Every finding on record at Broad Mountain Health and Rehabilitation Center

Based on select facility policy, a review of clinical records, grievances filed with the facility, and staff interviews, it was determined the facility failed to afford residents the right to refuse a resident's room change that was for the purpose of staff convenience for one resident out of 8 residents reviewed (Resident 1). Findings include:A review of the facility policy titled Room and Roommate Change Policy, last reviewed by the facility on January 19, 2026, revealed that it is the facility policy to notify the resident and resident representative prior to a room or roommate change, including the reason for the change. The resident and resident representative will be notified promptly of the room change and the reason for the change. Reasons for changing a resident's room include, but are not limited to, promoting resident safety, health, and well-being; room repairs or renovations; roommate incompatibility; clinical needs; specialized medical needs; specialized services or programming in an area of the facility; or emergency.A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).A review of Resident 1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 30, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 2 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 through 07 indicates cognition is severely impaired).A review of a room change notice form dated June 25, 2026, revealed Resident 1 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] due to long-term care.A progress note dated June 26, 2026, at 10:43 AM revealed Resident 1 transferred to room [ROOM NUMBER]. The note indicates Resident 1's representative was made aware of the move.A progress note dated June 27, 2026, at 1:46 PM revealed Resident 1's representative was not pleased with Resident 1's room change.A grievance filed with the facility dated July 8, 2026, revealed Resident 1's representative filed a complaint with the facility indicating that she would like Resident 1 moved back down to the 1st floor. The grievance form indicated the facility responded to the grievance, explaining that Resident 1 was kept on the 1st floor short-term care area to be with her husband. After Resident 1's husband passed, her room was moved. The grievance form indicated Resident 1's representative was not satisfied with the resolution of the grievance and wants Resident 1 to return to the 1st floor.A review of the Facility Assessment (a comprehensive, facility-wide evaluation to ensure a nursing home has the exact resources, staff, and environment needed to care for its specific residents) last reviewed by the facility on July 23, 2026, revealed no documentation designating any nursing areas as specialized units. The assessment provided no evidence that the floors maintain different staffing patterns, specialized training, or distinct clinical services that would necessitate moving a resident based on a transition from short-term to long-term care status.During an interview on August 27, 2026, at 1:30 PM, the above information was reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA and DON were unable to provide clinical justification, necessitating moving Resident 1 from room [ROOM NUMBER] to room [ROOM NUMBER] due to long-term care on June 26, 2026. The DON and NHA confirmed that there are no rooms that are furnished with specialized equipment or offer distinct clinical services. The facility failed to provide clinical justification for Resident 1's room transfer, demonstrating the resident was moved solely for the convenience of staff.28 Pa. Code 201.29 (a) Resident Rights

Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents for one out of the seven residents (Resident 3). Findings include: A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included paroxysmal atrial fibrillation (a type of irregular heart rhythm where the upper chambers of the heart beat chaotically and out of sync).A review of Resident 3's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2026, revealed Resident 3 was moderately cognitively impaired, with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that was used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicated cognition was moderately impaired). An admission activities observational report dated March 10, 2026, revealed Resident 3 indicated he enjoys listening to music, being around animals and pets, keeping up with the news, participating in religious practices, and going outside. These activities were documented as very important to him. Additionally, it was indicated that engaging in activities with groups of people was somewhat important to him. A clinical record review revealed no documented evidence the facility developed a care plan that included Resident 3's activity preferences and goals to ensure his needs and interests were met and to support his physical, mental, and psychosocial well-being. A review of Resident 3's clinical record revealed no documented evidence activities that met the resident's interests and needs were offered or attended by the resident. During an interview on August 27, 2026, at 12:34 PM, the director of activities indicated she was not familiar with Resident 3. She explained that Resident 3 did not actively participate in group activities but sometimes attended programs. The director of activities was unable to provide documented evidence of Resident 3's attendance in any group activities, his participation level, or the facility's attempts to engage Resident 3 in activities that met his needs or interests. The director of activities indicated the department had no records of Resident 3's activities engagement. The director confirmed the facility failed to develop a care plan goal to ensure the facility provided Resident 3, a resident with moderate cognitive impairment, with a program of activities that met his interests and supported his physical, mental, and psychosocial well-being. During an interview on August 27, 2026, at 1:30 PM, the above information was reviewed with the nursing home administrator (NHA) and the director of nursing (DON). The NHA and DON confirmed the facility failed to develop a care plan to ensure the facility provided Resident 3 with ongoing activities that met his needs and interests and supported his physical, mental, and psychosocial well-being. The NHA and DON were unable to provide documented evidence of Resident 3's attendance in any group activities, his participation level, or the facility's attempts to engage Resident 3 in activities that met his needs or interests. The facility failed to provide an ongoing activities program that met the needs and interests of Resident 3 and supported his physical, mental, and psychosocial well-being. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(3) Nursing services.

Based on review of select facility policy, the facility's infection control log, and staff interview, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program.Findings included: A review of the facility Infection Prevention and Control Program Policy last reviewed January 9, 2026, revealed it is the facility policy to maintain an organized, effective facility wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers, to conduct surveillance of communicable diseases and infectious outbreaks, and to monitor employee health. This program involves the intersection of many programs, policies, and services within the facility and is designed to meet the intent of regulatory guidance. Particular focus of the program will be on conducting assessment, surveillance, reducing healthcare associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary. The infection preventionist's responsibilities for infection prevention and control include conducting surveillance of staff and residents for facility associated or community associated infections and, or communicable diseases. A review of facility monthly infection control logs for April 2025 through December 2025 revealed the facility failed to consistently document critical infection related details such as location of infections and symptoms experienced by residents. The facility's infection control tracking did not reflect evidence of a current functioning tracking system to monitor and investigate causes of infection and manner of spread. There was no documented evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. During an interview with the Director of Nursing (DON) and Infection Preventionist on February 5, 2026, at 1:15 PM the DON failed to provide documented evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. The DON acknowledged that the facility's infection control logs were incomplete and failed to support a comprehensive infection prevention and control program. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of facility policies, clinical record review, and interviews with residents and staff, it was determined the facility failed to ensure residents were afforded the right to participate in the planning of their care and treatment, including failure to conduct care plan conferences and failure to invite residents to participate in the interdisciplinary care planning process, for two of 25 residents reviewed (Residents 80 and 36).Findings include: Review of the facility policy titled Comprehensive Care Planning Policy last reviewed January 19, 2026, indicated the interdisciplinary team (IDT) is responsible for resident care plans. The IDT includes, but is not limited to, the resident's attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition staff, to the extent practicable the resident and/or the resident's representative, and other staff as necessary to meet the needs of the resident, or as requested by the resident. The policy further states the care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with the Resident Assessment Instrument (RAI the mandated, standardized system used to assess nursing home residents and guide care planning) requirements. Review of the facility policy titled Care Plan Invitation Letter Policy last reviewed January 19, 2026, indicated the resident and the resident's responsible party or legal representative will be invited to attend the interdisciplinary care planning conference. The policy required a designated staff member to complete and deliver invitations to residents prior to the conference date and to mail or call family/responsible parties/representatives within seven days of the conference date. Copies of invitations are to be maintained as verification, and phone notifications are to be documented in the clinical record. The resident is to sign a copy of the invitation as verification of receipt. The policy also requires documentation in the electronic health record of all individuals attending the care planning conference, including the resident. Review of the clinical record revealed Resident 80 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), skin cancer, and Type 2 diabetes (chronic condition where the body resists the effects of insulin or does not produce enough, leading to high blood sugar levels). Review of Resident 80's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 22, 2025, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognition). During an interview on February 3, at 11:10 AM, Resident 80 stated that he had not been invited to participate in the care planning process and had not attended any care plan meetings with facility staff for a long time. He stated he would like to meet with staff to discuss his care. Review of the clinical record revealed no documented evidence that a care plan conference had been conducted for Resident 80 within the past year and no documentation that the resident was invited to participate in the development or review of his comprehensive care plan. Review of the clinical record revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses including congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), respiratory failure (not enough oxygen passes from the lungs to the blood, making it difficult to breath), and Type 2 diabetes. Review of Resident 36's quarterly MDS, dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. During an interview on February 3, at 11:25 AM, Resident 36 stated that he had not been invited to participate in the care planning process and had not attended a care plan conference with facility staff for at least one year. He stated he would like to meet with staff to discuss his care. Review of the clinical record revealed no documented evidence that a care plan conference had been conducted for Resident 36 within the past year and no documentation that the resident was invited to participate in the development or review of his comprehensive care plan. During an interview on February 5, 2026, at 1:05 PM, the Nursing Home Administrator reviewed the above findings. The Administrator confirmed there was no documentation to demonstrate that care plan conferences had been conducted for Residents 80 and 36 within the past year and no documentation to show the residents were invited to participate in the care planning process.28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on review of facility policy, clinical records, and interviews with residents and staff, it was determined the facility failed to ensure effective pain management and failed to implement, monitor, and revise pain interventions to maintain each resident's highest practicable level of well-being for two of 25 residents reviewed (Residents 11 and 4). Findings include: A review of the facility's Pain Management Protocol, last reviewed January 19, 2026, revealed the facility would assess residents' pain to maintain their highest practicable level of physical, mental, and psychosocial well-being. Evaluation of pain treatment effectiveness would be monitored and adjusted according to resident needs. Both medication and non-medication techniques would be utilized to maintain resident comfort to the extent possible. When medication-related interventions are required, documentation will be included in the resident's clinical record on the effectiveness or need to adjust treatment. Clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with a diagnosis of chronic pain and a Stage IV open pressure ulcer, (a severe open wound involving full-thickness tissue loss that may expose muscle, tendon, or ligament and is typically painful) located on the sacrum (lower back area near the tailbone). An admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care dated January 20, 2026, revealed that Resident 11 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact) and was identified to have a Stage IV pressure sore on admission. A review of the admission physician orders dated January 14, 2026, revealed treatment of the sacral wound every other day and as needed consisting of removal of the old dressing, cleansing of the wound, application of ointments, packing of the wound with dressing material, and placement of a protective covering to protect the wound from infection and promote healing. During an interview on February 6, 2026, at 9:15 AM, Resident 11 stated dressing changes to the sacral area were very painful, and that treatments performed on both day and evening shifts hurt. The resident explained that removal and replacement of the wound packing caused soreness and that staff were aware of this pain. Review of the care plan dated January 15, 2026, addressing pain related to skin integrity failed to indicate staff identified or considered the likelihood of pain during wound treatment procedures or implemented interventions to reduce procedural pain. A review of the January/February 2026 physician orders failed to indicate specific orders in which the resident would receive pain medication prior to the dressing changes to the sacral area to alleviate the pain and make the procedure more tolerable. A review of the treatment record for January and February 2026 revealed the resident received treatment for the Stage IV pressure ulcer five times since admission, in which there was no conclusive evidence that pain medication was offered prior to the treatment or that specific physician orders coordinated with the treatment to the sacral area were discussed/obtained to alleviate or reduce Resident 11's pain during the procedure.During an interview on February 6, 2026, at 12:15 PM, the Director of Nursing was unable to provide evidence that Resident 11's procedural pain during wound treatments had been addressed or that medication administration had been coordinated with treatment to reduce pain. Review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (degeneration of the cartilage, which acts as a protective cushion between bones in joints. It causes chronic pain, stiffness, swelling and reduced range of motion), cervical disc disorder with radiculopathy at the cervicothoracic region (a pinch nerve in the lower neck caused by an issue with the intervertebral disc. This causes pain, numbness, or weakness that radiates from the base of the neck into the shoulder, upper back or down the arm), and Hodgkin's lymphoma (cancer of the lymphatic system, a part of the body's immune system, which causes white blood cells to grow abnormally).Review of Resident 4's quarterly MDS, dated [DATE], revealed the resident was cognitively intact with a BIMS score of 13. Section J (Health Conditions for Pain) indicated the resident experienced pain in the last 5 days that was almost constant, occasionally affected sleep, frequently interfered with day-to-day activities, and was of moderate severity. During an interview on February 3, 2026, at 10:35 AM, Resident 4 stated he experiences chronic pain all the time. He reported he previously had an order for oxycodone (a narcotic opioid pain medication) PRN (as needed, meaning given when required for symptoms) but now receives oxycodone only once daily at bedtime. He described a recent off-site medical appointment requiring wheelchair van transportation, after which he returned with pain rated 10 out of 10 on a pain scale (a standardized measurement tool used to assess pain intensity, where 0 represents no pain and 10 represents the worst possible pain). The resident stated he requested pain medication but was informed he could only receive Tylenol at that time, which he reported did not relieve his pain. He stated staff did not respond to his statements that the medication was ineffective and that his pain is not adequately controlled, negatively affecting his quality of life. Review of physician orders dated August 30, 2025, revealed an order for oxycodone 10 milligrams by mouth every six hours as needed for moderate pain (rated 4 to 6). Review of physician orders dated October 29, 2025, revealed the PRN oxycodone order was discontinued and replaced with oxycodone 15 milligrams by mouth once daily at bedtime. Nursing documentation dated October 29, 2025, confirmed the change. Review of pain assessments revealed progressive worsening of pain:On October 28, 2025, the resident reported occasional pain that occasionally affected sleep and rarely affected daily activities.On November 17, 2025, the resident reported frequent pain that frequently affected sleep and rarely affected daily activities.On January 15, 2026, the resident reported pain that was almost constant, occasionally affected sleep, and frequently interfered with daily activities. The assessment also documented new symptoms of shortness of breath when lying flat and noted the resident complained of moderate pain. Nursing documentation indicated Tylenol was administered PRN, and the resident was instructed to request pain medication as needed.Despite documented increases in pain frequency and interference with daily functioning, the clinical record revealed no evidence that the resident's pain management regimen was reassessed, revised, or that the attending physician was timely notified to address the resident's escalating pain and reported lack of relief from current interventions.During an interview on February 6, 2026, at 12:07 PM the Director of Nursing (DON) confirmed licensed nursing staff failed to timely notify the resident's attending physician of increased pain complaints and failed to obtain new or revised orders to effectively manage Resident 4's pain. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services28 Pa. Code 211.10 (c)(d) Resident care policies

