29, 2025, that indicated Resident R2 required bed mobility assistance of two [people] during reposition and bed mobility. Review of Resident R2's clinical record revealed a nursing note dated October 14, 2025, that revealed Licensed Nurse, Employee E3, was called to Resident R2's room by nurse aide, identified as Employee E4. Nurse aide, Employee E4, stated when Resident R2 was rolled to the other side of the bed to remove the bed sheets, the resident rolled off the bed. Review of facility documentation revealed an undated incident report that indicated while Nurse Aide, Employee E4, was rolling Resident R2 to the opposite side [of the bed] to remove the soiled sheets, the resident rolled off the bed. Interview on October 22, 2025, at 12:00 p.m. with the Director of Nursing, Employee E2, revealed that Nurse Aide, Employee E4, rolled Resident R2 away from him/her when removing the bed sheets. Director of Nursing, Employee E2, indicated that residents should always be rolled toward the caregiver when turning them in bed. Interview on October 22, 2025, at 12:20 p.m. with the Nursing Home Administrator, Employee E1, confirmed Nurse Aide, Employee E4, should have followed Resident R2's plan of care and provided 2-person assistance for bed mobility. 28 PA. Code 211.12(d)(5) Nursing services

Based on observations, review of facility documentation and clinical records, and staff and resident interviews, it was determined the facility failed to ensure that one of four residents reviewed (Resident R51) was adequately secured during transportation in the facility's van. This failure resulted in actual harm to Resident R51 who sustained a fracture of the right knee after sliding out of the wheelchair on the way to an appointment. (Resident R51) Findings Include: Review of Resident R51's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 5, 2025, revealed the resident had diagnoses of muscle weakness, lack of coordination, Aphasia (communication disorder), Cerebrovascular Accident (CVA - stoke; loss of blood flow to part of the brain), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body). Continued review of Resident R51's MDS assessment revealed the resident's BIMS (Brief Interview of Mental status) score of 14, which indicated that the resident was cognitively intact. Further review of the MDS assessment indicated Resident R51 used a wheelchair for mobility. Review of Resident R51's comprehensive care plan dated January 18, 2018, revealed the resident had a potential for falls related to weakness, difficulty with walking, and CVA with hemiparesis. Review of information submitted to the Pennsylvania Department of Health by the facility on March 7, 2025, revealed Resident R51, who was noted to be alert and oriented x 3 (alert and oriented to person, place, and time) sustained a fall with knee injury during transport to oncology appointment on March 6, 2025. During wheelchair transport, the van came to an abrupt stop and Resident R51 hit the right knee. Review of Resident R51's clinical record revealed a nursing note dated March 6, 2025, indicating after the resident returned from the appointment, the right knee was noticeably swollen. The physician subsequently ordered an x-ray for evaluation of the right knee which showed an acute fracture of the kneecap. Further review of Resident R51's clinical record revealed the resident was subsequently transferred to the hospital for evaluation on March 6, 2025, when a fracture of the right knee was confirmed. Review of personnel file for the facility's van driver, Employee E24, revealed the employee was hired by the facility in June 2022 as the driver for resident transportation. Continued review of van driver, Employee E24's personnel file, revealed the employee received training on May 31, 2024, on Driver Safety Responsibilities which included driver and passengers are required to wear seat belts and shoulder harnesses. Further review of van driver, Employee E24's personnel file revealed the employee also received training on May 31, 2024, for driver basic skills evaluation which included the proper use of facility's Securement Checklist. Review of the Securement Checklist revealed before driving off, the van driver should put on the resident's seat belt with the lap belt buckle. Ensure belt fits tight across lap and under wheelchair armrest. Review of statement obtained by the facility van driver, Employee E24, dated March 6, 2025, revealed the employee needed to come to an abrupt stop and Resident R51 fell on (his/her) right knee. When the van driver, Employee E24, turned around Resident R51 was noted to be on (his/her) right knee (he/she) did have seatbelt on and wheelchair lockdown. Interview on May 7, 2025, at 10:00 a.m. with Resident R51, surveyor asked resident if the seat belt was on at the time of the fall on March 6, 2026, resident responded no. Attempts to interview Employee E24 were unsuccessful as Employee E24 is no longer employed by the facility and did not return phone calls. Review of facility documentation revealed the facility transportation van was assessed on March 7, 2025, by Maintenance staff, Employee E25, and E26, verified the seatbelt attachments functioned without issue. Observation of a hands on demonstration and description of securing a resident and wheelchair into the facility van was provided on May 7, 2025, at 2:18 p.m. with Maintenance staff, Employees E25 and E26. Surveyor physically got into a wheelchair in the van. When seatbelt was tightly secured, surveyor was unable to easily slide out of wheelchair without getting trapped under the seat belt and subsequently readjust self back into wheelchair. Maintenance Employee, E26 also reported shoulder harnesses should be used to secure resident in the wheelchair. 4 different floor straps to secure wheelchair, a lap seatbelt and 2 shoulder harnesses. Interview on May 7, 2025, at 12:21 p.m. with Nursing Home Administrator, Employee E1, revealed that she conducted the investigation into the incident. Administrator reviewed the written statement obtained form the van driver, Employee E24 revealed as I began to drive through the arm rail it began to came down then I had to stop abruptly on brake and [Resident] fell on (his/her) right knee. When I turn around the resident was on (his/her) knee (he/she) did have seatbelt on and wheel chair lock down. Further interview with Nursing Home Administrator, Employee E1, revealed the Resident R51 was only strapped in with the lap seat belt. NHA was asked if the shoulder harnesses were in use to which the NHA indicated the shoulder harnesses were not in use at the time of the fall. The facility failed to ensure Resident R51's seatbelt was adequately secured during transportation in facility's van. This failure resulted in actual harm to Resident R51 who sustained a fracture of the right knee after sliding out of the wheelchair on the way to an appointment in the facility's transport van. (Resident R51) 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of clinical records, interview with resident and staff, and review of facility policies, it was determined that the facility failed to adequately supervise one of six residents reviewed (Resident R2), who was able to board a bus and train and elope from the facility. This failure placed Resident R2 at high risk for injury and resulted in an Immediate Jeopardy situation. (Resident R2) Findings include: Review of the facility's policy title Elopement/ Missing Resident revealed that it is goal of the facility to provide a safe environment and to identify residents who are at risk for elopement. It strives to prevent harm while maintaining the least restrictive environment for residents. Under the heading Responsibility it stated that it is the responsibility of all staff members to report any residents suspected of not being in the facility, or attempting to leave the building, without checking out, in accordance with established policies immediately. Review of facility's policy titled Resident LOA revealed staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. The policy also stated that restrictions noted on the resident's chart concerning who may not sign the resident, must be honored unless otherwise prohibited by facility policy or state/federal law governing such releases. