Every finding on record at Birchwood Rehabilitation & Healthcare Center

Based on review of facility policies, clinical records, hospital records, and staff interviews, the facility failed to recognize and thoroughly investigate an injury of unknown origin involving potential neglect and failed to report the results of the investigation to the State Survey agency for one of three residents reviewed (Resident 5) resulting in actual harm evidenced by significant urethral trauma.Findings include:Review of the facility's Abuse Policy, last reviewed February 9, 2026, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy indicated neglect occurs when the facility knew or should have known of goods or services a resident required but failed to provide those goods or services, resulting in or potentially resulting in physical harm, pain, mental anguish, or emotional distress. The policy directed the facility to identify, investigate, and report possible incidents of abuse, neglect, mistreatment, or misappropriation within required federal timeframes. Review of the facility's policy entitled Suprapubic Catheter Replacement, last reviewed February 9, 2026, revealed staff were to verify the physician's order before replacing a suprapubic catheter (a tube inserted directly into the urinary bladder through an opening in the lower abdomen to drain urine) and review the resident's care plan to identify any special needs. The policy directed staff to document the date and time of the procedure; the name and title of the individual performing the procedure; assessment findings obtained during the procedure; the type of catheter removed; balloon size (inflatable portion near the catheter tip that holds the catheter in place within the bladder); French size (measurement of the outside diameter of a catheter); composition of the replacement catheter; method used to stabilize the catheter; return of urine flow; the resident's response; complications associated with the procedure; and the signature and title of the individual documenting the procedure. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and the ability to perform daily activities), benign prostatic hyperplasia (noncancerous enlargement of the prostate gland), and obstructive and reflux uropathy (a condition in which blockage of normal urine flow causes urine to back up within the urinary system). Review of Resident 5's admission evaluation dated January 7, 2026, revealed that the resident was admitted to the facility with a suprapubic catheter. Review of Resident 5's quarterly Minimum Data Set assessment (MDS, a federally required standardized assessment used to identify a resident's functional abilities and health needs), dated July 31, 2026, revealed a Brief Interview for Mental Status (BIMS, a standardized assessment of attention, orientation, and short-term memory) score of 10, indicating moderately impaired cognition. The assessment identified the presence of an indwelling urinary catheter. A physician's order dated April 22, 2026, directed staff to maintain a 16 French suprapubic catheter with a 10 cubic centimeter (cc) balloon and authorized staff to replace the suprapubic catheter as needed for malfunction or dislodgement. Nursing documentation dated April 27, 2026, at 6:36 PM identified a change in Resident 5's condition consisting of bleeding from the urethra (the tube that carries urine from the bladder to the outside of the body). Nursing documentation dated April 27, 2026, at 6:48 PM revealed staff transferred Resident 5 to the hospital emergency department due to urethral bleeding. A facility transfer form dated April 27, 2026, completed by Employee 1, Registered Nurse Supervisor, documented that Resident 5 was transferred to the hospital at 6:47 PM due to urethral bleeding. During an interview on August 18, 2026, at 1:50 PM Employee 1 stated that a nurse aide reported significant penile bleeding involving Resident 5. Employee 1 stated facility staff were unable to stop the bleeding and obtained a physician's order to transfer the resident to the emergency department. The employee stated staff informed her that Resident 5's suprapubic catheter had become dislodged during the night shift and that staff attempted to insert a Foley catheter (a flexible tube inserted through the urethra and into the bladder to drain urine) through the resident's urethra before recognizing that Resident 5 had a suprapubic catheter. Employee 1 stated that when she assessed Resident 5, the suprapubic catheter was in place and draining urine. Employee 1 stated she notified the Assistant Director of Nursing of the incident. A review of hospital emergency department discharge documentation dated April 27, 2026, at 10:12 PM indicated the resident sustained urethral trauma (bleeding from the urethra potentially caused by injury during the insertion of a urinary catheter, which may be complicated by enlarged prostate or urethral strictures, a known challenge with difficult resident anatomy). A nurse practitioner progress note dated April 28, 2026, documented that Resident 5 had been transferred to the emergency department because facility staff were unable to stop the urethral bleeding. The nurse practitioner documented that nursing staff attempted to place a Foley catheter instead of the resident's suprapubic catheter, encountered resistance during the attempted insertion, and caused trauma. A urology consultation dated April 29, 2026, documented urethral trauma due to attempted urethral catheter placement. The urologist recommended that Resident 5's suprapubic catheter be changed monthly and as needed by skilled personnel. During an interview on August 18, 2026, at 12:43 PM Employee 2, Registered Nurse Supervisor, confirmed that she was the Registered Nurse Supervisor assigned to the night shift on April 26, 2026. Employee 2 stated that Resident 5's suprapubic catheter became dislodged during that shift and that she inserted a new suprapubic catheter. Employee 2 could not recall how the suprapubic catheter became dislodged or the time the dislodgement occurred. Employee 2 stated that a Licensed Practical Nurse initially obtained Foley catheter supplies before staff recognized that Resident 5 had a suprapubic catheter. Employee 2 could not identify the Licensed Practical Nurse involved. Employee 2 confirmed that she did not document the catheter dislodgement or the subsequent suprapubic catheter replacement in accordance with facility policy. Review of Resident 5's Treatment Administration Record (TAR, a record used by nursing staff to document physician-ordered treatments and procedures) for April 2026 revealed Employee 3, Licensed Practical Nurse, documented suprapubic catheter care during the night shift on April 26, 2026. The surveyor attempted to interview Employee 3 regarding the circumstances surrounding the catheter dislodgement and catheter care provided during the night shift. A voicemail message was left for Employee 3; however, Employee 3 did not return the surveyor's telephone call. A review of Resident 5's clinical record revealed no documentation identifying when the suprapubic catheter became dislodged; the circumstances surrounding the dislodgement; who discovered the dislodgement; who attempted the urethral catheter insertion; when the attempted insertion occurred; the type or size of catheter used during the attempted insertion; whether resistance was encountered; assessment findings before or after the procedure; the resident's response; or when urethral bleeding initially developed. Although Employee 2 subsequently acknowledged replacing the suprapubic catheter, the clinical record contained no documentation of that procedure. The record lacked documentation required by facility policy, including the date and time of replacement, catheter type, balloon size, French size, composition of the replacement catheter, method of stabilization, return of urine flow, assessment findings, resident response, complications, and identification of the individual who performed the procedure. Despite Resident 5 developing significant urethral bleeding requiring emergency hospital transfer and subsequent medical documentation identifying urethral trauma associated with attempted urethral catheter placement, review of facility records revealed no evidence that the facility initiated an investigation to determine the circumstances surrounding the resident's injury. The facility did not obtain statements from staff involved in Resident 5's care, establish a timeline of events, identify the staff member who attempted the urethral catheter insertion, determine the circumstances surrounding the attempted insertion, evaluate whether the attempted procedure was consistent with the resident's physician orders and care needs, or determine whether the resident's injury resulted from neglect or other inappropriate care. The facility also failed to determine why Employee 2's replacement of the suprapubic catheter was not documented or reconcile the absence of catheter-related documentation with the resident's subsequent significant urethral bleeding and hospital diagnosis of urethral trauma. Review of facility documentation revealed no evidence that the facility recognized the incident as an injury of unknown origin involving potential neglect or initiated the investigative process required by facility policy. The facility did not report the incident to the State Survey Agency before surveyors identified the concern during the survey. During an interview on August 18, 2026, at 1:14 PM the Director of Nursing confirmed that staff failed to completely and accurately document the catheter-related assessments and procedures and that the facility did not conduct an investigation into the circumstances surrounding Resident 5's urethral injury. The Director of Nursing further confirmed that the facility did not report the incident as an alleged violation/injury of unknown origin to the State Survey Agency. The facility failed to recognize and thoroughly investigate Resident 5's injury of unknown origin despite significant urethral bleeding requiring emergency hospital evaluation and subsequent medical documentation identifying urethral trauma associated with attempted urethral catheter placement. Because the facility did not initiate an investigation, it failed to determine who attempted the urethral catheter insertion, when and under what circumstances the procedure occurred, whether the procedure was consistent with the resident's physician orders and care needs, and whether neglect or other inappropriate care contributed to the resident's injury. The facility's failure to investigate also prevented it from identifying the staff member responsible for the attempted urethral catheterization and determining whether corrective actions were necessary to protect Resident 5 and other residents from recurrence. 28 Pa. Code 201.29(a)(c) Resident rights28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(e)(1) Management28 Pa. Code 211.10 (c)(d) Resident care policies

Based on select facility policy, clinical record review, investigative documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to provide adequate staff supervision and effective safety measures to prevent a resident's elopement for one out of 6 residents reviewed (Resident 1). This deficiency is cited as past non-compliance.Findings include: A review of the facility policy entitled Elopement Management and Prevention, last reviewed by the facility on February 9, 2026, revealed it is the policy of the facility to identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Elopement risk screenings will be completed on residents on admission, re-admission, quarterly, significant change in status, and as needed. A review of the facility policy titled Change in a Resident's Condition or Status, last reviewed by the facility on February 9, 2026, revealed it is the policy of the facility to promptly notify the resident, their attending physician, and the resident representatives of changes in the resident's medical or mental condition or status. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve on its own without intervention by staff or by implementing standard disease-related clinical interventions. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical or mental condition or status. A review of the facility policy titled Out on Pass Unaccompanied, last reviewed by the facility on February 9, 2026, revealed it is the policy of the facility to maintain residents' highest practical level of independence, residents' rights, and safety regarding leaving the facility unaccompanied. Residents will review the resident responsibility to sign in and out every time they leave the facility and notify staff prior to leaving the facility. For a resident's right to leave the facility unattended to be restricted for any reason, the nurse will obtain a physician's order indicating such. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include anxiety (a mental condition that causes a feeling of worry, nervousness, or unease) and alcoholic cirrhosis of the liver (late-stage liver damage caused by long-term heavy alcohol use). A review of Resident 1's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 4, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of a wandering risk assessment dated [DATE], identified the resident as being at low risk for wandering. A review of a nurse progress note written by the Director of Nursing (DON), dated August 8, 2026, at 11:10 PM, revealed Resident 1's son had called the facility at 10:00 PM and indicated the resident was at her brother's house. It was noted the resident's son returned her back to the facility at 10:50 PM. A skin assessment was completed, with no injuries observed. The resident was wearing jeans, a shirt, and sneakers at the time of the incident. The resident stated to the DON that she did not sign out to leave but knew she had to. Resident 1 would not state how she got to her brother's house. A review of an interview given by Resident 1 dated August 8, 2026, revealed she walked through the double doors on the unit at the facility with a tall man with dark hair and exited through the front doors of the facility prior to 8:00 PM. Resident 1 stated that the front door receptionist was at the desk with their head down and did not notice the resident exiting the facility. Resident 1 stated she had walked for five minutes and then received a ride but refused to say with whom. Resident 1 was noted to be laughing and stated the only thing she did wrong was not signing out for leave of absence (LOA) and that she arrived at her brother's house in a neighboring town (5 miles away) around 9:00 PM. A review of a written statement dated August 8, 2026, from Employee 2, Registered Nurse Supervisor, revealed the employee stated after Resident 1 returned to the facility, she had mentioned a man held the doors open for her and that the receptionist had her head down and mimicked typing on a keyboard. The employee indicated the resident stated she had just walked out the front door. A review of a telephone statement dated August 8, 2026, from Employee 6, Licensed Practical Nurse, revealed prior to the incident she saw the resident sitting by the window packing a red bag. Employee 6 performed a blood glucose test at 7:15 PM, and it was noted to be 203. Employee 6 indicated that when the resident returned, Resident 1 stated she walked out with a tall guy with short hair out the front door. A review of a wandering risk assessment dated [DATE], revealed Resident 23 was reassessed and identified as being at risk for wandering.A review of a physician order dated August 8, 2026, at 11:15 PM, revealed an order was obtained for the application of a wander guard bracelet to the right wrist and to check placement every shift A review of a written statement dated August 11, 2026, from Employee 7, activities director, revealed they had met with Resident 1 on August 9, 2026, at 2:25 PM, and discussed how she exited the facility and walked down the road with her walker and through a tunnel. Resident 1 did not state that anyone had picked her up. It was noted that the resident appeared off during the conversation and was accusatory. A review of a written statement dated August 11, 2026, from Employee 7, activities director, revealed they had met with Resident 1 again on August 11, 2026, and discussed her recent elopement at the facility. Resident 1 indicated that she left the floor when two visitors were coming in the facility and held the doors open for her. Resident 1 stated she sat on the porch, and a man yelled at her and couldn't sit there, so she then left and walked up the street to a nearby convenient store and then kept walking up the street, and a guy driving by with his granddaughter had stopped and asked if they wanted a ride because they were going to a festival nearby. The resident then got in and went to her brother and sister-in-law's house. A review of a written witness statement dated August 11, 2026, from Employee 8, receptionist, revealed they had only let two female visitors out of the coded doors and that there were no other people with them and noted a tall male visitor with white hair exited out of the front doors at 7:30 PM while she was cleaning up a basket [NAME] area. Employee 8 noted they did not see Resident 1 exit the facility. A review of a form titled 'continuing education form' dated August 9, 2026, for Employee 8, receptionist, revealed the employee was educated that the front desk needs to be always supervised, if residents are to leave, they need to sign out, and any visitors are to have visible ID badges. During an interview conducted on August 18, 2026, at 1:20 PM, Employee 8, receptionist, revealed that she did not recall seeing Resident 1 leave the facility on August 8, 2026. Employee 8 stated that around 7:30 PM, she had returned [NAME] baskets into a back office not located at the front desk. She then left at 8:00 PM and locked the front door. During an interview conducted on August 18, 2026, at 2:20 PM, Resident 1 confirmed that on August 8, 2026, in the evening she exited the facility when she walked out with a male visitor. Resident 1 stated that she saw Employee 8, the receptionist, at the front desk and her head was looking down and they were typing on a keyboard. Resident 1 then exited the building through the front doors and proceeded to walk down the street. Resident 1 stated she walked to her brother's house in a neighboring town and did not get a ride. A telephone interview was attempted with Employee 6, Licensed Practical Nurse, on August 18, 2026, at 1:30 PM, and a message was left; however, there was no return phone call. An interview with the Director of Nursing on August 18, 2026, at 12:00 PM revealed Resident 1 had a previous LOA order with responsible party and that she goes on leave with her family, including a son, sister, and brother. The DON indicated that the resident was admitted to the hospital recently and that her LOA order with the responsible party was discontinued and a new order was never obtained. These findings demonstrated the facility failed to ensure effective supervision and monitoring resulting in an unsupervised exit from the facility. This deficiency is cited as past noncompliance. The facility's corrective action plan was to immediately conduct a head count at the facility; Resident 1 was assessed for injuries, and a wander guard bracelet was placed on the resident along with continuous one-to-one observation. Residents with leave of absence orders were reviewed and verified for accuracy and continued appropriateness. Residents were re-educated on the facility process for leaving the facility independently or as delegated in their LOA order. To prevent this from recurring, the NHA and Interdisciplinary Team (IDT) provided re-education to all facility staff regarding the facility's elopement policy, visitation process, LOA process, door code process, and residents who experience a change in condition, including procedures and protocols, initiated on August 8, 2026, with completion on August 11, 2026. To monitor and maintain ongoing compliance, the facility completed audits daily for seven days, weekly for two weeks, then monthly for two months. The facility completed random audits of the front desk to ensure it was not left unattended and monitored those who left on LOA. The findings of the plan of correction were submitted to QAPI for review. The facility's immediate corrective action plan was completed on August 11, 2026. 