Based on a review of facility policy, clinical record review, observations, and staff interviews, it was determined the facility failed to ensure the availability of required emergency dialysis supplies for one resident (Resident 5) and failed to plan individualized care for a resident receiving hemodialysis to ensure the resident's care plan was consistent with physician orders for one resident (Resident 14) out of two residents sampled who received hemodialysis.Findings include: According to the National Kidney Foundation, patients receiving hemodialysis (a machine that filters waste, salts, and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately) should have access to emergency care supplies, including at bedside, to promptly respond to complications such as bleeding from the dialysis access site. For residents with an arteriovenous (AV) fistula, a surgically created connection between an artery and a vein commonly used for dialysis access, rapid access to emergency supplies is critical, as complications such as ruptures or bleeds from the site can result in life-threatening blood loss. A review of the facility policy titled Hemodialysis Care Policy, last reviewed by the facility on January 19, 2026, revealed it is the policy of the facility that licensed staff with demonstrated competence will care for residents who require hemodialysis. Further review revealed that if bleeding occurs at the needle site any time after dialysis, apply moderate pressure over the site with a sterile 4 x 4 gauze pad for 5-10 minutes until bleeding stops, and contact the provider for excessive bleeding uncontrolled by moderate pressure. A clinical record review of Resident 5 revealed the resident was admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) with dependence on dialysis (a medical treatment that uses a machine to filter waste, excess fluids, and toxins from the blood when the kidneys can no longer perform this function properly). A review of an annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 30, 2025, revealed Resident 5 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A physician's order dated April 5, 2024, directed staff to maintain emergency equipment in an E-Kit (emergency supply kit), including hemostats (clamp), gauze, and tape, at the bedside, taped behind the headboard, and on the resident's wheelchair at all times for dialysis access emergencies. An emergency dialysis kit is there to control active bleeding at the fistula site, which can be a medical emergency if not addressed immediately. A care plan initiated May 20, 2024, identified the resident as receiving hemodialysis and included interventions such as avoiding blood pressure measurements or blood draws in the affected arm and ensuring the emergency dialysis kit was available behind the headboard and on the wheelchair. Observation on February 3, 2026, at 11:40 AM revealed no emergency dialysis supplies were present at the bedside or on the wheelchair. During interview at that time, Employee 2, Nurse Aide, confirmed emergency supplies for the dialysis access site were not present and stated they are normally kept behind the headboard and on the wheelchair. The above findings were reviewed during an interview with the Nursing Home Administrator (NHA) on February 5, 2026, at 1:00 PM, and confirmed the facility failed to ensure that emergency dialysis access supplies were available as ordered and required by the residents' care plan.Clinical record review revealed Resident 14 was admitted [DATE], with diagnoses including diabetes and end-stage kidney disease and received hemodialysis three times weeklyevery Monday, Wednesday, and Friday.A current physician order dated September 19, 2025, indicated the resident had a fistula (surgically created connection between an artery and a vein that allows blood to flow directly from the artery into the vein.dialysis access site in the left arm and directed staff to assess the site each shift for a bruit (a whooshing sound heard with a stethoscope indicating blood flow through the fistula) and thrill (a vibration felt over the site indicating blood flow). Staff were to notify the physician of abnormal findings. Review of the resident's care plan, initially dated December 31, 2024, and last reviewed December 1, 2025, revealed no interventions addressing monitoring or care of the resident's current fistula dialysis access site. The care plan indicated an intervention initially dated January 5, 2025, for a Permacath (catheter placed into the blood vessel in the upper chest and is threaded to the right side of the heart) to the right chest. Clinical record review confirmed the Permacath had been removed December 4, 2025. During interview on February 5, 2026, at 1:30 PM, the Director of Nursing confirmed Resident 14's care plan did not accurately reflect the resident's current dialysis access or care needs.28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of three medication storage rooms (first floor medication room).Findings include: A review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, last reviewed by the facility January 19, 2026, indicated that if a multi-dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. An observation of the first-floor medication room on February 5, 2026, at 10:45 AM, in the presence of Employee 1, Registered Nurse (RN), of medication stored in the medication refrigerator, revealed three multi-dose vials of Aplisol (solution used for screening tuberculosis) that had been opened and available for use but not dated when initially opened. A review of the manufacturer's dosage and administration recommendation for Aplisol revealed that vials in use for more than 30 days should be discarded. An interview with Employee 1 at the time of the observation on February 5, 2026, at 10:45 AM, confirmed the Aplisol had been opened and not dated, and the medications should have been removed from the medication refrigerator and discarded. An interview with the Director of Nursing on February 5, 2026, at 10:50 AM, confirmed that the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures for smoking safety, as evidenced by two out of six residents sampled for smoking. (Residents 5 and 53).Findings include: A review of the facility policy titled Smoking Policy, last reviewed by the facility on January 19, 2026, revealed it is the facility policy to establish resident smoking processes that consider both smoking and non-smoking residents and that comply with applicable federal, state, and local laws and regulations regarding smoking, smoking areas, and smoking safety. The policy indicated that any resident that chooses to smoke will be further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. A clinical record review of Resident 5 revealed the resident was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of an annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 30, 2025, revealed that Resident 5 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A clinical record review revealed a care plan initiated on May 20, 2024 indicating Resident 5 currently uses tobacco. Interventions in place to assist Resident 45 to safely smoke include staff supervision while smoking, with use of a smoking apron. A smoking risk observation report dated May 27, 2025, revealed Resident 5 was considered a safe smoker and can follow the facility policy for safe smoking. Further clinical record review for Resident 5 revealed no subsequent smoking risk observation reports or assessments for safe smoking. Following the surveyor inquiry, a smoking safety assessment was completed on February 4, 2026, confirming the resident remained a safe smoker. This assessment occurred 253 days after the prior evaluation, exceeding the 90-day quarterly requirement established by the facility's policy. A clinical record review revealed Resident 53 was admitted to the facility on [DATE], with diagnoses that included anxiety (a mental condition that causes a feeling of worry, nervousness, or unease) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of an annual MDS assessment dated [DATE], revealed that Resident 53 was cognitively intact with a BIMS score of 15 (a score of 13 to 15 indicates cognition is intact). A clinical record review revealed a care plan indicating Resident 53 currently used tobacco, initiated on April 30, 2024. Interventions in place to assist Resident 51 to safely smoke included ensuring staff to complete smoking assessments for safety and the use of a smoking apron and cigarette holder. A smoking risk observation report dated July 15, 2025, revealed Resident 53 was considered a safe smoker and was able to follow the facility policy for safe smoking. Further clinical record review revealed no subsequent smoking risk observation reports or assessments for safe smoking. Following the surveyor inquiry, a smoking safety assessment was completed on February 4, 2026, confirming the resident remained a safe smoker. This assessment occurred 204 days after the prior evaluation, exceeding the 90-day quarterly requirement established by the facility's policy. During an interview on February 5, 2026, at 10:00 AM, the Director of Nursing (DON) confirmed it is the facility's policy to assess residents' ability to safely smoke at least quarterly (90 days) or with any significant change, and confirmed it is the facility's responsibility to implement procedures to ensure residents are assessed and monitored for smoking safety. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 209.3 (a) Smoking 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for one resident out of 25 sampled (Resident 45).Findings include: A review of the facility's policy titled Oxygen Administration Policy, last reviewed January 19, 2026, revealed it is facility policy that licensed clinicians with demonstrated competence will administer oxygen via the specific route as ordered by a provider. Further review of the policy revealed that staff should perform hand hygiene and apply gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures included changing the tubing, mask, or cannula weekly. A clinical record review revealed Resident 45 was admitted to the facility on [DATE], with diagnoses that included asthma (a chronic lung disease causing inflammation and narrowing of the airways), chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), and dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 18, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A review of Resident 45's clinical record revealed a physician's order dated January 14, 2026, to administer oxygen at 2.0 liters per minute (L/min) via nasal cannula or mask. A nasal cannula is a flexible plastic tube with two small prongs that fit into the nostrils and is used to deliver supplemental oxygen to assist with breathing. A review of Resident 45's comprehensive care plan, last revised January 14, 2026, indicated the resident had an altered respiratory status (difficulty maintaining normal breathing function) related to asthma (a chronic lung condition that causes airway narrowing), chronic obstructive pulmonary disease or COPD (a progressive lung disease that limits airflow), and an upper respiratory infection (infection involving the nose, throat, or airways). The care plan included interventions such as providing respiratory therapy as ordered and monitoring oxygen saturation (percentage of oxygen carried in the blood) using pulse oximetry (small device placed on a fingertip that estimates oxygen levels in the bloodstream) as ordered. An observation conducted on February 3, 2026, at 11:05 AM, revealed Resident 45 seated in her wheelchair in her room with the oxygen turned off, despite having a physician's order for continuous oxygen. During the observation, Employee 3, a Licensed Practical Nurse (LPN), stated that the resident had an order for continuous oxygen and that it should remain on at all times. The LPN assessed the resident's oxygen saturation using a pulse oximeter and obtained a reading of 94%. Observation of the nasal cannula tubing revealed there was no documented date indicating when the tubing was last changed. The LPN then obtained new oxygen tubing and applied oxygen at 2 L/min via nasal cannula.At the time of the survey on February 3, 2026, the care plan did not specifically indicate that Resident 45 required continuous oxygen use. Following surveyor inquiry, documentation indicated that oxygen at 2 L/min continuous via nasal cannula was initiated on February 4, 2026. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 4, 2026, at 1:55 PM, the above findings for Resident 45 were reviewed. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to timely act upon a recommendation to reduce an antianxiety medication (medication used to calm the nervous system and balance brain chemistry) for one of 25 residents sampled (Resident 9). Findings include: A review of the facility Psychoactive Medication Policy(medication that affects brain activities associated with mental processes and behaviors, includes antianxiety medication) last reviewed January 19, 2026, indicated that all residents receiving psychoactive medications will have their behaviors, effectiveness of interventions (pharmacological and nonpharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. A review of the resident's clinical record revealed that Resident 9 was admitted to the facility on [DATE], with diagnoses that included a left calcaneus fracture (broken heel bone in the left foot) and anxiety. Review of admission physician orders dated January 5, 2026, revealed an order for Lorazepam 0.25 mg (antianxiety medication) twice per day by mouth for anxiety. Review of a consultant CRNP (certified registered nurse practitioner) psychology note dated January 6, 2026, revealed the resident noted that she was on the antianxiety medication for several years, felt she was no longer anxious, and wanted to try a lower dose of Lorazepam. The consultant CRNP agreed and requested a gradual dose reduction to Lorazepam 0.25 mg once daily. Review of the clinical record revealed no documented evidence that the facility notified the resident's physician to decrease the Lorazepam to 0.25 mg once daily per the consultant's recommendation. Review of a consultant CRNP psychology note dated January 13, 2026, revealed the resident still wished to have the Lorazepam decreased. The note indicated the request from January 5, 2026, was neither approved nor declined. A request to decrease the Lorazepam to 0.25 mg once daily was again noted. Review of a nurses note dated January 14, 2026, noted Gradual Dose Reduction (GDR) of Ativan (Lorazepam) per psych and resident's request due to not feeling anxious. Resident placed on daily charting times two weeks to monitor or any signs and symptoms of anxiety. All parties aware. Further review of the clinical record revealed no documented evidence the physician was notified to decrease Lorazepam to 0.25 mg by mouth to once daily as per the recommendation of the outside CRNP psych consultant and resident request. Review of Resident 9's January Medication Administration Record revealed that Lorazepam 0.25 mg was administered twice daily from January 6, 2026, through January 19, 2026. A physician order dated January 20, 2026 (14 days after the original request to GDR the antianxiety medication), noted an order to decrease Lorazepam 0.25 mg to once daily by mouth for a diagnosis of anxiety. An interview with the Director of Nursing on February 5, 2026, at 1:00 PM failed to provide documented evidence the facility timely reduced Resident 9's antianxiety medication when recommendation was made. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean and homelike environment in resident areas on two of two resident floors (first floor shower room and second floor dining room and residential units).Findings included:An observation on November 19, 2025, at 8:55 AM in the first-floor shower room revealed a large hole in the wall along the baseboard trim near the toilet and a missing ceiling tile in front of the privacy curtain. An observation on November 19, 2025, at 12:00 PM on the second floor East Wing revealed a 4-inch brown stain, resembling a water stain, with noted black stains within the brown on a ceiling tile near the nurses station.An observation on November 19, 2025, at 12:35 PM of the second floor East Wing dining room revealed three ceiling tiles that contained large brown stains, resembling water stains.An observation on November 19, 2025, at 12:40 PM of Resident 5's room revealed a used rubber glove, a used plastic cup, a towel, and multiple crumbs and debris under the resident's bed. An observation on November 19, 2025, at 12:45 PM of Resident 8's room revealed a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with the lid removed on the floor containing brown liquid. The brown liquid was splattered on the floor between Resident 8 and Resident 6's bed and was also noted to be splattered on Resident 6's fitted bed sheet. Under Resident 8's nightstand were multiple used tissues, napkins, and a used face mask. Interview with Resident 7, Resident 6 and 8's roommate, during the time of the observation, reported that housekeeping does not come into their room to clean every day. The residents stated, somedays the floor is so bad, it's embarrassing.Continued observation of Resident 7's room revealed a tabletop oscillating fan positioned on top of a transfer board (a flat, smooth board used in therapy and rehabilitation to help a person move safely from one surface to another when they cannot stand or bear full weight) which was on top of the push handles of her roommate's wheelchair. The fan was plugged into the wall outlet. When questioned about the unsafe location and position of the fan, Resident 7 stated that the fan had previously been on an over-the-bed table, but staff removed the table to give it to another resident and propped the fan on the back of the wheelchair handles. Further observation revealed two positioning wedges (wedges utilized to support a resident to maintain a side lying position to offload pressure on their backside) in direct contact with floor in the corner of her room by the window. Interview with the Nursing Home Administrator and Director of Nursing on November 19, 2025, at 3:50 PM confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18(e)(2.1) Management

Based on a review of nursing staffing hours and staff to resident ratios, resident census, clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to provide sufficient nursing staff to ensure that each resident received timely, person-centered care, services, and supervision necessary to maintain the physical, mental, and psychosocial well-being of the resident population for five of 18 sampled residents (Residents 1, 2, 3, 7, and 9).Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral vascular accident (stroke) with left-sided weakness and dementia (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment used to plan resident care) dated September 14, 2025, revealed the resident required staff assistance for activities of daily living and had a BIMS score of 14 (Brief Interview for Mental Status, a tool used to measure cognitive function; a score of 13-15 indicates cognition is intact). A review of a facility investigation dated October 26, 2025, at 3:30 PM revealed Employee 1, nurse aide, answered Resident 1's call bell and found the resident on the floor lying on her stomach, partially under the bed with blankets underneath her. The resident stated she had attempted to transfer from her bed into her chair and slipped, causing her to fall. Resident 1 resided on the east wing of the second floor. A review of the clinical record revealed Resident 2 was admitted on [DATE], with diagnoses including dementia. A quarterly MDS dated [DATE], revealed the resident required staff assistance for activities of daily living and had a BIMS score of 3 (a score of 0-7 indicates severe cognitive impairment). A review of a facility investigation report dated October 26, 2025, at 4:00 PM revealed Resident 2 was seated in a chair in the east wing resident dining room next to the wheelchair weight scale, which was stored and utilized in that area. Employee 2, nurse aide, was assisting the resident to the bathroom. Resident 2 stood up from the chair as Employee 2 turned to retrieve her walker. Resident 2 tripped over the wheelchair weight scale and fell, striking her head on the glass door. Documentation revealed she sustained a 2 centimeter by 0.4 cm (centimeter) laceration 9wound caused by tearing of the skim) on the top left side of her head and a 1.8 cm by 0.2 cm laceration to her left cheek. She was sent to the hospital and received three staples and steri strips (soft adhesive wound closure strips). A review of the clinical record revealed Resident 3 was admitted on [DATE], with diagnoses including dementia. A quarterly MDS dated [DATE], revealed the resident required staff assistance for activities of daily living and had a BIMS score of 3, indicating severe cognitive impairment. A review of facility investigative documentation dated October 26, 2025, at 4:30 PM revealed Resident 3 was wandering between the east and west nursing units and was on a 15-minute observation schedule related to a previous elopement from the facility on October 11, 2025. Employee 3, nurse aide, observed Resident 3 enter the shower room located between the east and west wing units. The resident sat down on the bathtub and fell backward into the tub. A licensed nurse assessed the resident, and no injury was documented. A review of a written witness statement dated October 26, 2025, at 4:30 PM from Employee 3, nurse aide, revealed documentation indicating that the employee reported seeing Resident 3 walking in the hallway from the west unit toward the east unit and that the employee followed the resident with the intention of bringing her back to the west unit, where the resident resided. The statement documented that Resident 3 turned into the west shower room, located between the east and west nursing units, and that when the employee turned the corner into the shower room, the resident was sitting on the edge of the bathtub. The written statement further documented that, as I approached her, she fell backwards into the tub, striking her head then her back on the inside of the tub. The statement noted that the resident had last been observed by the employee 15 minutes prior as part of the resident's every-15-minute monitoring. A review of the facility document titled Resident Observation/Monitoring Tool (every 15-minute watch record) dated October 26, 2025, revealed documentation that Resident 3 was recorded as ambulating and wandering in the hallway continuously from 2:15 PM through 3:30 PM, at which time the record documented that Employee 3 rendered care. The documentation further revealed that Resident 3 was recorded as continuing to wander in the hallway from 3:30 PM through 5:45 PM. A review of the facility census for October 26, 2025, for the 3:00 PM to 11:00 PM shift revealed a total census of 105 residents, with 39 residents on the second-floor west unit and 44 residents on the east unit. A review of nursing documentation revealed that during this shift there were two residents on the west unit who were placed on every-15-minute observation and one resident on the east unit who required one-to-one supervision (continuous direct visual observation by a designated staff member).A review of nursing staffing records dated October 26, 2025, revealed that one RN Supervisor was scheduled for the entire building. Documentation for the east wing showed two licensed practical nurses (LPNs) scheduled for four-hour shifts and one LPN scheduled for an eight-hour shift, along with three nurse aides scheduled for eight-hour shifts and two nurse aides scheduled for four-hour shifts for a census of 44 residents. Documentation indicated that the resident requiring one-to-one supervision required a staff member to remain with the resident continuously, rendering that employee unavailable to provide care to additional residents.A review of staffing documentation for the west unit revealed one LPN and three nurse aides scheduled for a census of 39 residents. Documentation further indicated that two residents on the west unit were on every-15-minute observation, including Resident 3, who was recorded throughout the day wandering on her unit and in other areas of the second floor. The documentation indicated that these monitoring responsibilities required dedicated staff time.A review of facility investigative documentation revealed that three resident falls occurred within one hour, between 3:30 PM and 4:30 PM, on October 26, 2025, during the 3:00 PM to 11:00 PM shift. At that time, residents on the second floor were documented as requiring safety checks, toileting, and other activities of daily living, including preparation for the evening meal. Based on review of the staffing records and monitoring assignments, the documented staffing levels did not demonstrate that sufficient personnel were available to complete these duties during this shift.During an interview on November 18, 2025, at 2:00 PM, the findings regarding staffing levels at the time of the three falls were reviewed with the Director of Nursing. No additional information was provided to indicate that staffing available during the shift exceeded the staffing levels documented in the staffing records. A review of Resident 7's clinical record revealed admission on [DATE], with diagnoses including congestive heart failure (a condition in which the heart cannot pump adequately), Type 2 diabetes (a condition affecting the body's ability to regulate blood sugar), and morbid obesity. An annual MDS dated [DATE], revealed total staff dependence for toileting, bed mobility, and transfers and a BIMS score of 15, indicating intact cognition. During an interview on November 18, 2025, at 12:45 PM, Resident 7 stated she often waited over one hour for call bell response and that she experienced incontinence and soiled bedding while waiting. She stated this occurred most often on second shift and also on third shift. A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included heart failure and muscle weakness.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 9 was totally dependent on staff for toileting, bathing/showers, bed mobility and transfers. The resident was cognitively intact with a BIMS score of 14. During an interview on November 18, 2025, at 3:14 PM, Resident 9 reported that his favorite activity in the facility was playing Bingo. The resident stated, I just love to play Bingo, and they don't have enough people to get me up and out of bed. So, I don't get to go. I know they're short (staffed) and I don't want to bother them. A review of the facility's shower schedule dated November 17, 2025, revealed that Resident 9 was scheduled to receive a shower during the 3:00 PM to 11:00 PM shift. Resident 9 reported during the interview on November 18, 2025, that he did not receive a shower or a bed bath the night before. A review of the shower schedule for November 17, 2025, revealed seven residents were scheduled to receive a shower during the 3:00 PM to 11:00 PM shift. A review of the shower logs revealed documentation that only one of the seven scheduled residents received a shower. The logs further revealed that four residents received bed baths instead of a shower, and two shower logs, including Resident 9's, were not completed. There was no documented evidence that any residents scheduled for showers on November 17, 2025, during the 3:00 PM to 11:00 PM shift declined a shower or preferred a bed bath. During a telephone interview on November 18, 2025, at 6:00 PM, Employee 5, reported that insufficient nurse aide staffing on the east wing resulted in delays in answering call bells, missed showers, and missed turning and repositioning schedules. Employee 5 reported that many residents on the east wing required the assistance of two staff members for toileting, bed mobility, and transfers and that two residents required one-to-one direct supervision (defined as continuous direct visual observation). Employee 5 reported that additional staff were not consistently scheduled to provide one-to-one supervision and that existing staff were expected to provide the one-to-one monitoring while also caring for the additional 42 residents on the wing. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 18, 2025, at 10:00 AM confirmed that there were two residents on the East Wing who require 1:1 supervision 24 hours/day. Review of the facility's policy titled Resident Observation Policy last reviewed by the facility on July 2, 2025, stated that if a resident is on 1:1 monitoring, the additional staff member assigned will remain with the resident in view at all times. Should the assigned staff member need to leave the area they are responsible for to ensure the resident is directly observed during their absence by another staff member. Staff members will complete the observation/monitoring tool. Review of the nursing schedule for November 17, 2025, for the 11:00 PM-7:00AM shift revealed only two nurse aides and one LPN (Licensed Practical Nurse) were assigned to the East Wing, which had a census of 44 residents. While an RN Supervisor was on duty, she was not assigned exclusively to the East Wing. The NHA and DON stated that the RN Supervisor's workstation had been moved to the East Wing on November 17, 2025, to assist staff as needed. Review of the Resident Observation/Monitoring Tool for the two residents on 1:1 dated November 18, 2025, revealed that Employee 6 (RN Supervisor) initialed entries for both residents at 2:45 AM, 3:00 AM, 5:00 AM and 5:15 AM despite the residents not being roommates or in adjacent rooms. During an interview on November 18, 2025, at 3:50 PM the NHA and DON confirmed that both residents could not have been continuously observed at the same time by Employee 6. A review of nursing time schedules, resident census data, and staff interview information revealed that the facility did not meet minimum nurse aide staffing ratios on five of fourteen reviewed dates (October 24, October 25, October 26, October 28, and November 17, 2025). A review of census records and staffing schedules revealed the number of nurse aides scheduled on those dates was below the minimum required ratios for the applicable shifts, and there was no documentation that additional higher-level staff were available to compensate. During an interview with the Nursing Home Administrator (NHA) on November 18, 2025, at 3:45 PM, the findings regarding nurse aide staffing ratios were reviewed, and no additional information was provided to demonstrate that required staffing levels were met.A review of nursing schedules, resident census data, and staff interview information revealed that the facility did not meet the minimum licensed practical nurse (LPN) staffing ratios on five of fourteen reviewed dates (October 25, November 12, November 15, November 16, and November 17, 2025). A review of staffing schedules revealed that the number of LPNs scheduled on those dates was below the minimum required ratios for the applicable shifts, and there was no documentation that additional higher-level staff were available to compensate. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding LPN staffing ratios were reviewed, and no additional information was provided to demonstrate that required staffing levels were met.A review of nursing staffing documentation, resident census data, and staff interview information revealed that the facility did not consistently provide the minimum 3.2 hours of general nursing care per resident per day as required under Pennsylvania state licensure regulations. A review of the facility's weekly staffing records revealed general nursing care hours below the required 3.2 hours on October 25, October 26, October 28, and October 30, 2025. During an interview with the NHA on November 18, 2025, at 3:45 PM, the findings regarding general nursing hours were reviewed, and no additional information was provided to demonstrate that the required hours were met. A review of clinical records, staffing schedules, census data, and interview information revealed the facility did not ensure sufficient nursing staff, based on actual resident census and acuity (the level of care and supervision required), to provide necessary services and supervision, and staffing documentation showed state minimum staffing ratios and required nursing hours per resident per day were not met on multiple reviewed dates. 28 Pa. Code 211.12 (c)(d)(1)(3)(4)(5) Nursing services 28 Pa. Code 201.18(b)(1)(e)(1)(2)(3)(6) Management