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnoses of personality disorder, type 2 diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood steam to cells), non-[NAME] lymphoma (a type of cancer that begins in your lymphatic system, which is part of the body's germ-fighting immune system) and major depression (loss of interest in pleasurable activities) and morbid (severe) obesity. Review of Resident R2's hospital discharge documentation dated January 12, 2024, revealed admitting diagnosis of suicidal ideation with a plan. Resident R2 was at the hospital for a 302 petition (an emergency involuntary examination and treatment when there is a reasonable belief that a person is severely mentally disabled to the extent that immediate treatment is required). Further review revealed 5 previous psychiatric hospitalization s this year. One of those suicidal attempts resulted in the resident in a coma in the Intensive Care Unit. Review of an elopement assessment completed January 31, 2024, revealed that the resident was assessed as not a risk for elopement. Review of Resident R2's Minimum Data Set (MDS- assessment of resident care needs) completed March 5, 2024, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 14, which indicated that the resident was cognitively intact. Review of Resident R2's care plan initiated January 30, 2024, revealed that the resident had a potential for falls related to a decline in functional status/ambulation dysfunction. The interventions included to assist with transfers. Review of Resident R2's clinical record revealed a physician order from March 13, 2024, stating Resident may NOT go out LOA (leave of absence) unaccompanied and on March 21, 2024, stating 'Resident may go out LOA with a responsible adult. Review of physician note dated March 19, 2024, revealed resident reported history of paranoid delusions and hearing voices. Review of the physician note dated March 23, 2024, noted that the resident needs a chaperone if going LOA. Review of Resident R2's electronic clinical record revealed under the census tab on Hospital Leave. Continued review of the resident's clinical record revealed that the last note written in the resident's clinical record was on March 26, 2024, at 11:04 p.m. Resident has eloped on yesterday 3/25. Resident has not returned during this shift. The nursing note was [NAME] out. Interview with the Director of Nursing, Employee E2, on April 1, 2024, at 1:24 p.m. revealed on March 25, 2024, resident left the facility by herself or AMA (against medical advice). She is cognitive enough to sign herself out and no staff members checked to see if a family or friend was here to pick her up. Facility realized resident was gone after the police called the facility to say she was in the Emergency department at a hospital in New Jersey. Police informed the facility that the resident took a bus and train to New Jersey. Facility arranged to pick up resident from the hospital however resident voluntarily committed herself to the hospital. Resident left all belongings including her cell phone at the facility. Interview with Director of Nursing, Employee E2 on April 1, 2024, at 2:15 p.m. stated that the resident often knows the code to the secure doors even when the facility changes them. Director of Nursing and Nursing Home Administrator are unsure how resident was able to leave facility since the front door needs a code. It was revealed during interview that Resident R2 was not officially documented as AMA (against medical advice) and no AMA paperwork was signed. The facility considered resident AMA since she left on her own. Further during interview with the Director of Nursing, Employee E2 revealed that there was no list at the front desk of residents with a physician order to be able to leave the facility for leave of absences (LOA) that the front desk receptionist can refer to. The proper procedure for leave of absence is for the 'responsible adult' of the resident to sign out on a log with the receptionist at the front desk. Review of Leave of Absence Release for Resident R2 revealed on March 25, 2024, at 6:46 p.m. under the heading 'Signature of person accepting responsibility for resident' there was a signature of Resident R2 . Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator (NHA) on March 1, 2024, at 3:27 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the Nursing Home Administrator. On April 4, 2024, at 8:08 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: 1. The identified resident is not in the facility at this time. 2. Residents who have an order that they may go on a LOA were educated on facility sign in/ sign out procedures by DON on March 26, 2024. 3. Wandering risk assessments were completed on all current residents on March 26, 2024. 4. Elopement risk care plans were updated for all current residents as appropriate by MDS on March 26, 2024. 5. Resident council meeting held to discuss the sign in/sign out policy by DON on March 26, 2024. 6. Ad-hoc QAPI completed with medical Director and QAPI team on March 27, 2024 on ensuring resides leaving the facility user proper LOA procedures and ensuring residents do not leave the facility unattended without staff or guardian supervision. 7. All door codes in facility changed. 8. NHA and ADON immediately began providing education to clinical staff regarding the facility policy for Elopement/ Missing Resident. The facility will complete 80% prior to the end of day April 4, 2024 with all staff, Staff will receive this education prior to starting their next scheduled shift until 100% of all staff are trained and educated. 9. Receptionists will be re-educated on the process for letting residents out of the building. 10. Facility will identify all others in the population with the potential to be affected by this deficient practice by 100% audit of all residents at risk for elopement and residents who have physician's order for leave of absence. 11. Facility will audit all residents who are identified at risk for elopement to ensure proper supervision is provided. 100% of all resident discharged will be reviewed daily x 7 days, weekly x 4 weeks then monthly x 2. 12. Facility will audit all residents who have physician's order for leave of absence to ensure proper supervision is provided based on order. 100% of all residents with physician's order for leave of absences will be reviewed daily x 7 days, weekly x 4 weeks then monthly x 2. 13. Facility will complete audits on doors to ensure proper functioning of egress alarm daily x 7 days, weekly x 4 weeks then monthly x 2. 14. Any tends identified in these audits will be reported to the facility QAPI committee and this plan of correction will be modified to address those trends as needed. 15. Facility will conduct elopement drill April 2, 2024, then every month x 3 months. 16. The facility Ad Hoc QAPI committee will review facility policies related to Missing Resident/ Elopement and Leave of Absence to ensure they adhere to state and federal requirements for proper supervision by end of day April 2, 2024. Interviews were conducted with facility staff on April 2, 2024, between 2:05 p.m.- 4:40 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the proper procedure for alerting management and police. Other facility residents interviewed on they verbalized their understanding of LOA policy. Review was conducted of the education provided to facility staff related to resident elopement. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on April 2, 2024, at 5:45 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Coe 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record reviews, interviews with staff, review of hospital records and review of policy and procedure, it was determined that the facility failed to properly discharge Resident Cl1 who was assessed by the facility as requiring guidance for safety awareness and problems with short term memory for one of three closed records reviewed. (Resident Cl1) This failure resulted in an Immediate Jeopardy situation for Resident Cl1 whose safety device was removed by facility staff allowing the resident to exit the building, discharging the resident against medical advice to an unknown location and without returning resident's identification documents. Further the facility failed to notify the required State authorities and resident's family of the resident's discharge. (Resident Cl1) Findings include: A review of the facility policy titled Discharging a Resident without a Physician's Approval dated August 2022, revealed that the resident's attending physician must be notified of a resident or resident's representative's desire for immediate discharge. This policy also indicated that a signed and dated order for approval of this discharge must be recorded in the clinical record. Continued review of the policy revealed that a resident must sign and date a release form and that two staff members must witness this form by signing and dating the form. A review of the policy titled Discharge Summary and Plan dated August 2022, revealed that each resident was to have an assessment and care plan for an expected discharge. The policy also indicated that a discharge summary and post-discharge plan was to be developed for each resident, to assist the resident to adjust to his/her new living arrangement. The policy indicated that the post discharge plan would be developed by the care plan team, the resident and his or her family that was to include: where the individual plans to reside, arrangements that have been made for follow-up care, a description of the resident's stated discharge goals, the degree of caregiver support and how the resident can prevent a readmission and contact with local community agencies. A review of the policy titled Resident Transfer and Discharge Policy and Procedure dated 2023, revealed that the purpose of this policy was to ensure that all residents being transferred or discharged were subject to a standardized process so that each discharge or transfer was according to regulatory process, ethics and quality of care. This policy also indicated that before the facility transfers or discharges a resident, the facility must notify the resident and the resident's representative of the reason for transfer or discharge in writing and a manner that the resident understands. Send a copy of the notice to a representative of the Office of State Long-Term Care Ombudsman. Record the reason for the transfer or discharge in the resident's clinical record. Inform the resident or the resident representative as to where the resident was being transferred was a Medicare or Medical Assistance provider. The policy said that the written notice shall include: The reason for the transfer or discharge, the effective date for transfer or discharge, the specific location to which the resident was to transfer or discharge (address of the residence), A statement of the resident's appeal rights (emailing or mailing address), the name address and telephone number of the State Long Term Care Ombudsman, for residents with mental disorder, intellectual an developmental disabilities or related disabilities the mailing address of the Protection and Advocacy groups. The policy indicated that the timing of the notice was 30 days before transfer or discharge. According to this policy the facility was responsible to provide orientation to the resident before transferring or discharging them. The facility was responsible for documenting sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. The orientation must be provided in a form and manner that the resident could understand. Review of Resident Cl1's clinical record revealed that the resident was admitted on [DATE], with a history of delirium and confusion due to a diagnosis of hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage). Review of nursing progress note dated February 9, 2024, indicated that Resident Cl1 was showing symptoms of unsteady gait and voiding on the floor; the resident said the reason for the voiding on the floor was because he had a hernia. The nursing note also stated that Resident Cl1 was frustrated because he could not get the proper words to speak. The certified nurse practitioner was contacted and gave orders to send the resident out to the hospital for treatment of hepatic encephalopathy. Continue review of nursing documentation revealed that the resident was readmitted to the facility on [DATE]. Review of Resident Cl1's admission Minimum Data Set (MDS- an assessment of care needs) dated February 15, 2024, indicated that the resident had moderately impaired cognition. The assessment also indicated that Resident Cl1 was exhibiting behaviors of inattention and disorganized thinking. The resident was noted saying that it was very important for family or close friend to be involved in discussion about his care. The assessment indicated impairment or limitations to funtional abilities for Resident Cl 1 of bilateral lower extremity impairments, with a need for a mobility device. Resident Cl1 required supervision, touching and cueing from staff, for safe transfers and to safely position from sitting to standing. The resident was occasionally incontinent of urine and frequently incontinent of bowel. Review of Resident C11's care plan initiated February 14, 2024, revealed that the resident was identified with a history of delirium or an acute confusion episodes related to metabolic/hepatic encephalopathy. The interventions included to monitor the resident's safety every shift. Continued review of the resident's care plan revealed that the resident was care planned for symptoms that increase safety risk which included confusion, delirium, dizziness and for the potential for fall related to a decline in functional statues. On February 28, 2024, a care plan was initiated for the resident having the potential for elopement related to exit seeking behavior. The interventions included to check resident's whereabouts frequently, make receptionist and other staff aware of elopement risk and notify social services for persistent attempts to leave building and not responding to redirection. On February 29, 2024, the intervention of wanderguard (alarming device that locks doors specific doors to prevent the resident for leaving the building) to right ankle was initiated. Review of physician's notes dated February 28, 2024, indicated that Resident Cl1 had increased anxiety and pacing behaviors. The resident had several elopement attempts from the facility, requiring a wanderguard. The resident confirmed the increased anxiety and wanting to punch somebody. The resident was reporting to the physician that he used alcohol three to four times a week. The physician indicated that this resident was oriented to name only with an anxious mood and behavior agitated when approached. The physician wanted psychiatry to exam and treat this resident. Interview with the Director of Nursing, Employee E2, on March 7, 2024, at 10:30 a.m. confirmed that the facility had not consulted the psychiatry or psychologist to assess, evaluate and treat Resident Cl1. Review of the Speech/Language/Swallowing Pathologist's notes dated March 1, 2024, revealed that the therapist was evaluating Resident Cl1 and determined that his cognition level was moderately impaired. The note indicated that the therapist had to provide moderate cues with memory compensatory strategies for the resident to recall dates, times. The therapist indicated that Resident Cl1 was extremely erratic with moments of aggression during therapy. Interview with Employee E21, Speech/Language/Swallowing Pathologist on March 7, 2024, at 1:00 p.m., confirmed that Resident Cl1 was moderately cognitively impaired, had short term memory loss, was forgetful and frustrated with his memory impairment. The therapist explained that this resident needed cues from staff for orientation and safety awareness. Review of Physical Therapist's note dated February 28, 2024, revealed that Resident Cl1 was using hand held assistance and supervision of one staff member for ambulation. Interview with the Physical Therapist, Employee E22, on March 7, 2024, at 1:30 p.m., revealed that Resident Cl1 was trialing a hand held assistive device (wheeled walker) to ambulate safely short distances of ten feet on March 1, 2024. Review of nursing note dated March 4, 