Every finding on record at Bristol Health & Rehab Center

Based on review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan related to hearing loss for one of eight residents reviewed (Resident R1).Findings include: Interview with the Registered Nurse and Unit Manager, Employee E3, conducted don July 31, 2025, revealed that Resident R1 is hard of hearing at times and he tells me he cannot hear me. Interview with Resident R1 conducted on July 29, 2025, at 10:30 a.m. revealed that the resident is hard of hearing. Continued interview revealed that Resident R1 received hearing aids last week but did not yet receive them this morning. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], and had a BIMS (brief interview for mental status) score of 15, indicating cognitive intactness. Further review of Resident R1's clinical record titled, Audiology Consultation dated February 25, 2025, revealed that the resident had a diagnosis of sensory-neural hearing loss in the right and left ear. Interview with the facility Administrator and Nurse Manager, Employee E3, conducted on July 29, 2025, at approximately 1:45 p.m. confirmed that a care plan was no developed for Resident R1's hearing loss; there were no focus, interventions, and goals care planned for Resident R1's diagnosis of sensory-neural hearing loss. 28 Pa Code 211.10 (c)(d) Resident care policies

Based on a review of clinical records, facility policies, observations and staff interviews, it was determined the facility failed to ensure one of seven residents reviewed (Resident R1) was free from neglect by not timely identifying, assessing, and providing treatment to Resident R1's right lower extremity wound. This failure resulted in actual harm to Resident R1, who developed a new and worsening wound on the right lower extremity, requiring transfer to the hospital and a right leg wound infection. This deficiency is identified as past non-compliance. Findings include: Review of an undated facility policy, Skin Care and Wound Management Overview revealed: The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident and /or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues Each resident is evaluated upon admission and weekly thereafter for changes in skin condition . Skin care and wound management program includes but not limited to: Daily monitoring of existing wounds . Communicate changes to the care giving team .Complete for all skin impairment issues that require measurement to indicate if healing is occurring. Review and select the appropriate treatment for the identified skin impairment. Document treatment in the Electronic Treatment Administration Record .communicate changes to the caregiving team. Review of Resident R1's clinical record revealed, Resident R1 was admitted to the facility on [DATE], with diagnoses including Psoriasis Vulgaris, (chronic autoimmune disease where the immune system mistakenly attacks healthy skin cells leading to the formation of raised, red, scaly patches called plaques on the skin) and Absence of Left Foot. Review of the Comprehensive Minimum Data Set (MDS-periodic assessment of a resident's care needs), dated May 22, 2025, revealed a BIMS (Brief Interview for Mental Status- screening tool aids in detecting cognitive function or impairment) score of 14, which revealed Resident R1 was cognitively intact. Further review of MDS assessment revealed the resident required substantial to maximum assistance with lower body dressing, partial to moderate assistance with personal hygiene, supervision with rolling from left to right and partial to moderate assistance when lying to sitting on the side of the bed. The resident also was assessed at risk of developing pressure ulcers/injuries. Review of Resident R1's care plan, initiated on July 7, 2023, revealed Resident R1 was at risk for skin impairment. Interventions included completion of weekly skin assessments, educate resident on need for turning and repositioning, monitor for any signs/symptoms of infection-bogginess, drainage, erythema and notify physician, and provide appropriate off-loading mattress. Review of Resident R1's physician orders dated February 20, 2025, revealed an order to apply, Clobetasol Propionate Cream 0.05 %, (corticosteroid used to treat skin condition of psoriasis) to lower extremities topically every day and evening shift. Review of Resident R1's physician orders dated March 13, 2025, revealed an order for weekly skin assessment to be completed, every Monday. Review of skin assessment documentation for Resident R1 revealed, no wounds/pressure areas were documented on the skin assessments dated April 5, 2025; April 25, 2025; May 2, 2025; May 9, 2025; May 17, 2025; or May 25, 2025. Further review of Resident R1's skin documentation dated April 11, 2025; and April 18, 2025, revealed Resident R1 refused the skin assessment on these dates. Additional review revealed on June 1, 2025, Employee E10, Licensed Practical Nurse answered on the skin assessment; Yes, to the question, are there any skin areas noted; and No to the question, is this area new since the last documented skin check. Review of nursing notes for dates beginning May 2025 through June 2, 2025, failed to reveal documented evidence of wounds and/or open skin areas identified on the resident's lower extremities. Review of Resident R1's May 2025 and June 2025 Medication Administration Record revealed Clobetasol Propionate Cream was administered by Licensed nurse, Employee E11, on May 24, 2025; May 25, May 26, May 27, May 28, and May 29, 2025, and on June 2, 2025, and June 3, 2025. Review of information dated June 3, 2025, and submitted by the facility to the State Survey Agency on June 3, 2025, revealed Resident R1 had wound which was not identified timely, and treatment provided. Further review of the information revealed, The complaint was substantiated and resulted in the termination of the employees who had been suspended pending the outcome of the investigation. An internal investigation was conducted, which included interviews with all care providers involved dating back to May 26, 2025. The investigation concluded, three licensed nurses and one nursing assistant failed to follow established facility policies regarding the reporting, documentation, assessment, and provider notification related to an alteration in a resident's skin integrity. Interview conducted with Nursing Home Administrator (NHA), Employee E1 on July 2, 2025, at 10:03 a.m. revealed during the investigation, it was determined the skin area of Resident R1 in question had not been identified prior to June 2, 2025. Staff reported they did not observe the skin area during routine care. During interview conducted by Nursing Home Administrator with [Nurse aide, Employee E12], on June 5, 2025, staff member revealed to NHA that she observed a closed, red area on resident's right leg on June 1, 2025, and informed the nurse. Continued interview with Nursing Home Administrator revealed, Employee E1 licensed nurse on duty on June 1, 2025, indicated during interview that she was unaware of any skin areas of concern and did not recall being notified. Nursing Home Administrator, Employee E1 added the facility concluded through investigation that neglect was substantiated on June 13, 2025. Review of Licensed nurse, Employee E10's employment record indicated, Employee E10 was terminated from service on June 13, 2025, with reason Employee E10 falsified documentation pertaining to the care of a resident; the falsified record concealed evidence of negligence, which subsequently contributed to the resident suffering harm. Review of Licensed nurse, Employee, E11's personnel file revealed that Licensed nurse, Employee E11 was terminated from service on June 13, 2025, with reason, on June 2, 2025, [Employee E11] failed to provide necessary treatment and failed to ensure that appropriate care was in place for a resident. Review of Certified Registered Nurse Practitioner (CRNP), Employee E7, progress note dated May 29, 2025, indicated, Musculoskeletal: Denies reported redness, swelling change in gait, pain. Skin: Visible skin; Clean, Dry, and Intact (CDI); no redness; swelling or rashes present. Continued review of Certified Nurse Practitioner (CRNP), Employee E7, progress note dated June 3, 2025, indicated, Chief Complaint / Nature of Presenting Problem: Unstageable wound to left foot, History of Present Illness: Resident was seen today for acute visit for unstageable wound to left foot. Resident has history of all toes amputation and impaired circulation. Wound care nurse was made aware of the wound on his medication nurse. Resident also has history of noncompliance with medications. Resident denies pain reports mild discomfort intermittently. Discussed in IDT (Interdisciplinary team) meeting, and with Medical Director; Skin: Dressing CDI to Right foot Wound noted open, with tendons exposed and sloughing. Interview conducted on July 7, 2025, at 9:52 a.m. with Certified Nurse Practitioner (CRNP), Employee E7 revealed, I did not observe the wound of [Resident R1] on June 3, 2025, but wrote the order based on the report given by the Charge Nurse. Review of nursing note dated June 3, 2025, by the Unit Manager, Registered Nurse, Employee E8, revealed she was called to resident room by facility wound nurse, resident in bed, wound on right foot noted, facility CRNP notified, order to send resident to ER (Emergency Room) for eval (evaluation) . Primary Care Provider responded with the following recommendations: send resident to ER for eval. (evaluation). Interview conducted on July 7, 2025, at 10:40 a.m., with Registered nurse, Employee E8 revealed that on June 3, 2025, I just saw the wound of [Resident R1], and called the facility [CRNP, Employee E7], and the CRNP ordered to send the resident to hospital. Review of nursing note completed by the Director of Nursing, E2, dated June 3, 2025, revealed Patient with wound that appears to be worsening, wound Nurse Practitioner (NP) made aware, and gave order to send to ED (Emergency Department) for further evaluation, order transcribed, call placed to ED, report given to Nurse, transport arrangements made, MD/RP aware. Interview conducted on July 2, 2025, at 12:26 p.m., with Wound Nurse Practitioner, Employee E5, revealed, I was following [Resident R1] for an abrasion to the left great toe which was resolved on April 30, 2025. I was not informed of any other wounds until June 3, 2025, when the Administrator reported a new area on the right medial ankle of [Resident R1]. Resident was not on the scheduled wound rounds for that day. A picture of the wound was presented and noted exposed bone. A decision was made with the DON (Director of Nursing) and Administrator to send resident out to hospital. Employee E5 further stated[Resident R1] was diagnosed with a right femoral artery blockage upon Hospital admission. Current diagnoses of [Resident R1] supports Arterial Insufficiency and supports quick decline of the circulation to the right lower extremity. Interview conducted on July 7, 2025, at 9:52 a.m., with the Director of Nursing (DON), Employee E2, revealed on June 3, 2025, she observed the wound on the right leg shin area of Resident R1, did not measure it, but the wound appeared having approximately 5 cm length, 2 cm width, and 1 cm depth, and Employee E2 did see the bone exposed. Review of hospital records of Resident R1, dated June 9, 2025, revealed; [Resident R1] presented to the emergency department with the complaint of worsening Right Lower Extremity Wound. Patient is poor historian who noted that (his/her) right shin had been painful and is very warm to the touch . The patient was admitted for Right Lower Extremity Cellulitis (Cellulitis is a bacterial infection of the skin and underlying tissues, commonly caused by streptococcus or staphylococcus bacteria. It appears as a red, swollen, painful area of skin that can spread rapidly if left untreated). CTA (Computed Tomography Angiography. A medical imaging technique that uses X-rays and a contrast dye to visualize blood vessels) of lower extremity right showed occluded right common Femoral Artery, Right Superficial Femoral Artery, Distal Left Superficial Femoral Artery. Mid Anterior Tibia with skin ulcers and subcutaneous infiltration of fat along the anterior Tibialis Muscle. Podiatry, Plastics, Vascular Surgery saw the patient and determined that he was not a candidate for Vascularization (process of blood vessel formation in a tissue or organ. This process is essential for delivering oxygen and nutrients to cells and removing waste products, supporting tissue growth, repair, and overall function). Interview with the Nursing Home Administrator and the Director of Nursing on July 7, 2025, at 11:20 p.m., confirmed the facility failed to identify, develop and implement interventions to prevent Right Lower Extremity Wound Development, and to promote wound healing in accordance with the resident's plan of care, facility polices and professional standards of practice. The Nursing Home Administrator presented information indicating the facility initiated a plan of correction on June 2, 2025. The facility plan of correction included the following: -On June 2, 2025, during the 3-11 shift, the Charge Nurse contacted the Wound Nurse to request an evaluation of Resident R1 for the following day after the resident refused treatment. On June 3, 2025, between approximately 7:30 and 8:00 AM, the Wound Nurse assessed Resident R1, who was not previously on the wound rounds list, and identified an open area on the right shin. The finding was immediately reported to the Director of Nursing (DON), Nursing Home Administrator (NHA), and the medical provider. At approximately 11:00 AM, the Wound CRNP evaluated the wound and issued orders to transfer the resident to the hospital for further evaluation. Resident R1 was sent to the Hospital emergency room and was admitted with a diagnosis of wound infection. An internal investigation was initiated, including staff interviews with a two-week lookback period. A full skin sweep of the facility was conducted and completed on June 3, 2025, with no new areas identified. Notifications were made to the appropriate parties, including the DON, NHA, and provider. A full-house skin audit was completed, as all residents could potentially be affected. No unreported injuries or areas of concern were identified during the assessment. Clinical Staff education initiated 06/03/2025: Educate nurses and aides on Abuse and Neglect, process for providing and documenting baths/ showers, including changes in skin, identifying and notifying providers of change in condition including skin injuries, proper performing of weekly skin checks, shower sheet/body skin inspection form for nurse aides and completion of stop and watch alerts in POC/PCC (Point Click Care). Training of nurses and aides on scope of practice for completion of treatments and medications. 