Based on clinical record review, facility policy review, staff interviews, and observation, it was determined the facility failed to ensure adequate supervision and implementation of safety interventions to prevent elopement for one resident (Resident 1). These failures placed 12 residents identified at risk for wandering and elopement (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) in an Immediate Jeopardy situation in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death.Findings include: A review of a facility policy for Elopement/Unauthorized \Absence Policy reviewed July 2, 2025, revealed the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner The policy defined elopement as a resident leaving the premises or a safe area without authorization. The procedure included, all residents will be assessed for the risk of elopement using the facility form on admission, quarterly and as needed. Residents identified at risk will have interventions promptly implemented to reduce the risk of elopement. Residents identified at risk will have their picture and face sheet placed in a binder that is kept in an area accessible by staff. Upon determining that a resident cannot be located, a headcount will be conducted. If a resident is still missing, Code Green using the resident's name, room number, and unit name will be announced. If the resident is not located on the premises, the team leader will direct staff to conduct an external search. The team leader or designee will notify the family/legal representative and inquire as to potential whereabouts. If the resident is not located in a reasonable period of time, based on the resident's physical/mental condition and environmental factors, the Administrator or designee will notify the local emergency response team three times. The clinical supervisor or designee will notify the administrator, Director of Nursing and the attending Physician. The highest ranking staff member becomes the team leader and coordinates the search effort. A floor plan will be used to ensure a thorough search of the interior. The facility utilized a wander guard system that alarms the inside of the facility exit doors in the facility. The second floor elevators have a locking mechanism that allows staff to access the elevators via a badge with a sensor in them, to open the doors, located on the wall outside the elevator doors. The facility outside exit door alarms operates on a separate alarming system. During the hours of 8:00 AM and 6:00 PM these doors are unlocked. If the bar on the door is pushed on from the inside, the alarm will sound, and the door will open. The alarm is audible at the site of the alarm (door area). There are alarm visual boxes located at each nurse's station. When the audible alarms sound, a corresponding light on the panel will illuminate and indicate a zone location. There should be a chart taped on the wall behind each nurse's station indicating the specific location of the alarming door. A review of facility records revealed that 12 residents were identified by the facility as being at risk for elopement. The following residents were included on the facility's elopement risk list: Resident 2 was identified by the facility as being at risk for elopement on October 2, 2025. Documentation showed a wander guard bracelet (a small, battery-operated monitoring device designed to alert staff when a resident wearing the device approaches an exit or restricted area) was applied on October 2, 2024. Resident 3 was identified as an elopement risk on July 29, 2024, and a wander guard bracelet was applied on the same date. Resident 4 was identified as an elopement risk on September 30, 2024, and a wander guard bracelet was applied the same date. Resident 5 was identified as an elopement risk on August 19, 2024, and a wander guard bracelet was applied on the same date. Resident 6 was identified as an elopement risk on March 3, 2025, and a wander guard bracelet was applied on the same date. Resident 7 was identified as an elopement risk on April 5, 2024, and a wander guard bracelet was applied on the same date. Resident 8 was identified as an elopement risk on August 2, 2024, and a wander guard bracelet was applied on the same date. Resident 9 was identified as an elopement risk on May 27, 2024, and a wander guard bracelet was applied on the same date. Resident 10 was identified as an elopement risk on March 1, 2025, and a wander guard bracelet was applied the same date. Resident 11 was identified as an elopement risk on April 11, 2025, and a wander guard bracelet was applied the same date. Resident 12 was identified as an elopement risk on October 2, 2025, and a wander guard bracelet was applied the same date. Resident 1 was admitted [DATE], with diagnoses including vascular dementia (a progressive decline in thinking and reasoning caused by reduced blood flow to the brain), glaucoma (a chronic eye disease that can lead to blindness), and abnormality of gait A review of a quarterly MDS assessment (Minimum Data Set, federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 4, 2025, revealed the resident to have a BIMS score of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information. A score of 0 to 7 indicates severe cognitive impairment) and required assistance with activities of daily living. Review of Resident 1's care plan for behavioral symptoms initiated June 4, 2025, addressed wandering and exit-seeking behaviors (often stated going home) and included interventions to approach the resident calmly, redirect safely, assure proper footwear, maintain a functional wander guard bracelet, and check the device each shift. The planned goal was that the resident would wander safely within boundaries. A corresponding elopement risk assessment dated [DATE], revealed that Resident 1 was at risk for wandering/elopement and included a physician's order for a wander guard bracelet. Review of facility documentation between admission and September 28, 2025, reflected ongoing wandering and exit-seeking behaviors. A review of facility investigative documentation completed by Employee 1, Registered Nurse Supervisor (RNS), on October 13, 2025, at 2:26 AM revealed that Resident 1 exited the building and was seen outside the laundry-area doors on October 11, 2025, at approximately 8:48 PM. Employee 1 (RN) reported she became aware of the elopement during her shift on October 13, 2025, when she reviewed a written statement left by Employee 2 (laundry aide) describing the event. Employee 1 stated she had not read the statement until that time and had not realized earlier that the resident had left the building. Employee 1 explained that while on duty the evening of the incident (October 11, 2025, 7:00 PM to 7:00AM), several door alarms sounded at least three separate times. During a telephone interview on October 16, 2025, at 4:19 PM Employee 1 stated she arrived for her 7:00 PM to 7:00AM shift and entered through the front lobby. At that time, Resident 2 attempted to exit through the lobby doors, triggering a wander-guard alarm. Employee 1 deactivated the alarm using the control box inside the lobby doors and observed that the smoking-area door across the hallway was unlocked. She locked and re-armed that door, instructed staff to complete a headcount on the second floor because the first-floor smoking door had been unsecured, and then proceeded upstairs to begin her medication pass. She stated no written record of the headcount was completed. This was the first door alarm activation that evening. Employee 1 stated that around 8:30 PM a second wander-guard alarm sounded while she was passing medications on the east nursing unit. She checked the indicator panel at the nurses' station but stated that there was no posted chart showing which zone corresponded to each exit door. She inspected both east-wing exit doors and the central elevator area but did not locate the source. She then went to the first floor, where she observed that the front lobby door alarm was sounding. Looking outside, she saw a man walking toward parked vehicles and assumed the alarm had been triggered by a departing visitor. She could not identify the man. Employee 1 turned off the alarm and resumed her medication pass.This was the second alarm activation that evening. Employee 1 stated that shortly thereafter, another alarm sounded, her estimate again around 8:30 PM to 8:35 PM. She checked the first floor, including the lobby and administrative areas, and was told by Employee 2 (laundry aide) that no alarms were active on the first floor. When she returned to the second floor west nursing unit, she noted the alarm panel lighted near the west dining-room stairwell door and reset the alarm at 8:35 PM. This was the third alarm activation that evening. At approximately 8:45 PM, Employee 1 stated she went downstairs again and observed Employee 2 (laundry aide) walking with Resident 1 in the administrative hallway. Employee 2 reportedly told her, I brought her back. Employee 1 stated that Resident 1 appeared clean and dry and that she did not complete vital signs or a physical assessment. No investigative report or investigation was initiated at that time. Employee 1 further stated that Employee 2 had left a written statement on the nurse's desk the same evening, but she did not review it. When she returned for her next scheduled shift on October 12, 2025, at 7:00 PM, she heard staff discussing an elopement that had occurred the previous night. She then reviewed the statement and realized Resident 1 had been outside the facility. At 2:45 AM. on October 13, 2025, she completed the investigative report and notified the Director of Nursing (DON). Two written witness statements completed by Employee 1 (RN) and dated October 13, 2025 (no time indicated) provided additional detail:In the first statement, Employee 1 wrote that while passing medications on the east-wing short hall, the code alert (wander-guard alarm) activated. She checked the indicator panel but found no zone list. After inspecting the east-wing exits, first-floor doors, and elevators, she determined the alarm originated from the second-floor west-wing stairwell leading to the laundry area. She went downstairs and saw Employee 2 walking with Resident 1. Employee 2 later told her that the resident had been outside knocking on the door. Employee 1 wrote, Today, after hearing that Resident 1 was outside, I remembered the laundry aide had laid a statement on the nurses' desk on October 11. I read it and made the DON aware. In the second written statement, Employee 1 reiterated that at approximately 8:30 p.m. to 8:40 p.m. she heard an alarm, checked multiple exits, and eventually located the alarm near the west-unit dining-room door. She again described seeing Employee 2 with Resident 1 but stated that Resident 1 could not have been outside very long. It was raining outside, and she did not appear to be very wet. Her arm was not wet at all. She stated, I looked at her arms/legs and there were no marks noted. She wrote that she did not review the aide's statement until Sunday night (October 12) and therefore did not know the resident had been outdoors at the time A review of a written witness statement dated October 11, 2025, (no time indicated) revealed that Employee 2 (laundry aide) was in the facility laundry room at approximately 8:40 PM when she received a call from the east nursing unit regarding the downstairs alarm. She stated, The nurse had already turned the alarm off. Then I heard knocking at the outside ambulance entrance door. Resident 1 was standing outside wearing wet slipper socks. I brought her back inside and walked her down the hallway toward the elevator. I explained the situation to the nurse. A telephone interview on October 16, 2025, at 5:31 PM with Employee 2, confirmed that the alarm sounded only when she opened the door to let Resident 1 inside. She silenced the alarm and proceeded through the interior wander-guarded door, which did not activate. The resident said several times that she was cold while being escorted back to her unit. An additional witness statement dated October 15, 2025, indicated that earlier in the evening, around 7:00 PM, on October 11, 2025, the lobby alarm at the inner double doors had sounded for about 10 minutes. Employee 2 stated, The nurse (Employee 1) turned the alarm off. At the same time the front exit doors were also alarming. The nurse told the aide who was taking the smokers out to turn the alarm off. A written statement dated October 15, 2025, revealed that Employee 3 (nurse aide) was providing care to another resident on the second floor when she heard an unfamiliar alarm. She stated, I saw a light flashing on the wall panel. I didn't know which door it was (the light location could not be identified at that time). The nurse said it was the kitchen door and went down in the elevator to check. She said she had it under control, and shortly after, the alarm stopped. At the end of her shift, Employee 1 told her, It was Resident 1 that got out of the building. She stated that she last saw Resident 1 at supper, walking and appearing agitated between the east and west units. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 3 (nurse aide) stated, I was with another resident providing care on the second floor when I heard an alarm go off. It wasn't an alarm sound that I recognized, so I went to the wall panel and saw a light flashing. It wasn't on the door panel, and the location of the light could not be identified at that time. I walked toward the elevator by the ice machine and saw the nurse (Employee 1, RN). I told her that I didn't know which door was alarming. She said it was the kitchen door, then got into the elevator and went down to the first floor. She told me she had the situation under control, so I went back to my unit. Shortly after that, the alarm was turned off. Employee 3 further stated, At the end of the shift, the nurse (Employee 1) came to the floor to get her clipboard and said it was Resident 1 that got out of the building. I had last seen Resident 1 at supper in the dining room. She was agitated and kept walking the hallway between the east and west nursing units. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 4 (nurse aide) stated, Around 8:30 PM. to 9:00 PM I heard an alarm while I was in a resident's room with Employee 3 (aide) providing care. I came out of the room into the hallway and saw the nurse (Employee 1, RN) walking on the second floor toward the east unit. Employee 3 and I checked the resident rooms, and I didn't notice that Resident 1 was missing. The nurse came back to the unit and told us to check the exit doors. I saw the nurse turn off the alarm by the door at the west dining-room stairwell. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 5 (LPN), who was assigned to the 3:00 PM to 11:00 PM. shift, stated, I was in the middle of my medication pass when I heard the door alarm going off. I'm not sure of the exact time, but it was after dinner. I was in a resident's room administering medication and couldn't leave right away. The alarm was sounding for about five to ten minutes. Employee 5 further stated, I went to the nurses' station where Employees 3 and 4 were sitting. They said a resident got out of the kitchen entrance downstairs. The nurse (Employee 1, RN) told me it was Resident 1 who got out. She asked if I knew that Resident 1 was the missing resident. I told her I did not. The nurse said Resident 1 got out down the steps and the laundry aide had the resident because she was called to let her know of the incident. Employee 5 added, I told the nurse that staff on the second-floor west unit were told the missing resident lived on the first-floor nursing unit, so no headcount was done. I saw the nurse (Employee 1) turn off the alarm by the second-floor west dining-room door. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 6 (nurse aide) stated, I was on the second-floor east nursing unit providing evening care to a resident between 8:00 PM and 9:00 PM when I heard something 'buzzing,' but it wasn't loud. When I came out of the resident's room, the alarm turned off. Another nurse aide told me that Resident 1 was outside knocking on the door. Resident 1 had been seen on the second-floor east unit about an hour earlier. I escorted the resident down the hallway past the elevator to the west unit and told her to keep walking. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 7 (nurse aide) stated, I was working on the second-floor east unit when I heard an alarm go off, but I'm not sure what time it was. I saw Employee 8 (nurse aide) at the nurses' desk calling someone. I saw her look at the alarm panel to see which alarm it was. The alarm was going off for maybe five minutes, less than ten. A review of written witness statements dated October 13, and October 15, 2025 (no times indicated) revealed that Employee 8 (nurse aide) stated, The alarm box at the east nurses' station was showing red, indicating the kitchen alarm. I called the kitchen, but there was no answer. I called the laundry to shut the alarm off, and the laundry aide (Employee 2) said she would. The alarm kept going off, so I called the nurse (Employee 1, RN) to turn it off. The alarm was turned off after that. In an additional statement dated October 15, 2025, Employee 8 stated, The door alarm went off after the 6:30 PM smoke break. The wall panel read Zone 5 and the paper on the wall said kitchen alarm. I called the kitchen and the laundry. I talked to the girl with glasses and asked her to turn the alarm off. The alarm was still going off, so I called the west wing and talked to Employee 11 (agency nurse aide); she said she would turn it off. Shortly after, the alarm stopped. The nurse (Employee 1) said we had to do a resident headcount because the smoking door was left open. I did a headcount on the east wing, and all residents were accounted for. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 9 (nurse aide) stated, I don't remember the exact time the alarm went off. I was coming back in from my fifteen-minute break and entered the building through the employee entrance. I started walking toward the front hallway. Employee 2 (laundry aide) was handing Resident 1 over to the nurse (Employee 1, RN). Employee 2 kept saying, 'I want the nurse to know I brought Resident 1 back inside.' I didn't turn any alarms off. A review of a written witness statement dated October 15, 2025 (no time indicated) revealed that Employee 10 (nurse aide) stated, I was working on the first-floor nursing unit providing resident care when I heard an alarm. The sounds were different for the door and the wander-guard alarms, one of them is higher pitched. It sounded like both were going off at the same time. I turned around and saw the laundry aide (Employee 2) walking Resident 1 from the laundry-room area toward the first floor. The elevator opened, and the nurse (Employee 1, RN) came off saying, What are you doing? An alarm is going off.' I was walking another resident back to her room because she was a fall risk. The nurse (Employee 1) said that Resident 1 got down the stairs. At that time, the alarm was turned off. I don't know which alarm it was. Employee 10 further stated, At about 6:30 PM. the nurse aide (Employee 9) took the resident smokers outside. She told me she had never taken the smokers out before, so I helped her get them set up and then went back to the resident floor. Both the inner and outer exit doors were propped open, and the smoking cart was wedged between them. She was behind the cart. I told her to close the first door (the inner door) when she went outside to keep the cold air from coming in. A review of a written witness statement dated October 13, 2025 (no time indicated) revealed that Employee 11 (agency nurse aide) stated, I was on the west wing. I saw Resident 1 walking in the hallway right before another nurse aide and I started evening care. It was right after dinner. We were in the middle of care when we heard the alarm go off. I looked out into the hallway and saw Employee 3 (nurse aide). She said it was the kitchen door alarm and that Resident 1 got out of the building and the nurse (Employee 1, RN) was taking care of it. The alarm wasn't going off for long, maybe five to seven minutes. It was the stairwell by the lounge that leads down to the ambulance entrance. I didn't turn off the alarm and I'm not sure who did. I didn't see Resident 1 near the door, but she does wander a lot. The east-wing staff said the laundry aide told them she found Resident 1 outside knocking on the door to be let in. During an interview conducted on October 16, 2025, at 4:00 PM. the Nursing Home Administrator (NHA) stated the incident involving Resident 1 was not communicated to administration or investigated for 30 hours after it occurred. The NHA stated, No interventions were implemented to ensure the safety of residents at risk for elopement. She explained that multiple staff witness statements were collected due to conflicting accounts of the event and confirmed the facility had not determined where the resident exited the building. Based on review of facility documentation, staff interviews, and administrative statements, it was determined the facility failed to ensure an effective and timely response to multiple activated door alarms; failed to identify that a resident had exited the building unsupervised; failed to complete a licensed nurse assessment or initiate the Code [NAME] procedure; and failed to promptly report and investigate the event in accordance with facility policy These systemic failures, combined with staff's inability to interpret alarm panels, the lack of posted zone identifiers, the repeated silencing of alarms without confirmation of resident safety, and the absence of an immediate administrative response, constituted a breakdown in supervision, communication, and safety systems necessary to protect residents identified as being at risk for elopement. As a result, the facility's noncompliance placed Resident 1 and all other residents at risk for elopement in an Immediate Jeopardy situation, as serious injury, harm, impairment, or death could have occurred while the resident was outside unsupervised and while other alarms went uninvestigated. The facility was notified of the Immediate Jeopardy on October 16, 2025, at 3:15 PM, and the Immediate Jeopardy template was provided to the facility at that time. In response, the facility submitted a written Immediate Jeopardy action plan on October 16, 2025, at 6:30 PM. The corrective action plan submitted by the facility included the following measures:1. The resident was accounted for, safe, and exhibited no adverse effects from the incident. An initial skin assessment was completed on October 13, 2025, and a follow-up skin assessment was completed on October 16, 2025. The resident's wander-guard bracelet remained intact and functional. Fifteen-minute safety checks were initiated on October 13, 2025, and continued thereafter. The resident's care plan was updated to reflect current interventions.2. The facility's elopement policy and door alarm protocol were reviewed and revised.3. All staff received education on elopement prevention, wandering, resident safety, and identification of alarm zones.4. All wander-guard door boxes and door alarms were checked and confirmed to be functioning.5. All residents with wander-guard bracelets were checked for proper device placement and functionality.6. Audits were completed to ensure that no other residents in the facility were affected by alarm or supervision concerns.7. New elopement risk assessments were completed for all residents.8. Elopement binders and resident care plans were reviewed and updated.9. Door checks were initiated on each shift to be completed by the Maintenance Director or designee daily for four weeks.10. Elopement drills were scheduled to be conducted weekly for four weeks by the Maintenance Director or designee.11. Results of the education, audits, and drills were to be reviewed at the next QAPI (Quality Assurance and Performance Improvement) meeting for continued monitoring. Following verification of the facility's corrective actions, including observation of door alarm function, confirmation of staff education, and tour of the premises, the Immediate Jeopardy was determined to be removed on October 17, 2025, at 12:00 PM. 28 Pa. Code 201.18 (e)(1) Management 28 Pa Code 211.10 (a)(c) Resident care policies 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services