2024, revealed that Resident Cl1 left the facility, because he was requesting to leave the facility. The nursing note indicated that the resident was ambulating as he left the facility. Interview with the Director of Nursing, Employee E2 on March 7, 2024, at 2:00 p.m., revealed that the wanderguard was removed from Resident Cl1's right ankle on March 4, 2024; so that Resident Cl1 could ambulate out the front entrance of the facility, without triggering the alarm system. Interview with the Nursing Home Administrator, Employee E1, on March 7, 2024, at 2:30 p.m., confirmed that Resident Cl1 had ambulated out the entrance of the facility. The Nursing Home Administrator, Employee E1 also confirmed that the facility had no idea of Resident Cl1's whereabouts. Interview with the Nursing Home Administrator, Employee E1, Director of Nursing, Employee E2 and Social Worker, Employee E6 at 9:00 a.m., on March 8, 2024, revealed that Resident Cl1 was asked to sign and date a release for discharge against medical advice form on March 4, 2024. Review of this form revealed that a signature; however, no date was completed. Further review of this form revealed that there was only one witness signature by staff on this form. According to the facility's established policy two witness signatures were required. Interview with the Director of Nursing, Employee E2 and the Social Worker, Employee E6, on March 8, 2024, at 9:30 a.m., revealed that prior to discharge of Resident Cl1 on March 4, 2024, there was no contact with the resident's physician's about anticipated discharge planning. Employees E2 and E6 also confirmed that before discharge of Resident Cl1, who was cognitively impaired, there was no contact with the resident's family and responsible party. Employees E2 and E6 confirmed during this interview that the office of the State Long Term Care Ombudsman was not notified before resident Cl1's discharge on March 4, 2024. Employees E2 and E6 also confirmed during the interview that the agency responsible for the protection and advocacy of mental disorders was not notified about the discharge of Resident Cl1 from the facility on March 4, 2024. Interview with the Licensed nurse, Employee E23, on March 8, 2024 at 10:00 a.m., revealed that this nurse was not aware on March 4, 2024 that Resident Cl1 left the facility alone and without an address or specific location to which he was discharged . The licensed nurse, Employee E23 stated that the resident's belongings (identification cards license and credit cards) were in the nursing medication cart. Licensed nurse, Employee E23 who was familiar with Resident Cl1 was concerned for his welfare being discharge with no walker; since he was at risk for falls, no medications, no safe place to live with food and water, no money and no friend or family contact or means of contacting friends, family or public help. Interview with nursing assistant, Employee E17, on March 8, 2024, at 10:30 a.m., revealed that Resident Cl1 was using the telephone at the nurse's station on March 2 and March 3, 2024, to contact a friend. The resident was telling the nursing assistant, Employee E17 on March 2 and 3, 2024, that he wanted to leave to get some money from his friend. Employee E17 reported that Resident Cl1 was confused and not steady on his feet. The resident did require her help with grooming (shaving) because Resident Cl1 lacked the coordination and dexterity to complete the task safely. Interview with nursing assistant, Employee 18, on March 8, 2024, at 10:45 a.m., revealed that Resident Cl1 was not alert and oriented. During conversations with Resident Cl1 the first three minutes of the conversation was lucid and the rest of the conversation was incoherent. Interview with the Licensed nurse, Employee E19 on March 8, 2024, at 11:00 a.m., revealed that Resident Cl1 presented to this nurse as exit seeking. He would be in the lounge starring out the window waiting for someone to pick him up or visit. The resident would say a person outside the facility owed him money. The nurse said that Resident Cl1 was disoriented and was not able to tell her who the person was or provide contact information for this person Resident Cl1 was trying to remember. Licensed nurse, Employee E19 reported that this resident was unkept unless staff would encourage him to dress, groom and bath regularly. Interview with the Nursing Home Administrator, on March 7, 2024 at 3:10 p.m., revealed that Resident Cl1 was located at the emergency room of a local hospital on March 4, 2024. A review of the hospital record dated March 4, 2024, revealed that Resident Cl1 arrived at the hospital emergency room by ambulance at 11:30 p.m., with a wet incontinent brief and stating he had no where to go. The hospital staff documented that they gave the resident clean pants, a brief, blankets, something to eat and allowed Resident Cl1 to use the phone. The hospital record indicated that Resident Cl1 needed a bed to sleep. The hospital staff documented that weather outside was raining with low air temperatures. The hospital staff conducted blood testing for Resident Cl1 and indicated that blood ammonia levels were elevated at 145UG/DL (Normal levels in the blood were 0 to 60 UG/DL). This deficiency was identified as Immediate Jeopardy for failure to provide and ensure the proper and orderly discharge of Resident Cl1 who was assessed with short term memory problems, requiring guidance for safety awareness and orientation and had a history of exit seeking behavior. An immediate jeopardy template (a document which included information necessary to establish each of the key components of the immediate jeopardy) was provided to the Nursing Home Administrator on March 8, 2024, at 11:46 a.m. The facility's action plan included the following: The facility will ensure that all residents with short term memory problems and/or a history of exit seeking behavior have a proper and orderly discharge. The facility will ensure a safe and proper discharge for all residents requiring guidance for safety awareness, orientation and problems with short term memory and that residents who are no longer appropriate for wander guard intervention are reviewed by the IDT and physician orders are received prior to removing the wander guard. 1. The identified resident was no longer residing in the facility. Facility nursing home administrator immediately notified adult protective services to ensure that they would follow up with the resident, who now resides in the community on March 8, 2024. 2. The facility nursing home administrator immediately began providing education to the clinical and social services staff regarding the facility policy for resident discharge and residents leaving against medical advice for residents requiring guidance for safety awareness, orientation and problems with short term memory loss based on the standard brief interview for mental status, clinical assessments and care plans. 3. The facility immediately began providing education to licensed nursing and social service staff on policies related to discharge and resident leaving against medical advice. The facility will complete approximately 80% education prior to the end of the day March 8, 2024. All licensed nursing and social services staff will receive this education prior to starting their next scheduled shift until 100% of all staff are trained and educated. 4. The facility nursing home administrator provided education to administrative nurses and social services staff on abuse and neglect and notification of adult protective services for residents who discharge to the community against medical advice or with concerns for post discharge safety. 5. The facility nursing home administrator provided education to administrative nurses and social services staff on escalation of issues when they are unable to reach the resident's family or responsible party and to notify the residents physician when multiple attempts to reach the family or responsible party are unsuccessful. 6. The facility nursing home administrator provided education to administrative nurses and social services staff on tracking and returning resident identification documents at discharge for against medical advice or planned discharges. 