28 Pa Code 201.14(a) Responsibility of Licensee.28 Pa Code 201.18(b)(1) (e)(1) Management.28 Pa Code 211.10 (c) Resident care policies.28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on review of select facility policies and procedures and clinical records, observations, and staff interviews, it was determined the facility failed to ensure a resident who needs respiratory care is provided such care, consistent with the professional standard of practice and the comprehensive person-centered care plan for one out of 27 residents reviewed (Resident 38) and failed to ensure tracheostomy care was provided consistently with professional standards of practice for one out of four residents reviewed with the presence of a tracheostomy (Resident 81).Findings include: A review of a facility policy entitled Tracheostomy Care, last reviewed by the facility on February 9, 2026, indicated tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. The policy indicated tracheostomy care includes checking physician orders, explaining the procedure to the resident, cleaning the removable inner cannula (inner tube within the tracheostomy tube that can accumulate secretions), cleaning the stoma (the surgically created opening in the neck) and surrounding site, and documenting completion of care in the resident's clinical record. Clinical record review revealed Resident 81 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm (a cancerous tumor) of overlapping sites of the esophagus (a hollow muscular tube that carries food and liquids from the throat to the stomach) and pharynx (the throat, a muscular tube in the neck that assists with breathing and swallowing), and tracheostomy (a surgical procedure in which an opening, called a stoma, is created through the front of the neck into the trachea or windpipe, allowing placement of a tube to maintain an open airway and assist breathing). Review of the resident's care plan initiated November 4, 2025, identified impaired respiratory status related to respiratory failure and need for a tracheostomy with goals for the resident to remain free of abnormal drainage around the tracheostomy site and free from complications related to altered respiratory status. Interventions included tracheostomy care as ordered, suction as per physician orders (suction removes mucus from the airway using a medical device, resident may self suction), and elevating the head of the bed to promote optimal breathing.A review of Resident 81's 5-day Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 8, 2025, revealed that Resident 81 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment/cognitively intact). Additionally, Section O0110. Special Treatments, Procedures, and Programs E1. Tracheostomy care was coded to indicate Resident 81 received tracheostomy care while a resident. Clinical record review from admission on [DATE], through March 4, 2026, revealed no physician orders for tracheostomy care were obtained and no documented evidence licensed nursing staff consistently performed tracheostomy care in accordance with professional standards of practice or facility policy.Review of a nurse progress note completed by Employee 6, Registered Nurse (RN), dated February 28, 2026, at 5:01 PM, revealed the nurse was called to assess the resident's tracheostomy site and identified a wound measuring 4 centimeters (cm) in diameter by 0.3 cm in depth classified as Stage 3 (a full-thickness wound extending through the skin into the fatty tissue layer, potentially forming a crater but not exposing muscle, bone, or tendon) located under the tracheostomy plate (the external portion of the tracheostomy tube that rests against the neck) at the 6 o'clock position. Documentation indicated a moderate amount of yellow slough (dead tissue) in the wound bed with a pink perimeter and moderate greenish-brown drainage with odor. Documentation indicated the resident was afebrile (without fever) and often positioned with chin to chest with complaints of pain to the area at times. Documentation indicated a call was placed to the physician and new orders were received to pack the wound with Dakin's 1/4 strength solution (a diluted antiseptic solution used to prevent or treat infection in wounds effective against a broad spectrum of pathogens, including bacteria, viruses, fungi, and yeasts, while being gentle on the skin) soaked gauze and cover with bordered gauze daily and as needed for soiling or dislodgement. Documentation indicated the resident and responsible party were notified of the wound and treatment orders. Clinical record review revealed that on March 4, 2026, at 8:37 AM, a contracted wound care Certified Registered Nurse Practitioner (CRNP) documented the area under the tracheostomy plate was a radiation ulceration (a wound caused by tissue damage from radiation therapy).During interview on March 30, 2026, at 10:30 AM, Resident 81 reported nursing staff performed tracheostomy care daily and were currently treating the site twice daily due to a small radiation ulceration under the tracheostomy plate. The resident reported the area was almost healed and denied current pain at the site. The facility was unable to provide documented evidence, licensed nursing staff performed tracheostomy care in accordance with professional standards of practice, physician orders, or facility policy.During interview on March 31, 2026, at 12:45 AM, the Director of Nursing (DON) reviewed the above findings and confirmed the facility did not have physician orders for Resident 81's tracheostomy care and could not provide documented evidence tracheostomy care was consistently completed according to facility policy.A review of the facility policy entitled Oxygen Administration, last reviewed February 6, 2026, indicated staff are to administer oxygen at the flow rate ordered by the physician and ensure the appropriate oxygen delivery device is in place, such as a nasal cannula (a flexible tube with two small prongs placed into the nostrils to deliver supplemental oxygen). The policy indicated that staff should ensure the oxygen device is functioning properly and delivering the prescribed oxygen flow.A clinical record review revealed that Resident 38 was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body).Review of physician orders revealed Resident 38 had an order dated February 3, 2026, for oxygen at four liters per minute via nasal cannula continuously related to chronic respiratory failure.Observation on March 28, 2026, at 11:15 AM revealed Resident 38 was seated in her wheelchair in her room wearing a nasal cannula connected to an oxygen tank. Observation revealed the oxygen tank was empty. During interview on March 28, 2026, at 11:23 AM, Employee 4, Registered Nurse (RN), confirmed the oxygen tank was empty and replaced the tank with a full oxygen tank. Employee 4 assessed the resident's vital signs and documented an oxygen saturation level of 94 percent (measurement of oxygen level in the blood) and heart rate of 62 beats per minute. Employee 4 indicated the resident's skin color appeared normal and there were no signs of distress. Employee 4 confirmed the resident had physician orders for continuous oxygen and staff should monitor oxygen tank levels. During interview on March 29, 2026, at 9:30 AM, the above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The facility failed to ensure Resident 38 received oxygen continuously in accordance with physician orders. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, select facility policy review, and staff interview, it was determined the facility failed to ensure effective pain management by administering pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions prior to administering an opioid pain medication ordered on an as needed basis for one of four residents reviewed for pain management (Resident 81).Findings include: A review of the facility policy titled Pain Assessment and Management, last reviewed by the facility on February 9, 2026, indicated that non-pharmacological interventions may be appropriate alone or in combination with medications to relieve pain. Examples of non-pharmacological interventions included environmental interventions such as adjusting room temperature, providing a pressure-reducing mattress, and repositioning the resident; physical interventions such as application of ice packs or warm or cool compresses; exercise interventions such as range of motion exercises (movement of joints to maintain flexibility and prevent stiffness); and cognitive or behavioral interventions such as relaxation techniques, music, or diversional activities. The policy indicated pharmacological interventions (analgesics, or medications used to relieve pain) may be prescribed; however, medications may not address the underlying cause of pain and may result in adverse effects such as drowsiness, decreased appetite, and increased risk for falls. Clinical record review revealed Resident 81 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm (a cancerous tumor) of overlapping sites of the esophagus (a hollow muscular tube that carries food and liquid from the throat to the stomach) and pharynx (the throat, a muscular passage that allows breathing and swallowing), severe aspiration (occurs when food, liquid, saliva, or stomach contents enter the airway or lungs instead of the stomach), aspiration pneumonia (a lung infection caused by inhaling food, liquid, saliva, or stomach contents into the lungs), respiratory failure (a serious condition in which the lungs cannot provide enough oxygen to the blood or remove carbon dioxide), and tracheostomy (a surgically created opening in the neck into the trachea, or windpipe, to assist with breathing). Review of Resident 81's physician orders revealed an order dated November 18, 2025, at 12:15 PM for Hydromorphone HCL Oral Liquid 1 mg/ml (an opioid medication used to treat moderate to severe pain), administer 4 ml via PEG tube (Percutaneous Endoscopic Gastrostomy tube, a feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition or medications when a resident cannot swallow safely) every four hours as needed for a reported pain level of 4 to 10 (moderate to severe pain on the pain scale). A pain level refers to a numeric rating scale typically ranging from 0 to 10, in which 0 indicates no pain, 1 to 3 indicates mild pain, 4 to 6 indicates moderate pain, and 7 to 10 indicates severe pain. Review of the resident's Medication Administration Record (MAR, a permanent legal record documenting medications administered to a resident by licensed nursing staff) revealed licensed nurses administered Hydromorphone HCL without documented evidence that non-pharmacological interventions were attempted prior to administration of the opioid medication. Documentation also included entries of N/A for pain level. N/A indicates not available or not assessed, meaning the clinical record did not contain documentation of the resident's pain level at the time the medication was administered. Documentation revealed the following: MAR dated November 18, 2025, through November 30, 2025, indicated Hydromorphone HCL was administered twenty-seven (27) times out of seventy-eight (78) opportunities for administration.MAR dated December 1, 2025, through December 31, 2025, indicated Hydromorphone HCL was administered ninety-two (92) times out of one hundred eighty-six (186) opportunities for administration.MAR dated January 1, 2026, through January 31, 2026, indicated Hydromorphone HCL was administered eighty (80) times out of one hundred eighty-six (186) opportunities for administration.MAR dated February 1, 2026, through February 28, 2026, indicated Hydromorphone HCL was administered seventy-nine (79) times out of one hundred sixty-eight (168) opportunities for administration.MAR dated March 1, 2026, through March 31, 2026, indicated Hydromorphone HCL was administered sixty-eight (68) times out of one hundred eighty-six (186) opportunities for administration. Review of Resident 81's MAR revealed licensed nursing staff administered Hydromorphone HCL outside of the physician ordered pain scale range of 4 to 10 on the following dates:November 18, 2025, at 12:16 PM, the recorded pain level was documented as N/A.November 20, 2025, at 11:59 AM, the recorded pain level was documented as N/A.November 21, 2025, at 12:02 PM, the recorded pain level was documented as N/A.November 23, 2025, at 8:10 AM, the recorded pain level was documented as N/A.November 24, 2025, at 7:28 AM, the recorded pain level was documented as N/A.December 1, 2025, at 7:50 AM, the recorded pain level was documented as N/A.December 1, 2025, at 12:16 PM, the recorded pain level was documented as N/A.December 4, 2025, at 11:53 AM, the recorded pain level was documented as N/A.December 10, 2025, at 12:04 PM, the recorded pain level was documented as N/A.December 19, 2025, at 9:19 AM, the recorded pain level was documented as N/A.January 2, 2026, at 7:50 AM, the recorded pain level was 3.January 3, 2026, at 9:02 AM, the recorded pain level was 2.January 4, 2026, at 9:08 AM, the recorded pain level was 0.January 5, 2026, at 9:05 AM, the recorded pain level was 1.January 6, 2026, at 2:40 PM, the recorded pain level was 2.January 7, 2026, at 11:50 AM, the recorded pain level was 1.January 8, 2026, at 9:06 AM, the recorded pain level was 0.January 9, 2026, at 2:14 PM, the recorded pain level was 3.January 16, 2026, at 9:18 AM, the recorded pain level was 0.January 17, 2026, at 9:35 AM, the recorded pain level was 0.January 19, 2026, at 9:10 AM, the recorded pain level was 3.January 23, 2026, at 9:09 AM, the recorded pain level was documented as N/A. The clinical record lacked documentation that licensed nursing staff attempted non-pharmacological interventions prior to administration of the opioid medication and lacked documentation that the medication was administered in accordance with the physician ordered pain scale parameters. During an interview on March 31, 2026, at 10:30 AM, the Director of Nursing was informed of the above findings. The Director of Nursing confirmed the facility could not provide documented evidence that non-pharmacological interventions were attempted prior to administering the opioid medication and confirmed that licensed nursing staff administered Hydromorphone HCL outside of the physician ordered pain scale for Resident 81.28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure accurate reconciliation and documentation of controlled substance medications for 3 out of 27 residents reviewed (Residents 6, 94, and 115).Findings include: A facility policy titled Controlled Substances, last reviewed by the facility on February 9, 2026, revealed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. A facility policy titled Administering Medications, last reviewed by the facility on February 9, 2026, revealed that medications are administered in a safe and timely manner, as prescribed, and the individual administering the medications initials the resident's eMAR after giving each medication and before administering the next ones. A review of facility clinical records revealed the facility utilizes a controlled substance (medications or drugs regulated by federal law due to their potential abuse, dependence or diversion) record to track, monitor, and reconcile each controlled medication, such as lorazepam. Review of facility clinical records revealed the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. Clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis (a chronic autoimmune disease in which the immune system attacks the lining of the joints, causing inflammation, pain, and joint damage) and generalized anxiety disorder (a mental health disorder characterized by persistent and excessive worry that interferes with daily activities). Review of Resident 6's clinical record revealed a physician's order dated October 4, 2025, for Ativan (lorazepam) 0.5 milligrams (mg) oral tablet every 12 hours as needed for increased anxiety. Lorazepam is a Schedule IV controlled substance (a medication with a recognized medical use and a lower potential for abuse relative to Schedule II or III medications). A comparison of Resident 6's Controlled Substance Record with the MAR from December 2025 through March 2026 revealed four (4) entries indicating lorazepam 0.5 mg was removed from controlled substance inventory; however, there was no corresponding documentation on the MAR indicating the medication was administered. Discrepancies were identified on the following dates:January 30, 2026, at 9:00 AMFebruary 7, 2026, at 1:00 PMFebruary 12, 2026, at 10:25 AMFebruary 17, 2026, at 12:30 PM A clinical record review revealed Resident 94 was admitted to the facility on [DATE], with diagnoses that include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 94's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 94 dated