Based on observations, review of clinical records, review of select facility policies, review of job descriptions, documentation provided by the facility, and interviews with residents and staff, it was determined the facility's administration failed to effectively use its resources to ensure resident safety and maintain the highest practicable physical and mental well-being of residents. The facility failed to ensure that measures were implemented to prevent one of twelve residents identified as being at risk for wandering (Resident 1) from exiting the building unattended into an unsafe environment. This deficient practice placed all residents at risk for harm and resulted in immediate jeopardy to residents' health and safety.Findings include:A review of the job description for the Nursing Home Administrator (NHA) dated and signed September 12, 2024, indicated the administrator will lead and manage the overall operations of the facility in accordance with policies, procedures, and current federal, state, and local standards, guidelines, and regulations. The NHA's essential duties and responsibilities include hiring, training, and developing department staff, verifying the physical environment is maintained appropriately, and directs overall activities and programs in accordance with current rules and regulations. The job description for Director of Nursing (DON) Services dated and signed May 11, 2025, documents the DON directs the overall operations of nursing service and collaborates with the NHA and medical director to ensure the highest degree of quality of care for all residents. The DON maintains maintenance of the master staffing schedule, ensuring daily work assignments are in place and appropriate staffing levels are present. In the absence of the NHA, the job description writes the DON will assume responsibility for the daily facility operations. The facility failed to ensure administrative responsibilities were carried out to maintain resident safety. On October 11, 2025, Resident 1 exited the facility without staff supervision and entered an unsafe area outside. This demonstrated that facility systems and oversight were not effective in preventing residents from leaving the building unsupervised. Residents identified as being at risk for wandering were not adequately protected, placing them in danger of injury or harm. Interviews with staff, residents, and facility the Nursing Home Administrator and Director of Nursing on October 16, 2025, at 3:00 PM confirmed that established safety measures were not followed and that both equipment and staff procedures failed. Staff reported uncertainty about their roles in monitoring exit doors and about communication protocols when a resident was missing. This lack of coordination and communication delayed identification of the incident and assessment of other residents at risk for wandering or elopement (leaving the facility or safe area without staff knowledge or supervision) and the potential for harm. The Administrator and Director of Nursing failed to fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety. This lack of oversight and failure to use available resources to identify and correct system problems resulted in conditions that placed residents in immediate jeopardy. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management. 28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that three residents (Residents 2,3, and 4) out of 3 sampled were free from physical abuse perpetrated by another resident (Resident 1). Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation last reviewed by the facility on May 2025, revealed it is the policy of the facility not to tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A separate facility policy titled Resident Observation last reviewed May 2025, indicated the policy objective is to provide enhanced observation as a temporary safety mechanism during an acute episode where a resident is endangered. The procedure specifies that the Director of Nursing (DON) will assign a staff member to complete appropriate observation interventions, which may include 15- or 30-minute checks or one-to-one (1:1) monitoring. The policy requires that staff assigned to 1:1 monitoring remain with the resident at all times and document monitoring at designated intervals. Clinical record review revealed that Resident 1's was admitted to the facility on [DATE], with diagnoses which included Huntington's disease (a progressive neurological disease that causes nerve cells to decay over time. The disease affects a person's movements, thinking ability and mental health). A review of the resident's Quarterly Minimum Data Set Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 4, 2025, indicated the resident was moderately cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status-a tool to assess cognition, a score of 0-7 indicates severe cognitive impairment), exhibited physical and verbal behaviors towards others, exhibited wandering behaviors and required the assistance of staff for ambulation.Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnosis to include dementia and was severely, cognitively impaired with a BIMS score of 1. Review of Resident 1's plan of care dated February 28, 2025, for psychosocial well-being with interventions to include education to the resident on treatments and expectations on outcomes, behavioral health consults, document symptoms, encourage the resident to express feelings and administer medications as ordered. Nursing documentation dated from the time of admission to the facility the resident exhibited aggressive violent impulsive behaviors towards staff and other residents. She made verbal threats. She would attempt to stand and ambulate unassisted, often running from the east wing to the west wing nursing units. She would not sleep in her bed but would sleep in a chair in the dining room. A review of nursing documentation dated April 14, at 8:04 P.M. revealed, at 2:30 P.M. Resident 1 ran from the east unit to the west unit, proceeded to go into the dining room and sit in a chair and began screaming. Attempts were made to redirect the resident. At 5:05 P.M., Resident 1 got out of the chair, jumped on top of a resident (facility could not identify resident) lying in a recliner chair and laid on top of her. Attempts to redirect the resident were unsuccessful. The resident was physically lifted off the other resident. Resident 1 became combative, punching and kicking staff with full contact. Attempts were made to calm her, she continued to punch and kick staff. Attempts were made to medicate the resident with an antianxiety medication, Ativan. The resident refused. A telephone call made to the attending Physician with orders to send her to the emergency department for Psychiatry evaluation.The resident was sent to the hospital for an emergency commitment hospitalization (302 involuntary commitment to the hospital). The resident was evaluated, and the hospital refused the emergency commitment and ordered her to be returned to the facility. The resident was readmitted to the facility on [DATE], at 10:00 P.M. Nursing documentation continued to note her physical and verbal aggressive behaviors, often running from one nursing unit to the other located on the opposite side of the building. Despite repeated behaviors, supervision and interventions remained inconsistent. Nursing documentation dated July 27, 2025, at 11:29 A.M., revealed Resident 1 became agitated with another peer (facility could not identify resident) who had entered her personal space. Resident 1 was removed from the common area. Resident 1 proceeded to follow the resident stating she was going to spank her, raising her arm and making gestures of hitting toward the other resident. Staff intervened. A review of nursing documentation dated July 31, 2025, at 11:58 A.M. revealed that Resident 1 was observed ambulating through the east wing dining room and pushing the wheelchair of another female resident (facility could not identify this resident). Resident 1 stated, I don't like her, so I pushed her away. Staff attempted to educate Resident 1 about wheelchair safety; however, Resident 1 replied, I would do it again, I don't like her, I would push her away again. The other resident was relocated for her personal safety. A review of facility investigative documentation and nursing documentation dated August 8, 2025, at 8:40 A.M. revealed Resident 1 hit Resident 2 on the left side of her head and then grabbed her arms while in the east wing dining room. This incident was witnessed by the facility's physical therapist shortly after breakfast. Staff immediately separated the residents. As an intervention, the facility initiated every 15-minute checks, instructed staff to monitor Resident 1's behaviors, and planned for reassessment after 72 hours (August 11, 2025). Staff were also instructed to redirect the resident with alternative activities. A review of a written witness statement dated August 8, 2025 (no time indicated) by Employee 1, Physical Therapist, documented that at approximately 8:20 A.M., Resident 1 was seen hitting Resident 2 on the left side of her head near the temple and then grabbing Resident 2's arms. The incident occurred in the east wing dining room while the therapist was assisting another resident with a transfer. Resident 2 was seated in a wheelchair, and Resident 1 was standing. There was no evidence that the 15-minute checks were completed after the August 8, 2025, incident. During an interview on September 10, 2025, at 11:00 A.M., the Director of Nursing confirmed the required 15-minute checks had not been carried out. A review of facility investigative documentation dated August 11, 2025, at 4:05 P.M. revealed that Resident 1 was observed pulling Resident 3's hair in the east wing dining room. This incident was witnessed by nursing staff. The residents were separated, and the incident was reported to state agencies as well as the local police. A new intervention was initiated requiring one-to-one (1:1) supervision for Resident 1. A review of the Interdisciplinary Team (IDT) documentation dated August 12, 2025, at 9:27 A.M. revealed the team met to discuss the August 11, 2025, incident. The IDT note documented that Resident 1 was not to pull Resident 3's hair and was placed on 1:1 supervision until she could be evaluated by psychiatric services. Resident 1 was counseled about the incident but demonstrated no remorse, stating, I don't care, I don't care. The IDT documentation did not reference the prior August 8, 2025, incident or the intervention requiring 15-minute checks. The note instead indicated that 15-minute checks would continue until the reassessment 72 hours later. A review of a psychiatric consultation notes dated August 12, 2025, at 2:15 P.M. revealed that Resident 1 was seen seated in the dining room where she pulled another resident's hair (Resident 3). The note did not reference Resident 1's earlier incidents of aggression, including the August 8, 2025, and August 11, 2025, resident-to-resident altercations. The psychiatric note also failed to mention that Resident 1 had been placed on 1:1 supervision by the facility. A review of facility investigative documentation dated August 27, 2025, at 11:30 A.M. revealed Resident 1 stood from her chair in the east wing dining room and approached Resident 3. The staff member assigned to provide 1:1 supervision followed closely and attempted to intervene by standing between the residents and raising her hand to block Resident 1. Resident 1 reached around the staff member and pulled Resident 3's hair. The residents were immediately separated. The incident occurred prior to lunch in the dining room, which was described as a noisy and highly stimulating environment. Staff were instructed to redirect Resident 1 to quieter areas and to continue 1:1 supervision. Clinical record review revealed that Resident 3 was admitted to the facility October 4, 2023, with diagnosis to include dementia and was severely, cognitively impaired with a BIMS score of 1. A review of facility investigative documentation dated September 8, 2025, at 8:25 P.M. revealed that Resident 1 stood up from her chair in the east wing dining room, walked over to Resident 4, and struck her on the back. The resident was redirected out of the dining room by staff. Documentation indicated Resident 1 had stated beforehand, I'm going to spank her. The intervention at that time was to continue 1:1 supervision, and nursing staff were reeducated to remain within arm's reach of the resident during 1:1 observation. A review of a witness statement dated September 8, 2025 (no time indicated), from Employee 2 (NA), Nurse Aide, revealed Resident 1 was seated near a window in the dining room and appeared to be asleep. Employee 2 (NA) was three chairs away, looking at personal phone messages, when Resident 1 suddenly stood up, approached Resident 4 (seated in her wheelchair), and struck her on the shoulder with an open hand. Employee 2 (NA) then redirected Resident 1 using her gait belt and escorted her to the meditation room (off the unit). Clinical record review revealed Resident 4 was admitted on [DATE], with diagnoses including dementia. Resident 4 was severely cognitively impaired with a BIMS score of 1. Nursing documentation revealed Resident 4 wandered frequently throughout the unit, entered other residents' rooms, and displayed disruptive vocalizations such as continuous shouting. The noted intervention for August 8, 2025, resident to resident incident was to implement every 15-minute staff monitoring. There was no evidence at the time of the survey that this intervention was implemented to prevent future incidents of resident abuse. Review of interventions revealed that following the August 8, 2025, incident, every-15-minute monitoring was ordered but not implemented. Following the August 11, 2025, incident, 1:1 monitoring was ordered. A review of 1:1 monitoring records dated August 11, 2025, through the date of survey revealed multiple gaps in documentation, including but not limited to: August 11, 15, 19, 20, 23, 25, 26, 27, 28, 29, 31; September 1, 2, 3, 4, 6, 7, and 8, 2025. Despite Resident 1's documented pattern of aggressive and intrusive behaviors, the facility failed to ensure consistent supervision and monitoring. As a result, Residents 2, 3, and 4, all severely cognitively impaired residents, were subjected to repeated physical abuse including hitting and hair-pulling. During an interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:00 P.M., both confirmed the facility failed to prevent Resident 1 from physically abusing (hitting and pulling hair) Residents 2, 3, and 4. The facility failed to implement sufficient supervision and monitoring measures to address Resident 1's known history of aggression, resulting in physical abuse of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to reasonably accommodate residents' need for call bell accessibility for four out of 30 residents sampled (Residents 35, 77, 75, and 83) and to ensure the accessibility of resident room display boards as expressed by 2 out of 6 residents during a resident group interview (Residents 24 and 45). Findings include: Observation on April 8, 2025, at 10:41 AM in resident room revealed that Resident 77 and Resident 75 were in their respective beds and unable to reach or access their call bells to summon staff assistance if needed. The call bells for both residents were observed on the floor, behind the head of the bed, and out of the residents' reach. Observation on April 8, 2025, at 10:50 AM revealed Resident 35 seated in a wheelchair along the right side of his bed in his room. The resident's call bell was on the floor on the left side of the bed, behind the headboard, and out of the resident's reach. During an interview at the time of the observation, Resident 35 stated the call bell is frequently on the floor and out of reach. He stated that if he required staff assistance, he would need to find another means to get the staff's attention, as the call bell was inaccessible in the current location behind the headboard. Observation on April 8, 2025, at 11:19 AM revealed Resident 83 awake and lying in bed. The resident's call bell was on the floor behind the resident's headboard and out of the resident's reach. An interview with Employee 3 (nurse aide) on April 8, 2025, at 11:40 AM confirmed the observation that Residents 77, 75, 35, and 83 did not have access to a call bell to summon staff assistance if needed. An interview with the Director of Nursing on April 10, 2025, at approximately 10:00 AM verified that call bells are to be placed within reach of each resident at all times. During a group interview with alert and oriented residents on April 9, 2025, at 10:30 AM, Residents 24 and 45 indicated the facility installed room display boards for their activity calendars. The residents explained the display boards were placed too high for them to access while seated in their wheelchairs. An observation on April 9, 2025, at 12:30 PM of the resident's room confirmed the display board was eye level at approximately 6 ft. At the time of the observation, Resident 45 confirmed the board was placed too high for her to access or read. An observation on April 9, 2025, at 12:35 PM of the resident's room confirmed the display board was just below eye level while standing at approximately 5 ft. At the time of the observation, Resident 24 confirmed the board was placed too high for her to access or read. During an interview on April 10, 2025, at approximately 12:30 PM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure the facility makes reasonable accommodations to meet the needs of the residents. The NHA confirmed the corkboards were to be lowered in Resident 45 and Resident 24's rooms to ensure residents' accessibility. 28 Pa. Code 211.12 (d)(5) Nursing Services 28 Pa. Code 201.29 (a) Resident Rights

