Every finding on record at Burgh Care Center

Based on review of facility policy, controlled medication shift reconciliation records and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting of controlled medications on two of four medication carts reviewed (Second floor Medication Carts One and Two).Findings include: Review of the facility policy Controlled Substance Administration & Accountability last reviewed 2/11/26, indicated it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Review of an anonymous complaint filed against the facility on 8/3/26, indicated facility staff did not count the narcotic medications at change of shift, and the keys were left for the oncoming nurse. Observation on 8/24/26, at 1:00 p.m. of the Second-Floor Medication Cart One's Controlled Substance Accountability Log Dated August 2026, indicated on 8/2/26, the 11:00 p.m. to 7:00 a.m. shift number of cards at the start of shift, the oncoming nurse signature, and the outgoing nurse signature failed to be present as required. Interview on 8/24/26, at 1:01 p.m. with Registered Nurse (RN) Employee E6 confirmed the Second-Floor Medication Cart One's Controlled Substance Accountability Log Dated August 2026, indicated on 8/2/26, the 11:00 p.m. to 7:00 a.m. shift the number of cards at the start of shift, the oncoming nurse signature, and the outgoing nurse signature failed to be present as required. Observation on 8/24/26, at 1:05 p.m. of the Second-Floor Medication Cart Two's Controlled Substance Accountability Log Dated August 2026, indicated on 8/2/26, the 11:00 p.m. to 7:00 a.m. shift the number of cards at the start of shift and the outgoing nurse signature failed to be present as required and 8/3/26, 7:00 a.m. to 3:00 p.m. shift oncoming nurse signature failed to be present as required. Interview on 8/24/26, at 1:06 p.m. with Registered Nurse (RN) Employee E3 confirmed the Second-Floor Medication Cart Two's Controlled Substance Accountability Log Dated August 2026, indicated on 8/2/26, the 11:00 p.m. to 7:00 a.m. shift the number of cards at the start of shift and the outgoing nurse signature failed to be present as required, and 8/3/26, 7:00 a.m. to 3:00 p.m. shift oncoming nurse signature failed to be present as required. Interview on 8/24/26, at 1:15 p.m. the Director of Nursing confirmed the facility failed to implement procedures to promote accurate accounting of controlled medications on two of four medication carts reviewed (Second floor Medication Carts One and Two). 28 Pa Code: 201.18 (b)(1)(3) Management.28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on review of facility policy, resident clinical records, facility documents, it was determined that the facility failed to conduct a thorough investigation of two allegations of abuse/neglect for two of three residents (Resident R1 and R2).Findings include: Review of the facility provided policy titled Abuse- Neglect and Exploitation dated 2/11/26, indicated that the facility will provide protections for the health, welfare, and rights of each residents by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. An immediate investigation is warranted when abuse or neglect is reported. All involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations must be identified. A complete and thorough documentation of the investigation must be maintained. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 7/6/26, indicated she had diagnoses that include diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and muscle weakness. Review of facility Concern Form dated 7/13/26, stated that Resident R1 reported their morning pills were not distributed at all, and the noon pills were given after 1 p.m. Review of facility documents did not include an investigation for the abuse/neglect incident that Resident R1 reported on 7/13/26. No witness statements were obtained or evidence the clinical record was reviewed. Review of Resident R2's admission record indicated he was admitted on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 7/27/26, indicated she had diagnoses that include diabetes, bipolar disorder (a lifelong mental health condition with episodes of high energy (mania or hypomania) and low mood (depression), and high blood pressure. Review of facility Concern Form dated 7/22/26, stated Resident R2 reported not receiving medications or a shower. Review of facility documents did not include an investigation for the abuse/neglect incident that Resident R2 reported on 7/22/26. No witness statements were obtained or evidence the clinical record was reviewed. During an interview on 8/25/26, at 12:56 p.m. the Social Service Director, Employee E4 stated an allegation of pills not being disturbed is considered an allegation of neglect. The Social Service Director, Employee E4 stated the Nursing Home Administrator and Director of Nursing are responsible initiating an investigation. It was indicated it is expected witness statements are obtained and the Medication Administration Record should have been reviewed to see if the resident received medication as ordered. During an interview on 8/25/26, at 1:05 p.m. the Director of Nursing and nursing Home Administrator confirmed the facility failed to conduct a thorough investigation of two allegations of abuse/neglect for two of three residents (Resident R1 and R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R4 and R5).Findings include: Review of the facility policy Medication Administration last reviewed 2/11/26, indicated to administer medications as ordered. Observe resident consumption of medication. Sign Medication Administration Record (MAR) after administered. Correct any discrepancies and report to the nurse manager. Review of the facility policy Medication Errors last reviewed 2/11/26, indicated a significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. Review of the admission record indicated Resident R4 admitted to the facility on [DATE], with diagnoses of sepsis (a life threatening medical emergency that happens when the body has as extreme runaway response to an infection), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R4's Medication Administration Record dated August 2026, indicated on 8/3/26, the resident did not receive their Glargine insulin (long acting) on 8/3/26, at 8:00 a.m. and did not receive their Lispro insulin (short acting( on 8/3/26, at 9:00 a.m. Each medication was signed off as administered on 8/5/26, at 11:21 p.m. by Licensed Practical Nurse (LPN) Employee E1. A total of two days later. Review of LPN Employee E1's payroll punch detail for 8/3/26, indicated the LPN punched in to work at 11:03 a.m. and was not present in the facility at the times of Resident R4's glargine insulin at 8:00 a.m. or the Lispro insulin at 9:00 a.m. Review of the admission record Resident R5 admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/21/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes. Review of Resident R5's Medication Administration Record dated August 2026, indicated on 8/3/26, the resident did not receive Lantus insulin (long acting) on 8/3/26, at 9:00 a.m., did not receive Ozempic (improves blood sugar control) on 8/3/26, at 8:00 a.m., and did not receive Novolog insulin (rapid acting) on 8/3/26, at 8:00 a.m. LPN Employee E1 signed off as administered as follows:-Lantus on 8/5/26, at 11:31 p.m.,-Ozempic on 8/5/26, at 11:33 p.m., and-Novolog on 8/5/26, at 11:34 p.m. Review of LPN Employee E1's payroll punch detail for 8/3/26, indicated the LPN punched in to work at 11:03 a.m. and was not present in the facility at the times Resident R5's Ozempic and Novolog at 8:00 a.m. or Lantus at 9:00 a.m. Interview on 8/24/26, at 11:56 a.m. the Director of Nursing confirmed Resident R4 and Resident R5's medications were not administered by LPN Employee E1 who was not in the facility at the time the medications were due. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.10(c) Resident care policies.28 Pa Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, resident clinical records, facility documents, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of verbal abuse for one of three sampled resident records (Resident R1 and R2).Findings include: Review of the facility provided policy titled Abuse- Neglect and Exploitation dated 2/11/26, indicated that the facility will provide protections for the health, welfare, and rights of each residents by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury. Review of Resident R1's admission record indicated she was admitted on [DATE]. Review of Resident R1's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 7/6/26, indicated she had diagnoses that include diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and muscle weakness. Review of facility Concern Form dated 7/13/26, stated that Resident R1 reported their morning pills were not distributed at all, and the noon pills were given after 1 p.m. Review of alleged abuse/neglect allegations submitted to the State field office did not include abuse/neglect incident involving Resident R1 reported on 7/13/26. Review of Resident R2's admission record indicated he was admitted on [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 7/27/26, indicated she had diagnoses that include diabetes, bipolar disorder (a lifelong mental health condition with episodes of high energy (mania or hypomania) and low mood (depression), and high blood pressure. Review of facility Concern Form dated 7/22/26, stated Resident R2 reported not receiving medications or a shower. Review of alleged abuse/neglect allegations submitted to the State field office did not include the allegation of abuse/neglect involving Resident R2 reported on 7/22/26. During an interview on 8/25/26, at 12:56 p.m. the Social Service Director, Employee E4 stated an allegation of pills not being disturbed is considered an allegation of neglect. The Social Service Director, Employee E4 stated the Nursing Home Administrator and Director of Nursing are responsible for notifying the state. During an interview on 8/25/26, at 1:05 p.m. the Director of Nursing and nursing Home Administrator confirmed that the facility failed to report allegations of abuse/neglect as required for two of three residents (Resident R1 and R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for one of three resident areas (Second Floor Activity Room) and one of four resident rooms (Resident R3).Findings include: Review of the facility policy Safe and Homelike Environment last reviewed 2/11/26, indicated in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Review of the admission record indicated Resident R3 admitted to the facility on [DATE]. Interview on 8/24/26, at 12:20 p.m. Resident R3 indicated a concern with the cleanliness of their resident room and also the Second-Floor Activity Room. Observation on 8/24/26, at 12:35 p.m. the Second-Floor Activity Room was occupied by several residents eating lunch. The floor of the room was heavily soiled with black smudges, spills, and debris. An unidentified employee indicated I've worked here three months and they've only mopped once. and confirmed the appearance of the floor. Observation on 8/24/26, at 12:45 p.m. Resident R3's room indicated a soiled floor with brown sticky substance, smudged floors and grime. Interview on 8/24/26, at 12:50 p.m. the Nursing Home Administrator was informed of the concerns with cleanliness of Second-Floor Activity Room and Resident R3's floor in their room. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management