7. The regional clinical consultant immediately began providing education to licensed nursing staff, social service staff and nursing home administrator on proper removal of wander guard devices. 8. The facility will identify all residents in the population with the potential to be affected by this deficient practice by auditing of all discharges, against medical advice and otherwise within the past 30 days to ensure proper notification of the responsible party, emergency contact, physician and state authorities was completed. 9. The facility will audit all discharges from the facility to ensure a proper and orderly discharge and to ensure that all proper notifications were made as follows: 100% of all resident discharges will be reviewed for the following 90 days. Any trends identified in these audits will be reported to the facility QAPI (Quality Assurance Program Improvement) committee and this plan of correction will be modified to address those trends as needed. 10. The facility Ad [NAME] QAPI committee will review facility policies related to resident discharge and discharge against medical advice to ensure they adhere to state and federal requirements for a safe and orderly discharge by the end of the day March 8, 2024. On March 8, 2024, at 5:45 p.m. the facility's immediate action plan was accepted. Interviews with licensed nursing staff, social services staff and administrative staff confirmed that they were knowledgeable of all facility's safe and orderly discharge policies and procedures that included discharges against medical advice. Interviews with licensed nursing staff, social services staff and administrative staff confirmed that they were knowledgeable about obtaining orders from the physician before the removal a wander guard device, identification of a resident with cognitive impairments through brief interview for mental status, clinical assessment and care plan, notifications of the physician, responsible party and state authority before discharge of a resident. The 30- day audit was reviewed to reveal that proper notifications to responsible party, emergency contacts, physicians and state authorities. On March 9, at 5:05 p.m., the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to residents. This failure resulted in Immediate Jeopardy situation to Resident R1 who spilled a hot water beverage on his leg and developed a second degree thermal burn, for one of six residents reviewed. (Resident R1) Findings include: Review of Resident R1's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 4, 2022, revealed that the resident was admitted to the facility February 19, 2021, and had diagnoses including paraplegia and immunodeficiency disease. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated that the resident was cognitively intact. Further review revealed that the resident required extensive assistance from two staff persons for bed mobility and was independent with eating. Review of Resident R1's Braden Assessment (used for predicting risk of developing pressure sores) dated August 19, 2022, revealed that the resident had no sensory impairment (the resident had no sensory deficit that would limit his ability to feel or voice pain or discomfort). Review of nursing note for Resident R1 revealed a note, dated October 23, 2022, at 10:31 a.m. which indicated that while the nurse aide was providing care, open skin areas were noted to the resident's left leg. The note continued that Resident R1 stated, I burned my left leg with hot water two days ago and I did not tell staff. Upon assessment, the resident's left leg had open skin with inflammation and had blisters. Resident R1 was subsequently sent to the hospital for evaluation. Review of hospital discharge records, dated October 23, 2022, revealed that Resident R1 was diagnosed with a first degree burn of the lower left extremity. The hospital recommended for Resident R1 to leave the wound dressing on until his scheduled follow-up appointment at the burn clinic as well as antibiotic therapy for three days. Continued review of progress notes revealed a note, dated October 24, 2022, at 1:43 a.m. which indicated that Resident R1 returned from the hospital. The note continued that the resident reported that he was making tea from the hot water that came from the dietary department and that the cup spilled on the bed. Review of consultant notes revealed a Burn Clinic note, dated October 25, 2022, which indicated that Resident R1 was evaluated for his scald burn of the left posterior (back) leg from hot water and was diagnosed with a second degree scald of the left leg. The note indicated that the resident's wound was dressed with mepilex (absorbent foam dressing) and tubigrip (elastic compression bandage) and advised not to remove the dressing until the next follow up appointment in one week. Review of facility documentation submitted to the Department of Health on October 24, 2022, revealed that Resident R1 was found with blisters and open areas on his left thigh and leg. The resident reported that he spilled hot water and burned himself. Continued review of facility documentation revealed that during an interview conducted on October 25, 2022, Resident R1 reported that he spilled hot water on himself on October 21, 2022, when his breakfast tray came up, The tea water spilled on my bed and got me wet, it didn't hurt. Resident R1 denied any staff reheating the water and stated that the hot water came up on his breakfast tray. Review of facility documentation, Nutritional Service Test Meal revealed that Test meals should be done on all three meals, all diets and textures, and on different dining locations and days of the week. The test meal should be sent with regular trays to floor and temps taken after all the trays in the cart are given out. An action plan should be made if any temperature fails to meet the required temperatures. Further review revealed that no other food temperatures were recorded for these meals and no serving temperatures of meals or beverage were available for review prior to October 23, 2022. Review of facility documentation, Temporary Food Temp Log revealed that between October 5, 2022, through October 22, 2022, the facility recorded food temperatures on 13 of 18 days. Continued review revealed that there was no indication on the log of where the food temperature was taken (whether it was kitchen tray line or serving temperatures). Interview on October 31, 2022, at 2:54 p.m. the Nursing Home Administrator (NHA) revealed that the Food Temperature Logs provided indicated food temperatures during tray line assembly in the kitchen. The NHA confirmed that no temperatures related to beverages, including hot beverages, were recorded. The NHA stated that he conducted audits of hot beverage temperatures after Resident R1 sustained a burn from hot water. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on November 8, 2022, at 11:55 a.m. for the facility's failure to ensure that hot beverages were served at safe temperatures, resulting in Resident R1 sustaining a second degree thermal burn from hot water. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 8, 2022, at 12:00 p.m. The facility submitted a written plan of action on November 8, 2022, at approximately 7:22 p.m. and implemented the plan of action which included: 1. On October 23, 2022, a resident was noted to to have a reddened area on his lower extremity. Resident stated I burned my left leg with hot water two days ago and I did not tell staff. Physician was notified and resident was sent out to ER for evaluation and treatment. 2. Investigation was immediately initiated. Resident recalled different dates/times aand how the event occurred. Facility unable to determinehow the burns occurred. Staff interviews determined area was not present the day prior to staff noticing. Interviews conducted with several other residents in the facility revealed no issues with beverages ever being too hot. 3. Department of Health was notified at the time of the incident. 4. Dietary Food Manager/Administrator/Manager on Duty or Designee will continue to monitor temperature of each meal service and any other time hot beverages are served. 