Based on a review of clinical records and select facility policy, observations, and resident and staff interview it was determined the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living (ADLs) consistently was provided showers as planned to maintain good personal hygiene and failed to provide a resident dependent on staff for ADLs, the necessary services to maintain good nutrition for two residents out of 30 sampled (Residents 35 and 103). Findings include: A review of Resident 35's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (a stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), and type 2 diabetes (trouble controlling blood sugar and using it for energy) with diabetic neuropathy (nerve damage caused by long-term high blood sugar levels). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 2, 2025, indicated the resident required moderate assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 13-15 indicates the resident is cognitively intact). During an interview with Resident 35 on April 8, 2025, at 10:50 AM, he reported that staff are not consistent with providing him a shower on his scheduled shower days. He stated, last month there were quite a few days I didn't get a shower. A review of the Resident 35's physician's order dated October 8, 2024, revealed the resident was scheduled to be showered on Wednesdays and Saturdays on the evening shift. A review of the March 2025 shower logs for Resident 35 revealed the resident did not receive a shower on Saturday March 1, 2025, Saturday March 15, 2025, and Wednesday, March 26, 2025. The resident also did not receive a shower but instead received a bed bath on Wednesday, March 5, 2025, Saturday March 8, 2025, and Wednesday, March 12, 2025. There was no documented evidence the resident refused a shower. There was no documented evidence the resident preferred a bed bath instead of a shower. There was no documented evidence the facility showered the resident twice each week as planned. During an interview with the Nursing Home Administrator (NHA) on April 10, 2025, at approximately 1:00 PM the NHA confirmed that Resident 35 should have been showered as scheduled and was unable to state why showers were not provided as scheduled and desired. A review of Resident 103's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include diffuse large B-cell lymphoma (aggressive, fast growing form of non-Hodgkin's lymphoma cancer of the lymphatic system) that affects B-cells, (a type of white blood cell that produces antibodies), and dysphagia (difficulty swallowing food or liquid). An admission MDS dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 6 (0-7 represents severe cognitive impairment) and the resident performed eating tasks (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) with supervision. Observation conducted on April 8, 2025, at 11:47 AM in the 2nd floor East dining room revealed Resident 103 seated upright in a Geri lounger (large padded cushioned reclining chair with a wheeled base designed to assist residents with limited mobility) at a table with a blanket on his lap. At 11:49 AM staff placed Resident 103's lunch tray on the table in front of him, which consisted of meatloaf, mashed potatoes with gravy, green beans and fruited gelatin. Staff provided setup assistance (cut meat, removed lid from dessert bowl, and removed lids from beverage cups) and walked away to continue to deliver lunch trays to other residents in the dining room. Continued observation of Resident 103 during lunch in the dining room revealed the resident grabbed the blanket on his lap and placed it in his mouth. The resident continued to put the blanket into his mouth and chew on the blanket for the next 24 minutes. At 12:13 PM the resident pulled the blanket out of his mouth and placed it on top of his food. At 12:14 PM, 25 minutes after his tray was setup in front of him, a staff member approached Resident 103 and offered to assist him with eating. The resident made no attempts to initiate or engage in self-feeding and allowed the staff member to feed him. A review of Resident 103's care plan dated March 24, 2025, identified a problem area related the resident's ADL functional status/rehabilitation potential with interventions to include: transfers with assist of two with a rolling walker (walker with front wheels); do not rush the resident, allow extra time to complete ADLs; follow PT/OT/ST recommendations; have consistent approach amongst caregivers; monitor for presence of pain/intolerance during self-care; provide adequate rest periods between activities; provide assistance as needed; and report any further deterioration in status to the physician. The current care plan, in effect at the time of the survey ending April 11, 2025, failed to identify Resident 103's functional ability to participate in activities of daily living such as eating, grooming, oral hygiene and dressing, and the staff assistance required to safely and successfully engage in these daily tasks. Review of nurse documentation dated April 1, 2025, at 12:00 PM revealed that Resident 103 was sent to the emergency room due to abnormal laboratory values. Nursing documentation dated April 4, 2025, at 6:18 PM revealed Resident 103 was readmitted to the facility. Review of the Occupational Therapy Evaluation dated April 6, 2025, revealed the resident's self-feeding ability was assessed as total dependence (level of support where a person requires constant and complete assistance from another to complete a task- the resident is unable to perform the task while the caregiver performs 100% of the task). Interview with the Nursing Home Administrator on April 10, 2025, at 10:30 AM revealed the residents' self-feeding ability is documented in the care plan, Point of Care History and the CNA huddle binder located at each nursing station. Review of the facility's Point of Care History (care tasks completed for the resident) for Resident 103 failed to identify the level of staff assistance required for the resident to safely perform self-feeding tasks. Interview with Employee 2 (Registered Nurse Supervisor) on April 10, 2025, at 1:45 PM revealed the residents' functional statuses (ability to self-feed, bathe, transfer, ambulate) are communicated to the nursing staff via a CNA huddle binder. Employee 2 explained that the huddle binder contains a document for each resident indicating the level of staff assistance required to perform activities of daily living. Review of the CNA huddle binder revealed that Resident 103 did not have a current file in the huddle binder. Employee 2 confirmed that based upon the current huddle binder information, staff would not know the functional status, or the level of staff assistance required, to safely and appropriately feed Resident 103. Review of an Occupational Therapy treatment encounter note dated April 10, 2025, revealed nursing staff requested re-assessment of self-feeding and beverage management. Resident with intermittent alertness but demonstrated no functional ability to grasp utensils or cups despite simple cueing and hand over hand assistance from therapist. Resident demonstrated no functional ability to load utensils in prep for placement of food item on utensil. Resident with periods of inattention and confusion noted throughout AM breakfast meal with inability to follow 1-step commands for utensil management or beverage management. Reviewed with primary caregivers for need of supportive feeding and beverage management. Interview with Employee 1 (Occupational Therapist) on April 11, 2025, at 8:50 AM indicated Resident 103 exhibited a significant decline in his functional status since returning from the hospital on April 4, 2025. She noted that Occupational Therapy did not establish self-feeding goals because therapy was asked to establish safe in and out of bed positioning so that staff could safely feed the resident. She reported that when a decline in functional status is noted by therapy, the Director of Rehab notifies the IDT team (interdisciplinary team) who then notifies the charge nurse, unit managers and primary caregivers. The physician orders and care plan would then be updated to reflect the resident's status. The facility was unable to provide documented evidence the facility communicated Resident 103's decline in self-feeding ability and the required staff assistance to the IDT team, nursing staff and his primary caregivers. The facility failed to effectively communicate Resident 103's functional decline and increased need for staff assistance for self-feeding. Interview with the Nursing Home Administrator on April 11, 2025, at approximately 11:30 AM confirmed the facility failed to document Resident 103's self-feeding status and the level of staff assistance required in the resident's care plan, physician orders and CNA huddle binder to provide the necessary services to maintain good nutrition for Resident 103. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on staff interview and a review of employee personnel records it was determined the facility failed to ensure the qualified part-time professional activities director responsibilities included directing the development, implementation, supervision and ongoing evaluation of the activities program, which includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. Findings include: Interview with the administrator on April 11, 2025, at approximately 10:00 AM revealed that the previous full-time qualified activities director resigned on September 20, 2024. The administrator stated that a qualified activities director from a sister facility was assisting with coverage until December 6, 2024. Since December 6, 2024, Employee 5 (activities director) has been the activity director with remote oversight from Employee 6 (vice president of life enrichment) who was a qualified activities professional. Review of Employee 5's (activity director) personnel file confirmed that Employee 5 (activity director) was hired as the activity director on December 5, 2024, and that employment was contingent on receiving certification as an activities professional. The facility has enrolled Employee 5 in a program which will begin on June 10, 2025, to obtain the required activities professional certificate. Interview with the administrator on April 11, 2025, at approximately 11:00 AM confirmed that Employee 6's (vice president of life enrichment) role at the facility was limited and failed to include directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. 28 Pa. Code 201.3 Definitions. 28 Pa. Code 201.18(b)(3) (e)(6) Management 28 Pa. Code 201.19 (3) Personnel policies and procedures

Based on clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to provide person-centered care for diabetes management and professional standards of practice for one resident out of 30 sampled (Resident 45). Findings include: A review of facility policy entitled Diabetic Protocol, last reviewed on March 20, 2025, indicated the provider and staff will work together to give appropriate treatment to manage diabetes, and for residents who have or are suspected to have diabetes, the provider will order pertinent testing. A review of the clinical record revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood and urine) and end-stage renal disease dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2025, revealed that Resident 45 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 45's clinical record revealed a laboratory report dated April 25, 2023, of a hemoglobin A1C (HgbA1c) result of 6.0% (a blood test that measures your average blood sugar levels over the past two to three months) of 6.0 and indicated that it was high. A review of a physician order dated April 4, 2024, revealed the resident had an order for Trulicity 3 mg/0.5 ml (milliliter) subcutaneous (under the skin) weekly for diabetes. A review of a physician order dated April 5, 2024, revealed the resident had an order for Lantus 8 units subcutaneous (under the skin injection) once a day at bedtime for diabetes. A review of the resident's physician orders to the skilled nursing facility revealed blood glucose (sugar) monitoring was not ordered by the resident's attending physician at the skilled nursing facility. A review of a May 2024 Consultant Pharmacist Medication Regimen Review revealed the consultant pharmacist indicated the resident had diabetes and did not have routine blood glucose monitoring documented in the medical record and recommended monitoring fingerstick blood glucose levels. A review of a physician's order dated June 2, 2024, revealed an order to obtain fingerstick blood glucose levels twice a day for two weeks and to notify the physician if less than 60 mg/dl or greater than 250 mg/dl, to start June 3, 2024, and end on June 17, 2024, in response to the consultant pharmacist recommendation. A clinical record review of Resident 45's fingerstick blood glucose monitoring revealed elevated glucose levels of greater than 250 mg/dl on several dates, which included, June 3, 2024, at 12:35 PM - glucose 288 mg/dl June 3, 2024, at 9:41 PM - glucose 309 mg/dl June 9, 2024, at 10:46 AM - glucose 273 mg/dl June 11, 2024, at 9:44 PM - glucose 260 mg/dl June 12, 2024, at 8:18 PM - glucose 277 mg/dl June 15, 2024, at 8:45 PM - glucose 299 mg/dl A review of a progress notes dated June 3, 2024, at 10:06 PM, revealed the nurse had made the physician aware of a fingerstick blood glucose of 309 mg/dl on June 3, 2024, at 9:41 PM. There was no documentation that nursing staff had informed the physician of the remaining elevated blood glucose levels as ordered by the physician to notify of any glucose over 250 mg/dl between June 3, 2024, and June 17, 2024. There was no documentation that nursing staff had consulted the physician regarding the resident's diabetes management needs at the skilled nursing facility. A review of resident 45's care plan for the problem of diabetes, dated June 3, 2024, revealed the resident was at risk for unstable blood sugars due to diabetes and to administer medications as ordered and evaluate, record, and report effectiveness. An interview with Resident 45 on April 8, 2025, at 12:40 PM, revealed she would like the facility to monitor her blood glucose levels more frequently. Resident 45 stated she could not remember the last time she had her blood glucose levels monitored. Further review of the clinical record revealed Resident 45's last documented blood glucose was on June 17, 2024, at 8:55 PM. Following inquiries made during the week of the survey regarding Resident 45's diabetes management and resident requests for more frequent monitoring of her diabetes, a physician's order dated April 9, 2025, revealed a laboratory order for hemoglobin A1C to be obtained on April 10, 2025. A review of a laboratory report dated April 10, 2025, revealed hemoglobin A1C result of 7.9% and indicated it was high, and referenced per the American Diabetes Association (ADA) target for diabetic control should be under 7%. Furthermore, a review of a physician's order dated April 10, 2025, revealed an order for a fingerstick blood glucose once every other day. An interview with the Director of Nursing on April 10, 2025, at 2:00 PM, confirmed the physician was not made aware of Resident 45's elevated blood sugars between June 3, 2024, and June 17, 2024, and confirmed there was no documented evidence of a person-centered care plan developed to address adequate diabetes management. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure that pain management is provided to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one resident out of 30 sampled (Resident 36). Findings include: A review of the facility policy titled Pain Management Policy, last reviewed by the facility on March 20, 2025, revealed it is the facility policy to ensure any resident admitted to the facility is assessed for pain and potential for pain in order for the resident to reach and maintain his or her highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy indicated a pain evaluation will occur with an onset of new pain. The evaluation will include the presence of indicators of pain or active pain, including type, intensity, characteristics, and frequency. The evaluation of the presence or severity of pain will occur using the appropriate pain scale for each resident: numeric pain rating scale, faces rating scale, or verbal descriptor rating scale. A clinical record review revealed Resident 36 was admitted to the facility on [DATE], with diagnoses that included systemic lupus erythematosus (a chronic autoimmune disease where the body's immune system attacks its own healthy tissues and organs, causing inflammation and potential damage) and poly-osteoarthritis (a condition where cartilage, the tissue that cushions the ends of bones in joints, wears down, causing pain, stiffness, and limited movement). A review of Resident 36's current plan of care identified acute and chronic pain, and potential for pain related to lupus and polyosteoarthritis. The plan of care indicated that the resident was on a regimen of pain medications and was assessed to be able to tolerate a pain level of 8 out of 10. Interventions listed in the care plan to address the resident's pain included: providing education to the resident and family regarding pain and available options for pain management; implementing non-pharmacological interventions to assist in reducing pain; assessing for both verbal and nonverbal signs and symptoms of pain; administering pharmacological interventions as ordered by the physician; and monitoring the effectiveness of the medication. A review of the clinical record revealed that a physician's order for acetaminophen (a non-opioid analgesic medication) 325 mg tablets, with instructions to administer two tablets (650 mg total) by mouth every six hours as needed for pain rated 1 to 3 on a pain scale of 0 to 10, was initiated on September 23, 2024. A review of the clinical record revealed a physician's order for oxycodone (an opioid analgesic) 5 mg tablets, with instructions to administer one tablet by mouth every four hours as needed, was initiated on April 5, 2024. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 4, 2025, revealed that Resident 36 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A nursing progress note dated January 24, 2025, at 6:33 AM indicated Resident 36 reported pressure in her lower left side, was tearful, and had a low-grade fever. The note documented that acetaminophen was administered for fever and that the nursing supervisor and physician were notified. No documentation was observed to indicate a comprehensive pain assessment was completed at that time. A progress note dated January 24, 2025, at 10:52 AM documented that Resident 36 continued to complain of lower back pain and had been assessed by nursing staff. The note indicated that the resident was alert and oriented and that acetaminophen was administered in accordance with the physician's order. It was also noted that the resident was afebrile and not in visible distress. The physician and resident representative were notified. The note did not include a numerical pain scale rating or further characterization of the pain such as duration, location, or exacerbating/relieving factors. A progress note dated January 24, 2025, at 2:39 PM indicated that Resident 36 was transported to the emergency department per her request. The note stated that the physician was notified. A review of the Medication Administration Record (MAR) for January 2025 indicated that Resident 36 received acetaminophen 325 mg, two tablets (650 mg), on January 24, 2025, at 4:57 AM for a fever of 100.4 F. The MAR also documented that Resident 36 received oxycodone 5 mg at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, and 4:00 PM on the same day. A review of documented vital signs for January 24, 2025, revealed two recorded pain assessments. At 7:04 AM, the pain level was recorded as 0 out of 10, and at 1:49 PM, the pain level was again recorded as 0 out of 10. These assessments did not correspond with the multiple documented complaints of pain on that date or the administration of five doses of oxycodone. There was no accompanying documentation found to indicate whether the resident's pain was assessed prior to or following administration of the oxycodone on January 24, 2025, nor was there documentation of the effectiveness of the medication administered. During an interview conducted on April 8, 2025, at 10:45 AM, Resident 36 stated that she had been experiencing low back pain for approximately two weeks prior to her hospitalization in January 2025. She reported the pain had been mild initially but became extreme during the early morning hours of January 24, 2025. Resident 36 indicated that she experiences pain daily and described the pain on the morning of January 24 as very extreme. She stated that although nursing staff administered acetaminophen, they did not appear to understand the severity of her pain. During an interview conducted on April 10, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) acknowledged that the clinical record indicated Resident 36 was tearful and had documented complaints of lower back pain. The NHA confirmed that the clinical record lacked documentation of a comprehensive pain assessment on January 24, 2025, including a pain scale rating, intensity, frequency, or description of the pain. The NHA also confirmed that it is the facility's responsibility to ensure pain management is provided in accordance with professional standards of practice, including ongoing evaluation and monitoring of pain. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of the facility's abuse prohibition policy, select incident reports and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident (Resident 25) out of 20 sampled residents was free from sexual abuse perpetrated by another resident (Resident 46). Findings include: A review of facility policy titled Pennsylvania Resident Abuse, last reviewed by the facility on March 24, 2024, revealed the facility will not tolerate abuse of residents by anyone. The policy defines sexual abuse as includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. A review of the clinical record revealed Resident 46 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood), major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts), and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2024, revealed that Resident 46 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment). Resident 46's care plan, initiated March 21, 2023, revealed that the resident displayed behaviors of threatening to punch staff, alleged perpetrator of sexual abuse towards roommate, and verbal {aggression} with staff. Planned interventions were noted as approaching calmly, speaking in a calm voice, discussing with him that either doing an act of violence towards others or making threats may result in police involvement, remaining with the resident when anxiety is high, and protecting others from injury by removing other residents if needed. A clinical record review revealed Resident 25 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks ). A review of an annual MDS assessment dated [DATE], revealed that Resident 25 was severely cognitively impaired with a BIMS score of 6 (a score of 0-7 indicates severe cognitive impairment). Resident 25's care plan, initiated November 11, 2020, revealed that Resident 25 can become hyper-fixated on male residents and the planned approach was for staff to redirect at these times with an activity of preference, and consult a medication management provider. An incident report dated January 3, 2024, at 3:25 PM indicated that Resident 25 and Resident 46 were observed kissing in the east lounge. The incident report indicated that Resident 46 was observed with his hand up Resident 25's shirt with his hand touching her breast. A witness statement dated January 3, 2024, provided by Employee 1, Licensed Practical Nurse (LPN), indicated that around 1:45 PM she observed Resident 46 and Resident 25 kissing in the East resident lounge. Employee 1, LPN, explained that Resident 46's hand was on Resident 25's breast. A witness statement dated January 3, 2024, provided by Employee 2, LPN, indicated that she observed Resident 25 and 46 kissing in the dining room. Employee 2, LPN, indicated that Resident 46's hand was inside Resident 25's shirt as he touched her breasts. Employee 2, LPN, indicated that the residents were immediately separated. A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, Social Worker (SW), met with Resident 46 to discuss the incident. Resident 46 indicated that Resident 25 kissed him, and he did not touch her inappropriately or in any way. Resident 46 indicated Resident 25 kissed him because he looked good today. A witness statement dated January 3, 2024, at 4:15 PM revealed that Employee 3, SW, met with Resident 25 to discuss the incident. Resident 25 indicated that nothing happened and that she feels safe in her surroundings. The Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists- American Bar Association Commission on Law and Aging- American Psychological Association indicates that the most widely accepted criteria, which are consistent with those applied to consent to treatment, are: (1) knowledge of relevant information, including risks and benefits; (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence); and (3) voluntariness (a stated choice without coercion). A clinical record review failed to find evidence that the facility assessed Resident 25 or 46's capacity to consent to a sexual relationship. Applying the reasonable person concept, in the case of Resident 25, who was unable to recall the incident, and the assessment of how most people would react to the situation of being sexually abused by Resident 46, Resident 25 would have suffered psychosocial harm and humiliation. A nursing evaluation form dated January 3, 2024, at 4:21 PM revealed that Resident 25 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain. A nursing evaluation form dated January 3, 2024, at 4:42 PM revealed that Resident 46 was assessed to be disoriented, pleasant, and without indications of pain or complaints of pain. Resident 46 declined to be interviewed during the week of the survey, ending on May 10, 2024. During an interview on May 10, 2024, at approximately 11:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) verified that the facility had no evidence that Residents 25 or 46 were assessed to determine if they had the cognitive capacity to consent to a sexual relationship. The NHA and DON confirmed that the facility failed to ensure that Resident 25 was free from sexual abuse perpetrated by another resident. This deficiency is cited as past non-compliance. The facility's corrective action plan was to assess Residents 25 and 46 for physical injuries or harm, provide both residents with emotional support, and notify the resident's physician and representatives. The facility's corrective action plan was to identify residents who had the potential to be affected. The DON or designee reviewed residents with past sexual behavior to ensure appropriate personalized interventions were in place. The social worker or designee interviewed residents with BIMS scores 12-15 (BIMS score of 13-15 indicates the resident is cognitively intact) to ensure they were not inappropriately touched and felt safe. Licensed nursing staff completed skin evaluations on incapable residents with BIMS 99-11 to ensure there were no signs or symptoms of abuse. The residents' evaluations and interviews revealed no additional findings of sexual abuse. To prevent this from reoccurring, the Assistant Director of Nursing (ADON) will educate current staff on the abuse prevention policy. The ADON will educate licensed nurses and the interdisciplinary team to ensure all care plans are individualized and related to residents' sexual behaviors. To monitor and maintain ongoing compliance, the DON or designee reviewed residents with sexual behaviors weekly x 4 then monthly x 2 to ensure appropriate personalized interventions were in place. To monitor and maintain ongoing compliance, the social worker or designee will interview five cognitively intact residents (BIMS 12-15) weekly x 4 then monthly x 2 to ensure they are not touched inappropriately and feel safe. To monitor and maintain ongoing compliance, the ADON or designee will complete skin evaluations on five incapable residents (BIMS 99-11) weekly x 4 then monthly x 2 to ensure there are no signs or symptoms of abuse. The facility's corrections were completed on January 5, 2024, which was verified during the survey of May 10, 2024. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide enteral feedings as ordered to maintain acceptable nutritional parameters and prevent a significant unplanned weight loss for one resident out of 20 residents sampled (Resident 83). Findings include: A clinical record review revealed that Resident 83 was admitted to the facility on [DATE], with diagnoses that included intracranial injury (brain dysfunction caused by an outside force) and cognitive communication deficit (brain damage that results in language and cognition impairment). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 12, 2024 revealed that Resident 83 was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). Resident 83's care plan initiated May 15, 2023, revealed that the resident had self-care deficits related to a motor vehicle accident resulting in traumatic brain injury and was dependent on staff assistance for toileting, dressing, bed mobility, and eating. Resident 83's care plan, initiated May 14, 2023, indicated that the resident require a feeding tube and will maintain adequate nutrition and hydration via feeding tube with planned interventions to administer feeding and hydration by way of feeding tube as ordered. A physician's order was noted October 31, 2023, for Resident 83 to receive Isosource 1.5 at 78 ml/hr for 16 hours (an enteral feeding formula providing a total of 1,248 ml, providing 1,872 kcal, 84 grams of protein, and 953 ml of water) three times a day for dysphagia. This order was discontinued on December 21, 2023. A physician's order was initiated on December 21, 2023, for Resident 83 to receive Isosource 1.5 enteral feeding, as needed, for a diet related to an injury to the small intestine with instructions to administer 240 bolus via PEG tube (a tube that is inserted through the wall of the abdomen directly into the stomach that can be used to provide medication, liquids, and liquid food) if 50% or less of the meal is consumed. A nutrition progress note dated December 21, 2023, at 1:09 PM noted that the interdisciplinary team discussed transitioning Resident 83 to bolus tube feeding to allow for increased oral intake of foods and fluids. The entry indicated that the resident depends on staff for feeding, with 50% of meals or more consumed per documentation. His most recent weight on December 4, 2023, was 154.8 lbs. It ws noted that with a steady feeding regimen, the resident had experienced a slow, necessary, and anticipated weight gain since admission. The note indicated that Resident 83's care plan will be updated to indicate that enteral feeding {Isosource 1.5 at 78 ml/hr} will be discontinued and the resident will receive Isosource 1.5 240 ml bolus feeding via PEG tube if he consumes 50% or less of his meal. A documentation survey report and Medication Administration Record (MAR) for the months of December 2023 and January 2024 revealed that: On December 23, 2023, the resident consumed 26-50% of his breakfast but there was no documented evidence on the December 2023 MAR that the facility administered a 240-ml bolus via PEG tube following the breakfast meal. On December 23, 2023, the resident consumed 26-50% of his lunch, but there was no documented on the December 2023 MAR that the facility administered a 240-ml bolus via PEG tube following the lunch meal. On December 25, 2023, the resident consumed 0-25% of his breakfast and there was no documented evidence on the Resident 83's MAR for December 2023 that staff administered a 240-ml bolus via PEG tube following the breakfast meal. On December 25, 2023, the resident consumed 0-25% of his lunch but there was no documented evidenced on Resident 83's December 2023 MAR that staff administered a 240-ml bolus via PEG tube following the lunch meal. On December 27, 2023, the resident consumed 26-50% of his dinner but there was no documented evidence on the resident's December 2023 that staff administered the 240-ml bolus via PEG tube following the dinner meal. On December 29, 2023, the resident consumed 26-50% of his dinner but there was no documentation on Resident 83's MAR for December 2023 that staff 240-ml bolus via PEG tube following the dinner meal. On December 30, 2023, the resident consumed 26-50% of his breakfast but there was no documentation on the resident's December 2023 MAR to indicate that staff administered a 240-ml bolus via PEG tube following the breakfast meal. According to the resident's clinical record the Resident 83 weighed 157.9 lbs on October 4, 2023, 155.2 lbs on November 7, 2023, and 154.8 lbs on December 4, 2023. On December 28, 2023, Resident 83's weight had decreased to 112.0 lbs, indicating a 27.6% loss in weight in 24 days. There was no documented evidence that the resident's nutritional status was assessed by the registered dietitian at that time. On January 1, 2024, the resident consumed 0-25% of his dinner but Resident 83's MAR for January 2024 revealed no evidence that staff administered a 240-ml bolus enteral feeding via PEG tube following the dinner meal. A physician's order was initiated on January 2, 2024, at 2:47 PM for Resident 83 to receive 240 ml bolus enteral feeding with House 2.0 Med Pass supplement (a nutritional supplement drink) if meal completion less than 75%. The order was discontinued on January 3, 2024, at 10:09 AM. On January 2, 2024, the resident consumed 26-50% of his dinner but there was no documented evidence on Resident 83's Janaury 2024 MAR that staff administered a 240-ml of the House 2.0 Med pass supplement by means of a bolus enteral feeding via PEG tube following the dinner meal. A nursing progress note dated January 2, 2024, at 10:00 PM revealed that Resident 83's feeding tube was pulled out and the physician was notified. The physician requested a consult with the dietitian. There was no documented evidence that the facility had timely identified and acted upon the resident's progressive weight loss. It was not until January 3, 2024, six days after the weight loss was noted on December 28, 2023, that the facility's registered dietitian had assessed the resident's nutritional status and parameters, and adequacy of the resident's current nutritional support regimen, in response to the physician ordered consult requested on January 2, 2024. A nutrition progress note dated January 3, 2024, at 9:39 AM revealed that Resident 83's most recent weight was 112 lbs. The note indicated that the weight was questionable because the resident was receiving steady nutrition via his PEG tube. There was no documented evidence that the dietitian identified that the facility had not been consistently providing the bolus enteral feedings to the resident when the resident consumed 50% or less at meals from December 23, 2023, through January 1, 2024, and 75% or less on January 2, 2024. A nursing progress note dated January 3, 2024 at 2:16 PM indicated that Resident 83 was sent to the emergency department for PEG tube reinsertion. Clinical record documentation revealed that Resident 83 weighed 109.8 pounds on January 4, 2024, indicating a 29.1% weight loss in 31 days. There was no documented evidence that the facility had consistently provided the resident with bolus enteral feedings when the resident's oral intake was 50% or below at meals as ordered during the month of December 2023, resulting in the resident's significant progressive weight loss. During an interview on May 10, 2024, at approximately 11:15 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence that the facility consistently provided the bolus enteral tube feedings, when the resident's oral intake was 50% or below at each meal, as ordered by the physician, to meet Resident 83's nutritional and daily caloric needs to prevent significant weight loss. The NHA and DON were unable to explain the six day delay in evaluating the resident's signifcant weight loss once identified, and confirmed that it is the facility's responsibility to ensure that the resident was provided the nutritional support feedings to maintain nutritional parameters. 28 Pa. Code 211.5 (f) Medical records 28 Pa Code 211.12 (d)(3)(5) Nursing Services