Based on resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Residents R4, R5, and R7).Findings include: Review of an anonymous complaint filed against the facility on 8/3/26, indicated a resident who was diabetic did not receive their morning medications. It was indicated it was because there was not a nurse available to administer their medications in the building. Review of the admission record indicated Resident R4 admitted to the facility on [DATE], with diagnoses of sepsis (a life-threatening medical emergency that happens when the body has as extreme runaway response to an infection), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R4's Medication Administration Record dated August 2026, indicated on 8/3/26, the resident did not receive their Glargine insulin (long acting) on 8/3/26, at 8:00 a.m. and did not receive their Lispro insulin (short acting( on 8/3/26, at 9:00 a.m. Each medication was signed off as administered on 8/5/26, at 11:21 p.m. by Licensed Practical Nurse (LPN) Employee E1. A total of two days later. Review of LPN Employee E1's payroll punch detail for 8/3/26, indicated the LPN punched in to work at 11:03 a.m. and was not present in the facility at the times of Resident R4's glargine insulin at 8:00 a.m. or the Lispro insulin at 9:00 a.m. Review of the admission record Resident R5 admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/21/26, indicated the diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and diabetes. Review of Resident R5's Medication Administration Record dated August 2026, indicated on 8/3/26, the resident did not receive Lantus insulin (long acting) on 8/3/26, at 9:00 a.m., did not receive Ozempic (improves blood sugar control) on 8/3/26, at 8:00 a.m., and did not receive Novolog insulin (rapid acting) on 8/3/26, at 8:00 a.m. LPN Employee E1 signed off as administered as follows:-Lantus on 8/5/26, at 11:31 p.m.,-Ozempic on 8/5/26, at 11:33 p.m., and-Novolog on 8/5/26, at 11:34 p.m. Review of LPN Employee E1's payroll punch detail for 8/3/26, indicated the LPN punched in to work at 11:03 a.m. and was not present in the facility at the times Resident R5's Ozempic and Novolog at 8:00 a.m. or Lantus at 9:00 a.m. Interview on 8/24/26, at 11:56 a.m. the Director of Nursing confirmed Resident R4 and Resident R5's medications were not administered by LPN Employee E1 who was not in the facility at the time the medications were due. Interview on 8/24/26, at 10:03 a.m. Nurse Aide (NA) Employee E2 indicated a nurse earlier in the month refused to take the medication cart and left the facility. Interview on 8/24/26, at 10:05 a.m. Registered Nurse (RN) Employee E3 indicated staffing has been low, when asked if there was enough staff to care for residents. We don't have another nurse today so that puts me as Supervisor and on the medication cart which makes it hard to supervise. Interview on 8/24/26, at 10:20 a.m. NA Employee E5 indicated usually we only have three aides, when asked if there was enough staff to care for residents, it was revealed that when there are only three nurse aides it's tough to get to showers, and find another person to help with the residents who require the assistance of two staff members. Interview on 8/24/26, at 10:30 a.m. Resident R6 indicated over the weekend, an aide put his roommate Resident R7 into the bathroom and then disappeared for an hour. The nurse came in another hour later and took care of Resident R7. Interview on 8/24/26, at 10:31 a.m. Resident R7 indicated he was left in the bathroom for two hours without assistance. Interview on 8/24/26, at 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Residents R4, R5, and R7). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, facility documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to create an environment free of accidents when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke (a serious health condition when the body temperature rises to 104 degrees or more due to exposure to high temperatures) while out of the facility. This created an immediate jeopardy situation for one of 37 residents who was approved for a LOA- (leave of absence- when the facility allows a resident to leave the facility for a short period of time) Findings include: Review of the facility admission Agreement indicated a resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Review of Resident R1's clinical record indicated that he was admitted to the facility on [DATE]. Review of Resident R1's clinical record revealed a care plan intervention dated 12/13/24, to allow resident to go out on a LOA. Review of Resident R1's clinical record revealed an order written by a Nurse Practitioner on 3/12/26, for independent LOA (leave of absence- when the facility allows a resident to leave the facility for a short period of time) - must return by 11 p.m. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/8/26, indicated diagnoses of amputation (right leg- above the knee), high blood pressure, and Peripheral Vascular Disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Section C0500 Brief Interview of Mental status indicated score of 15, indicative of being cognitively intact. Review of facility document Resident Leave of Absence revealed on 7/3/26, at 9:38 a.m. Resident R1 signed himself out of the facility. Destination was listed as shopping and Escort Name was listed as self. Review of Resident R1's clinical record revealed a progress note dated 7/3/26, at 2:46 p.m. that stated, Out of the building. Review of Resident R1's clinical record revealed a progress note dated 7/3/26, at 5:27 p.m. indicating the following: Nurse from [hospital] called supervisor phone. She informed me that resident is currently a patient in their ER (emergency room). Evidently resident was found by the police in his electric wheelchair. Wheelchair had stopped running and the tires had 'melted into the pavement'. On arrival resident's temperature was 106, he is being treated for 'heat exhaustion'. Review of Resident R1's clinical record revealed a progress note dated 7/3/26, at 7:31 p.m. indicating the following ER called back. Resident being admitted to their facility with diagnosis of heat stroke. His wheelchair is at the police station. During an interview on 7/7/26, at 9:12 a.m. Nurse Aide (NA) Employee E1 revealed she was aware of Resident R1's incident with his wheelchair and heat stroke on 7/3/26. NA Employee E1 stated, they used to have a green sheet that the facility utilized for when a resident would go out on a LOA. The resident would go to their nurse for the 'green sheet', which acted as sort of a 'hall pass'. The nurse would fill out the form with information such as resident name, if they had a doctor order for a LOA, where they were going, who the escort is, and when they would be back. The resident would then take the 'green sheet' to the lobby and show it to the receptionist, who would sign the resident out of the facility on another form located in a binder. Then the new Director of Nursing (DON) took them ('green sheets') away, and now the residents just come down to the lobby without checking with the nurse or getting a 'green sheet'. He [Resident R1] left to do laundry because our washing machine has been broken since May, and he likes to do his own laundry. We need the old sheets back. During an interview on 7/7/26, at 9:14 a.m. Receptionist, Employee E2 confirmed the above statement, then revealed the process changed around 6/10/26, and reported the residents now just sign out of the facility with her. There is a binder at the Front Desk that indicates if the resident has an order for a LOA, and if they do, they sign themselves out. Employee E2 stated that she signed Resident R1 out of the facility on the day of the incident 7/3/26, at 9:38 a.m., and that he left by himself. And when I left at 3:30 [p.m.] he wasn't back yet. During an interview on 7/7/26, at 10:25 a.m. Physician, Employee E3 revealed he was aware of the incident with Resident R1, and confirmed resident suffered a heat stroke, and has since returned from the hospital. When State Agency (SA) asked if it is typical for residents to have an order for an independent LOA, Physician Employee E3 stated We take it person by person, case by case. SA asked if the order for Resident R1 to have an independent LOA was appropriate, to which Physician Employee E3 stated I don't know where that order came from. Cognitively he (Resident R1) is able to be on a LOA, but being in motorized wheelchair and high heat complicates it. During an interview on 7/7/26, at 10:34 a.m. the Nursing Home Administrator (NHA) revealed, her first day working at the facility was 7/6/26, and that she had been called the day after the incident to fill in as interim NHA, as the previous NHA's employment was unexpectedly terminated on 7/3/26. The NHA confirmed the facility failed to prevent the incident by allowing Resident R1 to go out in extreme temperatures unsupervised, and that she had already begun implementing changes for resident safety, such as revising the policy, educating staff, and conducting a root cause analysis. During an interview on 7/7/26, at 11:21 a.m. Resident R1 confirmed he left the faciity on 7/3/26, to do laundry as the facility's only washing machine available for resident use was non functioning. I left early, about 9:30 as I knew it was going to be hot. I went to the laundromat on [Street Name] (0.9 miles away from the facility) and went to the store right next to it while my laundry was drying and bought an iced tea. I stopped every 30-40 yards on the way back to rest in the [NAME] areas for five to ten minutes at a time. When I got to [Street Name] (0.4 miles from facility) a bus was coming and I had to steer out of the way into some fresh asphalt and my wheelchair got stuck in it. I called the police when I got stuck. I could hear the sirens, and the next thing I knew I woke up in the hospital. My temperature was over 105. It about killed me. I also got sunburned on my arms. When it gets into the 90's and 100's [outside temperature] you have a problem. During an interview on 7/7/26, at 11:40 a.m. Registered Nurse (RN) Employee E4 confirmed the process for resident going out on a LOA has changed and with the new process You don't even know when they leave. If it's too hot or too cold, nobody goes out. It used to be that way [before the new process]. On 7/7/26, at 2:09 p.m., the NHA was made aware that an Immediate Jeopardy (IJ) was identified due to the failure to create an environment free of accidents when a resident was permitted to leave the facility in extreme temperatures unsupervised. The NHA was provided with an Immediate Jeopardy template, and a corrective action plan was requested. On 7/7/26, at 4:22 p.m. an acceptable Corrective Action Plan was received which included the following interventions: NoncomplianceInterim Leave of Absence/Out on Pass Policy issued effective 7/6/26, suspending all prior LOA/pass practice facility-wide.Policy requires a nursing/clinical check before every departure: staff must confirm a current physician order and that applicable assessment (e.g. elopement (when a resident leaves a supervised area without permission), falls, BIMS (Brief Interview for Mental Status- a brief test to assess mental ability) support the LOA, with or without supervision, before any resident leaves the building.Policy adds a weather/environmental limit; unsupervised leave may be restricted or suspended facility-wide during extreme heat, extreme cold, or other hazardous conditions.Unsupervised LOA suspended facility-wide until individualized review of every resident with an existing LOA order is complete; only supervised LOA (responsible party physically present) permitted until then.Serious Injury/HarmInvestigation opened 7/4/26 upon DON (Director of Nursing) notification: staff and resident interviews, reconstructed timeline of departure and return, and review of order/sign-out documentation/assessments in place at the time.Resident interview with [Resident R1] conducted on 7/6/26 upon readmission [from hospital stay], documented in the Interview Summary- resident confirming the timeline and circumstances