100% completion 06/05/2025. Corrective actions will be monitored to ensure that the deficient practice does not reoccur. The facility will conduct audits of five resident skin checks daily for five days, then weekly for three weeks, and monthly for two months. In addition, shower sheet completion will be audited for five residents daily for five days, then weekly for three weeks, and monthly for two months. Findings will be reviewed by the DON or designee, and results will be discussed during the facility's Quality Assurance Performance Improvement (QAPI) meetings for continued monitoring and compliance. The facility indicated their date of compliance was June 5, 2025. Review of facility documentation revealed the corrective action plan was implemented on June 2, 2025. Reviews conducted of staff education confirmed nursing staff were in-service on Abuse and Neglect, process for providing and documenting baths/ showers, changes in skin, and proper performing of weekly skin checks. Interviews with facility staff were conducted on July 18, 2025. Facility staff provided extensive feedback and understanding of the facility's abuse and neglect policy and scope of practice for completion of treatments and medications. Review of random resident clinical records reviewed with identified wounds revealed that residents received proper skin checks, wound checks and care and treatments, as ordered by the physician. The facility's action plan was accepted on July 18, 2025, and identified as past non-compliance. This deficiency was identified as actual harm past non-compliance for resident neglect in the facility failure to timely identify, assess and provide treatment to Resident R1's right lower extremity wound. This failure resulted in the resident developing a wound, requiring transfer to the hospital and diagnosis of a wound infection. 28 Pa Code 211.10(a)(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to preventing cross-contamination for one of eight residents reviewed (R3).Findings include:Review of Facility Policy on Skin Care and Wound Management undated indicated; application of treatment protocols based on clinical best practice standards for promoting wound healing.Review of Centers for Disease Control and Prevention's (CDC) 'Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all Settings , dated April 12, 2024, insisted to maintain separation between clean and soiled equipment to prevent cross contamination. In addition, the literature on ' Wound Care Observation Checklist for Infection Control' of Pennsylvania Department of Health, dated April 2018, indicated; wound care supply cart should never enter the patient/resident's immediate care area nor be accessed while wearing gloves or without performing hand hygiene firs. These are important to preventing cross-contamination of clean supplies and reiterates the importance of collecting all supplies prior to beginning wound care.Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities. Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE]. Diagnoses included Need for Assistance with Personal Care.Review of physician order dated May 28, 2025, for R3, indicated an order stating, Sacrum- Cleanse with wound cleanser, apply Prisma, cover with boarded dressing daily and as needed, every dayshift, for stage four pressure ulcer .On July 2, 2025, at 12:40 a.m., observed wound treatment administered to R3, by Employee E6, a License Nurse. The nurse did follow physician order for sacral wound treatment, except the infection prevention protocol. Employee E6, transported the whole wound care supply cart into the Resident R3's immediate care area, in R3's room. At the time of the finding, the same was confirmed with E6.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(d) Management

Based on the review of clinical records, facility policies, professional standards of practice, observations and staff interviews, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the development of a pressure ulcer resulting in actual harm to Resident R1 who developed Stage II pressure ulcer to the right heel for one of 14 residents reviewed. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of an undated facility policy titled Skin Care & Wound Management, revealed Develop a care plan for pressure ulcer prevention. Consider the following interventions for a resident at moderate risk. Add further interventions as indicated. A. Sensory Perception a. Evaluate areas of skin where the resident may have impaired sensation, such as feet. b. Instruct resident to notify staff of any changes in skin condition. D. Mobility c. Position with pillows/support devices to assist in maintaining position and comfort. d. Protect/elevate elbows and heels as indicated. G. Other c. Monitor treatment plans for diseases that impact sin impairment risk. 4. Revise intervention and/or goals as indicated. Review of Resident R1's clinical record revealed Resident R1 was readmitted to the facility on [DATE], after hip fracture and ORIF (Open Reduction and Internal Fixation - surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods). Resident's diagnoses include but not limited to following: Dementia (progressive degenerative disease of the brain) and cognitive deficit. Review of Resident R1's quarterly Minimum Data Set assessment (MDS-federally mandated standardized assessment process conducted periodically to plan resident care) dated November 8, 2024, revealed Resident R1 was independent for rolling left and right (ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to stand and mobility. This assessment was completed prior to the resident sustaining the fracture and subsequent surgical procedure. Continued review of MDS assessments revealed a significant change of status assessment dated [DATE], in which Resident R1 was assessed as requiring substantial assistance for rolling left and right also was dependent on staff for sit to stand. It was documented that the ambulation was not completed due to medical status. It was also documented in the MDS assessment the resident was at risk of developing pressure ulcers. Review of Resident R1's skin notes by the wound care practitioner dated December 25, 2024; January 3, 2025; January 8, 2025; January 16, 2025; January 30, 2025; and February 5, 2025 revealed the practitioner recommended to float heels while in bed. Review of Resident R1's clinical record failed to reveal documented evidence the facility provided offloading to resident heels as recommended by the wound care practitioner. Review of care plan for Resident R1 on March 26, 2025, failed to reveal evidence the facility updated resident's care plan with individualized interventions to address resident's decreased mobility status, increased staff assistance and higher risk for developing pressure ulcer. Review of nurse aide documentation from February 26, 2025 to March 10, 2025, for Resident R1's bed mobility revealed the resident was mostly dependent on staff for bed mobility activity. Review of Resident R1's skin note dated March 10, 2025, revealed, routine skin check was performed by Wound care provider on 03/10/25, wound care team observed the following skin alterations on patient, discoloration noted to right foot- dorsal surface, with full thickness, measuring approximately 2cm x 2.5cm, x 0.1cm, treatment provided, new order received to cleanse site with normal saline, pat dry with sterile gauze, apply medihoney, and wrap with rolling gauze, a skin alteration was also noted to right heel, approximately 0.5cm x 1cm, x 0.1cm, treatment provided, new order received to cleanse site with normal saline, pat dry with sterile gauze, apply medihoney, and cover with bordered gauze. Review of Resident R1's skin note by the wound care practitioner dated March 17, 2025, revealed the resident was seen for right heel pressure ulcer and right dorsal wound. The etiology for right heel was pressure injury and noted as Stage 2 (ulcer involving loss of the top layers of the skin) pressure ulcer. The right heel wound measured 0.4 centimeters (cm) x 0.7cm x 0.1 cm. The right dorsal wound was an abrasion wound which measured 1cm x 0.7 cm x 0.1 cm. The practitioner recommended to float heels while in bed. Review of Resident R1's skin note by the wound care practitioner dated March 24, 2025, revealed the resident was seen for right heel pressure ulcer and right dorsal wound. The etiology for right heel was pressure injury and was a stage 2 pressure ulcer. The right heel wound measured 0.4x 0.6 cm x 0.1 cm. The right dorsal wound was an abrasion wound which measured 1cm x 0.7 cm x 0.1 cm. The practitioner recommended to float heels while in bed. Observation of the resident on March 26, 2025, at 10:30 a.m. with the wound care nurse, Employee E3 revealed the resident had 2 wounds to the right lower extremity. There was a heel wound and a right dorsal wound. It was revealed the resident was wearing a heel boot to the right heel, but the left heel was flat on the bed without any offloading measures. Resident was also wearing a brace to right lower extremity which limited resident's movement. Interview conducted on March 26, 2025, at 10:30 a.m. with the wound care nurse, Employee E3 revealed the right dorsal wound was caused by a TED (Thrombo-Embolus deterrent (TED) stockings are also known as compression stockings or Anti-Embolism Stockings and are specially designed to help reduce risk of developing deep vein thrombosis (DVT) or blood clot in your lower leg after Surgery) stocking which was applied without an order. When the TED stockings were removed for skin check a wound was observed under the TED stocking. Review of Resident R1's clinical record and physician orders failed to reveal documented evidence the facility obtained an order for TED stocking and/or a removal schedule. There was also no cause of abrasion documented in the clinical record. Interview with Director of Nursing on March 26, 2025, at 2:00 p.m. revealed, it was the facility practice to find out root cause analysis (incident report) for skin alteration and implement corrective actions. However, there was no incident report completed for Resident R1. Interview with Nursing Home Administrator on March 26, 2025, at 2:00 p.m. confirmed there was no evidence the facility implemented wound practitioner's recommendation to off load heels and resident subsequently developed pressure ulcer to the heel. The facility failed to ensure that interventions to prevent the development of pressure ulcers were implemented which resulted in actual harm to Resident R1 who developed Stage II pressure ulcer to the right heel. 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 facility policies and procedures, observations and interviews with staff, it was determined that the facility failed to ensure treatment and services were provided to the resident to prevent development of wounds met the professional standards of practice for 4 of 14 residents reviewed. (Resident R1, R2, R4 and R5). Findings include: Review of an undated facility policy titled Skin Care & Wound Management, revealed Develop a care plan for pressure ulcer prevention. Consider the following interventions for a resident at moderate risk. Add further interventions as indicated. A. Sensory Perception a. Evaluate areas of skin where the resident may have impaired sensation, such as feet. b. Instruct resident to notify staff of any changes in skin condition. D. Mobility c. Position with pillows/support devices to assist in maintaining position and comfort. d. Protect/elevate elbows and heels as indicated. G. Other c. Monitor treatment plans for diseases that impact sin impairment risk. 4. Revise intervention and/or goals as indicated. Observation of Resident R4 on March 26, 2025, at 10:25 a.m. with the wound care nurse, Employee E3 revealed the resident was lying in his bed. The heel lift boot was sitting on the wheelchair. Review of clinical record revealed no evidence that the resident refused the heel boots or the reason staff did not apply the heel boots. Further review of the clinical record revealed that the resident had left heel full thickness Kennedy terminal ulcer (a type of skin breakdown that occurs in the final stages of life, often appearing suddenly as a pear-shaped or butterfly-shaped area of discoloration) to the left heel. Observation of the Resident R1 on March 26, 2025, at 10:30 a.m. with the wound care nurse, Employee E3 revealed the resident had 2 wounds to the right lower extremity. There was a heel wound and a right dorsal wound. It was revealed the resident was wearing a heel boot to the right heel, but the left heel was flat on the bed without any offloading measures. Review of Resident R1's skin notes by the wound care practitioner dated December 25, 2024; January 3, 2025; January 8, 2025; January 16, 2025; January 30, 2025; and February 5, 2025 revealed the practitioner recommended to float heels while in bed. Observation of the Resident R2 on March 26, 2025, at 10:45 a.m. revealed that there was heel lift boot sitting on the top of air-conditioning unit. Observation of the Resident R2 on March 30, 2025, at 10:34 a.m. revealed that there was heel lift boot sitting on the top of air-conditioning unit. Review of clinical record revealed no evidence that the resident refused the heel boots, or the reason staff did not apply the heel boots. Observation of the Resident R5 on March 26, 2025, at 10:45 a.m. revealed that there was heel lift boot sitting on the floor. Resident was lying on the bed. 28 Pa Code 211.12(c) Resident care policies 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on the review of clinical records, facility policies, facility documentation, interview with staff, it was determined that the facility failed to follow acceptable standard of practice for medical record documentation for one of 14 residents reviewed. (Resident R6) Findings Include: Review of undated facility policy entitled, Height and Weight, revealed that Nurses will follow the basic standards of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record, documenting legibly in English using only acceptable medical abbreviations. Timeliness and accuracy. a. Chart in real time when an event is occurring or shortly thereafter as is practicable. b. avoid over use of late entries. Late entries may be confusing and contradictory and only use sparingly. Review of meal intake documentation for Resident R6 dated November 1, 2024, to November 30, 2024, revealed that 25 of 30 documentation of breakfast and lunch intake/consumption documentation was completed at the same time of the day. There was no dinner documentation on November 13 and November 24. Review of meal intake documentation for Resident R6 dated December 1, 2024, to December 31, 2024, revealed that 18 of 31 documentation of breakfast and lunch intake/consumption documentation was completed at the same time of the day. There was no dinner documentation on December 15 and December 22. Review of meal intake documentation for Resident R6 dated January 1, 2025, to January 31, 2025, revealed that 12 of 31 documentation of breakfast and lunch intake/consumption documentation was completed at the same time of the day. There was no lunch and dinner documentation on January 19 and January 20. Review of meal intake documentation for Resident R6 dated January 28, 2025, to February 12, 2025, revealed that 8 of 16 documentation of breakfast and lunch intake/consumption documentation was completed at the same time. Interview with the Director of Nursing, Employee E2 on March 25, 2025, at 12:00 p.m. stated facility staff was expected to document in real time. 28 Pa. Code 211.5(d) Medical records.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for two of 14 residents reviewed (Residents R6 and R7). Findings include: Review of undated facility policy entitled, Height and Weight, that . Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh resident to verify weight. Stable resident swill be weighed monthly thereafter, unless physician or diagnosis indicate otherwise, Unstable residents will be reviewed by IDT team to determine frequency of obtaining weight a. Update Interdisciplinary Care plan as needed. Weight loss concerns are reported to the practitioner and discussed at the weekly clinical meeting. Review of the weight record for Resident R6 on August 7, 2024, revealed that the resident weighed 159.0 lbs.(pounds). On September 16, 2024, the resident weighed 150 pounds which was a -5.66 % loss over one month and 10.2 % loss over 6 months. Review of the clinical record revealed that a nutritional assessment was not completed until September 27, 2024. Further review of the clinical record revealed that the resident was not reweighed in a timely manner to confirm the weight loss according to the facility protocol. There was no evidence that the facility increased weight/nutritional monitoring for Resident R6 in response to the weight loss. Review of the weight record for Resident R6 on October 23, 2024, revealed that the resident weighed 145.5 lbs.(pounds) which was a 8.5% loss over three months and 14.4% loss over 6 months which was triggered for significant weight loss. Review of the clinical record revealed that a nutritional assessment was not completed until October 28, 2024. However, it was documented that previous weight changes addressed in previous note, recent weight change not significant, intake average for meals 75%-100%. Continue current diet as ordered. Further review of the clinical record revealed that the resident was not reweighed in a timely manner to confirm the weight loss according to the facility protocol. There was no evidence that the facility increased weight/nutritional monitoring for Resident R6 in response to the weight loss. Review of the weight record for Resident R6 on October 30, 2024, revealed that the resident weighed 144.0 lbs.(pounds) which was a 9.4% loss over three months and 15.3% loss over 6 months which was triggered for significant weight loss. Review of the clinical record revealed that a nutritional assessment was completed on October 31, 2024. However, it was documented that weight change not new, has been addressed in previous note. Continued review revealed that the resident was not reweighed in a timely manner to confirm the weight loss and there was no evidence that the facility increased weight/nutritional monitoring for Resident R6 in response to the weight loss. Review of the weight record for Resident R6 on November 5, 2024, revealed that the resident weighed 142.0 lbs.(pounds) which was 5 % Loss over one month, 10.7% loss over three months and 12.3% loss over 6 months which was triggered for significant weight loss. Review of the clinical record revealed that a nutritional assessment was not completed until November 12, 2024. There was no evidence that the facility increased weight/nutritional monitoring for Resident R6 in response to the weight loss. Review of the weight record for Resident R6 on December 3, 2024, revealed that the resident weighed 139.5 lbs.(pounds) which was 10.7% loss over three months and 13.9% loss over 6 months which was triggered for significant weight loss. Review of the clinical record revealed that a nutritional assessment was not completed until December 18, 2024. Review of the weight record for Resident R6 on January 8, 2025, revealed that the resident weighed 139.0 lbs.(pounds) which was 14.2% Loss over 6 months which was triggered for significant weight loss. Review of the clinical record revealed that a nutritional assessment was not completed until January14, 2025. Review of clinical record for Resident R7 revealed that the resident was not weighed, obtained physician order for monthly weight, documented reason for not obtaining monthly weight or documented refusal of monthly weight appropriately from January 2024 to January 2025. Interview with Employee E6, Medical Record Nurse on March 30, 2025, at 2:00 p.m. confirmed that there was no order for monthly weight or monthly weight for Resident R7. 28 Pa. Code 211.12(c) Resident care policies 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the wound treatment and enhanced barrier precaution for 4 of 14 residents reviewed. (Resident R1, R6, R9 and R11) Findings include: Review of an undated facility policy, Enhanced Barrier Precaution, revealed that Communication to staff and visitors-post sign on the resident door indicating enhanced barrier precaution is required. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include; Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy ventilator, Wound care: any skin opening requiring a dressing. In general, gowns and gloves would not be recommended when performing transfers in common areas, such as dining or activity rooms, where contact is anticipated to be in shorter duration. Outside the resident's room, EBP should be followed when performing transfers or assisting during bathing. In a shared/ common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. Residents are not restricted to their rooms or limited from participation in group activities. EBP is intended to be in place for the duration of the resident 's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. EBP are indicated for residents with any of the following: Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply Wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a MDRO) Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks, or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic venous stasis ulcers. Indwelling medical device examples include central lines including PICC, urinary catheters, feeding tubes, and tracheostomies. A peripheral IV line is not considered. Gowns, gloves, and hand sanitizer are readily accessible to staff. Observation of the facility second floor on March 26, 2025, at 10:20 a.m. revealed the following findings: Resident R6 was receiving tube feeding. Clinical record revealed that the resident had pressure ulcers. There was no sign at the door indicating enhanced barrier precaution. There was no personal protective equipment available in/near resident's room. Resident R11's door sign revealed that the resident was on enhanced barrier precaution. There was no personal protective equipment available in/near resident's room. Resident 9's door sign revealed that the resident was on enhanced barrier precaution. There was no personal protective equipment available in/near resident's room. Resident 1's door sign revealed that the resident was on enhanced barrier precaution. There was no personal protective equipment available in/near resident's room. Resident 4's door sign revealed that the resident was on enhanced barrier precaution. There was no personal protective equipment available in/near resident's room. A wound care observation of Resident R1 on March 26, 2025, at 10:30 a.m. with the wound care nurse, Employee E3 revealed the door sign at resident's door revealed that the resident was on enhanced barrier precaution. Employee E3 started the wound care, positioned the resident and removed the soiled/old dressings from resident's lower extremity with out wearing a gown as recommended by the enhanced barrier precaution sign and facility policy. Employee E3 only worn the gown after cleaning the wounds. Interview with Employee E3 on March 26, 2025, at 10:45 a.m. confirmed the above findings. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on review of clinical records, observations, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to ensure treatment and services were provided to the resident with bilateral lower extremity venous ulcer as recommended by the physician for one of 14 residents reviewed. (Resident R3) Findings Include: Review of wound care practitioners' recommendation dated March 19, 2025, revealed a recommendation to apply tubi-grip to lower extremity daily during the day and off at night. Review of wound care practitioners' recommendation dated March 26, 2025, revealed a recommendation to apply tubi-grip to lower extremity daily during the day and off at night. Observation of Resident R3 on March 30, 2025, at 11:00 a.m., with Employee E4, Licensed Practical Nurse Supervisor, revealed that the resident was sitting in her wheelchair. Her feet was on the floor. Resident was not wearing tubi grip or any compression measures to her lower extremity. It was observed that the resident had an ulcer to the left calf area. There was no dressing or wound care to the right leg. Continued observation revealed that there was new fluid filled blister to the right lower extremity. Interview with Employee E4, on March 30, 2025, at 11: 30 a.m. stated the tubi grips are applied for preventing swelling of the lower extremity and prevent development of ulcer. Employee E3 confirmed that the resident was not wearing tubi-grip or any compression measures to her lower extremity Review of physician orders for Resident R3 revealed that there was no order in her physician orders for tubi-grips as recommended by the practitioners. Review of Treatment Administration Record for Resident R3 revealed that there was no evidence that the resident was offered tubi-grip as recommended by the practitioner. 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, observations, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify resident's physician and representative of a change in skin condition of for one of 14 residents reviewed (Resident R2). Findings include: Review of undated facility policy titled Notification of Change in Condition, revealed The center must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. The medical practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. When a change in condition is noted, the nursing staff will contact the resident representative. Observation of Resident R2 on March 30, 2025, at 10: 34 a.m., with Employee E4, Licensed Nurse Supervisor, revealed a dark colored elevated area approximately 2 inches in diameter to the resident's anterior left foot. Employee E4 stated it could be a bruise or blood-filled blister. Interview with Employee E5, Nurse Aide, on March 30, 2025, at 11: 30 a.m. stated she saw the area two days ago and reported it to the Wound care nurse, Employee E3. Employee E5 stated she also saw this area on Saturday and that morning. Review of clinical record for Resident R2 revealed no documented evidence of the area identified on the resident's anterior left foot the area or the physician or resident/representative were notified of the area. Interview with Employee E1, Nursing Home Administrator, on March 30, 2025, at 2: 00 p.m. Administrator confirmed that there was no documented evidence in the clinical record to indicate the cause of the area such as an investigation or resident's physician was notified of the change in skin condition. 28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) for two of two employee records reviewed. (Employee E7 and E8). Findings Include: Observation of Resident R8 on March 26, 2025, at 11:00 a.m., revealed that the resident had a left upper extremity PICC line insertion. There was no documentation on the dressing to indicate the date and time the dressing last changed. Review Resident R8's active physician order on March 26, 2025, revealed an order to measure external catheter length with dressing change. However, there was no evidence that the staff obtained or documented external catheter length. Observation of Resident R9 on March 26, 2025, at 10:00 a.m., revealed that the resident had a left upper extremity PICC line insertion. Resident stated staff did not change her dressing weekly. There was no documentation on the dressing to indicate the dressing change date. A request for PICC line care and management competency for Employee E8, Registered Nurse and E9, Licensed Nurse was requested to the Director of Nursing. Facility did not submit the PICC line care and management competency for Employee E7 and E8 during the survey. Interview with Registered Nurse, Employee E9 who was responsible for staff education stated facility did not complete competencies for PICC line dressing changes. 28 Pa. Code: 211.12 (d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services

Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to serve foods that accommodate residents' allergies for one of 5 reviewed reviewed (Residents R1). Findings include: Interview with Resident R1 on December 26, 2024, revealed on November 18, 2024, during dining resident had a cookie on her tray. Resident R1 ate a few bits of the cookie where she realized it had peanuts in it because she started reacting to it by having an itchy throat. Resident is allergic to nuts and it was stated on her meal ticket. Nurse was informed that the resident was having trouble swallowing. The antihistaming Benadryl was administered. The Nurse practitioner was in facility and assessed hthe resident and EpiPen (medication used to treat life-threatening, allergic emergencies in people who are at risk for or have a history of serious allergic emergencies) was administered. Review of nursing notes for Resident R1 revealed a two nurses notes, dated November 18 and 19, 2024, which stated, At 17:30 (5:30 p.m.) nurse reported that the resident ate 1/2 of a cookie that has peanut on it she's allergic to peanuts and tree nuts. Upon Assessment resident was alert able to be explained what she ate and how much of it she had, and the of amount of anaphylactic shock she had in the past, vital sign were stable O2 (oxygen) sat was 98% at R/A (room/air) in house NP (nurse practicioner) was on-site one-time order for Benadryl and an EpiPen were given. Reassess for the first 15-minute resident verbalized relief, at 6:30 pm. 2nd assessment resident stated she's ok drinking with no problem. Interview with unit manger nurse, Employee E3 on second floor on December 26, 2024, at 12:00 p.m., confirmed that Resident R1 had an allergic reaction to the cookie that she ate on November 18, 2024. Also reported that the cookie looked like a sugar cookie and somehow it did contain nuts. Never happened before and they follow the protocol to make sure that resident is safe. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of clinical records, facility policies, and interview with resident and staff, it was determined that the facility failed to provide adequate supervision for one of six residents reviewed (Resident R1) who exited through two doors that were designed to lock and one to alarm. This failure resulted in Resident R1 eloping from the facility for approximately 4 hours and placed Resident R1 at high risk for injury that resulted in an Immediate Jeopardy situation. (Resident R1) Findings include: Facility policy titled Elopement Prevention and Management Overview (undated) indicated that the interdisciplinary team plans the least restrictive interventions to promote mobility and safety and to meet the individualized needs and goals of the resident. Components of the Elopement Prevention and Management Program include, but are not limited to, the following: elopement drills, environmental modifications to promote safety mobility with monitoring for effectiveness, protected list of names and photographs of those residents identified as being at for elopement, regular rounds, and structured group activities. Review of Resident R1's clinical record revealed an admitted [DATE], with a diagnosis of schizoaffective disorder (mental health condition that combines symptoms of psychosis and mood disorders), bipolar disorder (extreme mood swings), intellectual disabilities, and epilepsy (seizures). Review of Resident R1's most recent Minimum Data Set (MDS- assessment of resident care needs) completed October 1, 2024, revealed Resident R1 was assessed with a BIMS (Brief Interview of Mental Status) score of 10, which indicated that the resident had moderate memory impairment. Further review of Resident R1's MDS revealed on section E0800-Wandering- Presence and Frequency, Resident 1 did not exhibit wandering behaviors. Review of facility reported documentation submitted to the Department of Health revealed on October 12, 2024, Resident R1 left the facility at approximately 11:30 p.m. and walked approximately 4.2 miles, where Resident 1 stopped at a convenience store and asked a [NAME] to call police. Police arrive and Resident 1 requested to be returned to the facility. Resident R1 arrived back to the facility at 3:30 a.m. Resident R1 refused to go to emergency room for evaluation. Skin and pain assessment completed, and no issues were noted. Resident R1 was placed on 1:1 until psych cleared. Review of facility documentation revealed 12 interviews were completed by the facility. Two interviews indicated that Resident R1 was last observed in bed at approximately 11:10 p.m. All staff statements stated that no alarm sound was heard throughout the facility when Resident R1 eloped. Interview with Nurse Aide, Employee 4, on October 30, 2024, at 11:25 a.m. revealed no alarm sound was heard on October 12, 2024, when Resident R1 eloped from the facility and staff was unaware until notified by police. Review of facility documentation from September 23, 2024 through October 25, 2024 revealed doors, locks, and alarms were checked throughout the facility by an outside company Monday through Friday to ensure functionality. All dates reviewed revealed all doors, locks, and alarms passed inspection. Further review revealed doors, locks, and alarms were not tested by the outside company on October 12, 2024. Interview with Director of Nursing, Employee E2, and Assistant Director of Nursing, Employee 3, on October 30, 2024 at 10:20 a.m. stated that doors are checked every shift by supervisors and no issues were noted with all doors on October 12, 2024. Both employees confirmed that both doors Resident R1 exited through were working properly after Resident R1 eloped. Further interview with Director of Nursing, Employee E2, and Assistant Director of Nursing, Employee 3, revealed when the alarmed door is pushed on for 15 seconds the door opens and an alarm sounds, due to fire safety reasons. Interview conducted with Resident R1 on October 30, 2024, at 12:05 p.m. revealed the first door to the kitchen was unlocked and Resident R1 was able to push on the door and walk to the alarmed door. Resident R1 stated that she held the door for 15 seconds, which opened the door. Resident R1 stated she then walked a few miles and fell multiple times and revealed she did not sustain major injuries, but states her right knee hurts and Tylenol helps with the pain. Review of Resident R1's clinical records revealed Resident R1 had a fall on October 7, 2024 after getting up from bed at night, feeling dizzy causing her to fall. Resident R1 was assessed by physician on October 8, 2024 and was noted to have right knee pain and chronic lower back pain. Further review revealed Resident R1 was assessed by the physician on October 14, 2024. Physician note dated October 14, 2024, at 1:00 p.m. revealed Resident R1 had no physical complaints. Physician note dated October 15, 2024, at 5:27 p.m. revealed Resident R1 requested a brace for right knee pain. Right knee was examined with no issues noted. Physician concluded pain most likely related to arthritic pain on acute injury and Tylenol ordered as needed. Based on the above findings, an Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1, on October 30, 2024 at 1:13 p.m. for failure to ensure that Resident R1 received adequate supervision and safety of the resident's environment. Resident R1was able to exit through two doors that were designed to lock. This failure resulted in Resident R1 eloping from the facility for approximately 4 hours. An immediate action plan was requested from the Nursing Home Administrator, Employee E1 and the Immediate Jeopardy template was provided to the Nursing Home Administrator on October 30, 2024 at 1:22 p.m. On October 30, 2024, at 2:55 p.m. the facility submitted an immediate plan of action that included the following: - Incident Response: On October 13, 2024 Resident was assessed by facility registered nurse and found to have no injuries. Resident was placed on 1:1 observation awaiting psychiatric evaluation. Charge nurse completed wandering risk assessment, skin assessment, and pain assessment. The care plan was updated to include elopement risks on October 13, 2024, All facility doors were inspected by maintenance on the same date, and all were found to be in working order. A head count was conducted by nursing staff, confirming all residents were accounted for. All access codes for egress doors were changed on October 13, 2024. - Wandering risk assessment: an order listing report for all residents with Wander Guards was generated and checked for proper placement and function on 10/13/24 by Unit Managers. Care plans were reviewed and elopement book was updated. Resident named in deficient practice was added to the elopement risk list. Full house assessed for elopement risk, no new residents noted. Audit completed by Unit Managers. - Staff Education: All staff present received education on the elopement process, effective rounding, and proper operation of all egress doors on 10/13/2024 from the RN Supervisor. Staff not present received the same training from the Staff Development Coordinator/ designee. New staff will receive education on the elopement process during their orientation by the DON or designee. - Elopement Drills: Elopement drill will be conducted across all shifts, beginning on 10/13/24 and concluding on 10/16/24, overseen by the NHA and maintenance director. - Interdisciplinary Team Meeting: The IDT convened to discuss the resident's high risk for elopement, and the care plan was updated accordingly. - Behavior Monitoring: The DON or designee will monitor the clinical dashboard for any changes in behavior, including exit-seeking. Findings will be reviewed by the IDT, and new interventions will be implemented as needed to prevent future incidents. - Security Enhancements: The lock on the kitchen door was changed to an automatic lock, and the key code for all egress doors was updated. The action plan was reviewed and interviews were conducted with staff to verify the implementation of the action plan. Staff confirmed that in-service education was provided and were able to verbalize the elopement process and the importance of effective rounding. Following verification of the immediate action plan the Immediate Jeopardy was lifted on October 30, 2024 at 3:53 p.m. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to the elopement of one of six residents reviewed (Residents R1) which resulted in an Immediate Jeopardy situation. Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated that the primary purpose of the NHA's job description is to lead the nursing home facility and is responsible for the overall management and operational oversight of the facility, ensuring that high standards of care are maintained and regulatory requirements are met. This role requires strong leadership, excellent communication skills, and a commitment to providing outstanding care to our residents. Review of the job description for the Director of Nursing (DON) stated that the primary purpose of the Director of Nursing's job description is to oversee nursing services, ensure compliance with regulations, and foster a supportive and professional environment for nursing staff. The DON will possess strong leadership skills, clinical expertise, and a commitment to patient centered care. Review of Resident R1's clinical record revealed an admitted [DATE], with a diagnosis of schizoaffective disorder (mental health condition that combines symptoms of psychosis and mood disorders), bipolar disorder (extreme mood swings), intellectual disabilities, and epilepsy (seizures). Review of Resident R1's most recent Minimum Data Set (MDS- assessment of resident care needs) completed October 1, 2024, revealed Resident R1 was assessed with a BIMS (Brief Interview of Mental Status) score of 10, which indicated that the resident had moderate memory impairment. Further review of Resident R1's MDS revealed on section E0800-Wandering- Presence and Frequency, Resident 1 did not exhibit wandering behaviors. Review of facility documentation revealed on October 12, 2024, Resident R1 left the facility at approximately 11:30 p.m. and walk approximately 4.2 miles, where Resident R1 stopped at a convenience store and asked a [NAME] to call police. Police arrive and Resident R1 requested to be returned to the facility. Resident R1 arrived back to the facility at 3:30 a.m. Resident R1 refused to go to emergency room for evaluation. Resident 1 was placed on 1:1 until psych cleared. Interview conducted with Resident R1 on October 30, 2024, at 12:05 p.m. revealed the first door to the kitchen was unlocked and Resident R1 was able to push on the door and walk to the alarmed door. Resident R1 stated that she held the door for 15 seconds, which opened the door. Resident R1 stated she then walked a few miles and fell multiple times. Review of facility documentation revealed 12 interviews were completed by the facility. Two interviews indicated that Resident R1 was last observed in bed at approximately 11:10 p.m. All staff statements stated that no alarm sound was heard throughout the facility when Resident R1 eloped. Interview with Nurse Aide, Employee 4, on October 30, 2024, at 11:25 a.m. revealed no alarm sound was heard on October 12, 2024, when Resident R1 eloped from the facility and staff was unaware until notified by police. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on the review of clinical record, interview with resident and staff, it was determined that the facility failed to ensure that each resident receive the medications that were ordered for by their physician and do not be administer medications ordered for another resident for 1 of 4 residents reviewed. (Resident R 1) Findings Include: Review of facility policy Administering Medication states that observe the five right in giving each medication, the right resident, the right time, the right medication, the right dose and the right route. Review Physician Orders policy states medication administration record/ treatment administration record the legal medical record for recording medication and treatment. Review of Resident's R1 clinical record, revealed the diagnosis of dementia (progressive degenerative disease of the brain) without behaviors and high blood pressure. Reviewed the investigation reported revealed that on October 5, 2024, at 0900 (9:00 a.m.), resident a [AGE] year-old male with Diagnosis of dementia and HTN (hypertension- high blood pressure) and a BIM (Brief Interview of Mental Status)'s score of 7, was administered medications in error. Resident R1 received Ferrous Sulfate 325mg (milligrams), Gabapentin 800 mg, Lipro insulin 2 units and Keppra 750 mg, that were entered into his chart in error. Doctor and RR (responsible party) made aware. Resident R1 placed on enhanced monitoring. Blood sugar 99. Resident's family requested that resident be sent to the ER (emergency room ) for evaluation routine change in mental status. Resident R1 sent 911 (Emergency Medical Services) to ER for evaluation and admitted . Facility administration director nursing made aware. Reviewed witness statements from the Registered Nurse, Employee E4 revealed on October 4, 2024, at 6:45 pm, [Resident R2] was transferred to Sliver Lake health care center. I transcribed some of [Resident R2] medication from 3-b under [Resident R1] in room [ROOM NUMBER]-A not re realizing they were different residents with the same last names. On October 5, 2024, at 2:30am, I was informed by supervisor that some of the [Resident R2] meds were transcribe under [Resident R1]. I immediately rushed in the room to assess the resident. Vital includes, 114/70, 58, 97.6, 20, 98 quickly informed manger and [Resident R1] daughter at bed side made aware. 911 called never alone called, [Resident R1] send to . ER Via Ambulance for evaluation. Reviewed witness statements from the licensed practical nurse, Employee E5 revealed on October 5, 2024, I dispensed all AM medications ordered in the facility for [Resident R1]. After I passed medication around 11 am, I noticed his sugar was low, gave him a pudding and his sugar was elevated. The daughter came in to visit, she identified her father was not normal. I explained that this maybe a response to his new medication. The family was unaware of the changes in medication. I contacted the supervisor, Employee 6 came up to speak with the family. During medication review the diagnosis didn't match the order under [Resident R1]. At that time supervisor identified that there was a name alert and that the new medications were put into the wrong resident chart. Reviewed witness statements Supervisor Registered Nurse, Employee E6 revealed when I was making rounds Saturday, [Licensed Practical Nurse, Employee E5], told me that [Resident R1] daughter was concerned that new medication was ordered for her father without her involvement. After [Licensed Practical Nurse, Employee E5], told me what the medication were, I remembered that there was an admission with the same last name that came in Friday night, I did a quick review of the chart for [Resident R2] in post-acute and realized that medications that should have been entered and ordered for her were entered on [Resident's R1] MAR (medication Administration Record) accidentally. [Registered Nurse, Employee E4], had entered the orders on Friday evening and she was there Saturday morning. I told registered [Nurse, Employee E4] about the error and informed . Reviewed additional information from the hospital discharge records revealed presented to the ED (Emergency Department) with confusion and lethargy due to accidental administration of another resident's medication Sliver Lake Nursing Home, which included insulin aspart 2 units, Gabapentin 800mg and Keppra 750mg. Resident R1 arrived at the ED sleepy but alert and oriented. Resident's daughter also noticed speech was slurred. IV (intravenous) fluids in the ED and admitted for continued monitoring of accidental administration of incorrect medication and to rule out TIA/stroke due to change in speech and altered mental status. Labs including CBC (complete blood count), CMP (complete metabolic panel), lipid profile, urinalysis, and urine drug screen were all within normal limits. EKG showed sinus rhythm. Chest x-ray was normal. Interview with Nursing Home Administrator, Employee E1 on October 9, 2024, at 12:00 p.m. stated that it was accidental administration of another resident's medication due to another resident with the same last name. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R135, with a documented history of substance abuse, to prevent relapse and access to illegal substances. This failure resulted in Resident R135, accessing and using illegal substance and experiencing four incidents ([DATE]; [DATE]; [DATE] and [DATE]) of drug overdose which required immediate medical treatment/emergency medical intervention and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135). Findings include: Review of the facility's care plan policy titled Plan of Care Overview dated 2017, revealed it is the policy of this facility to provide each resident centered care that meets psychosocial physical and emotional needs and concerns of the resident's safety is the primary concern for all our residents staff and visitors. The primary purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and support the residents' goals choices and preferences. Review of facility policies and standard procedures on Individual Service Plan Overview with an effective date of [DATE], revealed that under Definitions: For the purpose of this policy, that individual service plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. Under section Policy: It is the policy of this facility to provide resident centered care that meets the site, cause, social, physical, and emotional needs and concerns of the resident safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's choices and preferences including but not limited to goals related to their daily routines and goals to potentially return to a community setting. Under section Procedure #1,d. The facility will: i Provide an interdisciplinary assessment of the residents in 30 days of admission and then an ongoing periodic review that provides the foundation for resident focused care and the service planning process, ii provide access to the Service plan within 24 hours. iii review service plans quarterly and or with significant changes in care. Review of facility policy titled Resident Substance Abuse in the Facility revealed the facility is to provide each resident with care based on their individual medical and emotional needs and their physical ability to self-perform or have assistance to perform the operation. The policy includes the procedures, management of acute episodes, residents receiving Narcan protocols, observations of other residents, follow-up care for resident abusing substances, documentation and care plan and education. Review of Resident R135's clinical record reveled that Resident R135 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of S\Psychoactive Substance Use Unspecified, Major Depressive Disorder, Adjustment Disorder. Review of resident social history assessment dated [DATE], revealed that Resident R135 has history of alcohol use, age of first use: [AGE] year, last used: three weeks ago (three weeks before [DATE]), frequency and amount used: Daily. Further, Resident R135 had history of heroin and fentanyl abuse: Age of first use: [AGE] year, last used: three weeks ago (three weeks before [DATE]), frequency: daily. Further, resident was not aware of any triggers and resident was not able to identify any relapse prevention strategies. Review of Resident R135's quarterly MDS (Minimum Data Set a federally required resident assessment completed at a specific interval) dated [DATE], section C0500 BIMS (brief interview for mental status- a standardized assessment tool used to screen cognitive function)) revealed a score of 15 suggesting that resident was cognitively intact. Review of Resident R135's care plan revealed that there was no comprehensive person-centered care plan addressing Resident R135's, history of illicit drug and alcohol abuse, and potential for relapse. Review of Resident R135's progress note revealed that on [DATE], time stamped 10:55 p.m. resident was observed by the nurse, unresponsive, gasping for air. 911 (Emergency Medical Services) called and resident taken to a local county hospital for evaluation. Review of hospital after visit summary dated [DATE], revealed that, Resident R135 was seen at the hospital with respiratory distress and responsive. Symptoms are most likely secondary to opiates which was injected, given by the friend at the nursing home. Further review of the hospital after visit summary revealed the resident was given Naloxone hydrochloride on [DATE]. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing the resident's illicit drug use was not developed until after Resident R135 overdosed on [DATE]. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's receiving opiates by a friend at the nursing home as documented in the hospital after visit summary dated [DATE]. Nursing Home Administrator, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions to prevent the distribution of drugs to other residents in the facility. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse and there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Review of nurses note dated [DATE], time stamped 8:11 p.m. revealed that writer was called by floor nurse at 7:15 p.m. to room [ROOM NUMBER], Upon writer arrived writer noticed resident in bed unresponsiveness, slowed breathing, snoring, skin cold, and pinpoint pupil. At 7:20 p.m. Narcan nasal spray 4 mg (milligrams) given. At 7:30 p.m. Resident respondent when name was called. 911 arrived at 7:32 p.m. Resident refused to go to the hospital. DON (director of nursing) notified order 1:1 observation, neuro check and vitals every four hours. Review of provider encounter (nurse practitioner) note dated [DATE], time stamped 1:00 a.m. revealed that Resident R135 was seen for status post overdose. She had an unresponsive episode, requiring Narcan and visit to ER (emergency room ). Resident overdosed on substance she reported buying from another resident. She refused to give the name of the resident but kept repeating that it's someone staff has been suspecting. Asked if it's a male or female, she said female. Asked the race of the resident, admitted resident is African American she said yes, and it is who you think it is. Drector of Nursing and Nursing Home Administrator made aware. Resident was placed on 1:1 supervision. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was developed after Resident R135 overdosed on [DATE]. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43a.m. revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Interview with ADON (Assistant Director of Nursing) conducted on [DATE], at 12:34 p.m., revealed that he was not involved in the investigation with Resident R135's incident of overdose on [DATE]. Further ADON also revealed that he was not aware of any investigation conducted regarding Resident R135's allegations that she bought the drugs from a resident of the facility. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse, there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Review of Resident R135's progress notes dated [DATE], revealed that IDT (interdisciplinary team) met and discussed resident's recent behaviors. It was determined, along with psych Certified Registered Nurse Practicioner, that 1:1 observation was no longer needed. Further review of Resident R135's clinical record revealed no plan of care on how to prevent relapse after 1:1 was discontinued. Further, there was no evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Review of nurses notes dated [DATE], time stamped 3:44 p.m. revealed that Resident R135 went to use the general bathroom, when her mother came out to report that resident was unresponsive in the bathroom. A code was called and two doses of Narcan was administered before the resident regained consciousness. While resident was being revived 911 was called and the EMT (Emergency Medical Technician) met the resident conscious. Resident R135 refused to go to the hospital, resident admitted to the EMT in the presence of this writer that she had a little heroine but refused to state where and how she got it. Plan of care continues. DON Employee E2 and Administrator Employee E1 were notified about the situation, and they advised that the police be called, police was called, the officer said he cannot search Resident R135's room if the resident doesn't want him to do so. Administrator made aware and she order every 15 minutes check on resident. Meanwhile, the physician ordered that all narcotics be put on hold until tomorrow. Review of Progress notes dated [DATE], time stamped 1:00 a.m. revealed that Resident was seen today for S/P (status/post) heroin overdose yesterday. Per nurses' note, resident went to use the hall bathroom. Her mother, who was visiting, came out to notify nursing resident was unresponsive. She required two doses of Narcan before regaining consciousness. Resident refused to be transferred to ER. She refused to tell the police and EMT where she got the heroin. Today during this visit, she named the resident whom she purchased it from through bargaining, she gave the other resident her food stamps for the heroin, Resident was placed on ,d+[DATE] supervision and was moved to another floor. Review of psychotherapy progress note dated [DATE], revealed the following: Goals Addressed: Anxiety, Depressive Symptoms, Acceptance of current setting, Use of Coping Strategies, Compliance with treatment regimen, Patient's Concerns/Focus: Resident seen on this date at the request of staff. Resident with overdose yesterday. Refused to go to outside hospital. Resident seen in private area immediately this morning. Currently being maintained on 1:1 observation. Resident is tearful. Discussing substance abuse and intent. Discussing feeling overwhelmed by both physical and emotional pain. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse, there was no person-centered care plan developed to address Resident R135's addiction, recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed after Resident R135 overdosed on [DATE]. Further interview with Nursing Home Administrator, Employee E1 revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated [DATE], revealed that Resident R135 was released from 1:1 observation Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed. Review of progress note dated [DATE], time stamped 3:14 p.m. revealed that Resident R135 was on LOA (leave of absence) to a local store. Resident R135 left at 1pm. The physician approved LOA. Review of progress note dated [DATE], time stamped 10:00 p.m. revealed that Resident R135 came back to the facility with her friend from her outing. Review of progress note dated [DATE], at 9:01 a.m. revealed that Resident R135 was found unresponsive by nurse at approximately 8:20 a.m. Code blue called. Resident R135 received Narcan x 3, Resident R135 became responsive after receiving Narcan. 911 was called. Resident R135 refuse transfer to ER (emergency room ). Resident stated she took half bag of Fentanyl hours ago. Review of nurse's notes dated [DATE]; time stamped 4:00 p.m. revealed that Resident R135 was placed on a 1:1 because she had an OD (overdose) on the nightshift. Review of psych note dated [DATE], revealed that follow-up psychiatric evaluation requested by the facility staff. Patient and her boyfriend had a community outing to (major city) and patient returned very lethargic and they had to administer Narcan three times today. When patient was interrogated about using any other substances while they were out, patient admitted to, doing one bag of fentanyl in the community. When patient was evaluated to discontinue the 1:1 observation, patient was asked if there is any drugs hidden in her room or the boyfriend's room patient denied, but when one of the facility staff suggested we search the rooms. Patient was very anxious and not acceptable to the idea. This was a clear indication that there might be some drugs still hidden within the facility and it was communicated to the facility management to search the rooms before the patient is taken off 1:1. At this time we continue 1:1 observation and will reevaluate the next visit on Friday. Further review of clinical records revealed that there was no documented evidence that an inter-disciplinary care planning meeting was convened to discuss resident substance abuse and there was no person-centered care plan developed to address Resident R135's addiction, his recent relapse, identify triggers, plans to prevent relapse, provision of support and counselling. There was no documented evidence that a consistent psychiatric, psychological counseling to address resident's addiction was provided to Resident R135. Interview with facility Nursign Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. confirmed that a comprehensive person-centered care plan addressing resident's illicit drug use was not developed after Resident R135 overdosed on [DATE]. Further interview with Nursing Home Administrator Employee E1 conducted on [DATE], at 11:43am revealed that there was no further investigation related to the indication that there might be some drugs still hidden within the facility as documented in the psych note dated [DATE]. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 9:55 a.m. for the facility's failure to develop and implement a comprehensive person-centered care plan for Resident R135 who had a documented history of drug abuse. This failure resulted in Resident R135 who had a documented history of substance abuse, accessing and using illegal substance which resulted in four incidents ([DATE]; [DATE]; [DATE], and [DATE]) of drug overdose which required immediate medical treatment / emergency medical management. An Immediate Jeopardy Template was presented to the facility on [DATE], 9:59 a.m. The facility submitted a written plan of action on [DATE], at 4:10 p.m. and implemented the plan of action which included: 1. Resident named in deficient practice has been discharged from the facility on [DATE]. 2. Assessment of all residents currently residing in the facility for history of substance abuse was completed in [DATE]. The Facility ensured that care plans were in place for each resident with history of substance abuse disorder on [DATE]th, 2024. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. On [DATE]. No residents were found to be suspicious for current use or found to have any materials. 3. All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence. 4. All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility. On [DATE]. Ad Hoc QAPI held on [DATE], to reviewed efficient practice. 5. Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration. o 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: o Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. o Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies o Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work. 6. 100% compliance in staff education by [DATE]. The action pan was accepted on [DATE], at 4:09 p.m. The action plan was reviewed, interviews were conducted with staff to confirm that the in-service education was completed. Facility documents and facility audits were reviewed to ensure care plans were developed. The Immediate Jeopardy was abated and NHA was notified on [DATE], at 12:27 p.m. that the I.J. was lifted. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management