December 23, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). Clinical record review revealed a physician's order dated March 6, 2026, for morphine sulfate 20 mg per milliliter (ml), administer 0.25 ml every two hours as needed for pain or shortness of breath. Morphine is a Schedule II controlled substance (a medication with accepted medical use but a high potential for abuse and dependence). A comparison of Resident 94's Controlled Substance Record with the March 2026 MAR revealed thirteen (13) entries indicating morphine was removed from inventory; however, there was no corresponding documentation on the MAR indicating administration of the medication on the following dates: March 9, 2026, at 9:00 AMMarch 10, 2026, at 2:11 PMMarch 11, 2026, at 12:30 PMMarch 12, 2026, at 9:30 AMMarch 13, 2026, at 10:00 AMMarch 16, 2026, at 6:14 AMMarch 16, 2026, at 4:17 PMMarch 17, 2026, at 1230 PMMarch 23, 2026, at 8:43 PMMarch 24, 2026, at 2:00 PMMarch 25, 2026, at 9:00 AMMarch 25, 2026, at 3:00 PMMarch 26, 2026, at 8:35 AM.A clinical record review revealed Resident 115 was admitted to the facility on [DATE], with diagnoses that included traumatic subdural hemorrhage (bleeding between the brain and its outer protective covering, often caused by head injury) and malignant neoplasm of the prostate (prostate cancer). A review of the clinical record for Resident 115 revealed a physician's order dated March 8, 2026, for Oxycodone HCL 5 mg oral tablet (Schedule II opiate narcotic medication; Schedule II drugs have a high potential for abuse) twice daily, and an additional physician's order dated March 12, 2026, for Oxycodone HCL 5 mg oral tablet every 24 hours as needed for chronic pain and breakthrough pain (sudden increase in pain despite ongoing treatment) rated 6 through 10. A comparison of Resident 115's Controlled Substance Record with the MAR from February 2026 through March 2026 revealed three (3) entries indicating Oxycodone HCL 5 mg was removed from inventory; however, there was no corresponding documentation on the MAR indicating administration of the medication on the following dates:March 7, 2026, at 9:00 PMMarch 8, 2026, at 3:39 PMMarch 9, 2026, at 9:00 PM Comparison of Resident 115's Controlled Substance Record and MAR revealed two (2) entries documenting administration of Oxycodone HCL 5 mg on the MAR; however, there was no corresponding documentation on the Controlled Substance Record indicating removal of the medication from inventory on the following dates: March 21, 2026, at 9:00 PMMarch 22, 2026, at 9:00 PM. An interview conducted on March 31, 2026, at 8:30 AM with the Director of Nursing (DON) confirmed the above findings related to discrepancies between the Controlled Substance Records and the Medication Administration Records. The DON acknowledged the facility failed to ensure effective reconciliation procedures for controlled medications. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to timely notify the physician of abnormal lab results for one resident out of 27 residents reviewed (Resident 15).Findings included: A review of the facility policy entitled Change in a Resident's Condition or Status, last reviewed on February 9, 2026, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A review of the facility policy entitled Lab and Diagnostic Test Results, last reviewed on February 9, 2026, indicated that nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the resident's clinical status is unclear or they have symptoms of acute illness or condition change and are not stable or improving, or there are no previous results for comparison. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], and had diagnoses that included anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning) and hypertension (blood pressure that is higher than normal). A review of Resident 15's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 10, 2026, revealed that Resident 15 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of a physician's order for Resident 15 dated March 23, 2026, revealed a laboratory order for urinalysis (UA) and C & S (culture and sensitivity). A urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection. A review of the final urine culture (C&S) results dated March 25, 2026, identified abnormal findings of greater than 100,000 colonies per milliliter of Enterococcus species (a bacterium). A review of nursing progress notes for Resident 15 dated March 24, 2026, at 11:47 AM revealed the urine culture results from March 24, 2026, were reviewed with the physician, and there were no new orders at that time. However, the final culture report did not result until March 25, 2026, at 3:22 PM. An interview with Resident 15 on March 28, 2026, at 2:00 PM, revealed they were upset because she had been experiencing urinary frequency and urgency and stated that when she asked the staff about her urine culture results, she had been told they were waiting for the final culture report. The resident stated she felt awful and fatigued and felt like something was off. She stated she had had sepsis ( a serious condition that occurs when the body has an extreme reaction to an infection) in the past due to a UTI and was worried about having a bad infection again. An interview with Employee 7, Registered Nurse (RN) on March 28, 2026, at 2:10 PM, confirmed that the physician would not have been made aware of the final culture results as they did not result until March 25, 2026. A review of a nurse's progress note dated March 28, 2026, at 2:45 PM, revealed there was a call placed to the on-call physician and was updated on the resident's urine culture results with new orders to start Macrobid (an antibiotic). A review of a physician's order dated March 28, 2026, at 2:47 PM, revealed an order for Macrobid 100 mg twice a day for five days for a UTI. A review of an antibiotic stewardship evaluation note dated March 28, 2026, at 4:32 PM, revealed the infection met McGeer's criteria (a standardized set of clinical guidelines used by healthcare professionals to help determine whether a resident in a long-term care facility has a true infection, based on specific signs, symptoms, and clinical findings. The criteria help ensure infections are identified consistently and not based on vague or non-specific symptoms alone). During an interview on March 29, 2026, at 12:45 PM, the director of nursing confirmed the above findings and that Resident 15 met McGeer's criteria and that the physician should have been made aware in a timely manner of the final culture results. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interview, it was determined the facility failed to ensure an environment free from potential spread of infection and failed to properly store resident personal care equipment on 2 of 2 nursing units (First Floor and Second Floor).Findings include: A review of the Infection Control Program Policy last reviewed February 9,2026 indicated the infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of communicable disease and infection. Personal care equipment such as bedpans and graduates may come into contact with bodily fluids. Bodily fluids (such as urine or stool) may contain microorganisms (germs) capable of causing infection. Infection prevention practices require contaminated equipment to be stored in a manner that prevents contamination of clean surfaces and reduces risk of transmission of communicable disease. An observation on March 28, 2026, at 11:02 AM in a resident room on the Second Floor nursing unit (room [ROOM NUMBER]) revealed a pink bedpan placed on the bedside table next to a roll of toilet paper and a telephone. The bedpan was not enclosed in a protective plastic bag and was not stored in a designated cabinet. A second observation of the same room on March 28, 2026, at 1:40 PM revealed the same bedpan remained unbagged on the bedside table next to the toilet paper and the resident's telephone. An interview with Employee 1 nurse aide on March 28,2026, at 1:44 PM stated the bedpan should be placed in a plastic bag and stored in the cabinet underneath the bedside table. An observation on March 28, 2026, at 12:15 PM revealed a graduate (a container used to measure urine output) placed on top of the counter next to the sink in the shared bathroom for resident rooms [ROOM NUMBERS]. At the time of the observation, Employee 5 nurse aide confirmed the graduate should not be placed on the bathroom counter next to the sink where handwashing occurs due to risk of contamination. An interview was conducted with the Director of Nursing on March 29, 2026, at 1:00 PM regarding the above findings related to the facility's failure to ensure personal care equipment, including a bedpan and graduate, were stored and maintained according to infection prevention practices. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa code 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure timely identification, confirmation, and physician notification of a significant unplanned weight loss for 1 of 27 residents reviewed (Resident 118). Findings include:A review of a facility policy entitled Weight Assessment and Intervention last revised by the facility February 9, 2026, indicated any weight change of 5 percent or more since the last weight assessment is retaken the next day for confirmation. The threshold for significant unplanned/undesired significant weight is 5 percent or more since the last weight assessment is significant, and would be evaluated by the dietitian, physician, and multidisciplinary team to develop interventions to stabilize/improve the residents' weight. A review of Resident 118's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills and characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning that interfere with a person's daily life and activities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's nutrition plan of care initiated October 23, 2023, indicated the resident was at risk for altered nutritional status related to dementia and weight fluctuations. The plan indicated a goal for the resident to avoid significant weight changes (gain or loss). Interventions included obtaining weights periodically and reporting significant weight changes to the Registered Dietitian (RD) physician, and family. A review of the resident's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 3, 2025, revealed that Resident 118 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment).Review of Resident 118's weight record revealed the following:On December 10, 2025, at 11:07 AM, the clinical record documented the resident's weight as 115.1 pounds (lbs.).On January 6, 2026, at 4:22 PM, the clinical record documented the resident's weight as 109 lbs., representing a weight loss of 6.1 lbs. (5.3 percent) within one month.The clinical record failed to reveal documented evidence that a reweight was obtained the following day to confirm the significant weight loss as required by facility policy. Clinical record review revealed a nutrition progress note completed by the Registered Dietitian dated January 12, 2026, at 7:27 AM, documented the resident's weight as 109 lbs., reflecting a 6.1 lb. (5.2 percent) weight loss in one month. The RD documented the resident historically weighed approximately 112 lbs., meal intake ranged between 76 to 100 percent with few exceptions, and the resident was receiving a regular diet with regular texture and liquids. The RD documented questioning the weight loss and indicated fortified foods (food enhanced with additional calories and protein to help maintain or increase body weight) would be requested and weekly weights would be monitored.Review of the weight record revealed that on January 14, 2026, at 9:57 PM, the clinical record documented the resident's weight as 108.2 lbs., confirming a 6 percent weight loss within 30 days. The clinical record failed to reveal documented evidence that the resident's attending physician was notified of the significant weight loss to allow timely medical evaluation and intervention. The facility failed to ensure that reweighing was completed timely to confirm significant weight loss and failed to ensure timely interdisciplinary evaluation and physician notification to address significant weight loss in accordance with facility policy and professional standards of practice. During an interview on March 30, 2026, at 2:00 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) the above findings were reviewed and confirmed. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, documentation provided by the facility, and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one of 27 residents reviewed (Resident 34) from sexual abuse perpetrated by another resident (Resident 33). Findings include: A review of the facility policy titled Abuse Policy, last reviewed by the facility on February 9, 2026, revealed it is the facility policy that residents have the right to be free from abuse. The policy indicates sexual abuse is defined as, but not limited to, non-consensual sexual harassment, sexual coercion, contact, or sexual assault. Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse. The policy indicates that staff will prevent abuse by identifying residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. A clinical record review revealed that Resident 34 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 34's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 24, 2026, revealed that Resident 34 had severe cognitive impairment with a BIMS score of 2 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 through 07 indicates cognition severely impaired). A clinical record review revealed that Resident 33 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of Resident 33's quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 33 had moderate cognitive impairment with a BIMS score of 11 (a score of 8 through 12 indicates cognition is moderately impaired). Further clinical record review revealed a care plan focus indicating Resident 33 had behaviors related to going into other residents' rooms, initiated on September 2, 2025. Interventions implemented to ensure Resident 33 had no adverse effects related to these behaviors including monitoring and documenting episodes of inappropriate behaviors, redirecting the resident when exhibiting behaviors, and offering activities of interest to keep the resident engaged in positive interactions. A progress note dated August 4, 2025, at 2:50 PM revealed Resident 33 was observed in a female resident's room. Resident 33 was rubbing the female resident's arm and leg. The director of nursing (DON) was made aware, staff were advised to watch for any further behaviors. A progress note dated August 6, 2025, at 3:00 PM revealed Resident 33 was propelling through hallways and entering other resident rooms. Resident 33 was educated and advised not to enter other resident rooms. Resident 33 verbalized understanding and agreed not to continue doing this action. A progress note dated November 27, 2025, at 11:46 AM revealed Resident 33 was observed coming out of a female resident's room. Education was provided to Resident 33. Review of facility-provided investigative documentation revealed a written witness statement from Employee 2, Activity Aide (AA), regarding an allegation of resident-to-resident sexual abuse that occurred on January 29, 2026. Employee 2 documented that between 2:30 PM and 4:00 PM she was facilitating a resident activity on the first floor. During the activity, Employee 2 observed Resident 33 and Resident 34 seated next to one another. Employee 2 documented that Resident 33 attempted to touch Resident 34's lower body multiple times and would stop when he noticed that she was observing him. Employee 2 documented that when the activity concluded, she moved Resident 34 to the second-floor hallway near the nurses' station. Employee 2 documented that she left the unit and indicated that Resident 33 was not present on the second floor at that time. Employee 2 documented that upon returning to the second-floor nursing unit she observed Resident 33 and Resident 34 facing each other in the second-floor activity room. Employee 2 documented that Resident 33 was leaning toward Resident 34 with his right hand down Resident 34's pants. Employee 2 documented that Resident 33 removed his hand from Resident 34's pants when he noticed he was being observed. Employee 2 documented that she notified Employee 3, Licensed Practical Nurse (LPN). Review of facility-provided investigative documentation revealed a written witness statement from Employee 3, LPN, regarding the same incident on January 29, 2026. Employee 3 documented that she was administering medications when Employee 2 AA reported that Resident 33 was touching Resident 34. Employee 3 documented that she directed Employee 2 to notify the Registered Nurse Supervisor (RNS). Employee 3 documented that she proceeded to the second-floor activity room to separate Residents 33 and 34. Employee 3 documented that upon entering the activity room, Residents 33 and 34 were seated facing one another and holding hands. Employee 3 documented that she provided education to Resident 33 and that Resident 33 left the room. Employee 3 documented that Resident 34 appeared her normal self after the incident. A skin inspection form dated January 29, 2026, revealed Resident 34 had no new observed skin issues.A trauma evaluation form dated January 29, 2026, documented that Resident 34 was inappropriately touched by another resident. The evaluation indicated no identified psychosocial harm. The assessment indicated that Resident 34 was unable to express feelings regarding the incident due to a BIMS score of 3 (Brief Interview for Mental Status score of 3 indicates severe cognitive impairment, meaning the resident has significantly impaired memory and ability to communicate needs or experiences). A progress note dated January 29, 2026, at 4:15 PM documented that Resident 33 was placed on one staff-to-one resident supervision. A progress note dated January 30, 2026, at 4:30 PM documented that the Director of Nursing (DON) assessed Resident 34 and observed no injuries, redness, complaints of pain, discomfort, or facial grimacing. The note documented that Resident 34's affect remained unchanged and no tearfulness was observed. The DON documented that Resident 34 smiled throughout the assessment. The DON documented that Resident 34's resident representative and Power of Attorney (POA, a legally authorized individual designated to make decisions on behalf of another person) were notified and offered the option of a forensic examination (a specialized medical examination performed to assess, document, and preserve evidence of