of the incident.Findings and corrective actions documented in formal QAPI (Quality Assurance and Performance Improvement) report; root cause identified as weather conditions not factored into the leave decision, no expected duration/return time documented, and no confirmed way to reach the resident during leave.Resident R1 reassessed and included in the facility's current LOA review.Need for Immediate ActionInterim LOA/Out on Pass Policy completed and in effect facility-wide as of today, 7/7/26.Facility-wide suspension of unsupervised LOA completed and in effect as of today, 7/7/26, until each resident with an existing LOA order is individually reviewed against the new policy.Initial Audit Sweep of all current residents with a LOA order or expressed desire for one to be completed by tomorrow, 7/8/26, confirming physician order, applicable assessments, and appropriate supervision level for each resident before any LOA (supervised or unsupervised) resumes; care plans will be updated accordingly once this review is complete.LOA Request Forms reimplemented facility-wide as of today, 7/7/26, documenting the facility's decision and any resident-specific instructions for every LOA going forward.Sign-Out/Sign-In Log implemented facility-wide as of today, 7/7/26, capturing destination, responsible party, phone number, supervision status, and staff signature for every resident leaving the building.Staff education on the revised policy and forms to be completed by tomorrow, 7/8/26, facility-wide, with signed staff acknowledgement on file.Ongoing 12-week audit tool completed and in place as of today, 7/7/26, covering new admissions, residents with LOA orders, and any resident with a change in condition or significant event, with findings reported to QAPI.Residents and responsible parties will be educated on the new interim policy through phone calls, one-to-one conversations, and resident council meetings. During an interview on 7/8/26, at 12:06 p.m. Housekeeping Employee E5 confirmed that he was made aware of the incident involving Resident R1 and stated: It was too hot out that day. Shouldn't go out in that heat. During an interview on 7/8/26, at 12:07 p.m. Maintenance Employee E6 also confirmed awareness of the incident and stated: I feel they shouldn't be out unsupervised regardless. They are here for a reason, and we need to keep them safe. During an interview on 7/8/26, at 12:22 p.m. Laundry Employee E7 stated They [residents] shouldn't be out [unsupervised] anyway. What if they have a motorized wheelchair and the battery dies or something? During an interview on 7/8/26, at 12:40 p.m. Driver Employee E8 stated Ain't nobody going nowhere without anyone with them. Review of facility documents, and clinical documentation on 7/8/26 revealed the following: LOA policy has been reviewed and revised to include that residents require a nursing check prior to departure, verification of physician order, weather limits, and supervision required Facility investigation completedQAPI completedFacility-wide suspension of unsupervised LOA was implementedAll residents who desire LOA (37 out of 74) have appropriate LOA orders as deemed appropriate, and all orders for LOA include to have supervision, and are care planned accordinglyLOA form is now being used, which is issued, and completed by the nurse. This is the [NAME] Sheet that staff had used and liked previously.New logbook at front desk files the LOA form, and residents and responsible party sign out with the receptionist in this book.Staff education completed on 100 out of 106 employees. This was verified by 29 employee interviews27 out of 37 families of residents who have orders for LOA have received education on new policy, and education will be ongoing.22 of 37 residents with LOA orders were educated on new policy, and education will be ongoing. The Immediate Jeopardy was lifted on 7/8/26, at 4:00 p.m. when the action plan implementation was verified. During an observation on 7/9/26, at 9:10 a.m. Driver Employee E8 was in the lobby when someone came down with a resident in a wheelchair to go to an appointment. Driver Employee E8 was heard stating the following: I'm not taking anyone anywhere without a LOA form. I don't mess with safety when it comes to the residents. During an interview on 7/9/26, at 10:40 a.m. RN Employee E4 confirmed that he was assigned to take care of Resident R1 on the day of the incident and stated I didn't know he was out that day until I went to give him his meds [medication] in the afternoon. I'm glad we went back to the old process. During an interview on 7/9/26, at 11:13 a.m. the Operations Manager Employee E9 confirmed that the facility failed to create an environment free of accidents when the facility allowed Resident R1 to leave the facility on a LOA unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke, resulting in immediate jeopardy for one of 37 residents who was approved for a LOA. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of Resident Council meeting minutes, and resident and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for two of two months (May, and June 2026).Findings include: Review of facility admission Agreement indicated that the resident has a right to organize and participate in resident groups in the facility. The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Review of facility provided Resident Council Meeting Minutes dated 5/26/26, indicated: Residents reported concerns regarding a washer that is in need of repair. Staff advised that the issue would be reported for maintenance and that repairs would be scheduled as soon as possible. Review of facility provided Resident Council Meeting Minutes dated 6/19/26, indicated: Residents reported that the washing machine continues to require repair. Management acknowledged the concern and advised that maintenance would be notified to address this issue. During an interview on 7/7/26, at 10:01 a.m. Maintenance Director (MD) Employee E10 stated that there is a washing machine on the Fourth Floor that residents can use if they desire to wash their own clothes, and that it has been broken. MD Employee E10 stated that he just brought up the washing machine that was in Occupational Therapy onto the Fourth Floor so that residents could use it on 7/3/26. During an interview on 7/7/26, at 11:21 a.m. Resident R1 stated that he prefers to do his own laundry so that it won't get lost, and that he would normally use the washing machine on the Fourth Floor, however it has been broken since May. Therefore he left the faciity on 7/3/26, around 9:30 in the morning to go to the laundromat. During an interview on 7/8/26, at 4:07 p.m. Operations Manager Employee E9 confirmed that the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for two of two months (May, and June 2026). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(4) Management.28 Pa. Code: 201.29(a) Resident rights.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Former Nursing Home Administrator (FNHA) and the Director of Nursing (DON) failed to effectively manage the facility when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke (a serious health condition when the body temperature rises to 104 degrees or more due to exposure to high temperatures) while out of the facility. This created an immediate jeopardy situation for 37 residents who were approved for a leave of absence (LOA) .Findings include: The signed job description for the Former Nursing Home Administrator Employee E13, dated 5/4/26, specified the primary purpose of the job position is to manage the Facility in accordance with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities To follow all facility policies and apply them uniformly to all employees. The ensure the highest degree of quality care is provided to our residents at all times. The signed job description for the Director of Nursing, dated 5/18/26, specified the purpose of the job is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. During an interview on 7/7/26, at 10:34 a.m. the Nursing Home Administrator (NHA) stated that her first day working at the facility was 7/6/26, and that she had been called the day after the incident to fill in as interim NHA, as the Former NHA Employee E13's employment was unexpectedly terminated on 7/3/26. Based on findings identified in this report, the facility failed to create a safe environment free of accidents when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke, which created an immediate jeopardy situation for37 residents who were approved for LOA in Immediate Jeopardy. The Former NHA Employee E13, and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 7/9/26, at 11:13 a.m. Operations Manager Employee E9 was notified that the Former NHA Employee E13, and the DON failed to effectively manage the facility by failing to create a safe environment free of accidents when the facility allowed a resident (Resident R1) to leave the facility unsupervised when the outside temperature was approximately 95 degrees, and the resident developed heat stroke, which created an immediate jeopardy situation for 37 residents who were approved for LOA in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to conduct ongoing clinical assessments to make certain that residents were provided appropriate treatment and care for two of two residents reviewed (Residents R2, and R3).Findings include: Review of facility policy Elopements and Wandering Residents dated 2/11/26, indicated that residents will be assessed for risk of elopement (when a resident leaves the facility without permission, and/or supervision) and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Review of facility policy Fall Prevention Program dated 2/11/26, indicated that upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/17/26, indicated diagnoses of high blood pressure, malnutrition (lack of sufficient nutrients in the body), and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R2's clinical record revealed that the last Elopement Risk Evaluation was completed on 3/27/25, when the resident was admitted to the facility. Review of Resident R2's clinical record revealed that the last Fall Risk Evaluation was completed on 11/24/25. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and muscle weakness. Review of Resident R3's clinical record revealed that the last Elopement Risk Evaluation was completed on 5/14/25, when the resident was admitted to the facility. Review of Resident R3's clinical record revealed that the last Fall Risk Evaluation was completed on 5/14/25, when the resident was admitted to the facility. During a telephonic interview on 7/8/26, at 10:20 a.m. the Director of Nursing (DON) stated that the facility has only been conducting Elopement Risk Evaluations, and Fall Risk Evaluations upon admission, and readmission to the facility after a hospitalization, and has failed to conduct ongoing clinical assessments to make certain that residents were provided appropriate treatment and care for two of two residents reviewed. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on staff interviews it was determined that the facility failed to employ a qualified Director Manager to manage the daily operations of the Dietary Department for six months.Findings include: During an interview on 4/8/26, at 11:45 a.m. Dietary Manager Employee E1 indicated the Registered Dietitian normally comes to the facility once per week, usually Thursdays. During an interview on 4/9/26, at 1:00 p.m. Dietary Manager Employee E1 stated he has been employed as the Dietary Manager since November 2025, and that he was not a Certified Dietary Manager. During an interview on 4/9/26, at 2:45 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary Manager Employee E1 met the qualifications for the position. Pa Code: 201.18(e)(6) Management.