5. Current food policy updated 2021 states, Temperatures of Time/Temperature Control for Safety (TCS) foods will be recorded daily at time of service and monitored during meal service. Additional policy updated 2020 titles, Safety of Hot Liquids states Food service staff will monitor and maintain temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Facility to create an additional policy titled, Food Temperature Monitoring to clarify the following: temperature monitoring and recording to assure compliance with food/liquid monitoring at each meal, point of service and during activities. Temperature will be monitored with facility approved thermometer, once at the initial pour and once at the time of service. Hot beverages will not be served above 150 degrees and staff will stop service, notify supervisor on duty of out of range temperatures. 6. Initial education for hot beverages temperature compliance was conducted on October 24, 2022 by the facility administrator. A binder has been placed in the kitchen with policies and instructions on monitoring and recording hot beverage temperatures. All staff will be required to review policies and procedures prior to starting their shift by Administrator/Manager on Duty/Cook Staff or Designee. 7. Administrator/Manager on Duty or Designee will conduct audits of hot beverage temperature daily to ensure compliance. Interviews with thirty-two staff members from all departments were conducted on November 9, 2022. All staff members reported that they received education regarding food temperature monitoring. The education was conducted by the Nursing Home Administrator and included review of new policy Food Temperature Monitoring which indicated food and beverage temperatures will be monitored to minimize potential for injury. Review of food temperature logs revealed that the temperature of hot beverages were been recorded to ensure safety. The Immediate Jeopardy was lifted on November 9, 2022, at 4:38 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(c)(d) Dietary Services

Based on a tour of the facility, facility documentation, clinical record review, and interviews with residents and staff, it was determined that the facility failed to protect the residents, and provide an environment that promotes, maintains, and enhances the quality of life for residents with regard to rodents for 3 of 3 nursing units observed (1 north, 2 North and 2 South), which directly impacted Resident R1, and resulted in Actual Harm to this resident, and an Immediate Jeopardy situation. Findings include: Resident R1, Admission Record dated [DATE], indicated that this thirty two year old the resident had [DIAGNOSES REDACTED]. Interview with the Director of Nursing on [DATE], at 4:00 p.m. revealed that the resident is able to move his wrists and hands. Review of facility documentation dated [DATE], at 2: 30 a.m. indicated that this resident was eating snacks, and a nurse aide was present, the resident reported he felt like something was crawling on his chest . The nurse aide removed the sheet and both the resident and nurse aide saw the mouse jump off the bed and scurry away. Resident R1 panicked and began screaming, and became short of breath. The nurse aide called for help and when the nurse arrived the resident was breathless, pulseless, and the resident's nail beds were cyanotic (bluish discoloration due to poor circulation). CPR was initiated and 911 emergency contacted, the resident responded to CPR, and was transferred and admitted to the hospital. The facility failure to maintain an effective pest control program and protect this resident who is unable to remove himself from this situation, resulting in actual harm, and an immediate jeopardy situation. During an initial tour of the building with the Director of Maintenance at 9:45 a.m. through 11:00 a.m. revealed interviews with residents who confirmed observations of mice in their rooms as follows; Resident R2 who resides on 2 North, identified on a quarterly MDS (minimum data set- assessment of care needs) dated [DATE], as being slightly impaired cognitively reported on interview that a mouse was on his bed last week and that the mouse walked up and around his face. Resident R3 who resides on 1 North is documented on an admission MDS dated [DATE], indicating that this resident was alert and oriented. The resident reported that she saw a mouse yesterday which ran across her room from the left corner to the right corner near the baseboard heater, and that she observes this every day. The resident also indicated reporting this to staff. Resident R4 on 1 North, who was assessed as being alert and oriented on an annual MDS dated [DATE], reported seeing a mouse a couple days ago and that it ran from the hallway into her room, and across toward the window. This resident added that this has happened before. Resident Resident R5, identified on her most recent quarterly MDS dated [DATE], as being alert and oriented reported seeing a mouse that runs across her room every day in the afternoon, and that the mouse runs from the left corner to her closet. Resident R6 who resides on 1 North and is the roommate of Resident R4, and is documented on a MDS dated [DATE], as having slight impairment cognitive, however the resident reported seeing a mouse run into her room, and that it ran under her bed. This resident also indicated that she has seen mice before in her room. Resident R7 who resides on 2 North, had nursing documentation dated [DATE], which revealed the resident was assessed as being slightly impaired cognitively, and this resident reported seeing a mouse go from the air conditioning unit, and that it ran under his roommates bed. Resident R 8 who resides on 2 South, had a MDS dated [DATE], indicated this resident is alert and oriented. This resident reported that two mice were in her room last night. One small mouse was caught on a sticky trap, and a larger mouse jumped into the air conditioner grate. This resident said that a housekeeping staff member was in her room at that time, and also observed the mice. Resident R9 who resides on 2 North was identified as alert and oriented on a MDS dated [DATE]. This resident indicated that she has seen mice regularly next to her roommates bed which is diagonal to her bed. The resident's daughter was also interviewed and reported that she has seen mice usually early evening, near the air conditioner, and that she has even seen them run down the hall way. The resident's daughter bought in a sticky trap and placed it near the air conditioning unit in her mothers room. Staff interviews on all units reported as follows; Employee E1 on 2 South reported that during standup meetings that at least twice weekly staff report problems with mice. Employee E2 on 2 South reported seeing mice in several residents rooms, and that she has reported it to the nurse, Employee E3 on 2 South reported seeing a mouse run across the hall between Resident R1 and R8's room, Employee E 4 on 1 North reported seeing a hole in Resident R2's room and has observed a mouse run into the hole, Employee E 5 on 1 North reported seeing mice in the back hallway rooms 101 through 106 frequently, Employee E 6 on 2 North reported that Resident R 9 had reported seeing mice to her on multiple occasions, and that she has seen mice also, Employee E7 on 2 North indicated seeing mice and that residents have reported to her concerns about mice. Interview with the Administrator regarding pest control revealed that the facility had been treated every two weeks, and now weekly since the event involving Resident R1 on [DATE]. The pest control log was requested, however, the only documentation provided by the maintenance director to review regarding pest control services was on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation to review that communication took place between the nursing units and maintenance, or that concerns which were identified were addressed regarding pest control issues. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on [DATE] at 12:57 p.m., pertaining to Resident R1 who had been identified with actual harm, this event was directly related to an ineffective pest control program, placing this resident, and other residents at risk for harm.