possible abuse or assault, including collection of physical evidence and evaluation for injury) at the hospital emergency department. The POA declined the forensic examination, indicating that the examination would be more detrimental to the resident's health than the alleged incident. The physician was notified A progress note dated January 30, 2026, at 10:36 AM documented that Resident 33 reported rubbing Resident 34's leg and indicated that Resident 34 was wearing pants. Resident 33 stated, I didn't mean no harm. I guess it was a mixed signal.A psychiatric progress note dated February 2, 2026, documented that Resident 34 was evaluated and appeared stable with current psychiatric medications. The psychiatrist documented that Resident 34 had no recollection of the resident-to-resident incident and did not appear distressed. During an interview conducted on March 28, 2026, at 11:10 AM, Resident 33 remained on one staff-to-one resident supervision and was unable to recall details of the incident. Resident 34 was unable to participate in an interview due to severe cognitive impairment. During an interview conducted on March 28, 2026, at 12:05 PM, Employee 2, AA, confirmed that on January 29, 2026, she observed Resident 33 attempting to touch Resident 34's lower body during an activity. Employee 2 confirmed that Resident 33 stopped attempting to touch Resident 34 when he noticed that she was observing him. Employee 2 reported that she did not implement interventions to redirect or separate Residents 33 and 34 during the activity. Employee 2 reported that Resident 33 has a history of touching female residents. Employee 2 confirmed that after the activity she escorted Resident 34 to the second-floor nursing station area and left the unit without notifying other staff of Resident 33's behaviors. Employee 2 confirmed that upon returning to the second-floor unit she observed Resident 33 facing Resident 34 in the activity room with his hands down Resident 34's pants. During the interview, Employee 2 reported that she removed Resident 34 from the activity room and ran down the hall to notify Employee 3, LPN, and was then directed to notify the RNS. This statement was inconsistent with Employee 2's written witness statement and inconsistent with Employee 3's written witness statement regarding the sequence of events and staff notification. During a telephone interview conducted on March 28, 2026, at 12:38 PM, Employee 3, LPN, confirmed that Employee 2 reported that Resident 33 had placed his hands down Resident 34's pants in the activity room. Employee 3 confirmed that she directed Employee 2 to notify the RNS and then proceeded to the second-floor activity room to separate the residents. Employee 3 reported observing Residents 33 and 34 seated face-to-face and holding hands. Employee 3 reported that she removed Resident 34 from the activity room and remained with her until an assessment was completed. Employee 3's interview was consistent with the written witness statement provided to the facility. During an interview conducted on March 31, 2026, at 11:00 AM, the above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator (NHA).The facility failed to ensure Resident 33 was free from resident-to-resident sexual abuse when Resident 33 was observed with his hand down Resident 34's pants on January 29, 2026. The facility failed to ensure residents were protected from abuse when Employee 2 observed Resident 33 attempting to touch Resident 34 during the group activity and did not immediately intervene. The facility failed to ensure the immediate safety of residents when Employee 2 did not promptly separate Residents 33 and 34 or notify licensed nursing staff upon first observing inappropriate touching behaviors. This deficiency is cited as past noncompliance. The facility's corrective actions included completion of a registered nurse assessment for Resident 34, which identified no skin alterations or behavioral changes of a sexual nature. Resident 33 was placed on one staff-to-one resident supervision. The physician and resident representative were notified. The Nursing Home Administrator initiated the investigation and completed required agency notifications. The facility completed skin assessments on current female residents with BIMS scores below 12 on January 29, 2026, with no new skin alterations identified. No current female residents with BIMS scores above 12 reported allegations of abuse. The facility re-educated staff on the abuse prevention program and resident behavior management process, including implementation of interventions for residents exhibiting new or increased negative behaviors. The Nursing Home Administrator or Director of Nursing will conduct weekly audits for four weeks, then monthly audits for two months, to ensure residents identified with new or increased negative behaviors have appropriate interventions implemented and to ensure staff adherence to the abuse prevention program. The Quality Assurance Committee will review audit results and implement additional follow-up as needed. The facility's date of compliance was February 2, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a discharge plan that accurately reflects a resident's discharge goals or preferences for one out of 27 residents reviewed (Resident 26). Findings included:A review of the facility policy titled Discharge Summary and Plan, last reviewed by the facility on February 6, 2026, revealed it is the policy of the facility to develop a post-discharge plan by the care planning interdisciplinary team with the assistance of the resident and his or her family and includes (1) where the individual plans to reside; (2) arrangements for follow-up care; (3) the degree of support availability, capacity, and capability to perform required care; (4) transition planning; (5) factors that may make the resident vulnerable to readmission; (5) a plan to address those factors. The policy indicates that if returning to the community is not feasible, it will be documented why this is the case and who made the determination. Furthermore, the policy indicates that every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. A clinical record review revealed that Resident 26 was admitted to the facility on [DATE], with diagnoses that included cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body) and cerebral infarction (brain damage that results from a lack of blood flow to the brain). A review of Resident 26's admission, Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 24, 2025, revealed that Resident 26 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A review of Resident 26's quarterly MDS assessment dated [DATE], revealed that Resident 26 had moderate cognitive impairment with a BIMS score of 11 (a score of 8 through 12 indicates cognition is moderately impaired). A care plan indicating Resident 26 was a short-term care resident and will return to the community was initiated on November 18, 2025. Interventions implemented to ensure Resident 26 would have a safe transition back to the community included providing the resident and family with written instructions upon discharge to ensure a safe return to the community. A review of Resident 26's Kardex (a tool nursing staff use to provide a quick, overview of patient's care needs) revealed Resident 26 was independent for bed mobility, transferring, dressing, eating, personal hygiene, and toileting. The Kardex indicated Resident 26 required physical help with bathing. A court document dated March 9, 2026, revealed Resident 26 suffered from cardiomyopathy, congestive heart failure, and kidney failure. Resident 26 was unable to receive and evaluate information effectively and make and communicate decisions essential requirements for his physical health and safety. A guardian was appointed with the authority to decide how Resident 26 shall live and how meals, personal care, transportation and recreation shall be provided. The Guardian shall authorize consent to medical treatment and surgical procedures necessary for the well-being of Resident 26. During an interview on March 28, 2026, 10:30 AM, Resident 26 indicated that he was frustrated and upset that he is in the nursing facility. He indicated that he is [AGE] years old and feels like he is missing out on his life in the community. Resident 26 indicated that he is independent and does not require nursing care. He explained the facility is not working with him on discharge planning. Resident 26 indicated that he does not want to cause any problems, but he wants to leave the facility. During an interview on March 29, 2026, at 9:30 AM, the above information was reviewed with the director of nursing (DON). The DON was unable to provide evidence the facility had documented Resident 26's discharge needs, determined capacity for self-care (e.g., self-administering medications or treatments), or identified required support necessary for the Resident 26's guardian to make an informed decision regarding safe discharge planning. The facility failed to identify Resident 26's capacity and capability for self-care and failed to communicate these clinical findings to the Guardian. This failure prevented the development of a discharge plan that addressed identified deficits necessary for a safe transition to the community consistent with the resident's expressed goals and the guardian's oversight.28 Pa. Code 201.18 (b)(2) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(3) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set (MDS) for one of 27 residents reviewed (Residents114).Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2026 requires that each MDS assessment accurately reflect the resident's status during the assessment reference period (the specific look-back period of days the assessor must review). The Manual requires that a registered nurse conduct or coordinate each assessment with participation of appropriate health professionals. The assessment process must include direct observation of the residents and communication with the residents and direct care staff on all shifts. A clinical record review revealed Resident 114 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the head of the pancreas ( pancreatic cancer), hemiplegia (paralysis on one side of the body), and moderate protein-calorie malnutrition (occurs when the body does not receive enough protein and calories to maintain proper health and functioning. It is common among terminally ill patients due to numerous factors, such as reduced appetite, difficulty eating, and weakened immune system). A review of Resident 114's clinical record revealed a physician's order dated February 25, 2026, at 11:05 AM, which revealed to admit the resident to hospice services (coordinated program of care and support for individuals with a serious or terminal illness that focuses on comfort symptom management) due to diagnosis of pancreatic cancer. A review of Resident 114's admission MDS assessment dated [DATE], revealed the assessment was coded to indicate the resident did not require special treatments, procedures and programs. Section O0110-K1 (Hospice Care) was coded to indicate the resident was not under Hospice Care. Section O of the MDS captures the use of Special treatments, procedures and programs such as Hospice, Chemotherapy, Radiation therapy, Oxygen therapy or Intravenous therapy. An interview conducted on March 29, 2026, at 1:30 PM with the Registered Nurse Assessment Coordinator (RNAC) acknowledged the admission MDS dated [DATE] did not accurately reflect the resident's admission to Hospice. An interview was conducted with the Nursing Home Administrator (NHA) on March 31, 2026, at 8:30 AM, to review the above information related to the facility's failure to accurately capture Resident 114's Hospice admission on the admission MDS dated [DATE], Section O (Special treatments). 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to address the presence, care, monitoring, and maintenance of a vascular access device for 1 of 17 residents reviewed (Resident 114).Findings include: A review of the policy titled Care Plans, Comprehensive Person Centered last reviewed by the facility on February 9, 2026, revealed a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Clinical record review revealed Resident 114 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the head of the pancreas (pancreatic cancer, a disease in which abnormal cells grow uncontrollably in the pancreas), hemiplegia (paralysis affecting one side of the body), and moderate protein-calorie malnutrition (a condition occurring when the body does not receive enough protein and calories to maintain proper health and functioning, commonly seen in individuals with serious illness due to reduced appetite, difficulty eating, and weakened immune system). A review of a nursing progress note dated February 21, 2026, at 8:04 PM documented, Resident has POC right upper chest. An implanted venous port (a small device surgically placed under the skin and connected to a catheter inserted into a large vein near the heart to allow medications, fluids, or blood products to be administered) requires ongoing monitoring and maintenance to prevent complications such as infection (invasion and growth of harmful microorganisms in the body), occlusion (blockage of the catheter), or device malfunction. A review of a physician's order dated February 21, 2026, documented Implanted Venous Port -Not Accessed -Maintenance: Flush each lumen (separate internal channel within the catheter used to administer fluids or medications) every month with 10 ml Normal Saline (sterile saltwater solution used to maintain catheter patency and prevent blockage) and 5 ml Heparin 100 units/ml (an anticoagulant medication used to prevent blood clots from forming within the catheter). Review of Resident 114's comprehensive care plan, initiated February 21, 2026, revealed the facility failed to develop a care plan that addressed the presence of the implanted venous port located in the resident's right upper chest, including interventions necessary to monitor the site and ensure the ordered maintenance treatment was implemented according to the physician's order. An interview was conducted with the Director of Nursing (DON) on March 29, 2026, at 9:30 AM to review the above findings related to the facility's failure to develop and implement a comprehensive person-centered care plan to address the resident's physical needs associated with the vascular access device. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c)(d) Resident care policies

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered residents' medications for two of 27 residents reviewed (Residents 94 and 121).Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the facility policy titled Administering Medications, last reviewed by the facility on February 9, 2026, revealed that medications are administered in a safe and timely manner, as prescribed, and are administered within one hour of their prescribed time, unless otherwise specified. A clinical record review revealed Resident 94 was admitted to the facility on [DATE], with diagnoses that include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 94's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 23, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of Resident 94's Medication Administration Record (MAR) for March 2026 revealed the resident was prescribed and scheduled to receive the following medications: Lorazepam (an anti-anxiety medication) 0.5 mg, 1 tablet by mouth at 7:00 PMTramadol (pain medication) 50 mg, 1 tablet by mouth at 4:00 PMTylenol (medication used for pain and fever) 325 mg, 1 tablet by mouth at 5:00 PMValproic acid (medication used for mood stabilization) 250 mg, by mouth at 6:00 PM. A review of the resident's medication administration audit report for March 2026 indicated that on March 23, 2026, all the above scheduled medications were documented as administered on March 23, 2026, at 8:22 PM. All the above medications were administered more than one hour later than ordered and as scheduled for the resident. A review of the clinical record revealed that Resident 121 was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal). A review of Resident 121's Quarterly MDS dated [DATE], revealed that Resident 121 was cognitively intact with a BIMS score of 15 (a score of 13 through 15 indicates cognition is intact). A review of Resident 121's March 2026 MAR revealed that the resident was prescribed and scheduled to receive the following medications: Atorvastatin (medication to lower cholesterol) 20 mg, 1 tablet by mouth at 9:00 PMPotassium chloride (potassium supplement) 20 mEq, 2 tablets by mouth at 9:00PMCitalopram (an antidepressant) 20 mg, 1 tablet by mouth at 9:00 PMFlomax (medication used to improve urine flow) 0.4 mg, 1 tablet by mouth at 9:00 PM.Losartan (medication to help lower blood pressure) 25 mg, 1 tablet by mouth at 9:00 PMLyrica (medication used to help treat nerve pain) 50 mg, 1 tablet by mouth at 9:00 PMRopinirole (medication used to help with restless leg syndrome) 2 mg, 1 tablet by mouth at 9:00 PM.Sotalol (medication used to help lower blood pressure and heart rate) 40 mg, 1 tablet by mouth at 9:00 PMXarelto (a blood-thinning medication) 20 mg, one tablet by mouth at 9:00 PM. A review of the resident's medication administration audit report for March 2026 indicated on March 23, 2026, all the above-scheduled medications were documented as administered on March 23, 2026, at 11:00 PM, two hours after the scheduled time for the resident. During an interview on March 31, 2026, at 8:30 AM, the above information was reviewed with the director of nursing, and it was confirmed that the late medication administration is not consistent with the professional standards and medications should be received in a timely manner. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on review of clinical records, facility investigative reports, and staff interviews, it was determined the facility failed to adequately investigate resident falls and timely develop and implement effective safety interventions to prevent falls for residents with a known history of falls and unsafe behaviors. This deficient practice resulted in repeated falls for one resident (Resident 3) and a serious injury (fracture of knee) requiring hospitalization for another resident (Resident 1), affecting two of the seven sampled residents.Findings include: A review of Resident 3's clinical record revealed admission to the facility on May 7, 2025, with a diagnosis to include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke), legal blindness, and end stage heart disease (advanced and irreversible stage of heart failure, where the heart is severely weakened and unable to pump blood effectively). The resident expired on September 5, 2025. A review of a quarterly MDS (Minimum Data Set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 15, 2025, revealed Resident 3 was moderately cognitively impaired with a BIMS score of 11 (BIMS-Brief Interview for Mental Status is a tool to screen and identify the cognitive condition of long-term care residents. A score of 8-12 represents moderate cognitive impairment). Resident 3 required substantial to maximal assistance of staff for activities of daily living. A review of the plan of care initiated May 12, 2025, identified Resident 3 was at risk for falls due to decreased strength, endurance, generalized weakness, and hemiplegia. Planned interventions included: educate the resident and family to call for assistance before transferring, keep call light, food/fluids and personal belongings within reach, keep bed in low position (not the lowest), keep environment free of clutter, provide activities that promote exercise and strength, and therapy evaluation. Nursing documentation revealed the resident exhibited increased anxiousness, self-ambulation, physical and verbal aggression toward staff, disruptive behaviors such as turning off roommate's air mattress, pushing roommate's belongings onto the floor, yelling obscenities and racial slurs, and removing oxygen tubing. Nursing documentation and facility investigative documentation from August 2, 2025, to September 3, 2025, revealed Resident 3 experienced ten falls: 7 unwitnessed falls and 3 witnessed falls. The incidents were as follows: August 2, 2025, at 1:15 PM: Resident 3 was found sitting on floor in his room with bruising and raised area to the left side of his head. The resident stated he slipped when going to the bathroom. Neurological checks (at a minimum assessment of pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength following a head injury) were initiated. August 7, 2025, at 10:00 AM: Resident 3 was found sitting on the left side of bed on his buttocks. The housekeeper witnessed the fall. Resident 3 reported he was sitting on the side of the bed and tried reaching for his soda on the floor and fell forward onto his knees. Incontinence care provided. August 8, 2025, at 2:10 AM: Resident 3 attempted to self-ambulate and his legs gave out. The resident reported he had a cramp in his leg and tried to walk it off. He stated his legs gave out and he fell. Neurological checks initiated. August 12, 2025, at 1:56 AM: Resident 3 was found sitting on the floor at the foot of his bed. Neurological checks initiated. The care plan revised to provide tap bell. August 24, 2025, at 7:30 AM: Resident 3 was found sitting on the floor in front of the nightstand. Noticeable red marks on his mid to upper right side of his back. Skin tears noted to the right lower extremity from scab removal from fall. Neurological checks initiated and treatment to right lower extremity provided. August 25, 2025, at 1:30 AM: Resident 3 was found sitting on the floor near his closet with both legs extended in front of him. The bedside table was knocked over. The resident reported that he did not want to wait. Neurological checks initiated. Resident encouraged and reminded to activate call bell for assistance. August 29, 2025, at 9:15 PM: Resident 3 found lying on the floor on the left side of the bed with his blanket covering him and holding his pillow. The resident reported he rolled out of bed. August 30, 2025, at 9:50 AM: Resident 3 attempted to stand near the wall/corner of hallway and fell on his right side. Small abrasion on his forehead. Neurological checks initiated. Care plan revised to offer toileting after meals. September 1, 2025, at 8:00 AM: Resident 3 heard yelling out and was found lying on the floor on his left side with his head towards the foot of the bed. The resident reported he slid out of bed. September 3, 2025, at 7:00 PM: Resident 3 observed throwing arms and legs over wheelchair armrest, fell as staff approached. The care plan revised September 3 to add fall mats while in bed; revised again September 4 to provide mattress on floor when agitated and unable to remain seated. Despite documented interventions, the facility failed to identify root causes or implement adequate enhanced supervision or individualized interventions. Resident 3 experienced repeated falls with injuries including bruising, abrasions, and skin tears.During an interview on September 17, 2025, at 3:45 PM, the Assistant Director of Nursing (ADON) confirmed that Resident 3 had multiple witnessed and unwitnessed falls and acknowledged that the facility's interventions were ineffective in preventing repeated falls. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include dementia, diabetes, and hypertension. A quarterly Minimum Data Set assessment dated [DATE], revealed a BIMS score of 9 (A score of 8 to 12 indicates moderate cognitive impairment). Resident 1 required two staff for transfers and toileting, was non-ambulatory, and used a wheelchair for mobility. A review of a plan of care for at risk for falling initiated March 21, 2025, revealed that staff were to keep the call bell within reach, keeping personal belongings within reach, implementing preventative fall interventions/devices, and a bariatric bed bolster overlay to the bed. A review of a care plan for ADL (activities of daily living) self-care performance deficit dated March 21, 2025, revealed the resident was an assist of two staff for bed mobility, toileting and a mechanical lift with assistance of two staff for transfers. Resident 1 was noted as non-ambulatory and utilized a wheelchair for ambulation. A review of facility investigation documentation and nursing documentation indicated between July 18, 2025, and September 2, 2025, Resident 1 sustained four falls:July 18, 2025, at 5:45 PM Resident 1 had an unwitnessed fall in his room. He was found on the floor next to his bed on his knees. He was assessed by nursing with no injury noted. He had nonskid socks on. The noted intervention to prevent future falls was to place a fall mat to the right side of the bed. There were no witness statements available at the time of the survey regarding the July 18, 2025, fall incident. There was no root cause analysis for this fall to determine the possible cause of the fall and to determine interventions to prevent future falls. August 4, 2025, at 4:05 AM Resident 1 had an unwitnessed fall from bed. He was found sitting on the floor leaning against the bed. He was on the left side of the bed. It appeared that he slid off the bed into a sitting position. The resident stated, I was going to shower. The resident was incontinent and was observed with dried BM (bowel movement). There was no documentation of the last time care was provided to this resident prior to the fall.Further review of the clinical record revealed no indication as to how this resident was toileted. The care plan-initiated March 21, 2025, for ADL care indicated that Resident 1 required the assistance of two staff for toileting, however, the plan did not include how often staff were to provide toileting care. There was no evidence that nursing assessed the resident for bowel and bladder continence and formulated a plan for toileting for this resident despite dependency on two staff for assistance.August 28, 2025, at 8:19 PM a review of facility investigative documentation and nursing documentation revealed Resident 1 had an unwitnessed fall from bed. He was observed lying on his back on the fall mat. The call bell was not activated. The head of the bed was noted to be at a 90-degree angle. Nursing assessed the resident. No injury was noted. There were no witness statements available at the time of the survey regarding the August 28, 2025, fall incident. There was no root cause analysis for this fall to determine the possible cause of the fall and to determine interventions to prevent future falls. A review of the care plan for at risk for falls revealed a new intervention dated August 29, 2025, to encourage Resident 1 to keep the head of the bed at 45 degrees or below at hour of sleep.On September 2, 2025, at 7:25 AM, facility investigative documentation and nursing documentation revealed the resident had another unwitnessed fall from bed. He was found naked on the right-side floormat. Nursing assessed him and noted he winced with pain upon minimal movement, though no signs of leg shortening or external rotation (potential signs and symptoms of possible hip fracture) were present. The physician was notified and ordered an X-ray of the left hip and pelvis. Documentation did not indicate if the resident was incontinent or the last time care had been provided. At 8:44 AM the resident complained of pain and staff administered Acetaminophen 650 mg. On September 3, 2025, at 1:32 PM, documentation noted an X-ray was to be obtained due to continued pain. At the time of this fall, interventions in place included a bed bolster overlay, a fall mat to the right side of the bed and keeping the head of the bed lower than 90 degrees when not eating. A new intervention was added to provide a stuffed animal for comfort.A review of a witness statement dated September 2, 2025, revealed Employee 12 (housekeeping) saw the resident on the floor while walking by the room and alerted the nurse. No additional witness statements were available. A review of the X-ray obtained September 2, 2025, indicated no fracture of the left hip. Documentation revealed the resident did not get out of bed again until September 6, 2025, at 8:39 PM. On September 5, 2025, at 5:15 PM, nursing documentation revealed the resident complained of leg pain during repositioning. The physician was contacted and ordered an X-ray of the left leg. Acetaminophen 650 mg was administered. On September 6, 2025, at 8:39 PM, documentation revealed the resident continued to complain of increasing pain. An X-ray of the left knee revealed an acute comminuted distal femoral fracture (a fracture in which the bone is broken into multiple pieces at the end of the femur near the knee). The physician was notified, and the resident was transferred to the hospital. Hospital documentation revealed the resident was evaluated with CT scans and X-rays that confirmed a left periprosthetic femur fracture. He was transferred to the trauma unit, admitted , and treated with pain management and therapy. The fracture was determined to be non-operative. The resident was discharged and readmitted to the facility on [DATE], at 4:31 PM. There was no evidence that Resident 1's falls were adequately investigated or that individualized fall prevention interventions, including ADL care needs, were developed and implemented to prevent falls. One of these falls resulted in a serious injury requiring hospitalization. During an interview on September 17, 2025, at 3:00 PM, the corporate nurse consultant, was unable to provide evidence that Resident 1's falls had been adequately investigated or that individualized fall interventions were implemented to prevent a fall with serious injury. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 4). Findings include: A review of a facility policy for Dementia-Clinical Protocols, reviewed August 2025 revealed, for residents with a confirmed dementia diagnosis, the interdisciplinary team will develop and implement a resident-centered care plan designed to maximize remaining function and quality of life. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnosis to include dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 3, 2025, revealed Resident 4 to be severely, cognitively impaired with a BIMS score of 3 (brief interview for mental status, is a cognitive screening tool that helps nursing staff measure how well residents can remember, process and recall information. A score of 0 to 7 indicates severe cognitive impairment) and required assistance of staff for activities of daily living.A care plan addressing behaviors, including yelling out and resistance with care, initiated July 24, 2024, directed staff to approach the resident in a calm manner to avoid frustration and escalation of behaviors. The care plan further instructed that if the resident became agitated and showed signs of escalation, staff were to stop the activity and re-approach the resident later to complete care when she was calmer. Review of facility investigative documentation and nursing notes dated August 30, 2025, at 7:30 PM, revealed Employee 5 (nurse aide) reported to Employee 6 (RN Supervisor) that she heard a noise from Resident 4's room that sounded like a muffled human voice. Employee 5 stated she suspected staff inside the room were holding their hand over Resident 4's mouth to prevent her from yelling. Employees 7 and 8 (nurse aides) were providing care to Resident 4 at the time. Both staff members were suspended and sent home pending the outcome of a facility investigation. A review of a witness statement dated August 30, 2025, revealed Employee 8 (nurse aide) stated, I did not cover Resident 4's mouth at any point. I understand the seriousness of this allegation, but it is not true. At the time of me changing Resident 4, she was very combative, screaming, and she was angry. A review of a witness statement dated August 30, 2025, from Employee 7 (nurse aide) indicated, I walked into Resident 4's room to assist Employee 8 (nurse aide) to put Resident 4 in her chair. At no time did either of us cover Resident 4's mouth. The resident was combative and screaming. At no point did anyone stop her from screaming. Although the facility's investigation did not substantiate abuse, there was no evidence that staff implemented the care-planned dementia interventions when Resident 4 became agitated. Specifically, there was no documentation or evidence that staff stopped the care and re-approached the resident at a later time as directed by the care plan. During an interview conducted on September 17, 2025, at 3:00 PM, the Assistant Director of Nursing and the Corporate Nurse Consultant confirmed that the individualized dementia care plan interventions were not implemented for Resident 4. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on review of the facility's abuse prohibition policy and procedures, report of alleged abuse, clinical record review, and staff interviews, it was determined the facility failed to fully implement its abuse prohibition procedures to identify potential sexual abuse, ensure timely notification of administration and the State Survey Agency, notify the resident's representative and physician, and promptly investigate an allegation of sexual abuse for one of seven sampled residents (Resident 2).Findings include: A review of the facility policy titled Abuse Policy last reviewed by the facility on August 14, 2025, revealed all allegations of abuse must be reported immediately to the Director of Nursing (DON). In the absence of the Director of Nursing such reports may be made to the Nurse Supervisor on duty. The Nursing Home Administrator (NHA) or Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the NHA and DON must be called at home or must be paged and informed. The facility's abuse policy defines sexual abuse as non-consensual sexual harassment, sexual coercion, contact or sexual assault. Further review of the policy revealed that any covered individual, which means the owner, operator, employee, manager, agent or contractor must report to the state survey agency and one or more law enforcement entities for the political subdivision in which the facility is located. Any alleged violations must be reported 1. Immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury. Review of a report of an allegation of abuse dated September 2, 2025, revealed the alleged incident occurred on August 26, 2025, at 11:30 AM involving Resident 2 and Resident 2's visitor. Review of a witness statement provided by Employee 1 NA (nurse aide) dated August 28, 2025, (no time indicated) revealed that the alleged incident occurred on August 26, 2025, at 11:30 AM. Employee 1 reported she heard what sounded like a kissing noise in Resident 2's room. The curtain was pulled. Employee 1 stated she did not see anything, just heard the noise and reported it to Employee 3 LPN (licensed practical nurse). Review of a witness statement provided by Employee 2 (nurse aide) dated August 28, 2025, (no time indicated) revealed on August 26, 2025, she heard talk about sexual abuse to a resident and reported it to Employee 3 LPN. Review of a witness statement provided by Employee 3 LPN dated August 28, 2025, (no time indicated) revealed Employee 1 the nurse aide reported to him that she walked into Resident 2's room and heard moaning noises. Employee 3, LPN indicated he reported it to the RN Supervisor (Employee 4). The exact date of the incident on Employee 3's witness statement was illegible. Review of a witness statement provided by Employee 4 (RN Supervisor) dated August 28, 2025, (no time indicated) revealed that she was notified on August 28, 2025, by Employee 3 that he was told the day before by the nurse aide that she heard inappropriate noises coming from Resident 2's room while her visitor was in the room. Employee 4 reported it to the NHA. A review of Resident 2's clinical record revealed no documentation of the alleged sexual abuse had occurred. There was no documentation the facility NHA, DON, attending physician, or the resident's responsible party were made aware of the alleged sexual abuse at the time of the incident. Review of the facility's internal investigation revealed the facility did not initiate an investigation until August 28, 2025, two days after the alleged incident. Review of reports submitted to the State Survey Agency revealed the facility failed to notify the agency within the required two-hour timeframe following the allegation of sexual abuse. During an interview with the Assistant Director of Nursing on September 17, 2025, at 10:15 AM, it was confirmed that Employee 3 did not report the allegation of abuse in accordance with facility policy, resulting in delayed identification, notification, and investigation. The facility failed to implement its abuse prohibition procedures by not promptly identifying the alleged sexual abuse of Resident 2, not ensuring timely notification of administration, physician, responsible party, and State Survey Agency, and by delaying the initiation of an investigation into the allegation. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c) Resident Rights. 28 Pa. Code 201.14(a)(c) Responsibility of Licensee. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code: 211.10 (c)(d) Resident care policies.