Based on a review of observations, and staff interviews, it was determined that the facility failed to properly monitor food temperatures creating the potential for cross contamination in the main kitchen of the facility, and failed to monitor refrigerator temperatures in one of three unit refrigerators (Ground Floor).Findings include: Review of facility policy Preventing Foodborne Illness- Food Handling dated 2/11/26, indicated that functioning of refrigeration and food temperatures will be monitored at designated intervals thorough the day and documented according to state-specific requirements. Federal standards require that refrigerated food be stored below 41-degrees Fahrenheit. During an observation in the main kitchen on 4/8/26, at 11:45 a.m., Tray line Temperature Log for March, April 2025, was noted to have missing data. 114 meals had been served during the month of March and beginning of April. 18 meals had no recorded food temperatures. The missing data was as follows: 10 breakfast meals with no recorded food temperatures 10 lunch meals with no recorded food temperatures 18 dinner meals with no recorded food temperatures During an interview on 4/8/26, at 12:30 p.m., Dietary Manager Employee E1 confirmed that the facility failed to monitor temperatures of foods to prevent food born illness. During an observation on 4/10/26, at 9:26 a.m. Receptionist Employee E22 entered into the Conference Room and asked State Agency (SA) if she could come in and grab a prepared, bagged lunch for a dialysis resident. Receptionist Employee E22 then proceeded to open a door to the refrigerator and take a prepared, bagged lunch. During an observation on 4/10/26, at 9:26 a.m. it was noted that the refrigerator did not have a thermometer, or Temperature Log to ensure that residents' lunches were being kept at an appropriate temperature. During an interview on 4/10/26, at 12:15 p.m. Nursing Home Administrator Employee E18 confirmed that the facility failed to properly monitor refrigerator temperatures in one of three unit refrigerators. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for three of five residents (Residents R4, R46, and R50).Findings include: Review of facility policy Antipsychotic Medication Use dated 2/11/26, indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Review of facility policy Consultant Pharmacist Services Provider Requirements dated 2/11/26, indicated the consultant pharmacist performs the medication regimen review (MRR) of each resident at least monthly, incorporating federally mandated standards of care in addition to other professional standards, and documenting the review and findings in the resident's medical record. Communicates to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders and recommendations for changes in medication therapy and monitoring, as well as regulatory compliance issues at least monthly. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/13/26, indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and psychotic disorders (severe mental illnesses that cause abnormal thinking and perception). Review of Resident R4's MRR failed to include documented evidence that June 2025, was completed by the physician. During an interview on 4/8/26, at 11:32 a.m. the Director of Nursing stated, I can't find a completed pharmacy review for June 2025. Review of Resident R4's MRR dated 2/10/26, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order for Zyprexa (a medication used to treat mental health disorders) 10 milligrams. Recommendation: Please assess the resident for a gradual dose reduction (GDR) of the Zyprexa order. Review of Resident R4's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 2/10/26. On 2/11/26, a Certified Registered Nurse Practitioner (CRNP) addressed the MRR stating, No GDR. After assessing resident, I would like to continue the Zyprexa order because it has been effective at alleviating the behavioral and physical symptoms that can present a risk of harm to the resident or others. During an interview on 4/8/26, at 9:53 a.m. the Director of Nursing confirmed that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for Resident R4. Review of the clinical record indicated Resident R46 was admitted to the facility on [DATE], with the diagnoses of dementia with agitation (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), stroke (damage to the brain from an interruption of blood supply), and anxiety. Review of Resident R46's MRR dated 1/10/26, indicated the following recommendation from the pharmacist to the physician: the resident has an order of Remeron (antidepressant medication) and Seroquel (antipsychotic medication) that do not have an FDA- (Food and Drug Administration) Labeled indication. Review of Resident R46's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/10/26. The recommendation was signed by Nurse Practitioner (NP) Employee E19. Review of Resident R46's MRR dated 1/23/26, indicated the medication regimen of the resident was reviewed, and a recommendation was made to the attending physician. Review of Resident R46's clinical record failed to include a description of the MRR and failed to have a response from the resident's attending physician regarding the recommendation made on 1/23/26. Interview on 4/11/26, at 11:30 a.m. Registered Nurse (RN) Employee E11 confirmed the MRR dated 1/10/26, was not completed by the physician, and that the MRR from 1/23/26, could not be located and the clinical record failed to have a response to the MRR from 1/23/26 for Resident R46. Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE], indicated diagnoses of high blood pressure, repeated falls and depression (persistent sadness). Review of Resident R50's MRR dated 5/30/25, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order for Effexor (a medication used to treat depression) 300 mg. Recommendation: Please reassess the order to determine if symptoms, conditions, or the risks of depression can be managed by: A potentially higher daily dose. A potentially lower daily dose. The current daily dose is appropriate. Review of Resident R50's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 5/30/25. On 6/6/25, the CRNP addressed the MRR stating, No, I have assessed the resident, and a GDR is contraindicated because a change in their current regimen will cause symptoms such as depression or anxiety to return or worsen. Review of Resident R50's MRR dated 11/24/25, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order of Effexor (a medication used to treat depression) 225 mg. Recommendation: Please reassess the order to determine if symptoms, conditions, or the risks of depression can be managed by: A potentially higher daily dose. A potentially lower daily dose. The current daily dose is appropriate. Review of Resident R50's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 11/24/25. On 11/25/25, the CRNP addressed the MRR stating, No, I have assessed the resident, and a GDR is contraindicated because a change in their current regimen will cause symptoms such as depression or anxiety to return or worsen. During an interview on 4/8/26, at 12:22 p.m. the DON confirmed that the MMR was not addressed by the resident's attending physician for Resident R50. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for five of five residents (Residents R4, R9, R10, R46, and R50).Findings include: Review of facility policy Consultant Pharmacist Services Provider Requirements dated 2/11/26, indicated the consultant pharmacist performs the medication regimen review (MRR) of each resident at least monthly, incorporating federally mandated standards of care in addition to other professional standards, and documenting the review and findings in the resident's medical record. Communicates to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders and recommendations for changes in medication therapy and monitoring, as well as regulatory compliance issues at least monthly. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/13/26, indicated diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and psychotic disorders (severe mental illnesses that cause abnormal thinking and perception). Review of Resident R4's MRR failed to include documented evidence that June 2025, was completed by the physician. During an interview on 4/8/26, at 11:32 a.m. the Director of Nursing stated, I can't find a completed pharmacy review for June 2025, for Resident R4. Review of Resident R4's MRR dated 2/10/26, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order for Zyprexa (a medication used to treat mental health disorders) 10 milligrams (mg). Recommendation: Please assess the resident for a gradual dose reduction (GDR) of the Zyprexa order. Review of Resident R4's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 2/10/26. On 2/11/26, a Certified Registered Nurse Practitioner (CRNP) addressed the MRR stating, No GDR. After assessing resident, I would like to continue the Zyprexa order because it has been effective at alleviating the behavioral and physical symptoms that can present a risk of harm to the resident or others. During an interview on 4/8/26, at 9:53 a.m. the Director of Nursing confirmed that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for Resident R4. Review of the clinical record indicated Resident R9 was admitted to the facility on [DATE]. Review of Resident R9's MDS dated [DATE], indicated diagnoses of high blood pressure, chronic pain, and diabetes. Review of Resident R9's MRR failed to include documented evidence that June 2025, was completed by the physician. During an interview on 4/8/26, at 11:32 a.m. the Director of Nursing stated that she was unable to find the pharmacy review for June 2025, for Resident R9. Review of the clinical record indicated that Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's MDS dated [DATE], indicated diagnoses of high blood pressure, bipolar disorder (a mental condition marked by alternating periods of elation and depression) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of Resident R10's MRR failed to include documented evidence that June 2025, was completed by the physician. During an interview on 4/8/26, at 11:32 a.m. the Director of Nursing stated that she was unable to find the pharmacy review for June 2025, for Resident R10. Review of Resident R10's MRR dated 5/31/25, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order of Detemir insulin (a long-acting insulin to treat high blood sugar). Recommendation: Please consider ordering a hemoglobin A1c (a blood test that measures average blood sugar over three months) Review of Resident R10's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 5/31/25. On 6/6/25, the CRNP addressed the MRR stating, No, do not order the recommended hemoglobin A1c because it isn't medically necessary at this time. During an interview on 4/8/26, at 12:22 p.m. the DON confirmed that the MMR was addressed by the facility CRNP and not the resident's attending physician for Resident R10. Review of Resident R46's MRR dated 1/10/26, indicated the following recommendation from the pharmacist to the physician: the resident has an order of Remeron (antidepressant medication) and Seroquel (antipsychotic medication) that do not have an FDA- (Food and Drug Administration) Labeled indication. Review of Resident R46's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/10/26. The recommendation was signed by Nurse Practitioner (NP) Employee E19. Review of Resident R46's MRR dated 1/23/26, indicated the medication regimen of the resident was reviewed, and a recommendation was made to the attending physician. Review of Resident R46's clinical record