Based on review of a clinical record, review of facility policy and procedure, facility documentation and interview with facility staff, it was determined that the facility did not ensure that one resident's advance directives were implemented as expressed which resulted in actual harm to the resident (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed an admission physician's order, dated [DATE], which indicated the following Diagnoses: [REDACTED]., (a progressive irreversible loss of memory), [MEDICAL CONDITION], ([MEDICAL CONDITION] - excessive body/lung fluid caused by a weakened heart muscle), and aspiration pneumonia (an inflammation of your lungs and [MEDICATION NAME] tubes due to inhalation of food and/or vomit that enters into the lungs). A review of Resident CL1's clinical record revealed that at the 72 hour Care Plan meeting (a meeting with resident/family and facility to discuss a newly admitted resident's Plan of Care) on [DATE], at 2:00 p.m., CL1's Power of Attorney (POA - one that is appointed to make decisions, for a person unable to make decisions) provided the facility with a copy of CL1's Combined Advance Health Care Declaration and Health Care Power of Attorney dated [DATE], which indicated that Resident CL1 did not want cardiac resuscitation (CPR - an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) and/or any type of advance medical treatment that would prolong life. At the 72 hour Care Plan meeting on this same day, the POLST (Physician Orders for Life Sustaining Treatment - a legal document that is completed by the resident and/or resident's appointed Power of Attorney that identifies the patients' wishes regarding medical treatment, specifically for honoring the patients' wishes for end-of-life treatment) form was initiated by the staff from the nursing department, Dietician, and Social Worker present at the meeting. An interview with the Nursing Home Administrator on [DATE], at 11:35 a.m., revealed that it was the nursing department's responsibility to follow up with CL1's physician, in a timely fashion, to verify the completion of the DNR (Do Not Resuscitation) order. A review of the POLST form initiated during the 72 hour Care Plan meeting, which was signed by Resident CL1's POA revealed the same resident wishes as the Combined Advance Health Care Declaration and Health Care Power of Attorney which indicated that CPR nor any type of life sustaining measures, such as being intubated, (inserting a tube, called an endotracheal tube, through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing. The tube is then connected to a ventilator, which pushes air into the lungs to deliver a breath to the patient) were to be performed for CL1. A review of a nursing progress note dated [DATE], written at 11:30 p.m., revealed a charge nurse (Employee E9) doing rounds, found Resident CL1 to be cyanotic (a blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation) and pulseless, (without a pulse). CPR was started and 911 was called, the nurse removed the resident's dentures, suctioned the mouth for a small amount of saliva, applied a mask and bagged with 100% of oxygen via an AMBU bag (a hand-held manual resuscitator, commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately), and chest compressions were initiated on Resident CL1 by the nursing staff at the facility. Further review of the nursing progress note dated [DATE], also indicated that nursing staff relinquished care to the EMTs, who intubated CL1, and continued to provide breath via the AMBU bag. Resident CL1 was transferred to a local hospital. The Nursing Home Administrator confirmed, [DATE] at 9:30 a.m., that the nursing department did not follow up timely regarding the completion of the POLST, with CL1's physician, causing the nursing staff to perform CPR on Resident CL1, who had expressed wishes of not wanting CPR or any type of advance medical treatment to prolong life. A review of the hospital records indicated that Resident CL1 remained on life support, for 9 days, before passing away on [DATE]. A review of the facility policy and procedure titled, Advanced Directives for Healthcare, undated, indicated that the POLST form shall be completed in conjunction with the Resident and/or Health Care Agents(s)/Representatives. An interview with the Nursing Home Administrator on [DATE], at 1:40 p.m., confirmed that the process of obtaining a physician's order related to the advance directives for Resident CL1 was not effective in implementing the advance directive wishes for Resident CL1. The facility failed to ensure that advance directive wishes for one resident were implemented as expressed resulting in actual harm. 42 CFR 483.25 Provide Care/Services for Highest Well Being Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 211.16(a) Social services 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE]

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to obtain laboratory results timely for one of two residents reviewed (Resident CL1), resulting in actual harm to that resident. Findings include: Review of the clinical record for Resident CL1 revealed a nursing admission note, dated [DATE], indicating the resident was readmitted to the facility from an acute care hospital with [DIAGNOSES REDACTED]. Review of facility bowel records for Resident CL1 revealed on [DATE], at 22:34 (10:34 p.m. military time), and again on [DATE], at 10:29 a.m., the resident was noted with loose stools/diarrhea. Review of a nursing progress note dated [DATE], revealed Resident CL1 was noted with nausea and loose stool. Review of another nursing progress note, dated [DATE], at 22:30 (10:30 p.m. military time), revealed that ID (infectious disease physician) was in to see the resident that shift, recommended that staff continue Resident CL1's antibiotics for one more day for completion on [DATE], recommended to obtain a stool specimen for evaluation of [MEDICAL CONDITION] ([MEDICAL CONDITION] - type of bacteria found in the colon) and if the lab report was positive for [MEDICAL CONDITION], to order [MEDICATION NAME] (antibiotic) 125 mg (milligrams) every six hours, for 10 days. Review of a physician's orders [REDACTED]. Review of a nursing progress note, dated [DATE], at 7:50 a.m., revealed the resident vomited clear liquid with thick yellow sputum. Review of another nursing progress note, dated [DATE], at 11:18 a.m., revealed the stool specimen was collected for Resident CL1. Further review of facility