Based on clinical record review, facility policy review, staff interviews, and observations, it was determined the facility failed to ensure the safety and supervision of two residents identified at risk for wandering and elopement. The facility allowed one resident lacking decision-making capacity and under court-appointed guardianship to leave the premises unsafely (Resident 2) and failed to prevent another resident with known wandering behaviors from exiting through malfunctioning or unsecured doors (Resident 3), resulting in serious injury for two of five residents. These failures placed five residents (Residents 1,2, 3, 4 and 5) at the facility in immediate Jeopardy in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death. Findings include: Review of facility policy titled Discharging a Resident without a Physician's Approval provided by the facility on [DATE], indicated that if the resident or the representative requests discharge without the approval of the attending physician, the resident and/or representative will be asked to sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. Review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnosis to include hemiplegia and hemiparesis (loss of strength on one side of the body) following a cerebral infarction (stroke), cognitive communication deficit, and major depressive disorder. An annual Minimum Data Set (MDS assessment completed periodically to plan resident care) dated [DATE], indicated that Resident 2 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). Review of a court document titled Emergency Order, dated [DATE], revealed the court determined Resident 2 may suffer irreparable harm without the appointment of Emergency Guardians. An Emergency Guardian was appointed on [DATE], and on [DATE], temporary guardianship was established. Resident 2 was officially notified that a petition had been filed to declare her an Incapacitated Person, indicating she was unable to receive and effectively evaluate information, communicate decisions, or manage her health, safety, or finances.Despite this legal determination, the facility allowed Resident 2 to leave the premises on [DATE]. Nursing documentation dated [DATE], at 8:18 AM, revealed that Resident 2 had been attempting to leave the facility since 7:30 AM. Staff attempted to redirect and de-escalate the situation. The resident stated, I need to go to the bank to get my money. I'm done here. I'm leaving, don't you dare try and stop me. Education was provided regarding safety risks and AMA (Against Medical Advice) procedures. Resident 2 was informed that the physician, guardian, and administrator would be contacted. Despite knowledge of the resident's legal incapacity and guardianship status, the facility allowed the resident to sign AMA paperwork and leave the facility. Staff notified police and remained with the resident. The resident exited the building in her motorized wheelchair, entering the parking lot, and eventually traveled approximately 455 feet from the front door, beyond the facility property line, to a public sidewalk. During an interview on [DATE], at 1:05 PM, Resident 2 declined to discuss the incident. During an interview on [DATE], at 1:20 PM, Employee 1 (RN Supervisor) confirmed being called to the front door where Employees 2 Registered Nurse (RN) and Employee 3 Licensed Practical Nurse (LPN) were trying to prevent the resident from leaving. Employee 1 RN Supervisor reported being directed by the Nursing Home Administrator (NHA) and the physician to contact police, have the resident sign AMA paperwork, and permit her departure. In an interview on [DATE], at 3:30 PM, Employee 2 (RN) stated she was aware of Resident 2's guardianship status and understood the resident was not permitted to leave independently. Employee 2 (RN) retrieved her car keys to follow the resident while Employee 3 (LPN) stayed with the resident. Resident 2 exited the facility, yelling and acting erratically, and proceeded toward the public sidewalk in her motorized wheelchair. In an interview on [DATE], at 5:00 PM, Employee 3 (LPN) stated that a housekeeper alerted her to the resident's intent to leave. Despite attempts to prevent exit, Resident 2 was allowed to leave after AMA forms were signed. Employee 3 followed the resident into the parking lot. The resident indicated she intended to take the bus to the bank. Efforts to contact the resident's legal guardian on [DATE], while onsite at the facility were unsuccessful. Subsequently in a telephone interview on [DATE], at 9:45 AM, Resident 2's court-appointed Guardian stated she was contacted by the facility on [DATE], regarding the resident's intent to leave AMA. The guardian stated she explicitly informed the facility that Resident 2 was not capable of making such decisions and must not be allowed to leave. The guardian was later informed that the resident had left the building despite this instruction and that two staff members were with her outside. During an interview on [DATE], at approximately 12:30 PM, the NHA confirmed that Resident 2 exited the facility in her motorized wheelchair after signing AMA paperwork, despite the facility's knowledge of her guardianship status and cognitive impairment. The resident returned approximately one hour later with support from staff and Emergency Medical Services (EMS). The facility's failure to ensure appropriate supervision and safety interventions for a resident lacking decision-making capacity and under court-appointed guardianship represents a significant breach of its responsibility to prevent avoidable accidents and ensure resident safety. A review of the facility policy dated [DATE] entitled Elopement management and prevention revealed, Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The policy revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Residents will be evaluated for wandering upon admission/readmission, quarterly and/or a significant change by a licensed nurse using the facility forms. Photographs of residents taken upon admission and incorporated into the electronic medical record. When a resident is identified as at risk, the interdisciplinary team (IDT) will develop a plan of care to include interventions to reduce risk of elopement and maintain safety. Residents identified as being at risk will have the Resident Identification Form completed with a current picture. The completed form will be placed in the Elopement Risk Binder, located at each nursing station and the front desk. An elopement bracelet (Wander guard system, an electronic bracelet that is associated with the electronic locking system on certain doors at the facility. When a resident gets within a few feet of the door, the mechanism will automatically lock the door and alert staff that a resident is near the exit door). Elopement drills will be conducted monthly. In the event of a missing resident, the following steps will be followed: Determine if the resident is out of the facility on an approved leave of absence. The charge nurse or designee will initiate the elopement procedure by announcing Code green and the resident name and room number. The staff will initiate room-to-room searches to include common areas. Nurse supervision will assign staff to initiate a search of the outdoor areas.A review of facility records for residents identified as being at risk for elopement revealed the facility had identified five residents with elopement risk.A review of clinical records revealed Resident 5 was identified by the facility as an elopement risk on [DATE]. The documentation showed a wander guard bracelet (a monitoring device designed to alert staff when a resident at risk approaches an exit or restricted door) was applied on [DATE].Resident 4 was identified by the facility as an elopement risk on [DATE], and a wander guard bracelet was applied on the same date.Resident 1 was identified by the facility as an elopement risk on [DATE], and a wander guard bracelet was applied on [DATE]. Clinical record review revealed Resident 3 was admitted on [DATE], with diagnoses including type II diabetes mellitus (a metabolic disease causing prolonged high blood sugar), hypertension (high blood pressure), and weakness and difficulty walking with impaired mobility requiring wheelchair use. A review of Resident CR1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that the resident's cognition was moderately impaired with a BIMS score of 12 (brief interview for mental status a section of MDS that assesses cognition) (a score of 08-12 indicates moderately impaired cognition) and utilized a wheelchair for mobility. A review of the care plan dated [DATE], revealed the resident was identified as having impaired cognitive function. The care plan noted the resident was at risk for falls and included interventions such as implementing planned measures to prevent falls and monitoring for changes in mobility. However, the care plan did not address the resident's wandering behaviors throughout the facility. A review of a quarterly nursing evaluation was conducted on [DATE], which indicated that the resident wandered throughout the building and was physically capable of leaving the building. A review of a wandering/elopement assessment dated [DATE], revealed that Resident 3 remained at a low risk despite his elopement from the facility the day before, [DATE]. A review of nursing documentation and facility investigative documentation dated [DATE], at 1:00 A.M., revealed, Resident 3 was observed by staff coming down the facility driveway into lower parking lot and due to incline of the hill, the resident's wheelchair accelerated, and he lost control. The wheelchair flipped forward, and the resident landed on the roadway. It was undetermined if the resident hit his head. An abrasion measuring 5 cm x 4cm x 0.1 cm to right outer elbow was noted. The resident reported tenderness to the right hip. The right leg appeared to be shortened (a symptom of a fractured hip). Resident 3 stated that he was looking for an exit to go downstairs and visit his daughter, who is an LPN on this shift, on the first-floor nursing unit. He also stated, I found one!(an exit to the first floor). The responsible party and the Physician were called, and the resident was sent to the hospital for evaluation. A review of hospital documentation dated [DATE], revealed that Resident 3 was assessed by hospital staff. A CT scan (computed tomography) or CAT (computed axial tomography scan is a type of imaging test that helps detect diseases and injuries. It uses X-rays and a special computer to create detailed pictures of the bones, organs and soft tissues) of the abdomen and pelvis. Results revealed an acute comminuted fracture (a severe type of bone fracture where the bone breaks into three or more pieces, often requiring surgical intervention for proper healing.) of the right acetabulum (the large socket the head of the hip bone fits into) extending into the iliac crest (a part of the pelvic bone), anterior column. Comminuted fracture lines extend into the superior pubic ramus/acetabular root. Acute displaced fracture of the right inferior pubic ramus (the front of the pelvis). An acute nondisplaced sacrococcygeal fracture (involves injury to the sacrum and coccyx, often resulting from trauma such as falls or direct blows) and a mild presacral stranding/contusion (fat stranding means that the normally dark fat is replaced by a brighter fuzzy appearance. This can be a small area or involving most of the pelvis. Fat stranding is an important finding that identifies an abnormality on CT scan. Fat stranding can be from many causes but most commonly inflammation. It can also be seen after trauma, surgery, cancer, scarring, in addition to others), and trace right pelvic sidewall contusion (commonly referred to as a bruised pelvis, is an injury that occurs when an impact or blunt force trauma is applied to the pelvic region, but not with enough severity to break the bones). The resident was readmitted to the facility on [DATE], at 4 :27 PM with instructions for an orthopedic consult appointment as well as physician's orders for the facility to make a trauma follow up appointment. Nursing documentation dated [DATE], at 1:30 AM revealed, upon investigation into the incident, nursing staff documented the resident had awoken at 12:15 A.M., he got into his wheelchair and came to the nurse's station inquiring about his surgery in the morning. Resident wakes at this time every night and goes to the first floor to visit his daughter, a facility LPN. The resident was slightly confused and was self-propelling in the hallways. At 12:45 A.M., a funeral home arrived at the second floor to transport an expired resident's body and went down to first floor entrance via elevator. At 12:50 AM, the second floor LPN heard a door alarm sound and went to the second-floor front entrance to investigate and saw no one outside. At this point she reset the door alarm and returned to the nurse's station. The second floor LPN was not aware that the funeral director had gone downstairs and thought he had set off the alarm. Approximately 10 minutes later at 1:00 AM the resident was seen rolling down the facility driveway in his wheelchair. Upon inspecting the front door entrance, the door alarms are noted to not be functioning correctly. When the right door is pushed or pulled upon, the alarm does not sound and the 15 second fire release does not engage, it requires excessive force to do so. The left door is functioning correctly. A review of a witness statement dated [DATE] (11 PM to 7 AM shift), employee 6 (nurse aide) stated, at 11:40 PM, Resident 3 was in his bed and attempting to get into his wheelchair. He was confused at the time, stating where am I and why am I here. I put him in his wheelchair and put his oxygen on him. The oxygen tank was on the back of his wheelchair. He was roaming around the hallway the last time I saw him at 12:00 AM. A review of nursing documentation written by Employee 3 (RN supervisor) [DATE], at 1:30 AM, upon investigating the front door entrance after the incident, the door alarms were not functioning correctly. When the right door is pushed or pulled on, the alarm does not sound and the 15 second fire release does not engage, it requires excessive force to do so. The left door is functioning correctly. The left door is functioning correctly. The note continued, Resident 3 was up and ambulating in his wheelchair. He was noted to be slightly confused and was self-propelling in his wheelchair. At 12:45 AM the funeral home director was in the building to make transport. The funeral director went down the elevator to the first floor. Employee 5 (LPN) heard the front door alarm and went to the second-floor front entrance to investigate and saw no one outside. She then reset the alarm and returned to the nurse's station. Employee 5 (LPN) was not aware that the funeral director did not go to the front door entrance to exit the building. She thought he had set off the alarm. At 1:00 AM. Resident 3 was observed rolling down the driveway in his wheelchair. A review of a written witness statement dated [DATE], at 1:30 A.M., from Employee 7 (LPN), revealed: I was outside speaking to the off-going nurse and aides when someone said, 'Who is that?' I turned around and someone said, 'It's your dad.' Resident 3 was coming down the hill in his wheelchair into the lower parking lot. The wheelchair accelerated down the hill, hit the curb, and flipped onto its right side. I ran over to him and asked what he was doing and how he got outside. He stated, 'The door.' I asked how, since it was locked, and he said, 'I pushed on it, and it opened up.' A review of a written witness statement dated [DATE], at 1:30 A.M., from Employee 8 (LPN), revealed: This nurse was on a break with a few other staff members. I was sitting with my back towards the parking lot. One staff member said, Who the hell is that? I turned around and saw someone coming down the parking lot on the pavement on the lower level. Before I could do anything, the person in the wheelchair flipped onto his right side. I ran into the building after confirming it was a resident and notified the RN supervisor. A review of a written witness statement dated [DATE], at 1:30 A.M., from Employee 9 (Nurse Aide), revealed: While I was on a break, I saw someone coming down the hill. I said, who the hell is that. The resident was coming down the hill (the driveway incline) into the lower parking lot in his wheelchair with an oxygen tank on the back of the wheelchair. The resident lost control, and the wheelchair flipped over onto the right side. Resident 3 stated, I just pushed the door, and it opened. A review of a written witness statement dated [DATE], at 1:30 A.M., from Employee 10 (Nurse Aide), revealed: I was on the lower level patio and witnessed the incident. I saw Resident 3 wheel himself down the driveway hill into the parking lot and fall. A review of a written witness statement dated [DATE], at 1:30 A.M., from Employee 11 (Nurse Aide), revealed: I was on break. While I was speaking with fellow co-workers, someone said who the hell is that? When I looked up, I said, is that Resident 3? As soon as I said that I got up from my chair. The resident started flying down the driveway into the parking lot at a high rate of speed and hit the curb resulting in the wheelchair flipping over. I went to the resident to help him get up and check him. I asked the resident how he got outside. Resident 3 responded, Through the door over there while pointing to the front door, main entrance. We then waited for the RN supervisor to arrive. An in person interview [DATE], at 9:30 AM, with Resident 3 stated that on the night of the incident he had been wandering around the second floor, checking that all the doors were locked. He wheeled himself to the front door, went through the first door. He stated that the outside door was open. He could not remember if the alarm sounded. He stated the door was open so I went through it to the outside. He stated his wheelchair started to go down the driveway incline and he attempted to stop it with the wheelchair brake handles. He stated that he made it around the corner at the end of the driveway, but the chair hit the concrete curb, and the wheelchair tipped over on top of him. He stated that the staff helped him, and he went to the hospital. He stated that his hip is broken and doesn't know if he will need an operation. He stated that he has hip pain at this time. An in person interview [DATE], at 12:00 PM., (staff member was not available for interview on [DATE]) Employee 4 (RN supervisor) stated that he was the nursing supervisor on duty on [DATE], 11 PM to 7 AM shift. He stated that he was off the floor when the resident left the building. He confirmed that there was a door lock release button behind the second-floor nurses' desk. He stated that the staff on duty were interviewed, and it could not be determined how the front door was opened that night prior to Resident 3 leaving the building. Employee 4 stated that several nursing staff had exited the building through the second-floor front doors that night at 12:30 AM. He stated that the doors were unlocked after the staff exited the building. He stated that the alarm was not sounding at that time to alert staff that the front door was open. He stated that about 1:00 AM he got called to come to the first floor outside patio area, that a resident got out of the facility and had an accident with his wheelchair. After taking care of the resident, he did check on the front doors by pushing on the doors and making sure that the doors were locked. He did confirm that he wrote the above noted nurses note [DATE], at 1:30 AM, after the incident noting the condition of the front doors at the time of the incident. A telephone interview [DATE], at 10 AM, Employee 5 (LPN) stated she was the LPN on duty on the second floor on the night of the incident. She stated that she last saw the resident on [DATE], at 12:50 AM, sitting in his wheelchair in the second-floor hallway. She stated that the resident's daughter worked on the first floor of the facility 11 PM to 7 AM shift and the resident often independently got onto the elevator and traveled from the second floor to the first floor during this overnight shift. She arrived at 12:00 AM that night for her shift (late for the shift). The funeral director was already on the floor when she arrived for her shift. She and the 2 nurse aides assisted him with another resident. Employee 5 (LPN) then returned to