failed to include a description of the MRR and failed to have a response from the resident's attending physician regarding the recommendation made on 1/23/26. Interview on 4/11/26, at 11:30 a.m. Registered Nurse (RN) Employee E11 confirmed the MRR dated 1/10/26, was not completed by the physician, and that the MRR from 1/23/26, could not be located and the clinical record failed to have a response to the MRR from 1/23/26. During an interview on 4/10/26, at 9:30 a.m. the Director of Nursing confirmed that the monthly medication regimen reviews are addressed by the facility and Nurse Practitioners and not the resident's attending physician for Resident R46 Review of the clinical record indicated Resident R50 was admitted to the facility on [DATE]. Review of Resident R50's MDS dated [DATE], indicated diagnoses of high blood pressure, repeated falls and depression (persistent sadness). Review of Resident R50's MRR dated 5/30/25, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order for Effexor (a medication used to treat depression) 300 mg. Recommendation: Please reassess the order to determine if symptoms, conditions, or the risks of depression can be managed by: A potentially higher daily dose. A potentially lower daily dose. The current daily dose is appropriate. Review of Resident R50's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 5/30/25. On 6/6/25, the CRNP addressed the MRR stating, No, I have assessed the resident, and a GDR is contraindicated because a change in their current regimen will cause symptoms such as depression or anxiety to return or worsen. Review of Resident R50's MRR dated 11/24/25, indicated the following recommendation from the pharmacist to the physician: Medication: The resident has an order of Effexor (a medication used to treat depression) 225 mg. Recommendation: Please reassess the order to determine if symptoms, conditions, or the risks of depression can be managed by: A potentially higher daily dose. A potentially lower daily dose. The current daily dose is appropriate. Review of Resident R50's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 11/24/25. On 11/25/25, the CRNP addressed the MRR stating, No, I have assessed the resident, and a GDR is contraindicated because a change in their current regimen will cause symptoms such as depression or anxiety to return or worsen. During an interview on 4/8/26, at 12:22 p.m. the DON confirmed that the MMR was addressed by the facility CRNP and not the resident's attending physician for Resident R50. 28 Pa Code: 201.14 (a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for five of ten residents (Resident R13, R34, R39, R53, and R72).Findings include: Review of the policy Resident Food Preferences dated 2/11/26, indicated the food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Meal observation on 4/7/26, at 12:15 p.m. Resident R39's mechanical soft hamburger, onion rings, peas and carrots and ice cream. Review of Resident R13's tray failed to include a hamburger bun. Review of the admission record indicated Resident R34 was admitted to the facility on [DATE]. Meal observation on 4/8/26, at 9:00 a.m. Resident R34's tray ticket indicated two slices of bacon, cold cereal, two waffles, diet syrup, margarine, orange juice, and milk. Review of Resident R34's tray failed to include bacon, cold cereal, or milk. The resident received two sausage patties instead of bacon, and hot cereal instead of cold, and no milk. Review of the admission record indicated Resident R53 was admitted to the facility on [DATE]. Meal observation on 4/6/26, at 12:15 p.m. Resident R53's tray ticket indicated apple/cranberry drink, baked chicken, gravy, potatoes, Brussel sprouts, fruit cocktail, and milk. Review of Resident R53's tray failed to include milk. Review of the admission record indicated Resident R72 was admitted to the facility on [DATE]. Meal observation on 4/6/26, at 12:10 p.m. Resident R72's tray ticket indicated apple/cranberry drink, baked chicken, gravy, potatoes, Brussel sprouts, fruit cocktail, and milk. Review of Resident R72's tray failed to include milk. Interview on 4/6/26, at 12:18 p.m. Nurse Aide (NA) Employee E20 confirmed Resident R72 and Resident R53's meal trays failed to include milk. Interview on 4/8/26, at 9:02 a.m. NA Employee E21 confirmed Resident R34 received two sausage patties instead of bacon, hot cereal instead of cold, and no milk. Review of the admission record indicated Resident R13 was admitted to the facility on [DATE]. Meal observation on 4/7/26, at 12:10 p.m. Resident R13's tray ticket indicated milk, hot beverage, turkey sandwich with Swiss cheese, onion rings, peas and carrots and ice cream. Review of Resident R13's tray failed to include turkey sandwich. Sandwich was bologna with American cheese because the kitchen was out of Swiss and turkey. 28 Pa. Code: 211.6(a) Dietary services

Based on review of facility policy, facility documentation, observations, and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025), failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R19), and failed to prevent cross contamination during a medication pass for one of three resident's (Resident R67). Findings include: Review of facility policy Surveillance for Infections dated 2/11/26, indicated the infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infection that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. Review of facility policy Administering Oral Medications dated 2/11/26, indicated the purpose of this procedure is to provide guidelines for the safe administration of oral medications. Review of the facility's Infection Control documentation for the previous 11 months (May 2025 - March 2026) failed to reveal surveillance for tracking infections for residents for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025). During an interview on 4/7/26, at 12:01 p.m. the Director of Nursing (DON) stated, The previous IP [Infection Preventionist Employee E16] handed me a bunch of papers in December to put in the infection control binder. I didn't like the way she did things. During this interview, the DON confirmed that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases for seven of 11 months (May 2025, June 2025, July 2025, August 2025, September 2026, October 2025, and November 2025). Review of the admission record indicated Resident R19 was admitted to the facility on [DATE]. Review of Resident R19's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/6/26, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Observation on 4/6/26, at 10:16 a.m. Resident R19's personal refrigerator was adorned with a temperature log dated January 2026. Interview on 4/6/26, at 10:16 a.m. Resident R19 indicated using the refrigerator daily. Interview on 4/6/26, at 10:20 a.m. Registered Nurse (RN) Employee E11 confirmed the facility failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R19). During a medication pass observation on 4/6/26, at 10:50 a.m. the Licensed Practical Nurse (LPN) Employee E12 was passing medications to Resident R67. The LPN Employee E12 put the medication in an ungloved hand, then put the medication in a medicine cup. LPN Employee E12 then administered the medication to Resident R67. During an interview on 4/6/26, at 11:01 a.m. LPN Employee E12 confirmed that the medication was touched without a glove and then administered to Resident R67 and failed to prevent cross contamination during a medication pass for one of three residents (Resident R67). 28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for two of three residents (Resident R62, and R77).Findings include: Review of facility policy Neurological assessment dated [DATE], indicated that neurological assessments (an evaluation of the nervous system's function to monitor mental status, nerve, motor, and sensory function, and reflexes) shall be conducted: Upon physician order When following an unwitnessed fall Subsequent to a fall with a suspected head injury When indicated by resident condition Review of the admission record indicated Resident R62 was admitted to the facility on [DATE]. Review of Resident R62's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/21/26, indicated the diagnoses of high blood pressure, right below the knee amputation (surgical removal of part of leg), and frostbite (severe cases include tissue blackening into gangrene (tissue death). Review of Resident R62's hospital discharge orders dated 2/17/26, indicated right lower extremity apply 4 x 4, ABD (abdominal) pad, kerlix (gauze wrap) and ACE wrap. Change every day. Review of Resident R62's physician orders dated 2/17/26, failed to include the order for right lower extremity - apply 4 x 4, ABD (abdominal) pad, kerlix (gauze wrap) and ACE wrap. Change every day. Review of Resident R62's physician orders indicated a treatment was not ordered to the right lower extremity surgical site until ten days later on 2/27/26. Interview on 4/10/26, at 11:45 a.m. RN Employee E11 confirmed a treatment was not ordered to Resident R62's right lower extremity surgical site until ten days later on 2/27/26. Review of the clinical record indicated Resident R77 was admitted to the facility on [DATE]. Review of Resident R77's MDS dated [DATE], indicated diagnoses of high blood pressure, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and repeated falls Review of Resident R77's clinical record revealed a nursing progress note dated 1/24/26, at 10:07 a.m. that indicated that resident was found on the floor after he tripped, and that facility should complete neurological assessments as follows: every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours , then every four hours for 24 hours. Review of Resident R77's clinical record revealed that a neurological assessment had been completed on 1/24/26, at 10:59 a.m. Further review failed to reveal that any subsequent neurological assessments had been completed after the first one on 1/23/26, at 10:59 a.m. During an interview on 4/9/26, at 12:21 p.m. the Director of Nursing confirmed that the facility failed to complete additional neurological assessments as ordered for Resident R77. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide (NA) personnel records (NA Employee E8, NA Employee E9, and NA Employee E10).Findings include: Review of facility policy In-Service Training, Nurse Aide dated 2/11/26, indicated the facility completes a performance review of nurse aides at least every 12 months. Review of NA Employee E8's personnel file indicated a date of hire on 12/8/20. Review of NA Employee E8's personnel record failed to include an annual performance evaluation at least every 12 months as required. Review of NA Employee E9's personnel file indicated a date of hire on 6/5/05. Review of NA Employee E9's personnel record failed to include an annual performance evaluation at least every 12 months as required. Review of NA Employee E10's personnel file indicated a date of hire on 2/21/24. Review of NA Employee E10's personnel record failed to include an annual performance evaluation at least every 12 months as required. During an interview on 4/8/26, at 1:23 p.m. the Nursing Home Administrator (NHA) stated, We discovered performance evaluations were not being completed when we identified that the previous Human Resources person was not completing staff education correctly. We did a performance evaluation for everyone in March. During an interview on 4/8/26, at 1:23 p.m. the NHA confirmed that the facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide personnel records (NA Employee E8, NA Employee E9, and NA Employee E10). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.19(2) Personnel records.