Based on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to provide supervision for Resident R135 with documented history of substance abuse. This failure resulted in Resident R135 accessing and using illegal substance which resulted in four incidents ([DATE]; [DATE]; [DATE] and [DATE]) of drug overdose which required immediate medical treatment / emergency medical management and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135) Findings include: Review of facility policies and standard procedures on Individual Service Plan Overview with an effective date of [DATE], reveal that under Definitions: For the purpose of this policy, that individual service plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. Under section Policy: It is the policy of this facility to provide resident centered care that meets the site, cause, social, physical, and emotional needs and concerns of the resident safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's choices and preferences including but not limited to goals related to their daily routines and goals to potentially return to a community setting. Review of facility policy titled Resident Substance Abuse in the Facility revealed the facility is to provide each resident with care based on their individual medical and emotional needs and their physical ability to self-perform or have assistance to perform the operation. The policy includes the procedures, management of acute episodes, residents receiving Narcan protocols, observations of other residents, follow-up care for resident abusing substances, documentation and care plan and education. Review of Resident R135's clinical record reveled that Resident R135 was a [AGE] year-old female admitted to the facility on [DATE], with diagnosis of Psychoactive Substance Use Unspecified, Major Depressive Disorder, Adjustment Disorder. Review of resident social history assessment dated [DATE], revealed that Resident R135 has history of alcohol use, age of first use: [AGE] year, last used: three weeks ago (three weeks before [DATE]), frequency and amount used: Daily. Further, Resident R135 had history of heroin and fentanyl abuse: Age of first use: [AGE] year, last used: three weeks ago (three weeks before [DATE]), frequency: daily. Further, resident was not aware of any triggers and resident was not able to identify any relapse prevention strategies. Review of Resident R135's quarterly MDS (Minimum Data Set a federally required resident assessment completed at a specific interval) dated [DATE], section C0500 BIMS (brief interview for mental status- a standardized assessment tool used to screen cognitive function)) revealed a score of 15 suggesting that resident was cognitively intact. Review of Resident R135's care plan revealed that there was no base line care plan for substance abuse developed within 48 hours of Resident's admission to the facility. Further, there was no comprehensive person-centered care plan addressing Resident R135's, history of illicit drug and alcohol abuse, and potential for relapse. Review of Resident R135's progress note revealed that on [DATE], time stamped 10:55 p.m. resident was observed by the nurse unresponsive, gasping for air. 911 (Emergency Medical Services) called and resident taken to a local county hospital for evaluation. Review of hospital after visit summary dated [DATE], revealed that Resident R135 was seen at the hospital with respiratory distress and responsive. Symptoms are most likely secondary to opiates which was injected, given by the friend at the nursing home. Further review of the hospital after visit summary revealed the resident was given Naloxone hydrochloride on [DATE]. Further review of Resident R135's clinical record revealed no documented evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's receiving opiates by a friend at the nursing home as documented in the hospital after visit summary dated [DATE]. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated [DATE], time stamped 8:11 p.m. revealed that writer was called by floor Nurse at 7:15 p.m. to room [ROOM NUMBER], upon writer arrived writer noticed resident in bed unresponsiveness, slowed breathing, snoring, skin cold, and pinpoint pupil. At 7:20 p.m. Narcan nasal spray 4 Milligrams (mg) given. At 7:30 p.m. Resident respondent when name was called. 911 arrived at 7:32 p.m. Resident refused to go to the hospital. DON (director of nursing) notified order 1:1 observation, neuro check and vitals every four hours. Review of provider encounter (nurse practitioner) note dated [DATE], time stamped 1:00 a.m. revealed that Resident R135 was seen for status post overdose. She had an unresponsive episode, requiring Narcan and visit to ER (emergency room ). Resident overdosed on substance she reported buying from another resident. She refused to give the name of the resident but kept repeating that it's someone staff has been suspecting. Asked if it's a male or female, she said female. Asked the race of the resident, admitted resident is African American she said yes, and it is who you think it is. DON and Administrator made aware. Resident was placed on 1:1 supervision. Interview with facility Nursing Home Administrator, Employee E1 conducted on [DATE], at 11:43 a.m. revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Interview with ADON (Assistant Director of Nursing) conducted on [DATE], at 12:34 pm, revealed that he was not involved in the investigation with Resident R135's incident of overdose on [DATE]. Further ADON also revealed that he was not aware of any investigation conducted regarding Resident R135's allegations that she bought the drugs from a resident of the facility. Review of Resident R135's progress notes dated [DATE], revealed that IDT (interdisciplinary team) met and discussed resident's recent behaviors. It was determined, along with psych Certified Registered Nurse Practicioner, that 1:1 observation was no longer needed. Further review of Resident R135's clinical record revealed no plan of care on how to prevent relapse after 1:1 was discontinued. Further, there was no evidence of environmental monitoring and behavioral monitoring to identify potential sources of illegal substance. Review of nurses notes dated [DATE], time stamped 3:44 p.m. revealed that Resident R135 went to use the general bathroom, when her mother came out to report that resident was unresponsive in the bathroom. A code was called and two doses of Narcan was administered before the resident regained consciousness. While resident was being revived 911 was called and the EMT (Emergency Medical Technician) met the resident conscious. Resident R135 refused to go to the hospital, resident admitted to the EMT in the presence of this writer that she had a little heroine but refused to state where and how she got it. Plan of care continues. Director of Nursing, Employee E2 and Nursing Home Administrator, Employee E1 were notified about the situation, and they advised that the police be called, police was called, the officer said he cannot search Resident R135's room if the resident doesn't want him to do so. Nursing Home Administrator made aware and she order every 15 minutes check on resident. Meanwhile, the MD ordered that all Narcotics be put on hold until tomorrow. Review of progress notes dated [DATE], time stamped 1:00 a.m. revealed that Resident was seen today for S/P heroin overdose yesterday. Per nurses' note, resident went to use the hall bathroom. Her mother, who was visiting, came out to notify nursing resident was unresponsive. She required two doses of Narcan before regaining consciousness. Resident refused to be transferred to ER (emergency room ). She refused to tell the police and EMT where she got the heroin. Today during this visit, she named the resident whom she purchased it from through bargaining, she gave the other resident her food stamps for the heroin, Resident was placed on ,d+[DATE] supervision and was moved to another floor. Review of psychotherapy progress note dated [DATE], revealed the following: Goals Addressed: Anxiety, Depressive Symptoms, Acceptance of current setting, Use of Coping Strategies, Compliance with treatment regimen, Patient's Concerns/Focus: Resident seen on this date at the request of staff. Resident with overdose yesterday. Refused to go to outside hospital. Resident seen in private area immediately this morning. Currently being maintained on 1:1 observation. Resident is tearful. Discussing substance abuse and intent. Discussing feeling overwhelmed by both physical and emotional pain. Interview with Nursing Home Administrator revealed that there was no investigation conducted regarding Resident R135's report that she bought the drugs from a resident at the facility. Further, Employee E1 also confirmed that there was no evidence that the facility implemented steps and interventions that prevents the distribution of drugs to other residents in the facility. Review of nurses note dated [DATE], revealed that Resident was released from 1:1 observation Further, there were no evidence of environmental monitoring and supervision to identify potential sources of illegal substance. Review of progress note dated [DATE], time stamped 3:14 p.m. revealed that Resident R135 was on LOA (leave of absence) to a local store. Resident R135 left at 1p.m. Physician approved LOA. Review of progress note dated [DATE], time stamped 10:00 p.m. revealed that Resident R135 came back to the facility with her friend from her outing. Review of progress note dated [DATE], at 9:01 a.m., revealed that Resident R135 was found unresponsive by nurse at approximately 8:20 a.m. Code blue called. Resident R135 received Narcan x 3, Resident R135 became responsive after receiving Narcan. 911 was called. Resident R135 refuse transfer to ER. Resident stated she took half bag of Fentanyl hours ago. Review of nurse's notes dated [DATE]; time stamped 4:00 p.m. revealed that Resident R135 was placed on a 1:1 because she had an OD (overdose) on the nightshift. Review of psych note dated [DATE], revealed that follow-up psychiatric evaluation requested by the facility staff. Patient and her boyfriend had a community outing to (major city) and patient returned very lethargic and they had to administer Narcan three times today. When patient was interrogated about using any other substances while they were out, patient admitted to, doing one bag of fentanyl in the community. When patient was evaluated to discontinue the 1:1 observation, patient was asked if there is any drugs hidden in her room or the boyfriend's room patient denied, but when one of the facility staff suggested we search the rooms. Patient was very anxious and not acceptable to the idea. This was a clear indication that there might be some drugs still hidden within the facility and it was communicated to the facility management to search the rooms before the patient is taken off 1:1. At this time we continue 1:1 observation and will reevaluate the next visit on Friday. Further interview with Nursing Home Administrator conducted on [DATE], at 11:43 a.m. revealed that there was no further investigation related to the indication that there might be some drugs still hidden within the facility as documented in the psych note dated [DATE]. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE] at 9:55 a.m. for the facility's failure to supervise Resident R135 who had a documented history of drug abuse. This failure resulted in Resident R135, accessing and using illegal substance which resulted in four incidents ([DATE]; [DATE]; [DATE], and [DATE]) of drug overdose which required immediate medical treatment / emergency medical management. An Immediate Jeopardy Template was presented to the facility on [DATE], 9:59 a.m. The facility submitted a written plan of action on [DATE], at 4:10 p.m. and implemented the plan of action which included: 1. Resident named in deficient practice has been discharged from the facility on [DATE]. 2. Assessment of all residents currently residing in the facility for history of substance abuse was completed in [DATE]. The Facility. Ensured that care plans were in place for each resident with history of substance abuse disorder on [DATE]th, 2024. Any residents that were found to have a history of substance abuse were also assessed for signs of current illicit drug use and room checks completed during the shore rooms for free from hazardous materials. On [DATE]. No residents were found to be suspicious for current use or found to have any materials. 3. All residents identified to have substance abuse history received physician's orders to monitor for signs of impairment upon return from the hospital or leave of absence. 4. All direct care staff will be educated by Assistant Director of Nursing or designee on how to monitor for signs of substance abuse, monitoring residents and with permission, residents, personal belongings and room check following leave of absence and hospital stay. And policy title, residents, substance abuse and facility. On [DATE]. Ad Hoc QAPI held on [DATE], to reviewed efficient practice. 5. Audits will be completed by administrator or designee five times weekly for four weeks and then monthly for three months to ensure all residents are assessed for history of substance abuse upon admissions and that those residents with history of substance abuse will be monitored. Following any hospital stays and leave of absence, audits will be reported to the Quality Assurance Performance Improvement committee for further review and consideration. o 67% of our direct care staff have completed training focused on key areas related to resident substance abuse. This training includes: o Resident substance abuse in the facility. Entry assessments. Management of acute episodes. Observations of residents suspected or confirmed of usage. Care planning and resident education. o Overview of substance use disorder. Identifying science. Acceptance use disorder. Understanding types of substance use disorders implementing person centered care applying harm reduction strategies o Developing individualized patient care center plans individualized care planning effective interventions, implementations and evaluations creating care plans that truly work. 6. 100% compliance in staff education by [DATE]. The action plan was accepted on [DATE], at 4:09 p.m. The action plan was reviewed, interviews were conducted with staff to confirm that the in-service education was completed. The Immediate Jeopardy was abated and NHA was notified on [DATE], at 12:27 pm. that the I.J. was lifted. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan

Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that meals were served timely on two of three nursing units observed (First floor and Second floor nursing units). Findings include: Review of the facilities policy titled Dining Services Department policy and procedure Manual revealed adequate staffing will be provided to prepare and serve palatable attractive nutritiously meals at proper temperatures and at appropriate times and to support proper sanitary techniques being utilized. At least three daily meals will be provided at regular times comparable to normal mealtimes in the community and the time between a substantial evening meal and breakfast following will not exceed 14 hours. Review of facility documentation titled Mealtimes, revealed that facility mealtimes are as follow: Breakfast at 7:00 A.M., lunch starts at 12:00 P.M. and dinner starts at 5:00 P.M. Observation of first floor dining room wall posting of mealtimes revealed breakfast is served at 8:00 a.m. lunch is served at 11:30 a.m., and dinner is served at 5:00 p.m. Observation of residents dining at lunchtime in the first-floor main dining room on September 3, 2024, revealed the first tray was delivered to a seated resident at 12:46 p.m. and the last tray was delivered to a resident at 1:14 p.m. In the dining room. Observation of first floor nursing unit on September 3, 2023, at 1:28 pm. Revealed Resident R130 waiting in the nursing unit corridor for the food truck delivery. Interview with Resident R130 at time of above observation revealed that he never knows what time the meals will be brought to the floor. All meals come at all different times. Resident 130 received his lunch tray at 1:39 p.m. Observation of lunch in the first-floor dining room September 4, 2023, revealed the first tray was delivered to a seated resident at 12:10 p.m. and the last tray was delivered on the floor at 12:44 p.m. Interview with Resident R136 on September 4, 2024 at 9:31 a.m. revealed this resident feels the food is always late, dinner is not served until 6:30 p.m. This resident tried to complain but stated the dietary door is always locked and no one ever answers. Interview with Dietary Director, Employee E8 on September 5, 2024, at approximately 2:00 p.m. revealed that this employee is aware and confirmed that the dining times have been inconsistent. Review of facility documentation, Meal Times undated, revealed that, Breakfast starts 7:00 a.m.; lunch starts 12:00 p.m.; dinner starts 5:00 p.m. Observation on the Second Floor Nursing Unit on September 3, 2024, revealed that the first lunch truck arrived at 12:40 p.m. Continued observation revealed that the second lunch truck did not arrive until 1:37 p.m. which was almost an hour after the first lunch truck had arrived. Further observation revealed that afternoon snacks, including sandwiches, pudding, and applesauce were delivered to the unit a 1:41 p.m. A group meeting held at 11 a.m., on September 4, 2024, on the first floor in therapy gym with 9 alert and oriented residents (Residents R5, R130, R71, R76, R102, R77, R57, R136, and R112 ) revealed that these residents are getting breakfast, lunch and dinner late daily. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa.Code 201.18(b)(3) Management

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to infection surveillance for two of two residents reviewed with infections (Residents R154 and R33), infection data reporting, enhanced barrier precautions and infection committee meetings, and Enhanced Barrier Precaution for one of one resident reviewed (Resident R165). Findings include: Review of facility policy, Infection Prevention Program dated last reviewed February 24, 2022, revealed that the facility uses a systematic and data-driven method to prevent, track and trend infections, surveil for outbreaks and monitor infection control practices for compliance. Continued review revealed that the Infection Preventionist is responsible for monitoring infections and completing monthly line listings and report forms. The infection prevention program includes staff and resident education on risk of infection and practices to decrease risk. Further review revealed that the infection prevention program includes a system for reporting to local, state and federal authorities as required for each disease or suspicion of disease. Act 52 of 2007 mandates that nursing homes develop and implement comprehensive infection control plans and reporting of healthcare-associated infections as serious events. The Pennsylvania Patient Safety Reporting System (PA-PSRS) was created as a system for facilities to submit the required information. Review of the Facility Assessment, dated updated August 8, 2024, revealed, The Infection Prevention Nurse is required to provide surveillance, analysis, and plan to recognize and prevent the spread of infection. Review of facility policy, Enhanced Barrier Precautions dated effective April 1, 2024, revealed that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms. Communication of enhanced barrier precautions is via signage posted on resident doors. Continued review revealed that enhanced barrier precautions are indicated for any residents with infection or colonization of multi-drug resistant organisms, wounds and/or indwelling medical devices, such as intravenous lines, urinary catheters and feeding tubes. During Entrance Conference on September 3, 2024, at 9:31 a.m. the Director of Nursing revealed that the role of the infection preventionist was shared between herself and Employee E4, Assistant Director of Nursing. Observation on September 3, 2024, at 10:41 a.m. and on September 4, 2024 at 10:50 a.m. revealed Resident R154 was resting in bed. The resident had a feeding tube and urinary catheter. There was no posted signage to indicate that the resident required enhanced barrier precautions. Review of the facility's wound tracking logs, dated August 30, 2024 revealed that Resident R154 had a stage four pressure ulcer on her sacrum (deep wound that affects muscles and bone). Review of Resident R154's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated August 12, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including multi-drug resistant organism (bacteria that is difficult to treat because it is resistant to commonly used antibiotics), pneumonia (lung inflammation caused by bacterial or viral infection), septicemia (a life-threatening infection that occurs when bacteria enter the bloodstream), and sacral pressure ulcer. Continued review revealed that the resident had a feeding tube and indwelling urinary catheter. Review of hospital records for Resident R154, dated August 9, 2024, revealed that the resident was treated in the hospital for shortness of breath and was found to have pneumonia. Resident R154 had sputum cultures completed that were positive for Klebsiella and ESBL (multi-drug resistant organisms) and was treated with intravenous antibiotics. The hospital records recommended to continue treatment with the intravenous antibiotic aztreonam for seven days upon discharge. Review of progress notes for Resident R154 revealed a nurses note, dated August 9, 2024, which indicated that the resident was readmitted to the facility. Continued review revealed a note, dated August 12, 2024, which indicated that lab results were received that the resident was positive for CRE (multi-drug resistant organism) and to initiate the intravenous antibiotic ertapenem for seven days. Review of Resident R154's Medication Administration Records (MARs) for August 2024, revealed physician orders, dated August 13 and 14, 2024, for ertapenem one gram intravenously every 24 hours for seven days. The medication was administered August 13 through 19, 2024. Further review of MARs revealed that there was no indication that the intravenous antibiotic aztreonam was administered as recommended in the hospital records. Review of Resident R33's Quarterly MDS, dated [DATE], revealed that the resident was admitted to the facility on [DATE], and had diagnoses including urinary tract infection. Continued review revealed that the resident was taking an antibiotic medication. Review of progress notes for Resident R33 revealed a note, dated August 8, 2024, at 3:31 p.m. which indicated that the resident had a fall and was transferred to the hospital for evaluation. Continued review revealed a practitioner note, dated August 14, 2024, at 3:01 p.m. which indicated that the resident was admitted to the hospital with a diagnosis of urinary tract infection and to administer cefdinir (antibiotic medication) August 13 through 18, 2024. Review of Resident R33's MARs for August 2024, revealed that the resident received cefdinir from August 14 through 18, 2024. Review of the Facility Matrix, dated September 3, 2024, at 10:13 a.m. revealed that thirteen residents had indwelling urinary catheters, one resident had a feeding tube and three residents had intravenous therapy. Review of the facility's wound tracking logs, dated August 30, 2024 revealed that 40 residents had wounds. A tour of the facility was conducted on September 5, 2024, between 11:38 am to 12:02 p.m. Observations revealed that enhanced barrier precautions signage had been posted on only two resident rooms for Residents R154 and R165. Interview on September 5, 2024, at 1:00 p.m. Employee E4, Assistant Director of Nursing, stated that he did not perform any of the functions of the facility's infection preventionist role. Interview on September 5, 2024, at 1:12 p.m. the Director of Nursing presented an antibiotic order listing for August 2024, however, continued interview revealed that she was unable to provide any evidence at the time of the survey to indicate infection surveillance that included tracking of infectious symptoms, infectious organism or evaluation of whether the infection was acquired while the resident was in the facility. The Director of Nursing was unable to provide any infection surveillance data for any months prior to August 2024. Continued interview, the Director of Nursing confirmed that enhanced barrier precautions were not implemented for Residents R154 and R165 until September 5, 2024, and that they were not implemented for all residents with indwelling urinary catheters, intravenous lines and chronic wounds as required. In addition, the Director of Nursing was unable to provide any evidence at the time of the survey to indicate that any staff received training related to enhanced barrier precautions. Continued interview revealed that no one at the facility had access to the PA-PSRS system and that they were unable to provide any utilization or infection reporting data. Further interview revealed that the Director of Nursing was unable to provide any documentation at the time of the survey of infection committee meetings. Review of clinical records revealed that Resident R165 was admitted in the facility on August 9, 2024, with diagnoses including Osteomyelitis of Vertebra, Thoracic Region (Osteomyelitis is an infection in a bone). Review of physician order for Resident R165, dated August 19, 2024, indicated a physician order; Enhanced barrier precautions related to: PICC Line Placement, When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting, Every shift until September 23, 2024 . On September 4, 2024, at 11:17 a.m., observed that a Registered Nurse (RN), Employee E 23 administered to Resident R 165, Unasyn Injection Solution Reconstituted 3 (2-1) GM (Ampicillin & Sulbactam Sodium), use 3 grams intravenously 6 hours for infection. Employee E23 did not implement Enhanced Barrier Precautions while providing the medication to Resident R165 intravenously. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management

Based on observations, review of facility's policies, interview with staff and resident, it was determined that the facility did not ensure that residents were treated with dignity and respect for 1 of 35 residents reviewed (Resident R62) Findings include: Review of facility investigation report for Resident R65 from February 12, 2024, revealed that the previous administrartor was reported on February 10, 2024, that a licensed nurse Employee E20 called Resident R65 wicked b*!*h. Reviewed investigation for Resident R65 statement on February 10, 2024, revealed [licensed nurse Employee E20] came to my room and didn't knock I asked her to knock, and she pulled open the privacy curtain and didn't close it. She called me a wicked white b*!*h. I was in the hallway. This was Saturday morning. Between 6am-7am. Further reviewed investigation statement from licensed nurse Employee E20 stated did anything happen with [Resident R65] on Saturday morning? Yes, I am always having problem with [Resident R65]. Every night I have to put her on behavior monitoring when you care for B bed. I have to chairs and curtain to B bed. When I check on B bed, [Resident R65] always comes out of room and follows me out. [Resident R65] will yell and scream at me at the nurse station saying it her room, I need to knock louder. On Saturday morning staff was in the room and [Resident R65] was screaming at staff. [Resident R65] keeps saying she shouldn't be in there; I went into the room to calm down the situations and tell [Resident R65[ she's not allowed to move curtain back. [Resident R65] than followed me out of room. Said I shouldn't working here. You are b*!*h then [Resident R65], began to yell racial slurs your black, I'm white and I did say you wicked witch, go back to your room. Investigation completed on February 14, 2024, with concluded Licensed nurse, Employee E20 provided statement which said she called resident wicked witch and the Licensed nurse, Employee E20 was terminated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 211.12(d)(1) Nursing services

Based on review of clinical records, review of facility documentation, review of hospital records and staff interviews, it was determined that the facility failed to ensure that Resident R1 with a history of aggressive behaviors towards staff and residents was properly supervised to prevent a serious bodily injury to Resident R2, for two of four residents reviewed (Resident R1 and Resident R2). This failure resulted in actual harm to Resident R2 who sustained a bruised, swollen and painful area surrounding the left cheek/eye area. Findings include: Review of Resident R1's July 2021 physician orders revealed that Resident R1 was admitted into the facility on [DATE] from another skilled facility with the diagnoses of cognitive communication deficit, unspecified sexual dysfunction, senile degeneration of the brain, [CONDITION(S)] (a serious mental illness characterized by extreme mood swings that can include extreme excitement episodes or extreme depressive feelings), post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event that an individual either experienced or witnessed), [CONDITION(S)] (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), anxiety (intense, excessive and persistent worry and fear about everyday situations). Review of Resident R1's interdisciplinary notes from September 30, 2020 through July 22, 2021 indicated behaviors that included: resident wandering/elopement attempts, resident touching and kissing female resident and female staff members, combative with staff, kicking another resident, and punching a nursing assistant, and delusion thoughts. Review of Resident R1's behaviors resulted in the facility contacting the police, mobile crisis, and the resident having at least two in-patient psychiatric hospitalization s due to his behaviors. Review of Resident R1's person-centered plan of care revised dated October 6, 2020 indicated a plan of care with a focus on the resident's behavioral problems related to senile degeneration of the brain, sexually inappropriate advances and statements at staff, in addition to physical and verbal aggression to staff and residents-hitting and yelling. The interventions outlined to assist the resident in this focus area include one-on-one supervision, which was initiated on November 17, 2020, by the facility approaching the resident in a calm manner, in addition to minimizing the potential for the resident's disruptive behaviors by offering the resident tasks which divert his attention. Continued review of the resident's person-centered plan of care