bowel records for Resident CL1 revealed the resident continued with loose stools/diarrhea on [DATE], at 2:06 a.m., 6:26 a.m., and 10:55 a.m.; on [DATE], at 10:34 a.m., and [DATE], at 11:19 a.m., and 14:27 (2:27 p.m. military time). Review of a Nursing Change in Condition note, dated [DATE], at 23:37 (11:37 p.m. military time), revealed Resident CL1 was complaining of shortness of breath and abdominal pain. Review of a physician's orders [REDACTED]. Review of a [MEDICAL CONDITION] (physician specializing in lungs and breathing problems) consult, dated [DATE], revealed the pulmonolgist was called to see the resident emergently for labored breathing, was experiencing nausea, and recommended that Resident CL1 required [MEDICAL CONDITION] (Bi-level Positive Airway Pressure-machine that helps people with [MEDICAL CONDITION] keep their airways open and oxygen levels up) continuously. Review of a Triple Care (telemedicine-physician who assesses and evaluates a resident from a remote location) physician Episode Note, dated [DATE], at 7:59 p.m., revealed the nurse called the telemedicine physician concerned about Resident CL1's status, that the resident was seen by the pulmonologist earlier that day and placed on [MEDICAL CONDITION], and labs drawn last night were, "very concerning," for sodium level of 113 mEq/L (milliequivalents per liter-normal range ,[DATE] mEq/L) with most recent sodium level of 127 mEq/L; and white blood cell (WBC-elevated level can indicate infection) count of 59 mcL (microliters-normal range 4XXX,[DATE].8) with WBC count of 30, "less than one week ago." The Episode Note further stated that Resident CL1 was reporting abdominal pain, the resident was evaluated over telemedicine applications, was described as very lethargic but arousable, and anasarcic (extreme generalized [MEDICAL CONDITION]), with presumed [DIAGNOSES REDACTED]. The Episode Note stated, "Very concerned about this person. (Resident CL1) is hemodynamically (blood levels) unstable and manifest (sic) acute metabolic [MEDICAL CONDITION] (imbalance in the brain)," was in acute respiratory distress, that the resident needed to be stabilized in an acute care facility and undergo an extensive medical workup. The Episode Note stated, "Transfer to ED (emergency department) immediately." Review of a Nursing Discharge Summary note, dated [DATE], revealed Resident CL1 was transported via 911 emergency services to an acute care hospital at 8:25 p.m., and was admitted to the intensive care unit with [DIAGNOSES REDACTED]. Review of a Resident Transfer Form (information regarding the resident's status upon transport to the hospital) dated [DATE], revealed no documentation of communication that the resident's stool specimen for [MEDICAL CONDITION] was still pending, or communication that the resident had been experiencing diarrhea and loose stools intermittently since [DATE]. Further review of the clinical record revealed no documentation that the facility received the results of the [MEDICAL CONDITION] stool test, that was documented as collected by the facility on [DATE], prior to the resident's emergent transfer to the hospital on [DATE], four days after the stool was documented as sent to the lab. Review of the laboratory report for Resident CL1's stool specimen results, documented as date and time received as [DATE], at "8:33," with date collected as [DATE], revealed Resident CL1's stool specimen for [MEDICAL CONDITION] was positive (presence of [MEDICAL CONDITION] in the stool). Review of hospital medical records for Resident CL1 revealed an undated progress note indicating the resident had [DIAGNOSES REDACTED].) and sedated. Review of a hospital consult report, dated [DATE], revealed Resident CL1 had ventilator (breathing machine) dependent [MEDICAL CONDITION] and [MEDICAL CONDITION] secondary to (related to) [MEDICAL CONDITION]. Further review of hospital progress notes dated [DATE], at 2:15 a.m., revealed the resident was extubated (breathing tube removed) per the wishes of Resident CL1's power of attorney, and the resident expired. Interview with the Nursing Home Administrator and Director of Nursing on [DATE], at approximately 5:30 p.m., confirmed that Resident CL1 was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. The facility failed to ensure Resident CL1 received the appropriate care and services necessary to maintain the resident's highest practicable physical, mental, and psychosocial well-being. This failure caused actual harm to the resident. 28 PA Code 201.14(a) Responsibility of licensee. 28 PA Code 201.18(b)(1)(e)(1) Management. 28 PA Code 211.5(f) Clinical records. 28 PA Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility documentation, and staff interview, it was determined the facility failed to adequately monitor and provide a safe environment for one resident who sustained a fall and fracture resulting in actual harm to this resident. ( Resident R138 ) Findings include: A review of Resident 138's clinical record revealed an admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of an MDS ( Minimum Data Set - a tool used to identify resident needs), dated December 13, 2011, revealed the resident was subject to falls within the previous twelve months, was unable to transfer without assistance or supervision, was not steady for walking or during transitions from one point to another, and was only able to stabilize with assistance, and needed the support of two persons during transfers and during toilet use. A review of a resident care plan dated October 20, 2011 identified the resident as having an ADL ( activities of daily living ) performance deficit related to fatigue, limited mobility, confusion, and impaired balance. A review of nursing documentation indicated that on March 9, 2012, at approximately 12:45 a.m., the resident had received help from a nursing assistant to use a commode in his room. An interview with the DON stated that the nursing assistant put a clip alarm on the resident prior to leaving the bathroom. While unsupervised, the resident reported that attempting to pick something up off the floor, lost his balance, and fell to the floor. The resident was found on the floor reporting pain to his left hip. The resident was transported to the hospital and diagnosed with [REDACTED]. The facility failed to adequately supervise and monitor the resident resulting in the resident having a fall which resulted in actual harm. 28 Pa. Code 211.12 (d) Nursing services