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of three residents (R25, R26, and R70).Findings include: Review of facility policy Administering Medications through a Nebulizer dated 2/11/26, indicated the purpose of this procedure is to safely and aseptically administer particles of medication into the resident's airway. Store in a plastic bag with the resident's name and date on it. Change equipment tubing every seven days. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of Resident R25's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Review of physician orders on 4/6/26, indicated Ipratropium-Albuterol Solution (a medication used to treat lung diseases) inhale orally every six hours as needed via nebulizer (a machine used to deliver medication) for shortness of breath, wheezing, or coughing. During an observation on 4/6/26, at 11:30 a.m. Resident R25 was lying in bed with nebulizer machine on over bed table. The nebulizer tubing was not dated, was not being stored in a bag when not in use, and the nebulizer machine had dried debris on the front of it. Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and depression. Review of physician orders on 4/6/26, indicated Albuterol Sulfate Nebulization Solution (a medication used to treat lung diseases) orally every six hours for cough. During an observation on 4/6/26, at 11:37 a.m. Resident R26 was lying in bed with nebulizer machine on bedside table. The nebulizer tubing was dated 3/19/26, and was not being stored in a bag when not in use. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated diagnoses of schizophrenia, Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking), and anxiety. Review of physician orders on 4/6/26, indicated Ipratropium-Albuterol Solution orally every eight hours for shortness of breath and wheezing. During an observation on 4/6/26, at 11:41 a.m. Resident R70 was sitting in wheelchair with the nebulizer machine on the windowsill. The nebulizer tubing was dated 3/19/26, and was not being stored in a bag when not in use. During an interview on 4/6/26, at 11:48 a.m. Licensed Practical Nurse (LPN) Employee E12 stated that the tubing should get changed weekly and confirmed nebulizer tubing that was dated 3/19/26 or failed to have a date on the tubing, nebulizer tubing and masks not stored in bags when not in use and a nebulizer machine with dried debris on it for Resident R25, R26, and R70. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of five residents sampled with facility-initiated transfers (Residents R2, R7, R40, and R76), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of five resident hospital transfers (Residents R2), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for four of five resident hospital transfers (Residents R2, R7, R36 and R76). Findings include: Review of facility policy Transfer or Discharge, Emergency dated 2/11/26, indicated transfers may be necessary to protect the health or well-being of the resident. Should it become necessary for transfer, prepare a transfer form to send with the resident. Review of facility policy Transfer or Discharge Notice dated 2/11/26, indicated a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Review of facility policy Bed-Hold and Returns dated 2/11/26, indicated residents are informed (in writing) of the facility bed hold policies. Resident or representatives are provided bed hold policy at the time of transfer. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/9/26, indicated diagnoses of high blood pressure, coronary artery disease (damage or disease in the heart's major blood vessels), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain). Review of the clinical record indicated Resident R2 was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of Resident R2's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R2's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and seizures (abnormal electrical activity in the brain). Review of the clinical record indicated Resident R7 was transferred to the hospital on 3/16/26, and returned to the facility on 3/16/26. Review of Resident R7's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 4/8/26, at 1:56 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R2, and R7 and failed to notify the resident or resident's representative of the facility bed-hold policy for Residents R2. Review of clinical record indicated Resident R36 was admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set, MDS (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 3/27/26, indicated the diagnoses of congestive heart failure (chronic condition where the heart is unable to pump blood effectively), anemia and coronary atherosclerosis (buildup of plaque inside the coronary arteries). Review of the clinical record indicated Resident R36 was transferred to the hospital on 1/16/26 and returned to the facility on 1/23/26. During an interview on 4/7/26, at 9:39 a.m. the Social Worker Employee E15 confirmed that there was no evidence that the State Ombudsman office was notified for transfers to the hospital for Resident R36. Review of the clinical record indicated Resident R40 was admitted [DATE]. Review of Resident R40's Minimum Data Set, MDS (minimum data set a periodic review of assessment needs) dated 2/2/26, indicated diagnosis of epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures), spinal stenosis ( narrowing of space within the spine, which can compress the spinal cord and nerves) and chronic obstructive pulmonary disease(lung disease causing restricted airflow and breathing problems). Review of the clinical record indicated Resident R40 was transferred to the hospital on 8/7/25 and returned to the facility on 8/12/25. Review of Resident R40's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 4/9/26, at 1:15 p.m. the Director of Nursing confirmed the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R40 as required. Review of the clinical record indicated Resident R76 was admitted to the facility on [DATE]. Review of Resident R76's MDS dated [DATE], indicated diagnoses of diabetes, nicotine dependence, and chronic pain. Review of the clinical record indicated Resident R76 was transferred to the hospital on 3/19/26. Review of Resident R76's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 4/8/26, at 1:55 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for Residents R76 During an interview on 4/7/26, at 9:39 a.m. the Social Worker Employee E15 confirmed that there was no evidence that the State Ombudsman office was notified for transfers to the hospital for Resident R2, R7, R36, and R76. 28 Pa. Code: 201.14(a)Responsibility of licensee.

Based on review of facility policy, job description, clinical record review, personnel records, resident and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of four residents reviewed which resulted in actual harm requiring a transfer to the hospital (Resident R1). Findings include: The facility Skin breakdown policy last reviewed 9/18/24, indicated that the nurse staff and practitioner will assess and document an individual's significant risk factors. The physician will help identify factors contributing to skin breakdown. The physician will help identify medical interventions related to wound management, for example treating a soft tissue infection, removing necrotic tissue, and managing pain. The facility LPN Supervisor job description last reviewed 9/18/24, indicated to administer professional services such as applying and changing dressings. Supervision in this position must be in accordance with current federal, state, and local standards, guidelines and regulations. Review of Resident R1's admission record indicated she was originally admitted on [DATE]. Review of Resident R1's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 3/25/25, indicated she had diagnoses that included spinal stenosis (compression of nerves in the spinal cord causing pain and discomfort), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hypothyroidism (decrease in production of thyroid hormone). Review of Resident R1's care plan dated 1/17/ 25, indicated Resident R1 had potential for skin impairment. Review of Resident R1's physician orders dated 2/17/25, indicated licensed nurse to perform skin head-to-toe checks and document. Physician orders on 4/18/25, indicated to administer Cephalexin (antibiotic) for infection. A physician order dated 4/20/25, indicated to cleanse area to upper back. The record did not indicate any physician orders to excise, debride or open any skin areas to Resident R1. Review of Resident R1's skin assessment on 4/17/25, indicated a new abscess measuring 4.5 cm x 4.0 cm x 0 cm. Review of Resident R1's clinical progress note dated 4/17/25, indicated Resident R1 alerted staff that she has abscess on her back, midline. 4.5 cm x 4 cm, redness noted and warm to touch. Some tenderness noted. Doctor notified. Verbal order obtained for antibiotic 500 mg four times a day for seven days, also vitals per shift. Resident R1 updated, verbalized understanding. Review of Resident R1's Nurse Practitioner note dated 4/18/25, indicated Resident R1 was seen for an abscess on her back. It was noticed yesterday, and she was started on antibiotic. She has had no fevers, other vitals stable per nursing, but Resident R1 reports the area is very tender. Nursing reportedly tried to drain the area earlier, unclear the procedure but concern for infection so patient was sent to Emergency Department. Review of Resident R1's discharge hospital records dated 4/19/25, indicated she was seen on 4/18/25 due to abscess. Facility documents submitted to the state dated 4/18/25, indicated that Resident R1 reported to 3-11 supervisor and her attending doctor that the daylight LPN excised a cyst to left midline scapula. Resident R1 stated that she felt that the LPN used some type of 'tool' to open her skin. Licensed Practical Nurse (LPN) Employee E1 provided statement via phone dated 4/18/25. He stated that Resident R1 requested if he could do something about the cyst on her back. He said he could. He stated he grabbed a couple of things such as alcohol wipes, 4 x 4 gauze. He then went to Resident R1's room, applied Lidocaine gel (pain reducing ointment) to try and numb the area before he squeezed the cyst. He stated he had tweezers but did not use them. Assistant Director of Nursing (ADON) Employee E2 provided statement dated 4/18/25. She stated she was getting report on the beginning of her shift. Licensed Practical Nurse (LPN) Employee E1 stated that Resident R1's cyst was coming to a head and he wanted to pop it. She told him wound team would look at it. Licensed Practical Nurse (LPN) Employee E1 later told her he took care of Resident R1's cyst and covered it with a bandage. Review of Licensed Practical Nurse (LPN) Employee E1's personnel record indicated he was hired on 3/24/25 and signed the LPN job description. His employment ended 4/23/25. During an interview on 4/28/25, at 9:24 a.m. Resident R1 stated the following: my back. Yes, a nurse operated on me. I think it was a male nurse Licensed Practical Nurse (LPN) Employee E1. He got instruments from a cart. The instruments were not sanitized. He used lidocaine cream to numb it. He lanced the cyst. When he cut it, it hurt. From one to ten, the pain was a ten. He did not use alcohol or anything on his instruments. Later on that night, a supervisor asked me to look at my back. And I had to go to the hospital. They had to cut it open at the hospital. During a phone interview on 4/28/25, at 11:15 a.m. Licensed Practical Nurse (LPN) Employee E1 stated the following: As I recall, yes it was on 4/18/25. Resident R1 told me she had uncomfortable cyst on back. There was a tiny white head on medial area. I had set of tweezers. They were blunt. I took two 4x4 gauze. She was already on an antibiotic. I applied some pressure, and there was a little bit of blood and pus. She said it comes back every 12 months or so. I did not have any tools that could have lanced it. I had alcohol. I do not carry a scalpel. It was larger than the little bit of pus came out. I was working the floor by myself that day. She had a lidocaine cream, and she asked me to apply it to her back. That belongs to the Resident R1. I cleaned the area with alcohol swab and put gauze over it. She said she felt better. When asked if there was an order to squeeze it or to perform any procedure, LPN Employee E1 stated no. During an interview on 4/28/25, at 11:57 a.m. Assistant Director of Nursing (ADON) Employee E2 stated: I did not see him with any tools. When I came on that Friday, I was getting report with him and another nurse. Resident R1 had abscess on her back. He mentioned he could squeeze it. I told him to leave that alone. That is not what we do. We do wound rounds, and I was going to mention it to the wound nurse. An LPN is not supposed to Lance anything. Never. There was no order. I told him not to do anything to that cite! During an interview on 4/28/25, at 12:10 p.m. Registered Nurse (RN) Employee E3 was asked about lancing resident if they have a abscess and she stated: never. Never. A nurse must contact a doctor. During an interview on 4/28/25, at 12:39 p.m. Registered Nurse (RN) Supervisor Employee E4 stated the following: I was doing a smoke break that evening. Resident R1's doctor who does rounds on the evenings was here. Resident R1 spoke to her doctor, and she brought it to my attention. I then spoke to the DON and NHA and made them aware of the concern. You do not lance as an RN or LPN. That is outside the scope of practice. During an interview on 4/28/25, at 3:25 p.m. information disseminated to the Nursing Home Administrator (NHA) and Director of Nursing) that the facility failed to provide care and services to meet the accepted standards of practice for Resident R1 which resulted in actual harm requiring a transfer to the hospital. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on observation, review of clinical record, review of facility policies, interview with staff and resident, it was determined the facility failed provide tracheostomy care consistent with professional standards of practice for two of two residents. This failure resulted in an Immediate Jeopardy situation for Resident R32 and R34 who had a tracheostomy obstruction, experienced respiratory and emotional distress and potential death. (Resident R34) Findings include: Review of the facility policy Tracheostomy Care Protocol Licensed Staff last reviewed [DATE], indicates respiratory care must be provided per professional standards, physician orders are required for all aspects of tracheostomy (trach) care, including suctioning and oxygen use. Care plans must be resident-specific, updated upon condition change, and interdisciplinary. A baseline care plan must be developed within 48 hours of admission for all resident with a tracheostomy. Step by step tracheostomy care education for licensed staff includes but not inclusive to: A. Preparing for trach care: Review residents care plan and orders. B. Explaining the procedure C. Suctioning (if needed prior to cleaning) D. Inner Cannula care E. Stoma and skin care F. Dressing and ties G. Oxygen and humidification management H. Monitoring I. Emergency Preparedness J. Infection prevention K. Resident -centered considerations Tracheostomy monitoring and infection prevention: II. Signs and symptoms of tracheostomy infection III. How to obtain a trach culture IV. Documentation and reporting Review of the admission record indicated R32 was admitted to the facility on [DATE], with the diagnosis of respiratory failure (lungs have trouble loading your blood with oxygen), heart failure (heart doesn't pump the way it should), and tracheostomy (surgical hole in the windpipe that helps with breathing) status. Review of Resident R32's Minimum Data Set (MDS- assessment of resident's care needs) dated [DATE], section C0200 BIMS (Brief interview for mental status) revealed that Resident R32 scored 13 which indicated that Resident R32 was cognitively intact. Review of section O (Special treatments and procedures) 0110, C1 (oxygen therapy) and E1 (tracheostomy care) confirmed that Resident R32 received oxygen and tracheostomy care. Section D1 (suctioning) revealed suctioning completed. Review of Resident R32's care plan initiated [DATE], with revision on [DATE], indicated Respiratory: Resident has a tracheostomy related to impaired breathing mechanics; diagnosis of chronic obstructive pulmonary disease (COPD) and is dependent with oxygen since 2017. Resident is self-sufficient with trach care, including cleaning and changing inner cannula and suctioning as needed. Review of Resident R32's physician orders dated [DATE], indicated check stoma weekly as needed for diagnosis of tracheostomy status check stoma site for skin breakdown/maintenance, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated tracheostomy care check stoma every evening shift for diagnosis of tracheostomy status check stoma site for skin breakdown, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician order dated [DATE], indicated tracheostomy care - ensure clean ties daily every evening shift. clean ties daily, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated tracheostomy care - ensure clean ties daily as needed for diagnosis of tracheostomy status clean ties for trach, orders were discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated change inner cannula daily Shiley XLT 6.0 every day shift for diagnosis of tracheostomy status, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's physician orders dated [DATE], indicated oxygen 6 liters to maintain oxygen (02) sat greater than 92% via trach mask. every shift for oxygen dependency, order was discontinued on [DATE], at 2:02 p.m. Review of Resident R32's nursing progress notes dated [DATE], 2:29 p.m. indicated resident was discovered on floor face down in moderate amt pooled blood. Wound to head actively bleeding. No loss of consciousness noted. Resident remained alert and oriented to baseline throughout assessment. Complained of back, left leg and head pain. Unable to obtain VS due to position on floor. EMS called for emergency transport to hospital per Resident request. Physician notified. Review of Resident R32's nursing progress notes dated [DATE], 2:29 p.m. indicated resident was transferred to hospital. Review of Resident R32's nursing progress note dated [DATE] 6:18 p.m. resident admitted to hospital with diagnosis of encephalopathy. Review of Resident R32's nursing progress note dated [DATE], at 8:00 p.m. indicated Resident R32 returned from hospital. Alert and oriented X4 with no confusion. Admits to pain of 6. Pupils equal, round, reactive to light accommodation (Perrla). Diagnosis of urinary tract infection (UTI) now with 16F foley (tube inserted into the bladder) draining clear yellow urine without difficulties. Vital within in normal limits (wnl) of resident baseline. Trach intact with 6XLT Shiley. No noted fever. Pills whole, regular diet with thin liquids. bed in lowest position. Resident is able to make her needs known. call light within reach. will continue to monitor. Review of Resident R32's re-admission assessment dated [DATE], form V10.8 indicated tracheostomy present. Review of Resident R32's current physician orders on [DATE], failed to include current orders for tracheostomy care. Review of Resident R32's [DATE] medication administration record (MAR) indicated trach care discontinued on [DATE]. Review of Resident R32's [DATE] MAR indicated tracheostomy Care - Ensure clean ties daily was discontinued on [DATE]. Review of Resident R32's [DATE] MAR indicated Oxygen 6 liters to maintain 02 sat greater than 92% via trach mask. every shift for Oxygen Dependency was discontinued on [DATE]. Review of Resident R34's clinical record revealed that Resident R34 was admitted to the facility on [DATE], with diagnoses of tracheostomy (tube inserted through the neck to assist breathing) status, repeated falls, and hip fracture. Review of Resident R34's physician's order dated [DATE], indicated to administer 10 liters (L) of oxygen via trach mask every shift for oxygen dependency. Review of Resident R34's progress note dated [DATE], revealed the resident has a tracheostomy and was on three liters of oxygen. The facility failed to administer oxygen as ordered or notify physician of the change in oxygen demand. Review of Resident R34's progress note dated [DATE], indicated trach care was provided and Registered Nurse (RN), Employee E12 was unable to insert inner cannula. The resident was taken to the hospital for evaluation. Review of Resident R34's progress note dated [DATE], revealed Licensed Practical Nurse (LPN), Employee E13 went into the resident's room to answer her call light and the resident was found holding her trach in her hand and was unable to put it back in. The supervisor was notified and 911 was called. Review of Resident R34's Minimum Data Set (MDS- assessment of resident's care needs) dated [DATE], section C0200 BIMS (Brief interview for mental status) revealed that Resident R34 scored 13 which indicated that Resident R34 was cognitively intact. Review of section O (Special treatments and procedures) 0110, C1 (oxygen therapy) and E1 (tracheostomy care) confirmed that Resident R34 received oxygen and tracheostomy care. Section D1 (suctioning) revealed suctioning was not a treatment that was performed. Review of Section GG (Functional Abilities) reveled that Resident R34 required supervision or touching assistance in bed mobility and required substantial/maximal assistance with transfers. Review of Resident R34's baseline care plan dated [DATE], failed to include a care plan for suctioning, tracheostomy care, and isolations precautions. The facility failed to implement a baseline care plan within 48 hours of admission. Review of Resident R34's progress note dated [DATE], revealed the resident required significant assistance for ADL (activity of daily living) tasks. It was indicated nursing was working on trach care, the son was going to bring in cleaning supplies as resident completed this on her own before. Review of Certified Registered Nurse Practitioner, Employee E15 progress note dated [DATE], revealed the resident was assessed and the resident had a history of laryngeal cancer and had a permanent trach. It was indicated to have respiratory therapy as ordered. Review of Resident R34's progress note dated [DATE], revealed the RN Supervisor notified Assistant Director of Nursing, Employee E8 that Resident R34 was having respiratory difficulties intra cannula from trach was dislodged. The resident was transferred to the hospital. Review of Resident R34's progress note dated [DATE], indicated the resident's inner cannula was removed and staff were unable to reinsert. The resident stated she can breathe easier with the inner cannula out. RN, Supervisor, Employee E2 indicated the hospital discharge paperwork were reviewed to identify next steps. Review of Resident R34's physician order dated [DATE], indicated the resident was scheduled a tracheostomy evaluation on [DATE], at 10:00 a.m. Review of Resident R34's physician order dated [DATE], indicated to obtain a culture one time only for trach infection site on [DATE]. Review of Resident R34's [DATE] Treatment Administration Record (TAR) failed to indicate Resident R34's culture was obtained as ordered. Review of Resident R34's care plan dated [DATE], revealed the resident had a tracheostomy. The resident's goal was to have no signs and symptoms of infection. Interventions included to ensure trach ties are secure and monitor/document for restlessness, agitation, confusion, increased heart rate, and bradycardia. It was indicated to monitor/document respiratory rate, depth, and quality every shift/as ordered, and to suction as necessary. The care plan failed to include tracheostomy care including, cleaning and the size of the inner cannula. Review of Resident R34's physician order dated [DATE], indicated to administer one tablet of 100 milligram (mg) Doxycycline Hyclate (antibiotic that treat bacterial infections) by mouth, two times a day for infection for 10 days. Review of Certified Registered Nurse Practitioner, Employee E15 progress note dated [DATE], revealed Resident R34 had recent concerns for trach maintenance and care. Review of Resident R34's physician order dated [DATE], indicated to obtain a culture one time only for trach infection site. Review of Resident R34's office visit summary dated [DATE], revealed the resident was referred to see an otolaryngology (ear, nose, and throat, is a medical specialty that focuses on the diagnosis and treatment of conditions affecting the ears, nose, throat, and related structures of the head and neck) provider for a consultation for the resident's tracheostomy status. Resident R34 used a metal [NAME] tracheostomy tube. While a resident at a skilled nursing facility, Resident R34's inner cannula dislodge, and staff were unable to reinsert and the resident was sent to the hospital. Resident R34 was transferred to the hospital and underwent a laparoscopy (a surgical procedure in which a small incision is made through which a viewing tube is inserted) which showed some circumferential mucus making reinsertion challenging. A saline irrigation and suctioning was performed to remove the crusting, and then a new inner cannula was inserted. Resident R34 presented a month later, on [DATE], with