initiated October 2, 2020 indicated a plan of care with a focus on the resident's mood problem related to anxiety, [CONDITION(S)], post-traumatic stress disorder, restlessness, and agitation. The intervention related to the focus area was to administer resident's [CONDITION(S)] medications as ordered. Review of Resident R1's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated May 18, 2021, indicated that the resident was severely cognitively impaired. The MDS also indicated that the resident was ambulatory (able to walk) and did not require the assistance of any mobility device (e.g. wheelchair, walker, cane). Review of Resident R2's Quarterly MDS assessment dated [DATE] indicated the diagnoses of depression (mood disorder that causes a persistent feeling of sadness and loss of interest) difficulty walking, muscle weakness and dysphagia (difficulty swallowing). The MDS also indicated that the resident was cognitively intact, was not ambulatory, and depended on the use of a wheelchair for mobility. Resident R2 required extensive assistance from staff with dressing, toilet use and personal hygiene (e.g. combing hair, brushing teeth, shaving). Review of facility documentation related to a resident to resident incident that occurred on March 2, 2021, at approximately 2:50 p.m. revealed that Resident R1 was involved in an incident that caused injury Resident R2. The incident occurred on Unit 1 nursing unit which resulted in Resident R2 sustaining a swollen and bruised left eye after being punched by Resident R1. The incident description included that Resident R1 entered the room of Resident R2 after Resident R1 was left unsupervised by nursing assistant, Employee E3. At the time of the incident, Employee E3 was to be providing one-on-one supervision to Resident R1. During an interview with nursing assistant, Employee E8 on July 22, 2021, at approximately 12:00 p.m. revealed that she was providing Resident R1 with one-on-one supervision for her shift, and that she asked nursing assistant, Employee E3 to watch the resident while she went outside to start her car and use the bathroom. Employee E8 reported that when she left, nursing assistant, Employee E3 and Resident R1 were sitting in front of the nursing station. Nursing assistant, Employee E8 reported that when she returned to the unit, she did not see Resident R1 or nursing assistant, Employee E3, so she walked to the dining room to see if they were both in that location. Nursing assistant, Employee E8 reported that when she came out of the dining room, she saw Resident R1 coming from out of the area where Resident R2's room was located. Nursing assistant, Employee E8 reported that she then saw Employee E8 coming out of the bathroom that was located behind the nurse's station. Employee E8 reported that she went to get Resident R1 and as she was getting Resident R1, she saw Resident R2 coming out of her room crying, and the resident stated that Resident R1 punched her. During an interview with nursing assistant, Employee E3 on July 22, 2021, at approximately 3:15 p.m. Employee E3 reported that she was asked by nursing assistant, Employee E8 to keep an eye out on Resident R1 while Employee E8 went out to her car. Employee E3 reported that she told Employee E3 ok when she was asked. Employee E3 reported that she was sitting next to the resident across from the nursing station when Employee E3 had to use the bathroom, and could not wait anymore for Employee E8 to come back in. Employee E3 reported that she stated that she told the people sitting at the nursing station that she will be back. Employee E3 reported that she stated, I'm going to the bathroom, someone keep an eye out. Employee E3 reported that at the time she left Resident R1 was coloring. Employee E3 reported that she was eventually told by the staff at the nurse station that they did not hear Employee E3 make the statement about leaving Resident R1. Employee E3 reported that when she came out of the bathroom, she saw licensed nursing staff, Employee E5 speaking with Resident R2. Employee E3 reported that during this time licensed nursing staff, Employee E5 notified staff that Resident R1 hit Resident R2. During an interview with licensed nursing staff, Employee E5 on July 22, 2021, at approximately 11:28 a.m. Employee E5 reported that she was on the unit and witnessed Resident R2 crying. Employee E5 reported that Resident R2 informed her that Resident R1 punched her. Employee E5 reported that Resident R2's left eye was swollen, and that she stayed with Resident R2 until the ambulance arrived to transport Resident R2 to the hospital. Review of Resident 2's pain assessment completed on March 2, 2021 indicated that that resident reported a pain level of 6 out of 10 and that the resident had Verbal Moderate Significant Pain. Review of Resident 2's skin assessment completed on March 2, 2021 confirmed a bruise under Resident R2's left eye measuring 1 centimeter in length and 1 centimeter in width. During an interview with nursing assistant, Employee E6 on July 22, 2021 at approximately 11:39 a.m. Employee E6 reported that she saw Resident R2 crying in the hallway and asked the resident what was wrong. Employee E6 reported that Resident R2 told her that she was hit by Resident R1. Employee E6 reported that she did not witness anything that led up to what Resident R2 told her. Review of the hospital records revealed that the resident was transported to the hospital emergency room from the facility for evaluation. Further review of hospital records indicated that the resident, presents to the emergency department after being punched in the left cheek area by another patient at the nursing facility. Hospital records indicated that Resident R2 was diagnosed with a facial contusion (a bruise that appears on an individual's face after any injury), and mild pain. Resident R1 was subsequently transported back to the facility on [DATE] after the completion her hospital evaluation. 28 Pa Code 201.18 (b)(3) Management 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of facility documentation, and the review of facility policies and procedures, and hospital records, it was determined that the facility failed to ensure that Resident R2 was free from physical abuse from another resident who was not properly supervised (Resident R1), for one out of four residents reviewed. This failure resulted in Resident R2 being punched in the face by Resident R1 and sustaining a bruised, swollen and painful area on the left cheek/eye area. Findings include: Review of the facility's policy, Abuse, Neglect & Misappropriation with a revised date of 4/1/2019. The facility policy outlines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress. The facility policy stated the term willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident R1's July 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's interdisciplinary notes from September 30, 2020 through July 22, 2021 indicated behaviors that included: resident wandering/elopement attempts, resident touching and kissing female resident and female staff members, combative with staff, kicking another resident, and punching a nursing assistant, and delusion thoughts. Review of Resident R1's behaviors resulted in the facility contacting the police, mobile crisis, and the resident having at least two in-patient psychiatric hospitalization s due to his/her behaviors described above. Review of Resident R1's person-centered plan of care revised date October 6, 2020 indicated a plan of care with a focus on the resident's behavioral problems related to senile degeneration of the brain, sexually inappropriate advances and statements at staff, in addition to physical and verbal aggression to staff and residents-hitting and yelling. The interventions outlined to assist the resident in this focus area included one-on-one supervision, which was initiated on November 17, 2020 by the facility, approaching the resident in a calm manner, in addition to minimizing the potential for the resident's disruptive behaviors by offering the resident tasks which divert his/her attention. Continued review of the resident's person-centered plan of care dated October 2, 2020, indicated a plan of care with a focus on the resident's mood problem related to anxiety, [CONDITION(S)], post-traumatic stress disorder, restlessness, and agitation. The intervention related to the focus area was to administer resident's [CONDITION(S)] medications as ordered. Review of Resident R1's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated May 18, 2021, indicated that the resident was severely cognitively impaired. The MDS also indicated that the resident was ambulatory (able to walk around), and did not require the assistance of any mobility device to (e.g. wheelchair, walker, cane). Review of Resident R2's Quarterly MDS assessment dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated that the resident was cognitively intact, was not ambulatory, and depended on the use of a wheelchair for mobility. Resident R2 also required extensive assistance from staff with dressing, toilet use and personal hygiene (e.g. combing hair, brushing teeth, shaving). Review of facility documentation revealed that on March 2, 2021, at approximately 2:50 p.m. Resident R1 was involved in an incident that caused injury to Resident R2 on the Unit 1 nursing unit. Resident R1 was left unsupervised by nursing assistant, Employee E3. Resident R1 entered Resident R2's room and punched Resident R2 in the face. The incident resulted in Resident R2 sustaining a swollen and bruised left eye. During an interview with nursing assistant, Employee E8 on July 22, 2021 at approximately 12:00 p.m. Employee E8 reported that she was providing Resident R1 with one-on-one supervision for her shift, and that she asked nursing assistant, Employee E3 to watch the resident while she went outside to start her car and use the bathroom. Employee E8 reported that when she left, Employee E3 and Resident R1 were sitting in front of the nursing station. Employee E8 reported that when she came back, she did not see the resident or Employee E3, so she walked to the dining room to see if they were both in that location. Employee E8 reported that when she came out of the dining room, she saw Resident R1 coming from out of the area where Resident R2's room was located. Employee E8 reported that she then saw Employee E8 coming from out of the bathroom that was located behind the nurse's station. Employee E8 reported that she went to get Resident R1 and as she was getting Resident R1, Resident R2 came out of his/her room crying, and stated that Resident R1 punched her. During an interview with nursing assistant, Employee E3 on July 22, 2021 at approximately 3:15 p.m. Employee E3 reported that she was asked by Employee E8 to keep an eye out on Resident R1 while Employee E8 went out to her car. Employee E3 reported that she told Employee E3 ok when she was asked. Employee E3 reported that she was sitting next to the resident across from the nursing station when Employee E3 had to use the bathroom, and could not wait anymore for Employee E8 to come back in. Employee E3 reported that she stated that she told the people sitting at the nursing station that she will be back. Employee E3 reported that she stated, I'm going to the bathroom, someone keep an eye out. Employee E3 reported that at the time she left Resident R1 she was coloring. Employee E3 reported that she was eventually told by the staff that they did not hear Employee E3 make the statement about leaving Resident R1. Employee E3 reported that when she came out of the bathroom, she saw licensed nursing staff, Employee E5 speaking with Resident R2. Nursing assistant, Employee E3 reported that during this time Employee E5 notified staff that Resident R1 hit Resident R2. During an interview with licensed nursing staff, Employee E5 on July 22, 2021, at approximately 11:28 a.m. Employee E5 reported that that she was on the unit and witnessed Resident R2 crying. Employee E5 reported that Resident R2 informed her that Resident R1 punched her. Employee E5 reported that Resident R2's left eye was swollen, and that she stayed with Resident R2 until the ambulance arrived to transport Resident R2 to the hospital. Review of the hospital records revealed that the resident was transported to the hospital emergency room from the facility for evaluation. Further review of hospital records indicated that the resident, presents to the emergency department after being punched in the left cheek area by another patient at the nursing facility. Hospital records indicated that Resident R2 was diagnosed with a facial contusion (a bruise that appears on an individual's face after any injury), and mild pain. Resident R1 was subsequently transported back to the facility on [DATE] after the completion her hospital evaluation. Refer to F689 28 Pa Code 201.18 (b)(3) Management 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of clinical records, facility documentation, facility policy and interviews with facility staff, it was determined that the facility failed to provide adequate supervision and monitoring to ensure the safety of a resident identified as an Elopement and Fall risk resulting in actual harm for one of 3 residents (Residents R1). Review of Resident R1's clinical record revealed admission orders [REDACTED]. An Elopement Risk assessment dated [DATE], identified Resident R1 as an Elopement Risk and required an electronic bracelet. A review of the facility's policy on Elopement Management, (last revised March 2007), revealed that staff should redirect and reassure the resident with elopement behaviors. A review of Resident R1's plan of care assessment tool, last updated July 23, 2013, revealed that the resident was an elopement risk with cognitive and psychological impairment who was restless and irritable and has a history of a fall. Review of a nursing note dated August 6, 2013, at 4:21 a.m. revealed that Resident R1 could not be located at 2:20 a.m. on his second floor nursing unit. The licensed nurse stated that Resident R1 was last seen by her a few minutes ago walking away from his room towards another hallway. This note also stated that no alarms were heard on this floor, however, the licensed nurse went down to the first floor unit via the elevator where she was notified that a resident was lying outside the lobby entrance at 2:32 a.m. and the alarm was sounding at the bottom of the stairwell across from Resident R1's room. A review of the next nursing note dated August 6, 2013, at 6:43 a.m. revealed that the resident was admitted to the hospital with [REDACTED]. Interview with Employee E4 (Assistant Director of Maintenance) on September 18, 2013, at 11:30 a.m. revealed that the alarm on the second floor where Resident R1 resided malfunctioned and did not alarm when Resident R1 entered it. A review of the facility's documentation did not reveal that the resident was redirected or reassured as identified in the facilities Elopement Policy. + The facility failed to consistently supervise and monitor this resident to prevent elopement and ensure this resident's safety resulting in actual harm to the resident.. 28 Pa. Code: 201.18(a)(1) Management. (Previously cited 1/25/2013) 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 Pa. Code: 211:12(d)(5) Nursing services. (Previously cited 1/25/2013)