her medication cart. Staff were unaware of Resident 3's whereabouts at the time. The funeral director left the floor. Employee 5 (LPN) assumed that the funeral director exited the building through the second-floor front doors. The funeral director took the elevator and exited through the first floor exit doors. Employee 5 stated within one minute, the front door buzzer sounded. She estimated that it took her 3 to 4 minutes to get to the front door. The door was noted to be open when she arrived. She stated that she looked outside the door and did not see or hear anything. She stated that she assumed that the funeral director had exited through the doors and the doors did not close behind him. Employee 5 stated that she attempted to close the doors and re-alarm the locking mechanism by entering the code 4 times before the system would work again. She stated that it was very difficult to close the door. She also stated that the automatic handicap door opener on the inside front door had not been functioning for months. She stated that the front door locking mechanism had also been broken for months. Employee 5 explained the second-floor main entrance doors will be unlocked during specific hours (8:00 AM to 4:00 PM) and free access is possible. These doors are equipped with a safety feature. If you push on the door handlebar for a continuous 15 seconds, the lock will disengage and open the door. An alarm sounds at the door during the 15 second time frame. This alarm does not sound on the nursing units. An observation [DATE], at 1 PM at the second-floor nurses' station in the presence of the NHA and DON, there was an intercom system located on the wall behind the nurse's desk. The intercom was audio only and utilized only for the front entrance to the building. The system included a button to release the locking mechanism of the front door. The NHA and DON could not state which staff utilized this system. During an interview on [DATE], at 1:30 PM, the facility maintenance director and the corporate maintenance director both stated that the remote door unlocking mechanism at the second-floor nurses' station had been disconnected a long time ago and was not functional. However, an observation on that date at 1:35 PM, along with the surveyor, the maintenance director and corporate maintenance director observed that the remote unlocking mechanism at the second-floor nurses' station was operational. The unlocking mechanism was then immediately disconnected by the maintenance director. They both confirmed at that time that this remote unlocking mechanism should not have been in use at the facility. During an interview [DATE], at 11:00 AM, the NHA stated that immediately following the incident on [DATE], Employee 4 (RN supervisor) checked the functionality of the front door locking mechanism by pushing on the door bar. He stated that this indicated that there were no issues with the door. He further stated that the following morning, the NHA, DON, maintenance director and corporate administration also assessed the function of the front door locking mechanism by pushing on the front door and assuring that the alarm sounded and that the door could be reactivated by entering a code into the keypad located on the wall next to the door. The NHA stated that there was no further assessment of the function of the door and that it was not necessary to contact the manufacturer or any outside professional to ensure that the door was functioning properly. During an interview [DATE], at 9:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that prior to Resident 3's exit from the facility, the procedure to gain entrance to the facility after regular hours from 8:00AM until 8:00PM (after receptionist leaves for the day) was to:Ring the bell located outside the second-floor main entrance and staff at the second-floor nurses' station will speak to the visitor through the intercom. Staff have the ability to release the locking mechanism of the front door via a release button associated with the intercom system at the nurse station. There is no video capability at the nurses' station to identify the person at the front door.Staff should then walk to the front door to identify the visitor. Put the code into the keypad located on the wall next to the front door and admit the visitor. The NHA and DON could not confirm that at the time of the elopement incident that staff did not engage the remote unlocking mechanism from the second floor nursing station, opening the door. During interviews with the NHA, DON, and corporate administration on [DATE], they all denied that the front door locking mechanism was not functioning properly and that Resident 3 pushed on the fire release bar for the noted 15 seconds, releasing the lock, opening the door and pushing himself out of the facility. A demonstration of the 15 second release of the door was conducted [DATE], at approximately 11:00 AM by the NHA and corporate administrator observed by the surveyor. A maximum amount of force had to be applied to the bar for the entire 15 seconds for the locking mechanism to be released. Maximum pressure had to be applied to the door to manually open it. The facility's conclusion was that the resident had wheeled himself to the second-floor main exit, pushed on the fire release bars on the exit door for the 15 seconds it takes to release the locking mechanism on the door. The alert alarm sounded at the door for 15 seconds. When the lock is released, an alarm sounds at the nurse's station. The facility then stated that Employee 5 (LPN) responded to the front door (after the initial 15 seconds and walking from the nurse's station, through the closed double doors at the end of the hallway then through the lobby to the front doors). She looked outside, saw no one, shut the door and reset the alarm on the door before returning to the nursing unit. The facility confirmed that she did not conduct a search for the resident. The facility's conclusion failed to mention the intercom/front door release button located at the nurses' station as a possibility to have remotely open the door from the mechanism at the nurses' station. It could not be determined how the resident exited the front doors. Surveyor observation of the driveway revealed a steep hill that leads to a sharp left turn, another sharp left turn, traveling a total of 390 feet, finally crashing into an approximate 12-inch-high concrete curb, resulting in 2 fractures. Acute comminuted fracture (bone broken into three or more pieces) of the right acetabulum (hip socket) extending into the iliac crest and pubic ramus.Acute displaced fracture of the right inferior pubic ramusAcute nondisplaced sacrococcygeal fracture (lower spine).Pelvic contusions and soft tissue injuries. The resident had a tank of oxygen on his wheelchair at the time of the incident. The resident was wandering in the facility. Staff were unaware that the resident had eloped from the building until notified by staff on a break, outside the building. Staff failed to monitor the residents' whereabouts although the resident was at risk for wandering and was noted to be confused prior to the elopement. Immediate Jeopardy was identified on [DATE], at 12:30 PM. due to the facility's failure to timely identify a resident's absence from the facility and prevent an elopement and failed to ensure that a resident deemed incompetent by the court was assessed as capable to leave the facility against medical advice to prevent the resident's absence from the facility and provide a safe environment with resident identification by staff and provision of supervision. The facility was notified of the Immediate Jeopardy on [DATE], at 12:20 PM. and the IJ template was provided to the facility. The facility's immediate action plan provided to the survey team at 9:00 AM on [DATE], was as follows:1. The facility doors were checked for security function by the RN supervisor and the maintenance department 2. Residents with wander guard monitoring devices were checked for function.3. The 2 residents affected were reassessed and care plans updated4. Current residents in the facility were assessed for wandering/elopement risk and care plans updated5. Facility staff were educated on facility policy/procedures regarding wandering, elopement, and resident safety including how to conduct a complete ground search during a missing resident process activation6. The DON completed audits on [DATE], and [DATE], to ensure that no other resident had been affected7. An elopement drill was conducted [DATE], and will be conducted monthly on various shifts and results reported to QAPI8. The facility interdisciplinary team and the medical director will review residents who request to leave the facility against medical requests to determine if the resident is competent to be able to make the decision to discharge from the facility.9. The facility IDT and Medical Director will review residents who request to leave the facility AMA to determine if the resident is competent to be able to make the decision to discharge from the facility. Residents deemed incompetent to make the decision will receive support from the facility social service designee and further. Pull up for services as applicable. During the onsite visit to the facility on [DATE], verification of the implementation of the facility's removal plan was completed and the Immediate Jeopardy was lifted on [DATE], at 9:30 AM. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices. 28 Pa Code 201.18(b)(1) (e)(1) Management. 28 Pa Code 201.14(a) Responsibility of Licensee. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records, select investigative reports, and employee job descriptions and staff interview it was determined the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical and mental functioning of residents in the facility by failing to monitor one resident's whereabouts and prevent an elopement for one (Resident 3) out of 5 sampled residents and failed to ensure the safety and supervision of a resident who lacked decision-making capacity and required protective oversight, allowing the resident to exit the building, placing the resident at risk for serious harm (Resident2) which created an Immediate Jeopardy situation. Findings included: A review of the job description for the Administrator dated October 7, 2024 revealed the administrator must be knowledgeable of and demonstrate the ability to provide quality care by fostering a safe environment for residents and staff; providing emotional and psychological support for the residents within the facility, direct and oversee the day to day operation of the facility to ensure the highest degree of quality of care is maintained at all times in accordance with current state and federal standards, and implement and enforce company policies and procedures. The position responsibilities include, plan, develop, organize, implement, and direct programs and activities. Assist departments in the use of departmental policies and procedures. Explain interdepartmental rapport and foster a culture of teamwork, excellence, and safety. Assure that all employees, residents, and visitors follow established policies and procedures. The facility failed to ensure these responsibilities were carried out, as evidenced by the elopement of Resident 3 and the unsafe exit of the building for Resident 2. This demonstrated a lack of effective oversight to address identified elopement risks for at-risk residents. The Job Description for Direction of Nursing Services dated January 27, 2025 outlines responsibilities including planning, organizing, developing and directing the overall operation of the resident care department in accordance with all current regulatory standards to ensure the highest degree of quality care, knowledge of professional nursing theory and practice to provide first class patient care, expert knowledge of policies, regulations and procedures governing resident care, expert knowledge of medical equipment and instruments to administer resident care, demonstrate the ability to apply the principles, methods, and techniques of professional nursing associated with long term resident care; preparing and maintaining detailed records, writing reports, and responding to correspondence; cultivate and manage effective working relationships with residents, medical staff, and the community; effectively manage regulatory and company compliant quality control standards and demonstrate effective verbal and written English communication. The position responsibilities include evaluate effects of care delivered and assign special treatments when indicated, assure resident safety through nursing staff, integrate and coordinate care with other disciplines, determine and schedule the staffing needs to meet the total care needs of the residents, develop, implement, and maintain an effective staff orientation plan, ensure that personnel follow established departmental policies and procedures and provide discipline as necessary. The DON failed to provide adequate monitoring or to implement effective interventions to prevent Resident 3's elopement and Resident 2's unsafe exit from the facility. Additionally, there was insufficient coordination of staff to ensure the safety of other residents at risk for elopement. Based on the findings the facility's inability to implement and enforce policies to monitor Resident 3 and 2 and address elopement risks and an unsafe discharge resulted in Immediate Jeopardy to the health and safety of 8 residents identified as at risk for elopement. This demonstrates a systemic failure in the administration's oversight and resource allocation to ensure a safe environment for residents. The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F689) 483.25(d)(1)(2) Accidents, revealed the facility's administration did not fulfill essential job duties to ensure resident safety and regulatory compliance. This included a failure to evaluate and mitigate risks associated with elopement for identified at-risk residents. Refer F689. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(3) (e)(1) Management. 28 Pa. Code 211.12 (c)(d)(1) (2)(3)(5)Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective, individualized, person-centered care plan to address a resident's dementia-related behavioral symptoms for one of 5 residents reviewed (Resident 1).Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety disorder (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). A quarterly Minimum Data Set (MDS an assessment completed periodically to plan resident care) dated June 23, 2025, indicated that Resident 1 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). A review of nursing documentation from April 20, 2025, through August 14, 2025, revealed repeated instances of dementia related behavioral symptoms. These included verbal and physical aggression toward staff (e.g., hitting, kicking, yelling), intrusion into other residents' rooms, refusals of care, accusatory statements directed at staff, and physical aggression toward a visiting family member of another resident. Documentation also noted the resident was often difficult to redirect. The resident's current care plan for cognitive impairment related to dementia failed to identify these specific behaviors and lacked individualized, person centered interventions to address and manage each behavioral symptom. There was no documented evidence the care plan incorporated information based on a thorough assessment of the resident's preferences, social history, customary routines, or personal interests, as required to support effective behavioral management strategies. An interview with the Director of Nursing on August 14, 2025, at 4:40 PM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors.28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to evaluate nutrition and hydration requirements to ensure acceptable parameters of nutritional status and hydration status to the extent possible for one resident out of 12 sampled (Resident A1). Findings include: Review of the facility Nutritional Assessment Policy last reviewed March 13, 2025, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: usual body weight, current weight and height, description of the resident's usual intake and appetite, current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors, current laboratory results related to fluid and electrolyte status, an estimate of calorie, protein, nutrient and fluid needs, and whether the resident's current intake is adequate to meet his or her nutritional needs. Review of the facility Resident Hydration and Prevention of Dehydration Policy last reviewed March 13, 2025, the facility will strive to provide adequate hydration and to prevent and treat dehydration. The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. The dietitian and nursing staff will educate the resident and family regarding hydration and preventing dehydration. Nurses will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. The physician will be notified. Orders for medications that may exacerbate dehydration (e.g. diuretics) will be reviewed and held if medically appropriate. If laboratory results are consistent with actual dehydration, the physician may initiate IV (intravenous- administered into a vein) hydration. Hospitalization will be recommended, as necessary. A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and chronic obstructive pulmonary disease (COPD- group of lung diseases that block airflow and make it difficult to breathe). Further review of the clinical record at the time of the survey ending June 17, 2025, revealed no documented evidence that a complete nutritional assessment was completed by the registered dietitian to evaluate the nutritional and hydration needs and nutritional risk for Resident A1 who was admitted to the facility on [DATE]. Review of a physician order dated May 2, 2025, noted an order for Lasix (a diuretic or known as water pill) 20 mg one tablet by mouth once daily for edema (collection of fluid in the tissues of the body). Review of the resident's May Medication Administration Record revealed the prescribed Lasix 20 mg was administered from May 2, 2025, through May 16, 2025. A lab report dated May 15, 2025, documented a BUN level of 59 mg/dL (normal range 6-20 mg/dL) and a Creatinine level of 1.9 mg/dL (normal range 0.50-1.10 mg/dL), both of which may be elevated in cases of dehydration. Review of the resident's fluid intake from May 13, 2025, through May 15, 2025, indicated the following: May 13, 2025: 240 cc's total for all meals May 14, 2025: 660 cc's total for all meals May 15, 2025: 600 cc's total for all meals There was no documented evidence that the nurses' aides notified nursing of the resident's low fluid intake. A nursing progress note dated May 16, 2025, at 7:30 PM, indicated the resident's representative requested hospital transfer due to change in mental status. The certified registered nurse practitioner (CRNP) was notified and gave an order to transfer the resident to the emergency department of the hospital. The hospital report dated May 17, 2025, documented a diagnosis of acute kidney injury with dehydration, and noted physician orders to hold Lasix and initiate IV (intravenous/administered into a vein) fluids. The resident was readmitted to the facility on [DATE]. During an interview with the Director of Nursing on June 17, 2025, at 1:40 PM, the DON confirmed a comprehensive nutritional and hydration assessment was not completed by the registered dietitian for Resident A1, and that nutritional interventions were not established to meet the resident's needs to the extent possible. 28 Pa. Code 211.5 (f) (ii) (ix) Medical Records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of a facility investigation, and staff interview, it was determined the facility failed to implement planned interventions to prevent a fall with injury, resulting in a facial fracture for one resident (Resident 1) out of 5 reviewed. Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include critical illness myopathy (a common neuro-muscular complication of intensive care treatment associated with increased morbidity and mortality), chronic respiratory failure (a condition in which your blood doesn't have enough oxygen), and Langerhans Cell Histiocytosis (a rare disorder that can damage tissue or cause lesions to form in one or more places in the body). A quarterly MDS assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 23, 2024, revealed the resident was severely cognitively impaired and required maximum assistance for activities of daily living. A review of the resident's plan of care initially dated June 25, 2024, revealed the resident was at risk for falls. A review of interventions initiated on July 7, 2024, indicated staff were to monitor and report for new signs and symptoms of pain, bruising, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation. A review of the resident's plan of care initially dated June 25, 2024, revealed a care plan for ADL (activities of daily living) self-care performance deficit related to generalized weakness and impaired mobility. A review of interventions initiated on August 9, 2024, indicated the resident was to have a mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) used for transfers with assist of two staff members and the resident required two person total assistance with toileting. A review of a facility investigation report and nursing documentation dated October 1, 2024, at 7:30 AM, revealed Resident 1 was assisted to the toilet with the assistance of two staff members and the apex lift (a sit to stand lift, assists a resident from a sitting to standing position). While on the toilet, the resident started to lean. The nurse aide (Employee 1) yelled for assistance. At that time no staff answered the nurse aide's calls. The nurse aide stuck her head out of the door to call the nurse, and then she heard Resident 1 fall to the floor. A review of a nursing note dated October 1, 2024, at 07:45 AM, revealed, the resident was found on the floor in front of the toilet with her head facing sink and feet facing the toilet, her slipper socks, brief and pants were on at her knees. The resident had complaints of pain to her nose and a small amount of bleeding. The physician was notified a new order was noted for facial X-ray. A review of the resident's clinical record revealed the resident was not sent to the hospital to be evaluated after the fall. A review of a facial bones x-ray result dated October 2, 2024, revealed a fixator seen along the right temporal bone extending up to zygomatic-temporal arch with nondisplaced fracture (facial bone fracture). A review of a witness statement dated October 1, 2024, (no time indicated) revealed Employee 1 NA (nurse aide) stated Resident 1 was transferred with the APEX lift by Employee 2 LPN (license practical nurse) and herself. The Employee 1 indicated the nurse, Employee 2 LPN then left the bathroom. Employee 1 stated while the resident was on the toilet, she seemed unsteady and was leaning off the toilet. Employee 1 indicated she called for help but could not find anyone to answer. The employee stated at that time she peeked her head out of the resident's room to call for help and heard the resident fall. There was no witness statement from Employee 2 LPN available at the time of the survey. During an interview October 24, 2024, at 2:30 PM, Employee 1 NA stated that she and Employee 2 LPN transferred Resident 1 with the sit to stand lift from the bed to the toilet. Employee 1 stated Employee 2 then left the bathroom. Employee 1 indicated she saw the resident start to lean off the toilet. She stated that the resident looked bad. Employee 1 stated when the resident started to lean off the toilet, she panicked, left the bathroom, stepped outside of the resident's room, and yelled for help. Employee 1 indicated during that time the resident fell to the floor. Employee 1 stated that she was aware that Resident 1 was an assist of two staff for toileting and should not have left the resident alone in the bathroom. During an interview October 24, 2024, at 2:35 PM, Employee 2 LPN stated that she assisted Employee 1 to transfer the resident with the sit to stand to the toilet. Employee 2 stated she left the resident on the toilet with Employee 1 and left the resident's room. Employee 2 stated that she was aware that Resident 1 was an assist of two for toileting and should not have left the resident and Employee 1 in the bathroom alone prior to the fall. During an interview October 24, 2024 at 2:45 PM, the Director of Nursing confirmed staff failed to provide the proper supervision with toileting as indicated in the resident's plan of care resulting in a fall with a facial fracture. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records, select incident reports and clinical documentation and staff interview it was determined that the facility failed to provide sufficient staff supervision and effective safety interventions to prevent a fall with serious injury ([MEDICAL CONDITION]) for one resident one out of 22 residents sampled (Resident 92). Findings include: A review of Resident 92's clinical record revealed admission to the facility on (MONTH) 22, (YEAR), with diagnoses, which included diabetes, overactive bladder and a history of falls. According to the resident's quarterly MDS assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 8, 2019, the resident was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status-a tool used to assess cognitive function) score of 10 (a score of 8-12 indicates moderate cognitive impairment). The resident required extensive staff assistance of two people for bed mobility, dressing, toilet use, bathing, hygiene and for transfers with two persons. The resident was noted as frequently incontinent of bowel and bladder. Upon the resident's admission, (MONTH) 22, (YEAR), a fall risk screening was conducted, which revealed that the resident was at high risk for falls. The facility interventions included the planned use of a low bed, keep call bell in reach at all times, keep personal items in reach and non-skid shoes when out of bed and non-skid socks when in bed. A review of a facility fall investigation report dated (MONTH) 16, 2019, at 6:20 a.m. indicated that the resident was observed lying on the floor, on her back, at the side of her bed. The resident was had been incontinent of bowel at time of fall. The resident complained of lower back pain and an x-ray was completed of the resident's lower back with no injury noted. Facility initiated intervention at this time was to start a three day bowel and bladder diary. A review of a facility fall investigation report dated (MONTH) 25, 2019, at 5:45 a.m. indicated that the resident was observed sitting on the floor of her bathroom. Resident relayed to staff that she had attempted to self transfer to the toilet. Resident was found to be incontinent of bowel and bladder at time of fall. No injury noted. Facility initiated intervention at this time was to start a scheduled toileting program. A review of a facility fall investigation report dated (MONTH) 2, 2019, at 5:40 a.m. indicated that the resident was observed lying on her right side on the floor in front of her bathroom. Resident indicated to staff that she had attempted to self-transfer to the toilet. The resident was found to be incontinent of bladder at time of fall. Investigation revealed a skin tear on right elbow. Facility initiated intervention at this time was again to start a scheduled toileting program, wake and toilet at end of evening shift, 10 p.m. -11 p.m., start of night shift 12 p.m. -1 a.m., and middle of night shift 3 a.m. -4 a.m. A review of a facility fall investigation report dated (MONTH) 14, 2019, at 3:40 a.m. indicated that the resident was observed lying on her right side, on the floor on the side of her bed. Resident relayed to staff that she had attempted to self transfer to the toilet. No injury noted. No new interventions were planned at the time this fall. The facility noted continuation of the toileting schedule initiated after the (MONTH) 2, 2019, fall. A review of a facility fall investigation report dated (MONTH) 28, 2019, at 1:51 a.m. revealed that the resident was found sitting on the floor of her bathroom in front of toilet. The resident relayed to staff that she had attempted to self-transfer to the toilet. No injury noted. The facility initiated intervention at this time of this fall was to attach a bathroom sensor alarm to alert staff of resident movement. A review of a facility fall investigation report dated (MONTH) 27, 2019, at 5:50 a.m. indicated that the resident was found lying on her left side, on the right side of her bed. The resident reported to staff that she had rolled out of bed unexpectedly. The resident complained of pain to the right hip and an x-ray was ordered. A mobile x-ray was completed in the facility, which revealed a likely-fracture of resident's right hip. Resident 92 was sent to emergency roiagnom on (MONTH) 27, 2019. The facility was notified the resident's admission to the hospital and pending surgery to repair the fracture of right hip on (MONTH) 27, 2019 at approximately 4:00 p.m. Further review of Resident 92's clinical record revealed no documentation that the facility had implemented the interventions of maintaining the resident's bed in a low position and scheduled toileting program, which were planned upon the facility's identification of the resident's high risk for falls on (MONTH) 22, (YEAR), and following the resident's repeated falls related to toileting needs during January, (MONTH) and (MONTH) 2019 . Interview with the Director of Nursing (DON) on (MONTH) 22, at 11:00 a.m. revealed that the DON was confirmed that there was no evidence that adequate safety measures were in place, including sufficient staff supervision and planned interventions including low bed and toileting program, to prevent this fall, with serious injury, for a resident at risk for falls. The facility failed to adequately supervise Resident 92, who was identified at risk for falls, had a history of [REDACTED]. 28 Pa. Code 211.11(d) Resident care plan Previously cited 6/29/18 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 6/29/18, 4/29/19

Based on a review of clinical records and select facility policy, observations and staff interviews it was determined that the facility failed to consistently provide care and services to prevent pressure sore development for one of three residents sampled with pressure sores (Resident 57). Findings include: A review of a facility policy for management of skin conditions guideline dated as reviewed by the facility (MONTH) 5, 2019, revealed the completion of a comprehensive initial assessment and reassess the resident's skin alteration at least weekly using the weekly skin alteration tool in the electronic chart, electronic documentation and observation of interventions consistent with the residents plan of care. Nursing assistants will monitor residents skin daily during care and report alterations to the charge nurse. The licensed nurse will complete a body audit in the electronic chart on a weekly basis or more frequently if indicated. Implement additional preventative measures or treatment protocols if necessary. A review of the clinical record revealed that Resident 57 was admitted to the facility on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. A review of facility weekly wound evaluation records dated (MONTH) 25, 2019 revealed that Resident 57 had a 0.5 cm x 0.5 cm purple/black area on his left heel with the surrounding skin noted as boggy (skin that feels like it has fluid in it-vulnerable to skin damage). This area on the left heel was noted to be resolved on (MONTH) 3, 2019. A review of the resident's care plan dated (MONTH) 3, 2019, revealed that the resident was at risk for impaired skin/skin breakdown. Interventions planned included to turn and reposition the resident every hour, side to side, avoid back positioning, use pillows and /or positioning devices as needed. A review of 14-day Minimum Data Set assessment dated (MONTH) 17, 2019 (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was moderately cognitively impaired, required maximum assistance with activities of daily living and was at risk for developing pressure areas. A review of a facility ulcer and pressure sore investigation dated (MONTH) 15, 2019, revealed that a deep tissue injury (an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die) was noted to the resident's left heel measuring 5 cm x 5 cm. The investigative report noted that prior interventions to prevent pressure sore development included heels floated, turning and repositioning the resident every 2 hours and a low air loss mattress (the facility standard mattress). There was no complete description of the DTI area to the resident's left heel documented upon discovery. New interventions put into place at the time of the discovery of the pressure area were heel off boots (soft fabric boots ) to be worn at all times and 30 ml of a liquid protein supplement twice a day and a treatment ordered, [MEDICATION NAME] applied daily to site. A review of a physician wound consultant assessment dated (MONTH) 16, 2019, revealed that Resident 57 had a full thickness wound of the left heel measuring 3 cm x 3.5 cm. The wound base was purple/maroon localized area of discolored intact skin with a blood filled blister. The new interventions noted by the physician wound consultant was to apply [MEDICATION NAME] to the affected area twice daily, continue repositioning as per facility policy, float heels on pillows while in bed and maintain heels off boots at all times, except with hygiene and transfering. There was no indication or description in the facility staff documentation that this pressure area was described as a fluid filled blister or of the possible cause of the blister in an attempt to relieve any pressure on this resident's heels. A review of a facility ulcer and pressure sore investigation dated (MONTH) 19, 2019, revealed that the resident had a DTI measuring 3 cm x 3 cm, non blanchable area on her right heel. It was noted that a new skin treatment was ordered by the physician and to continue prior preventative measures. A review of nursing documentation dated (MONTH) 19, 2019, at 2:30 PM revealed a 3 cm x 3 cm reddened, non blanchable area to Resident 57's right heel. The physician was contacted and a treatment, skin prep ( a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) was ordered along with the prior interventions for pressure sore prevention. A review of electronic turning and repositioning records dated (MONTH) 3, 2019, through (MONTH) 30 2019, revealed that staff completed documentation, once per shift noting that the resident was turned and repositioned at the planned frequency throughout that shift. However, there was no documented evidence at the time of the survey that the resident's heels were floated off the mattress to relieve pressure and to attempt to prevent the formation of these two pressure areas. During an observation on (MONTH) 22, 2019, at approximately 10 AM the resident's right heel was observed to measure 0.5 cm x 1 cm, 100% eschar ( is a slough or piece of dead tissue that is cast off from the surface of the skin), with the surrounding skin pink and blanchable (healthy skin) with no drainage noted. The left heel pressure area measured 2.8 cm x 3 cm, 100% black eschar with intact pink blanchable surrounding skin and no drainage noted. According to interview with the Director of Nursing on (MONTH) 22, 2019, at approximately 11:15 AM, the confirmed that the facility's documentation and investigations of skin breakdown failed to initially identify the areas as blood filled blisters. The DON also stated that at the time of the discovery of these heel blisters, Resident 57 was attending therapy sessions and activity events out of her room while seated in her wheelchair, but these activities were not included in the investigation to determine potential causative factors for the pressure sore development. The facility failed to demonstrate the consistent implementation of measures planned to prevent and treat pressure ulcers. The resident was at risk for skin breakdown with a history healed pressure area on the left heel on (MONTH) 3, 2019. The resident's developed another pressure ulcer on the left heel on (MONTH) 15, 2019, and on the right heel on (MONTH) 19, 2019. The facility failed to evaluate the adequacy of the existing pressure sore preventions measures in place to deter future pressure sore development on the resident's heels and failed to ensure consistent staff implementation of measures planned following identification of skin breakdown to promote healing and prevent additional skin breakdown. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 4/12/19, 6/29/18 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/29/18 28 Pa. Code 211.10(a)(d) Resident care policies

Based on review of clinical records, incident/accident reports and event reports submitted to the State Survey Agency and staff interview, it was determined that the facility failed to provide sufficient staff assistance or necessary assistive devices to prevent an accident with significant injury for one resident out of 21 sampled residents (Resident 64). Findings included: Resident 64 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The review of the Quarterly Minimum Data Set (MDS, an assessment tool completed at specific intervals to determine care needs) assessment dated [DATE], indicated that Resident 64 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. The upper extremity deficits were noted in range of motion with impairment on both sides. The review of an Event Report submitted to the State Survey Agency on December 23, 2010, at 10:54 AM, revealed that on December 21, 2010, at 10:00 AM, Resident 64 was in the bed receiving morning care when she rolled out of the bed onto the floor, sustaining a displaced fracture to the left ulna (bone in the forearm). The review of the incident/accident report for this fall revealed that Resident 64 was receiving the assistance of one staff person at the time of the fall. The staff person turned Resident 64 in bed, rolling the resident towards the opposite side of the bed and Resident 64 rolled off the bed. According to the Event Report submitted to the State Survey Agency, when the staff person rolled Resident 64 onto her side, "the resident also threw her leg over to this side. This action caused the momentum of the roll to continue, which led to her rolling out of the bed." A review of the "Resident Event Interview" of Employee 3, Nurse Aide, who was providing the resident's care on December 21, 2010, at the time of the resident's fall from the bed, revealed, "...I was giving her AM care when I rolled her to one side so that I put a brief under her. (Resident name) rolled off the bed and fell to the floor." A review of an inservice conducted by Employee 2, Registered Nurse Supervisor, on December 21, 2010 revealed that six nurse aides, including Employee 3, were educated on "when rolling a resident in bed, be sure to pull resident close to you before rolling them in the opposite direction. This gives you plenty of room and does not leave resident at the edge of the bed." The review of Resident 64's care card (a tool representing an abbreviated copy of the care plan placed in the resident's closet for quick reference by the staff) which was in effect at the time of the fall on December 21, 2010, confirmed that Resident 64 was to be a two person assist for bed mobility. A review of Resident 64's care plan, which was revised by the facility on January 13, 2011, and following the resident's fall on December 21, 2010, revealed that the resident's care plan now specified that Resident 64 required the assistance of two persons for bed mobility, transfers, personal hygiene and bathing, which was not specifically noted on the plan of care prior to the resident's fall. Bolsters (supportive devices to maintain the resident's position in the bed) were also added to the resident's bed per the physician's orders [REDACTED]. A review of the facility's policy statement "Turning a Resident on His/Her Side Away From You" dated August 2007 reveled that the staff is to "cross the resident's leg nearest you over the leg farthest from you. Place one hand on the resident's shoulder nearest you. Place your second hand under the resident's buttock. Gently turn the resident away from you." During an interview on June 17, 2011, at approximately 1:00 PM, the Director of Nursing failed to provide evidence that the facility used the necessary amount of staff when providing the resident's care or that needed safety interventions were in place during this care to prevent a fall resulting in injury. 483.25(h) Accidents Previously cited 7/30/09, 5/7/10, 7/15/10 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services Previously cited 7/30/09, 5/7/10, 7/15/10