Based on review of clinical records, information submitted by the facility and select facility incident reports, and staff interview it was determined that the facility failed to assure that two residents of six sampled (Resident 8 and 93) were free from a significant medication errors that compromised one resident's clinical condition and health (Resident 8). Findings include: Clinical record review revealed that Resident 8 had diagnoses which included unspecified convulsions. A physician order dated May 16, 2022 for Phenytoin Sodium Extended capsule (an anticonvulsant medication) 100 mg every 8 hours for a diagnosis of unspecified convulsions. Lab results dated May 5, 2023, revealed that the resident's Phenytoin level was low at 5.6 (normal range is 10.0 -20.0). A nurses note dated May 6, 2023, indicated that certified registered nurse practitioner on-call was notified of the abnormal lab results with no new orders at this time, medication changes to be made by physician on Monday (May 8, 2023) should they deem it necessary. Orders faxed to physician for review. Further review of the resident's clinical record revealed no documented physician evaluation of Resident 8's low phenytoin level or changes in medication ordered following CRNP notification on May 6, 2023, deferring orders to the physician after review on Monday May 8, 2023. A nurses note dated June 14, 2023, at 11:50 AM indicated that nursing was called to assist with the resident having seizures and nursing staff to promote safety and maintain airway. The resident's skin was pale & cool, SPO2 (pulse oximetry - oxygen saturation level) was 72 (low) on room air. Nasal oxygen 2 liters/minute was initiated and as needed Ativan administered per order, the resident was sluggish to verbal and tactile stimuli. The physician was made aware and an order to send the resident to emergency room was received. The resident's responsible party and certified nurse practitioner were also make aware. Review of the emergency room report dated June 14, 2023, indicated that the resident presented with seizures and intubation was required to protect airway. The resident was transferred from the emergency room to a neurointensive care unit. Resident 8 was readmitted to the facility on [DATE], with diagnoses, which included status epilepticus (a seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures), grand mal seizure (type of seizure that involves a loss of consciousness and violent muscle contractions). Review of Resident 8's May 2023 and June 2023 Medication Administration Records from May 1 through hospitalization of June 14, 2023, revealed that Phenytoin Sodium Extended capsule (an anticonvulsant medication) 100 mg every 8 hours for a diagnosis of unspecified convulsions was documented as administered by licensed staff as ordered by the physician daily. Review of information dated June 14, 2023, submitted by the facility indicated that Resident 8 presented with intractable seizures (drug resistant seizures). The facility noted that a review of Resident 8's May 2023 and June 2023 Medication Administration Records revealed that the physician prescribed anticonvulsant medication was signed out by licensed nursing staff as administered to the resident as ordered. However, extra doses were found in the medication cart. Per pharmacy record 90 pills were delivered on May 1, 2023, and 90 tabs were delivered on May 31, 2023. There were 96 tablets remaining in the cart on June 14, 2023. The physician, responsible party, and pharmacy were made aware. There were no documented resident refusals to account for the extra pills. The facility concluded that nursing staff had not administered Phenytoin Sodium Extended capsule (an anticonvulsant medication) 100 mg every 8 hours for a diagnosis of unspecified convulsions to Resident 8 as ordered by the physician. Interview with the resident's attending physician on July 13, 2023 at 2:00 PM revealed that the physician did not recall being notified about Resident 8's low phenytoin level in May 2023 and if notified he would have adjusted the resident's seizure medication. Interview with the Director of Nursing on July 14, 2023 at 1:30 PM failed to provide documented evidence that Resident 8 was free from a significant medication error contributing to the resident's seizure activity requiring hospitalization . This deficiency is cited as past non-compliance. The facility's corrective action plan included the following. The facility's corrective action plan was to transfer Resident 8 to the emergency room due to seizure activity. The physician and responsible party were aware. To identify like residents that have the potential to be affected the director of nursing (DON)/designee will review labs drawn in the last 14 days to ensure physician notification and follow-up if indicated, responsible party notification if applicable, and documentation in the electronic medical record. To identify like residents that have the potential to be affected the regional director clinical services/designee will review six months of labs related to Dilantin, Keppra, Depakote, Tegretol, and Lamictal related to seizures to ensure lab was drawn and follow-up completed. To identify like residents that have the potential to be affected the DON/designee will review residents that are on Dilantin, Keppra, Depakote, Tegretol, and Lamictal for seizure disorder to ensure medications are ordered and administered appropriately. A three month time frame will be reviewed. To identify like residents that have the potential to be affected the social worker/designee will interview capable residents to see if medications are being received. To identify like residents that have the potential to be affected the assistant director of nursing (ADON)/ SDC (staff development coordinator)/designee will complete med competencies with licensed staff to ensure competency of nurses for medication pass. To prevent this from happening again the DON/SDC/designee will educate licensed nurses on receiving labs and appropriate follow-up and documentation in the medical record with the physician. To prevent this from happening again the RDCS educated the NHA/DON/ADON/SDC on the CMM (comprehensive medication management) process and ensuring lab book is brought to CMM to ensure appropriate follow-up. To prevent this from happening again the SDC/designee will educate licensed nurses on the importance of adherence to medication regimen to prevent seizures. To monitor and maintain ongoing compliance the ADON/designee will audit labs drawn 5 days a week times 4 weeks then monthly times two to ensure labs drawn that have physician notification and follow-up if indicated, responsible party notification if applicable, and documentation in the electronic medical record. To monitor and maintain ongoing compliance the ADON/designee will review residents that are on Dilantin, Keppra, Depakote, Tegretol, and Lamictal for seizure disorder weekly times 4 then monthly times 2 to ensure medications are ordered and administered appropriately. To monitor and maintain ongoing compliance the social worker/designee will interview five capable residents weekly times 4 then monthly times 2 to ensure medications are being received. To monitor and maintain ongoing compliance the SDC/designee will complete three med competencies with licensed staff weekly times 4 then monthly times 2 to ensure competency of licensed staff. To monitor and maintain ongoing compliance the RDCS/RVPO (regional vice president of operations)/designee will attend CMM weekly times 4 then monthly time 2 to observe CMM process and ensuring lab book is brought to CMM to ensure appropriate follow-up. Attendance can be remotely via TEAMS. The facility's completion date was June 18, 2023. Clinical record review revealed that Resident 93 had a physician orders dated May 12, 2023, for Apixaban (used to prevent serious blood clots from forming due to a certain irregular heartbeat (atrial fibrillation) or after hip/knee replacement surgery) 2.5 milligrams (mg) two times daily. Review of a facility investigation dated July 6, 2023 at 3:00 p.m. revealed that Pharmacy sent 2 cards, each containing 14 pills, of Apixaban 5 mg to the facility on [DATE], instead of 2.5 mg ordered. The investigation found that pharmacy delivered 28 pills of 5 mg and nurses began administrating the increased dose of the medication on June 30, 2023, and administered 13 incorrect doses of the medication. Review of the Medication Administration Record (MAR) for June 2023 and July 2023 indicated that the Apixaban 2.5 mg was administered from June 30, 2023 to July 6, 2023 at 9:00 a.m. but the only medication the facility had in the medication cart was the Apixaban 5 mg and that was administered from June 30, 2023 to July 6, 2023 at 9:00 a.m. Interview with the Director of Nursing on July 12, 2023 at 1:00 p.m. she confirmed that 13 doses of Apixaban 5 mg were given to Resident 93 from June 30, 2023 to July 6, 2023 at 9:00 a.m. instead of the Apixaban 2.5 mg that the physician had ordered. This deficiency is cited as past non-compliance. The facility's corrective action plan was to assess Resident 93 for potential side effects. None were found at the time. A body audit was completed and no new areas were noted. Resident 93's vital signs were stable. Apixaban 5 mg was removed from the medication cart. Pharmacy was made aware and the correct order was sent to the pharmacy. Apixaban 2.5 mg was received for the evening dose on July 6, 2023. To identify other residents with the potential to be affected, the Director of Nursing /designee completed an audit for all residents on Apixaban. Current order in Point Click Care was compared to current medication on hand to ensure they match. Medications in the medication carts matched orders for all other residents on Apixaban. To prevent this from happening again the Director of Nursing /designee completed one on one education with the nurses that administered the Apixaban 5 mg dose on the 5 rights of medication administration and proper verification of physician's orders to current medications on hand. To prevent this from happening again the Director of Nursing /designee completed education on the 5 rights of medication administration to all licensed nurses. To monitor and maintain ongoing compliance the Assistant Director of Nursing /Designee will audit residents on Apixaban to ensure correct medication is on hand weekly times 4, monthly times 2, or until compliance is reached. To monitor and maintain ongoing compliance the Assistant Director of Nursing /Designee will audit to ensure the 5 rights of medication administration is being followed by nurses on the medication carts, 2 nurses per shift times 1 week, 5 nurses a week times 4 weeks, monthly times 2, or until compliance is reached. The facility's completion date was July 10, 2023. 483.45 (f)(2) Residents are free of any significant medication errors 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.

Based on a review of clinical records, information submitted by the facility, select facility policy and incident investigations and staff interviews, it was determined that the facility failed to implement the planned intervention of staff supervision necessary to prevent a fall with injury, a fractured elbow, for one of four sampled residents (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include, Alzheimers disease and a history of wandering and falls. An annual Minimum Data Set assessment (MDS- is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated April 18, 2022, revealed that the resident was severely cognitively impaired with a BIMS score (the Brief Interview for Mental Status is a structured evaluation aimed at evaluating aspects of cognition in elderly patients) of 5, (a score of 0 to 7, severe cognitive impairment) and required the limited assistance of one person with a walker for ambulation. The resident's care plan, initially dated May 28, 2020, identified the resident's problem of being at risk for behaviors and/or mood issues as evidenced by wandering, tearfulness, combativeness and verbal abusive towards staff, anger and restlessness, and resident to resident altercations. The resident's plan of care noted that the resident does have an aversion to men, is easily distracted, confused, does wander in hallways repeating help, help with no need noted. The plan of care noted that the resident can become physically aggressive or strike residents and staff unprovoked. The plan of care also indicated that the resident was non-compliant with assistance of one staff for transfers. The planned interventions, most recently initiated November 20, 2021, were to provide 1:1 supervision of the resident when the resident was out of the resident's room. The facility policy Resident Observation dated as reviewed by the facility May 2021, revealed that if a resident is on 1 to 1 monitoring, additional staff members assigned will remain with the resident in view at all times. Should the assigned staff member need to leave the area, they are responsible to ensure the resident is directly observed during their absence by another staff member. Staff members will complete the observation/monitoring tool. A review of a facility incident investigation and information submitted by the facility revealed that on May 14, 2022, at 9:29 AM Resident 1 was seated in the resident dining room and incurred a fall, that was unwitnessed by staff. According to other residents in the nearby vicinity, Resident 1 stood up with her walker and immediately fell to the floor. The investigation noted that Resident 1 required the assistance of one staff member with ambulation. The residents nearby stated that Resident 1 possibly hit her head. Resident 1 was found with swelling of her right hand and knee. The resident also reported that she hit her head. The physician and the responsible party were notified and the resident was sent to the emergency room for evaluation and treatment. Nursing documentation dated May 14, 2022, at 9:40 AM indicated that the RN supervisor was called to the east unit dining room. Resident 1 was found sitting on the floor with her back supported by staff. She was walking with her walker prior to the fall. Other residents in the dining room stated she cracked her head hard. The resident was awake and responding appropriately upon arrival. Assessment reveals right hand to base of small finger with large hematoma and right knee swelling through her jeans. Resident responded oww whenever she was touched on any part of her body. No obvious abnormality of the head. Does have blood in her mouth. As resident was being assessed, she was beginning to become increasingly groggy and minimally responding to stimulation. The resident was sent to the ER for evaluation. A review of an employee witness statement dated May 14, 2022 (no time indicated), from Employee 1, a nurse aide, stated that she was on break when Resident 1 fell in the dining room. According to Employee 1, at the time of the resident's fall, there were only two nursing staff members on duty. Employee 1 and Employee 2, LPN. Employee 1 stated that Resident 1 was last seen seated in the dining room when Employee 1 had delivered her breakfast that morning. A review of an employee witness statement dated May 14, 2022, (no time indicated), from Employee 2 (LPN) stated I was administering medications in the back hallway when two residents yelled out Resident 1 fell and hit her head. I immediately locked my cart and attended to Resident 1. Call placed overhead for assistance. RN supervisor came to assess the resident. The witness statement indicated that Employee 2 (LPN) last saw the resident seated in the dining room eating her breakfast. A review of facility 1 to 1 documentation dated May 14, 2022, revealed that no evidence that staff had provided 1:1 or every 15 minute checks of the resident from 7 AM through 1 PM on May 14, 2022, the day the resident fell in the dining room. The resident's fall was unwitnessed by staff as the resident was unsupervised in the dining room at the time of the fall. An x-ray report dated May 16, 2022 at 2:11 PM revealed that Resident 1 had sustained radial neck fracture without significant malalignment, acute appearing radial neck fracture. Nursing documentation dated May 17, 2022, at 04:04 AM revealed that at the request of the resident's family the resident was sent back to the emergency room for further evaluation and treatment of the fracture, which was confirmed during interview with the Director of Nursing on May 25, 2022, at 1 PM. A review of hospital documentation revealed that Resident 1 was admitted to the hospital on May 17 2022, and readmitted to the facility on [DATE]. A CT scan (Uses several X-ray images and computer processing to create cross sectional images) of the right upper extremity completed on May 17, 2022 revealed a severly, comminuted fracture (A comminuted fracture is a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma such as in vehicular accidents.) involving the radial head and neck with displaced fragments. An ace wrap and an arm sling was placed on the resident and the resident was sent back to the facility and was to see orthopedics in one week. During an interview May 24, 2022, at approximately 1:15 PM, the Director of Nursing stated that Employee 1, the nurse aide, was assigned to conduct the 1 to 1 observation of Resident 1 on May 14, 2022, during the 7 AM to 3 PM shift. At the time of the resident's fall, Employee 1 was on break and Employee 2 (LPN) was be responsible for the 1 to 1 observation. The DON stated that Employee 2 left the resident alone in the dining room to answer the telephone when the resident fell . However, both employees statements do not indicate that either staff member had the responsibility for the 1:1 observation of the resident that shift. According to Employee 2's (LPN) statement she was administering medications to residents on a different hallway when she heard residents yelling for help from the resident dining room because Resident 1 had fallen. Employee 1's statement indicated that she was on break at the time the resident fell . The employee did not indicate who was responsible for conducting the 1:1 observation of the resident while she was on break. The facility's incident investigation noted that the residents were alone in the dining room at that time and residents had alerted staff to Resident 1's fall. The facility failed to implement planned supervision of Resident 1 to prevent this fall with fractured elbow. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services

Based on review of clinical records, information submitted by the facility and select incident investigations, and staff interviews, it was determined that the facility failed to implement effective safety interventions and/ sufficient staff supervision of a resident with known unsafe behaviors to prevent the resident from removing life-sustaining equipment, which resulted in the death of one resident out of 11 sampled. (Resident CR8) Findings include: Clinical record review revealed that Resident CR8 was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory, a [CONDITION(S)] ([CONDITION(S)] - a surgical opening created in the throat), [CONDITION(S)] ([CONDITION(S)] is the medical term for an unusually large tongue. Severe enlargement of the tongue can cause cosmetic and functional difficulties in speaking, eating, swallowing and sleeping) and a [CONDITION(S)] ( a bright red birthmark that shows up at birth or in the first or second week of life. It looks like a rubbery bump and is made up of extra blood vessels in the skin. A [CONDITION(S)] can occur anywhere on the body, but most commonly appears on the face, scalp, chest or back). A significant change Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired, required maximum staff assistance for all activities of daily living, utilized oxygen therapy, suctioning, required [CONDITION(S)] care and was fed through a gastric feeding tube. Physicians orders dated [DATE], were noted for continuous 21% humidification without oxygen of the [CONDITION(S)], for comfort measures and shortness of breath. A review of a nurses note dated [DATE], at 2:56 PM revealed Call placed to group home where resident resides, spoke with a group home employee to inquire communication with resident. {Resident CR8} is best reading lips to understand. Simple yes and no questions are best. Resident is non-verbal, hard of hearing and has minimal eyesight. A review of a nurses note dated [DATE] at 07:35 AM revealed While resident having a routine blood draw, resident coughed and dislodged her [CONDITION(S)]. This nurse attempted to get it back in with no success. Resident was in no resp distress, spo2 on rm air 96% and 100% on nasal o2. RN supervisor attempted [CONDITION(S)] change x 2 without success. Decision was made to send resident to ER for replacement of [CONDITION(S)]. Currently resting in bed quietly with head of bed up and nasal O2 on. Resident CR8 was transported to the hospital emergency room and her [CONDITION(S)] was replaced by hospital staff. The resident returned to the facility on that date. Review of a nurses note written by Employee 1 (LPN) dated [DATE] at 11:44 AM revealed that therapy reported that the resident was resistant & punching therapy staff. The resident was pulling at her [CONDITION(S)] during care and did not want to get out of bed, but was incontinent and agreed to ambulate into bathroom for care, then return to bed. Nursing approached Resident CR8, as she would not get out of bed and stated that she wanted to go back to group home. Employee 1 noted I reinforced the importance of the [CONDITION(S)], made aware she is not appropriate for return due to having [CONDITION(S)], she indicated she understood & still declined to get out of bed or agree to [CONDITION(S)] care at this time. According to the documentation, Employee 1 (LPN) reinforced the need for the [CONDITION(S)] and educated Resident CR8, who was severely cognitively impaired, on the risk of self-removing the [CONDITION(S)], also the benefits of maintaining the [CONDITION(S)]. Further review of nursing documentation dated [DATE], at 12:33 PM revealed that nursing staff approached Resident CR8 for [CONDITION(S)] care and noted that the resident was a bit resistant & didn't want to sit up. Nursing told Resident CR8 that the [CONDITION(S)] holder and drain sponge were soiled and to do proper care she needed to sit up. Nursing noted that {Resident CR8} sat on bedside and while I was changing [CONDITION(S)] holder collar she grabbed a big chunk of my hair and pulled it. A review of a nurses note dated [DATE], at 10:53 PM revealed that {Resident CR8} pulled [CONDITION(S)] out, removed [CONDITION(S)] ties, unable to locate anywhere in room. 35% [CONDITION(S)] collar applied, attempt to insert #6 Shiley [CONDITION(S)] cuffless, unable to insert, resistance met. No signs of respiratory distress, Oxygen saturation 96 to 98% on 35% TC. Call placed to the physician, updated, order to send to emergency room (ER) received and noted. Resident CR8 returned to the facility on [DATE] at 09:21 AM with a new [CONDITION(S)] in place. On [DATE], at 12:15 PM nursing assessed Resident CR8 and observed a scant amount of blood around the [CONDITION(S)]. The area was cleansed and no frank bleeding was noted. The [CONDITION(S)] was dislodged approximately 1 inch and nursing staff was unable to advance due to meeting resistance. The resident's airway was maintained. Resident CR8 relayed to nursing staff that she had been pulling on [CONDITION(S)]. Nursing staff educated resident. Nursing contacted the hospital for instruction. The resident was in no acute respiratory distress and was seated on the bed having lunch. A nursing note dated [DATE] at 12:16 PM revealed Spoke with the On-call Ear, Nose and Throat Physician. The Physician voiced concerns over {Resident CR8} self-removing [CONDITION(S)]. The physician discussed the length of time, he perceived [CONDITION(S)] was dislodged, with correction provided that it wasn't greater than 1 hr. Dr. voiced difficulties that the local hospital is having re-establishing [CONDITION(S)] related to the [CONDITION(S)] and that with any subsequent self de-cannulation, {Resident CR8} must be sent to a different hospital where she is a known patient. Order entered to reflect same. Nursing reinforced the risk of self removing the [CONDITION(S)], the potential for acute respiratory distress and death. A nursing note dated [DATE] at 12:43 PM revealed that nursing contacted the Ear, Nose and Throat Physician to update on the physician on the resident's current condition. The resident returned from hospital after dislodging the [CONDITION(S)] and was already attempting to dislodge again, awaiting return call with any new orders. A nurses note dated [DATE], at 23:27 PM revealed Resident CR8 was noted to be in respiratory distress this evening. The resident did return to facility this morning after being at the hospital for [CONDITION(S)] dislodgement. The entry noted Attempts made by this nurse and LPN on unit to suction resident. Unable to suction resident due to meeting resistance and causing resident discomfort. Call placed to 911, and resident sent to hospital for further evaluation and treatment. Initially O2 sat was 99%. After EMS arrived, SPO2 dropped into the 80's. Resident left facility with emergency medical services via stretcher at 11:20 PM. Review of a nursing note dated [DATE], at 08:41 AM, revealed that hospital staff called to update facility on Resident CR8's current condition. The entry noted that the resident was awaiting transport back to the facility. ER staff responded to resident yelling when she was noted to have decannulated herself in the ER. ER staff was successful with re-establishing [CONDITION(S)] site and administered required medications through [CONDITION(S)], currently being observed. Review of a nurses note dated [DATE], 11:37 AM revealed Hosptial Staff contacted facility to provide update on {Resident CR8}. Hospital staff reported that Resident CR8 was currently being resuscitated, and wanted to clarify that Resident is indeed a full code. Code Status confirmed with hospital staff, awaiting any further updates regarding same. As of current reports hospital discharge is now on hold, hospital staff will update facility on Resident's status with resuscitation efforts. There was no documented that after the above instances of the resident pulling and dislodging her [CONDITION(S)], that the facility had updated the resident's plan of care to address the resident's repeated attempts to remove the [CONDITION(S)] and had developed and implemented necessary safety measures, including increased staff supervision and monitoring of the resident's due to these unsafe behaviors. The resident subsequently was readmitted to the facility on [DATE] at 8:30 PM. Review of a nurses note dated [DATE] at 04:09 AM, revealed {Resident CR8} self-removed [CONDITION(S)]. Oxygen placed on resident prophylactically and then # 6 shiley [CONDITION(S)] re-inserted without difficulty. SPO2 noted to be 96% with re-insertion. No signs and symptoms of respiratory distress. Reminded resident importance of keeping [CONDITION(S)] intact and she shook her head 'yes' to same. A review of a nursing note dated [DATE], at 8:24 PM revealed that at 6:36 PM, a nurse aide found that Resident CR8 was not breathing, with no pulse, a code blue called, CPR initiated. It was noted that resident had pulled out her [CONDITION(S)], it was observed to the right of her head. The entry noted Compressions and Ambu bagging continued, AED applied, no shocked advised. 911 called. 6:40 PM, CPR continues, no pulse no respirations, 6:45 PM EMT arrived , CPR continued, fluid intake and output initiated, left lower leg, IV started wide open 1st Epi ([MEDICATION(S)], also known as adrenaline, is a medication and hormone. As a medication, it is used to treat a number of conditions, including [MEDICATION(S)], [CONDITION(S)]) given. 6:57 PM, 2nd epi given, remains asystole (Asystole is one of the four possible states found in an unconscious patient who has undergone a [CONDITION(S)]. It is characterized by the complete and sustained absence of electrical activity of the heart, resulting in no contraction of the heart muscle) on monitor, compressions continue. At 7:08 PM, EMT called for medical command, order to stop CPR given. Call placed to County Coroner, ok for this RN to pronounce. Call placed to the Physician, advised of same, order to pronounce received and noted. Call placed to RP and niece, advised on resident's passing. A review of a nursing discharge summary dated [DATE], at 1:39 PM revealed that Resident CR8 was visualized at 5 PM, sitting upright in her bed, smiling, and then looking out her window. Approximately ,d+[DATE].5 hrs later on that date, while feeding her roommate, a nurse aide observed that the resident was not engaging in conversation, and upon further investigation, found that the resident's [CONDITION(S)] was out, and found lying next to the resident's pillow. The resident was pulseless and apneic. CPR was initated, once the EMTs arrived, Medical Command was contacted, with order provided to cease all attempts. The Coroner was contacted, and release of body was obtained. The summary also noted that {Resident CR8} did have a past history of removing her [CONDITION(S)], but since last admission from the hospital, she had not made attempts at same. She had indicated in the past she did not want the [CONDITION(S)], as she wanted to return home, her perception included the [CONDITION(S)] being the reason she could not return home (to the group home). A review of a facility incident report investigation dated [DATE], at 6:36 PM revealed that a nurse aide found Resident CR8 in bed not breathing. The report noted that CPR was initiated, it was noted that the resident had pulled out her [CONDITION(S)], it was (lying on the bed) to the right of her head. Code blue called. CPR initiated. Emergency medical services called and arrived at the facility at 6:45 PM. The coroner was contacted and arrived at the facility. The Physician was contacted and the resident was pronounced dead at that time. A review of an employee witness statement dated [DATE], no time identified, revealed that Employee 2 (nurse aide) stated that she and another nurse aide completed care for Resident CR8 on [DATE], between 3:30 PM and 4 PM noting that the resident was in good spirits. The statement noted that between 4 PM to 5 PM I noticed Resident CR8 sitting up in her bed, looking out of the window, toward the side, I didn't see her face. Nurse's notes from the resident's October [DATE] through Resident CR8's death on [DATE], revealed that the resident had attempted to, and successfully removed her [CONDITION(S)] tube. Nurses notes, as well as, Interdicsiplinary progress notes indicated that this resident was advised that she could not return to her prior living arrangements, the group home, due to the resident's need for the [CONDITION(S)]. Interview with the Director of Nursing (DOB) on February 22, 2022, at 3 p.m., confirmed that no investigation was completed after Resident CR8 pulled out her [CONDITION(S)] on [DATE], requiring a hospital visit to reinsert the [CONDITION(S)] and subsequent respiratory arrest and CPR resuscitation. No new interventions were attempted in response to her history of multiple attempts at self-decannulation especially after staff reminded this resident that she could not return to her prior group home living setting because of the [CONDITION(S)]. The facility did not update the resident's care plan at that time and in response to these events and to meet the resident's current physical safety needs and psychosocial and behavioral needs. There was no evidence that the facility provided adequate staff supervision or effective safety interventions for this high risk resident to prevent recurrence of these incidents of similar nature and the resident's eventual death. The facility alleged past non-compliance for this federal deficiency. The alleged date of compliance was [DATE]. The Plan of correction included: Step#1: -Resident CR8 was observed not breathing, CPR initiated, AED applied and 911, emergency services were called. Step#2 -Like residents with the potential to be affected will be identifed and staff will review the residents who have non compliant issues and ensure that their care plan reflects the non compliance, corrections will be made as needed. -To identify the residents with the potential to be affected, staff will review progress notes times 14 days on residents with feeding tubes, trachs or IV's or other invasive devices to ensure if they have had issues related to pulling out their tubes, an incident report will be completed. -To identify other like residents, staff will review orders for residents with trachs to ensure care plans reflect current status. Step#3 -To prevent reoccurrence, administrative staff will complete education with the clinical Interdicsiplinary team staff related to ensuring preventative measures are in place for residents that are non compliant and care planning issues related to residents with non compliance. -Administration will complete education to licensed nursing staff related to ensuring preventative measures are in place for residents that are non complaint and care planning issues related to residents with non compliance. -Administration will complete education with licensed nursing staff on completing incident and accident report on residents that pull out their [CONDITION(S)], enteral feeding, IV or foley catheter or other invasive devices. Step#4 -To prevent reoccurrence, staff will: -audit progress noted three times a week for 4 weeks then monthly times four months to ensure that all episodes of [CONDITION(S)], enteral feeding, IV or foley catheter or other invasive devices being pulled out have an incident and accident investigation report. The results of the audits will be forward to the facility QAPI committee for further review and recommendations. - To maintain ongoing compliance the Social worker will audit progress notes five days a week for four weeks, then monthly times two, in clinical morning meeting to to ensure that residents with non complaint behavior have preventative measures in place and is care planned. Te results of the audits will be forward to the facility QAPI committee for further review and recommendations. -To monitor and maintain ongoing compliance Nursing Administration will complete [CONDITION(S)] care with three licensed staff, weekly times four weeks then monthly times two to ensure [CONDITION(S)] care is completed per competency. The results of the audits will be forward to facility QAPI committee for further review and recommendations. The plan of correction was fully implemented by [DATE], as verified during the survey of February 22, 2022. Refer F695 28 Pa. Code 211.12 (a)(c)(d)(1)(3) Nursing services 28 Pa. Code 211.11(d)(e) Resident care plan

Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to assure that a resident was provided the necessary assistance devices during transport to prevent a fall resulting in serious injury, a fractured arm, for one of five residents reviewed (Resident 3) Findings include: A review of clinical record revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)] (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination) and history of falls with facial fractures. An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 23, 2021, revealed that the resident was moderately cognitively impaired and required supervision with locomotion on unit and the physical assistance of one person. Review of Resident 3's clinical record revealed that on July 13, 2021, the resident was self-propelling through the unit, wandering in an out of other resident's rooms. A review of a facility incident report dated July 13, 2021, at 5:50 PM, revealed that the resident had been trying to find his room, wandering in and out of other resident rooms. Employee 1 (nurse aide) was assisting the resident down hallway in the wheelchair, when Resident 3 abruptly put his feet down and fell out of the wheelchair unto his left side. A review of a witness statement from Employee 1, dated July 13, 2021, revealed that the resident was looking for his room prior to fall and she was assisting him back to room (by pushing the resident in his wheelchair). Employee 1 stated Resident 3 had abruptly put his feet down on the ground (during transport) causing the wheelchair to tip and the resident fell out of the wheelchair onto his left side. A review of the post fall huddle dated July 13, 2021, revealed that the resident's wheelchair did not have leg rests attached, and the root cause of the fall was due to not having leg rests on his wheelchair. A review of a progress notes in the resident's clinical record dated July 14, 2021, revealed that the resident had sustained a fracture of the left ulna bone, as well as, a skin tear to the left elbow as the result of the fall. A review of hospital documentation dated July 14, 2021, revealed that resident had an x-ray, which indicated the resident had a fracture of his left ulna (The ulna is one of two bones that make up the forearm, the other being the radius. It forms the elbow joint with the humerus and also articulates with the radius both proximally and distally. It is located in the medial forearm when the arm is in the anatomical position. It is the larger of the two forearm bones). The facility staff was aware, and had documented, that prior to the resident's fall the resident was displaying restless behavior and wandering. The facility failed to safely transport the resident, who had been displaying restless behavior, by failing to assure that leg/footrests were attached to the wheelchair. The resident put his feet on the ground during transport and fell out of the chair and sustained a fractured arm. An interview with the NHA (nursing home administrator) on July 27, 2021, at approximately 1:30 PM confirmed the facility failed to provide effective safety interventions, leg rests on the wheelchair, for a resident who was a fall risk resulting in a fall with serious injury. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, to identify which residents self-propel their wheelchairs with their legs to self-propel. To identify residents with the potential to be affected the DON/designee assessed all residents who self-propel their wheelchairs that would require leg rests for transport. To prevent this from recurring the Staff Development coordinator /designee educated all staff that residents who self-propel their wheelchairs with their legs which require wheelchair legs for transport had their wheelchair identified by placing an orange zip tie to the right handle of their wheelchair. To monitor and maintain ongoing compliance the idt/designee will complete observation audit weekly x 4 weeks then monthly x 2 to ensure all residents with orange zip ties have leg rests present during transport. The facility's immediate corrective action plan was completed July 23, 2021. 28 Pa Code 211.12(a)(d)(3)(5) Nursing services

Based on review of clinical records and select resident incident/accident reports and staff interview it was determined that the facility failed to provide necessary staff supervision and implement person-centered safety measures based on individual resident needs to promote resident safety and prevent falls for three residents ( Resident 54, 63, and 15) and serious injuries, fractures, for two residents (Resident 54 and 63) out of three residents sampled incurring falls (Resident 54 and 63). Findings include: A review of the clinical record revealed that Resident 63's most recent admitted to the facility was March 18, 2017. The resident had [DIAGNOSES REDACTED].g. [DIAGNOSES REDACTED], vascular or multi-infarct dementia; mixed dementia; [DIAGNOSES REDACTED] such as [DIAGNOSES REDACTED]; and dementia related to stroke, [MEDICAL CONDITION] or [DIAGNOSES REDACTED]s) pattern of deteriorating intellectual function), mild intellectual disabilities (involves problems with general mental abilities that affect functioning in two areas: intellectual functioning (such as learning, problem solving and judgement) and adaptive functioning (activities of daily life such as communication and independent living), and [MEDICAL CONDITION] (a mental condition characterized by a disconnection from reality). A review of a quarterly Minimum Data Set Assessment ( MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 21, 2020, revealed that the resident's BIMS score (Brief interview for mental status- a tool to assess cognitive function) was 8, indicating that the resident was moderately impaired cognitively. Review of Resident 63's fall assessment initiated by the facility on October 19, 2020, and Locked on October 24, 2020, revealed that Resident 63 was identified as a high fall risk. The assessment indicated that the resident displays behaviors such as easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy; mental function varies over the course of the day; wanders; and abusive and resists care. A review of interdisciplinary progress notes revealed that on November 21, 2020, at 4:39 PM, Employee 2, a Registered Nurse, was called to the resident's room in response to the resident's fall from bed. The resident's bed was elevated and the resident confirmed he had elevated the bed. The Registered Nurse noted that Resident 63 is known to put his bed in the highest position at times despite education regarding the safety of the same. The resident was assessed and noted to complain of pain to the left lower thigh near his knee. Physician was made aware and a x-ray was obtained. A review of a witness statement provided by Employee 3 a Nurse Aide revealed that on November 21, 2020, the resident's bed was at a high level, when the resident had attempted to reach for a flashlight that was under his bed and the resident fell from bed. Review of a diagnostic report dated November 21, 2020, revealed that Resident 63 had sustained an impacted metaphyseal fracture (impacted fracture occurs when broken ends of the bones are jammed together by the force of the injury, metaphyseal fracture are fractures that involve the metaphysis (are the wide portions of long bones) of tubular bones) of the distal femur (femur-the bone of the thigh, articulating at the hip and the knee). Conclusion of the diagnostic imaging was reported as acute distal femur fracture. The resident was transferred to an acute care hospital on that date. A review of the resident's current plan of care-initiated May 4, 2019, and revised on November 22, 2020, after the resident's fall revealed that the facility identified that resident would raise the bed to an elevated height despite education on safe height. However, although the facility identified this safety risk and unsafe behavior the resident continued to display despite education, the facility failed to develop and implement alternate safety measures prior to the resident's fall on November 21, 2020, to ensure safe use of the bed controls and bed height positioning. A review of the facility's post fall Huddle report dated November 21, 2020, revealed that the facility had indicated at the time of the resident's fall, the resident's bed was in an elevated position and the facility noted that the resident raises the bed on his own. A review of the faciltiy's Root Cause Analysis no date provided, referenced the date of the fall November 21, 2020, revealed that the resident was care planned to move his bed up and down as per his preference. The care plan indicated that Resident 63 elevates his bed despite education and further review of the facility's Root Cause Analysis revealed that the facility noted Resident 63 was not able to understand education regarding safety of bed height. However, the facility failed to develop specific measures to promote the resident's safety while in bed and address the resident's increased risk for injury and falls related to the resident's use of the bed controls and elevated bed height. The facility failed to timely address the known accident hazard in the resident's environment, the elevated bed, and the resident fell from bed and sustained an impacted femur fracture. A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set assessment dated [DATE], revealed that the resident's BIMS score was 5, indicating that the resident had severe cognitive impairment. Resident 54 was occasionally incontinent and required extensive assistance for activities of daily living to include, bed mobility, transfer and toilet use. Review of Resident 54's fall assessment-initiated October 2, 2020 and locked October 2, 2020, revealed that Resident 54 was identified as a high fall risk. The assessment indicated that the resident displays behaviors such as easily distraction, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy; mental function varies over the course of the day; wanders; and abusive and resists care. The fall assessment indicated that Resident 54 had impaired vision, required assistance with elimination, ambulates with problems and required assistance. Review of Resident 54's current plan of care-initiated October 2, 2020, and last revised October 2, 2020, revealed that the resident was incontinent of urine. A planned intervention in place at the time of a fall, on November 29, 2020, was to toilet Resident 54 when he yells out. The facility had developed and implemented an individualized toileting plan or schedule for the resident based on the resident's history of bladder activity or voiding patterns. However, a review of interdisciplinary progress notes from November 20, 2020 through November 28, 2020, revealed multiple entries indicating that the resident displayed the behavior of yelling. The progress notes indicated that the resident's behavior of yelling out was not limited to his toileting needs. The resident yelled out after and during toileting according to process note documentation. Review of select facility reports revealed that on November 29, 2020, at 12:30 AM, Resident 54 was yelling out for help as the result of a fall that occurred while the resident was attempting to toilet himself. Resident 54 was expressing pain in the area of his right hip. Review of interdisciplinary progress notes revealed an entry by Employee 4, a Registered Nurse, on November 29, 2020, at 12:45 AM, which indicated that after the fall, Resident 54 had told Employee 4 that he was trying to go the bathroom when he fell . A witness statement from Employee 3, Nurse Aide, revealed that prior to the resident's fall on November 29, 2020, while the resident was attempting self-toileting, the last time that staff had toileted the resident was on November 28, 2020 at 9:45 PM. Resident 54 was transferred to an acute care hospital on November 29, 2020, and remained in the hospital during the survey ending December 4, 2020, for the treatment of [REDACTED]. The facility failed to ensure that a resident identified at risk for falls and requiring staff assistance with bed mobility, transfers and ambulation and assistance was provided with timely toileting assistance. At the time of the resident's fall on at approximately 12:30 AM on November 29, 2020, the resident had not been toileted since 9:45 PM on November 28, 2020. Interview with the Director of Nursing (DON) on December 4, 2020, at 1 PM revealed that Resident 54 did not yell out for help with toileting. The DON stated that the facility had care planned to toilet the resident when he yells out and as a result the resident was not toileted or checked and changed for incontinence at the change of shift or at least every two hours as other residents are scheduled. However, the DON confirmed that the resident's yelling behavior was not solely displayed for toileting needs and that staff reliance on the resident's yelling to provide toileting was not effective based on the resident's severely impaired cognition. The facility failed to plan and implement an individualized toileting schedule to ensure timely toileting assistance to deter unsafe attempts at self-toileting. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. obsessions and compulsions that interfere with daily activities and cause significant distress). The MDS assessment dated [DATE], revealed that the resident's BIMS score was an 8, indicating that the resident was moderately impaired cognitively. The resident required two plus person physical assistance with bed mobility, transfers, dressing, toileting and personal hygiene activities. A fall care plan was developed on August 23, 2018, identifying Resident 15 at risk for falls due to history of falls with injury. The goals identified on fall care plan included having no fall related injuries (initiated 8/11/2020), will not have any falls until next review (initiated 8/23/2019). Resident 15's fall care plan interventions included the following: to reinforce need to call for assistance (initiated 8/23/2018), staff to ensure all cords are off the floor before exiting the room (initiated on 11/30/2020), staff in-serviced (initiated 10/23/2020), educate staff not to allow resident to go alone to room after meal and assist with needs after meals (initiated 12/30/2019), in-service staff on toileting program (8/13/2020), and area to be free of clutter and call light to be in reach (initiated 8/23/2018). According to the clinical record, on August 8, 2020, at approximately at 10:00 PM, Resident 15 fell from bed attempting to plug in the call bell, which became disconnected from the wall. The Post Fall Huddle (PFH) Fall Scene Investigation Form dated August 8, 2020, revealed that the resident called for help, but fell out of bed attempting to plug the call bell back into the wall and could not reach the plug. The investigation revealed a chair was obstructing the plug and the resident fell as a result of poor safety awareness. The facility's planned interventions in response to this fall was to remove the chair from the resident's room and educate the resident to ask for assistance. Clinical record documentation revealed that on August 12, 2020, at approximately 3:30 PM, Resident 15 asked a Nurse Aide for assistance to go to the bathroom. The Nurse Aide left the resident's room to seek assistance from another Nurse Aide to assist with the transfer to the bathroom, instead of activating the call bell to request additional staff assistance. However, while staff left the resident unattended, the Resident 15 fell to the floor. The facility's fall intervention was staff education to promptly toilet Resident 15 when requesting to go to the bathroom and education to the resident to ask for assistance. On October 22, 2020, at approximately 3:10 PM, Resident 15 requested to be taken to the bathroom. The Nurse Aide left the room to retrieve a mechanical lift to perform the transfer. While waiting and left unattended, the resident attempted to move a garbage can and fell to the floor. Facility fall interventions was staff education to promptly toilet Resident 15 when requesting to go to the bathroom and education to the resident to ask for assistance. Interview with the Director of Nursing on December 4, 2020, at 1:10 PM, confirmed that the facility failed to develop and implement individualized interventions for the safety of one resident (Resident 15). 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 10/7/20, 2/12/20, 7/12/19, 6/7/18

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely identify declines in skin integrity and provide prompt treatment and services to prevent the development and worsening of a pressure sore, for one resident (Resident 72) out of 21 resident's sampled. Findings include: A review of the facility policy entitled Prevention of Skin Issues, last reviewed by the facility June 5, 2015, indicated that it is the facility's policy to ensure that a resident entering the center without pressure ulcers does not develop pressure ulcers. They recognize even the most vigilant nursing care may not prevent the development and/or worsening of pressure ulcers in some cases and that intensive efforts will be directed in the areas of managing risk factors, providing preventative interventions and providing treatment. A review of a Braden Skin Assessment Scale (an assessment tool that identifies risk for pressure sore development) dated October 1, 2014, revealed that Resident 72 scored a 14 and was considered to be at moderate risk for development of pressure areas. The following Braden Skin assessment (no date noted) revealed a score of 15, indicating that the resident was at minimal risk. The resident had a history of [REDACTED]. A review of Resident 72's clinical record revealed current [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - a standardized assessment conducted periodically to plan resident care) dated November 4, 2104, revealed that the resident's cognition was moderately impaired. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, bathing and toilet use. The resident was frequently incontinent of urine and was at risk for developing pressure ulcers. A review of the resident's care plan for the problem of urinary incontinence dated April 7, 2014, revealed that the resident was incontinent of urine and was placed on a program, which consisted of checking and changing the resident every two hours. The facility was unable to provide documented evidence that the resident's incontinence was addressed every two hours as planned. The resident's treatment record dated January 2015, included weekly skin assessments. The skin checks were completed on January 4, 11, 2015, but not again until January 18, 2015. During September 2014 the resident had a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer) pressure sore to the sacrum being treated with Solosite (wound treatment), which was changed to Allevyn (wound treatment) on September 11, 2014. There was a treatment change on September 17, 2014, to Replicare (facility spelling on orders and TAR as Replica) every 3 days and prn (as needed) soilage/dislodged after cleansing with wound cleanser. A physician order dated October 1, 2014, directed the application of Replicare ([MEDICATION NAME] wound dressing) to the resident's sacrum every 3 days and as needed soilage/dislodgement and to apply skin prep prior to application as a preventative. The resident's January 2015 treatment administration revealed that the Replica patch was changed on January 2, 5, 7, 11 (four days), 13, and 17 (four days), 2015. The change times were inconsistent with the physician's order. A review of a resident incident report dated January 18, 2015, at 10:15 AM, revealed that while a nurse aide was rendering care to Resident 72, she noticed an area under the Replicare patch, which was black, red and purple at the sacral area. The nurse aide who discovered the area indicated in a written statement that she had previously reported a tiny open area (on the resident's sacrum) to Employee 1, LPN (licensed practical nurse) on January 15, 2015. The nurse aide noted that it was reported numerous times to the LPN, that the Replica treatment was irritating the resident's skin and pulling at her skin. However, Replica continued to be used of the on the resident. There was no documented evidence regarding of the small open area that the nurse aide reportedly informed the LPN of on January 15, 2015. There was no statement from Employee 1, LPN included with the incident report. The incident report concluded that the resident was had an unstageable area (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) on her sacrum, which measured 9 cm by 10 cm by 0.25 cm, black in color. A review of a disciplinary action report dated January 29, 2015, indicated that Employee 1 failed to address the reported concern that Resident 72's Replicare was irritating her skin, which subsequently resulted in the unstageable area on the resident's sacrum identified as a pressure ulcer on the ski grid dated January 15, 2015. The disciplinary report also noted that Employee 1 failed to measure the area, change the treatment to the irritated area, or report the area to her supervisor or unit manager. A physician order dated January 19, 2015, was noted for a consult at the wound clinic for this pressure ulcer. A review of the wound clinic consultation report dated February 20, 2015, revealed that the resident was evaluated for a sacral decubitus after a debridement. The necrotic tissue (unstageable) pressure ulcer measured a 5.2 cm x 3.4 x 3.2 cm on her sacrum. Following debridement the area presented itself as a Stage III pressure ulcer according to the consult report. At the time of the survey, according to the skin grid dated July 22, 2015, the sacral pressure sore was identified as a Stage III (full thickness tissue loss), red in color, measuring 1.1 cm x 0.9 cm x 1.0 cm in depth with bloody drainage During an interview with the Nursing Home Administrator and Director of Nursing on July 23, 2015, at approximately 1:30 PM, these staff members were unable to explain why the resident's area of skin impairment was not identified promptly acted upon to prevent progression to an unstageable pressure area. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 6/5/14, 11/1/14, 4/20/15 28 Pa. Code 211.10 (a)(c)(d) Resident care policies Previously cited 6/5/14, 4/20/15

Based on review of clinical records, incident/accident, and an Event report submitted to the State Agency and staff interviews, it was determined that the facility failed to provide adequate supervision and/or staff assistance to prevent an accident with injury for one out of 24 sampled residents (Resident 44). Findings include: Clinical record review revealed that Resident 44 had [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident required two person physical assistance for bed mobility and toilet use and displayed limited mobility of both lower extremities. Review of therapy notes dated November 3, 2009 revealed the residents mobility status for rolling was moderate assist of two staff. Review of an "Accident/Incident Report" dated August 16, 2010 at 2:40 a.m. and an Event Report submitted to the State Agency, revealed that while the nurse aide (Employee 1) was giving incontinence care to the resident, Employee 1 had the resident turned onto her right side. Employee 1 placed the bottom sheet and brief underneath the resident and was about to roll the resident onto her back when the resident rolled out of the bed. The resident complained of pain in her left knee. The resident sustained [REDACTED]. The resident was transported via ambulance to the hospital on August 16, 2010 and arrived at 4:08 a.m. X-ray of the left knee was positive for a fracture of the distal femur. An immobilizer was utilized to stabilize the left leg and the resident was transported back to the facility, with an order for [REDACTED]. Review of the facility's investigation into the incident dated August 16, 2010 at 1:00 p.m., revealed that during incontinence care the resident was turned onto her side and her knees were over too far causing an uneven weight distribution. The resident was using enabler rails (quarter size bed rails) to roll to assist with bed mobility. The resident rolled out of bed and onto the floor along with pillow and bedding. Interview with Resident 44 on July 5, 2011 at 10:30 a.m., revealed that the resident remembered the incident of August 16, 2010. The resident stated that it is necessary to use two staff for turning and repositioning because she has little use of both legs for mobility and that at the time of the incident there was only one nurse aide in attendance. Interview with the Nursing Home Administrator and Director of Nursing on July 6, 2011 at approximately 10:40 a.m., failed to provide evidence that the resident was provided the proper assistance level to prevent this accident with injury. 483.259(h)(i) Free of Accident Hazards/Supervision/Devices. Previously cited 6/11/10 28 Pa. Code: 211.12(a)(d)(1)(3)(5) Nursing services. Previously cited 6/11/10, 10/19/10, 2/16/11