the inability to place the inner cannula. The assessment revealed Resident R34's metal [NAME] tracheostomy has progressively gotten obstructed and with a biofilm. Redness was observed around the skin of Resident R34's tracheostomy. Upon examination, Resident R34 had a complete obstruction of the tracheostomy. An inner cannula was unable to placed. The tracheostomy tube was removed and the inside of both the trach and the inner cannula was extensively cleaned. Resident R34's trach was replaced and Resident R34 was observed to be clear and was able to breathe significantly better. Prior to this, Resident R34 had inspiratory stridor (a high-pitched sound that occurs when breathing through a narrow or obstructed airway, indicating difficulty in breathing. It can be a sign of an abnormality in the airway that may require medical attention). The plan was to start antibiotics for low grade tracheostomy infection, diligent trach care, 20 mg famotidine (medication that decreases stomach acid production), one tablet, for reflux symptoms, change 40 mg pantoprazole (use to treat certain stomach and esophagus problems), one tablet, to 30 minutes before dinner, and to follow up in one month. Review of Resident R34's physician order dated [DATE], indicated to administer one table of ,d+[DATE] mg Amoxicillin-Pot Clavulanate (a combination antibacterial medication used to treat various types of bacterial infections), one tablet by mouth every 12 hours for a tracheostomy bacterial infection for 10 days. Review of Resident R34's physician orders dated [DATE], indicated to administer 10 mg famotidine, one tablet by mouth, one time a day for reflux. The facility failed to ensure Resident R34 received 20 mg of famotidine as ordered by the provider at the office visit on [DATE]. Review of Resident R34's physician orders revealed multiple orders for pantoprazole. Resident R34 was ordered 40 mg pantoprazole, one tablet, once a day on [DATE], and 20 mg of pantoprazole, one tablet, once a day on [DATE]. Review of Resident R34's March MAR revealed Resident R34 received both orders of pantoprazole, a total of 60 mg on seven days. The facility failed to ensure Resident R34 received 40 mg pantoprazole before dinner as ordered by the provider at the office visit on [DATE]. Review of Resident R34's progress note dated [DATE], entered by LPN, Employee E13 indicated trach care was performed. The facility failed to have an order for trach care and the size of the inner cannula. During an interview on [DATE], at 10:08 a.m. Resident R34 was observed lying in bed, not wearing 10 liters of oxygen as ordered. The oxygen was observed across the room, turned off, without tubing, and not within reach of the resident. The resident stated I never had to wear oxygen. Resident R34 was tearful and stated staff do not know how to care for the tracheostomy. It was indicated prior to being admitted to the facility, the facility indicated staff can provide care for residents with a tracheostomy. An undated gallon of distilled water was observed open and on the floor. Resident R34 indicated the gallon of distilled water was used for trach care. During an interview on [DATE], at 11:26 a.m. LPN, Employee E1 was asked if they were trained on tracheostomy care. LPN, Employee E1 indicated it was their first day and the facility did not train or educate LPN, Employee E1 on tracheostomy care. LPN, Employee E1 confirmed they were assigned to Resident R34 and indicated they had experience in pediatric trach care. LPN, Employee E1 confirmed Resident R34 was not receiving oxygen as ordered. During an interview on [DATE], at 11:20 a.m. RN Supervisor, Employee E2 confirmed Resident R34's tracheostomy culture was not completed. It was indicated Resident R34 went out to an appointment and was placed on antibiotics. RN, Supervisor, Employee E2 stated Resident R34 was on doxycycline for the tracheostomy infection. It was indicated RN Supervisor, Employee E2 and licensed practical nurses provide care to Resident R34's trach. RN, Supervisor, Employee E2 confirmed Resident R34's office visit from [DATE], for the tracheostomy evaluation was not available and was not located in the resident's clinical record. RN, Supervisor Employee E2 stated Resident R34 was sent out to the hospital a few times due to the inability to reinsert the inner cannula. It was indicated the resident is monitored every shift and it should be documented in the Treatment Administration Record (TAR). During a phone interview on [DATE], at 11:47 a.m. with Resident R34's otolaryngology provider's office, it was confirmed Resident R34 was evaluated on [DATE], and had a follow up appointment scheduled for [DATE]. Review of Resident R34's clinical record on [DATE], at 11:52 a.m. failed to include an order to follow up with the otolaryngology provider on [DATE]. Review of Resident R34's physician orders failed to include orders for the resident's tracheostomy care, including cleaning, size of inner cannula, suctioning, enhanced barriers, and how often to change the neck ties on the resident's tracheostomy. The facility failed to include orders to monitor/document for restlessness, agitation, confusion, increased heart rate, and bradycardia as the resident's care plan indicated. There were no orders to monitor/document respiratory rate, depth, and quality. Review of 4 of 4 employee files (LPN, Employee E1, RN Supervisor, Employee E2, LPN, Employee E9 and LPN, Employee E11) on [DATE], failed to include evidence they were educated and competent on tracheostomy care. During an interview on [DATE], at 1:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed the facility failed to implement interventions for residents with a tracheostomy, ensure residents have orders and care plans for trach care and suctioning, obtain trach cultures as ordered (Resident R34), and ensure staff were competent in tracheostomy care for two of two residents (Resident R32 and R34). Review of the facility assessment on [DATE], at 2:06 p.m. failed to include tracheostomy care. During an interview on [DATE], at 2:08 p.m. the Nursing Home Administrator confirmed tracheostomy care was not listed in the facility assessment. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on [DATE], at 3:47 p.m. for the failure of the facility to provide tracheostomy care to a resident in accordance with professional standards of practice for two of two residents (Resident R32 and R34). This failure resulted in Resident R34 having a complete tracheostomy obstruction and experiencing respiratory and emotional distress. An Immediate Jeopardy template was provided to the Nursing Home Administrator. On [DATE], at 5:41 p.m. the facility submitted a plan of correction. The plan was reviewed and it was rejected. The facility failed to contain a root cause analysis, who was responsible for the POC, how long the facility was to monitor. On [DATE], at 7:19 p.m. the facility's plan of correction was received and accepted which included the following interventions: The facility developed the following approved action plan: A root cause analysis was completed that determined the cause to be inconstant coverage of information in the clinical meetings due to not following a specific checklist that can be followed by other clinical team members when the DON is not able to be at the daily meeting. A specific checklist will be implemented on [DATE]. 1. Identified Residents -Resident 32 is not in the facility. She will be assessed and reevaluated upon return by the Director of Nursing or designee. R34 baseline care plan was completed on [DATE] by the DON. Order for enhanced barrier precautions obtained by the DON on [DATE]. Order for O2 discontinued for nonuse by the DON on [DATE]. Trach care orders obtained and updated by the DON on [DATE]. Care plan was updated by the MDS Nurse to reflect current status on [DATE]. 2. Like Residents -House review completed by DON and designee on [DATE]. 3. System Correction and Education's -The Director of Nursing and Regional Clinical Director reviewed the trach care policy on [DATE]. No updates were needed. -The licensed staff will be educated on the Trach Care Policy by the DON or designees on [DATE]. -Nursing will sign education signature sheet prior to their next worked shift, if they completed the Carefeed training. Training for all licensed nurses will be completed on [DATE]. -The facility assessment was updated to include trach care was update by the Administrator on [DATE]. 4. Monitor and Audit -An Ad Hoc QAPI meeting was held by Administer on [DATE]. -All new admissions and readmissions will be audited daily in the Clinical Meeting by the DON or designees utilizing a clinical checklist to include trach care, barrier precautions and care plans weekly for 4 weeks beginning on [DATE]. On [DATE], at 7:22 p.m. the NHA and DON were notified the facility was still in immediate jeopardy and in order to lift, the facility must provide evidence the plan of correction was implemented. The DON and NHA were notified staff must be interviewed to verify competency. On [DATE], 12:23 p.m. the NHA was asked if information related to the facility's plan of correction was available for review. It was indicated the facility was pulling stuff together. On [DATE], at 2:18 p.m. the Director of Clinical Operations, Employee E24 provided the education that the facility trained all their licensed staff for tracheostomy care. During an interview on [DATE], at 3:03 p.m. the Director of Clinical Operations, Employee E24, NHA, and DON were asked what professional standards of practice or guidance did the facility utilize to educate the facility's licensed nursing staff. It was indicated staff were educated using the policy and competency tool. The policy and competency tool failed to include what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, suctioning, enhanced barriers, physician orders and care plans. The DON stated it is not the facility's policy to have a smaller trach size available for emergencies. The DON stated an Ambu bag is located on the facility's crash cart located in the common area on each nursing unit. The DON indicated training for emergency care for a resident with a tracheostomy is no different than cleaning or changing the inner cannula when placing one in an emergency. All nurses are CPR certified and CPR training covers how to use an Ambu bag. During an interview on [DATE], at 3:30 p.m. the Nursing Home Administrator was asked to provide the education that was sent on care feed. On [DATE], at 3:36 p.m. the education that was provided on care feed was provided by the Director of Clinical Operations, Employee E24. On [DATE], at 3:52 p.m. a review of the documents provided by the facility for the plan of correction failed to include evidence staff were educated on what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, suctioning, enhanced barriers, physician orders and care plans. On [DATE], at 9:15 a.m. Director of Clinical Operations, Employee E24 provided the education that staff were trained on. The education included what to do with the emergency tracheostomy kit, what emergency supplies must be available at the bedside, trach care including, cleaning, suctioning, enhanced barriers, physician orders and care plans. On [DATE], at 9:22 a.m. Director of Regional Clinical Operations indicated the facility was reeducating all licensed nurses. The facility failed to ensure all licensed staff were educated prior to the start of their shift. During an interview and observation completed with Resident R32 on [DATE], at 9:31 am Resident R32 stated I have had a trach since 2016. No one changes my tracheostomy neck ties, I can't do that. The resident's suction machine was observed unplugged, on the side table to the left side of her bed. Resident R32 stated I have to stretch to reach it and they have to plug it in. A yellow/tannish substance was observed in the suction tubing and the cannister. The suction tubing was lying over the machine and was not stored properly in a bag. Resident R32 further stated, I have to pull my table over, change the suction catheter, then staff would have to plug it in. I have waited as long as 45 minutes for them to come in. Upon asking about hand hygiene, she replied I did have hand sanitizer in here, I can't find it. Three 6XL cuffed tracheostomy kits were observed at Resident R32's bedside. Resident R32 stated I am cuffless. Resident R32 stated the extra cannulas (2 in white bag in drawer) and the suction kit (on the overbed table) was provided from the hospital, I like them better. The ones they have here are really long. An expired gallon of distilled water dated [DATE], was observed at the resident's bedside. Resident R32 indicated the water was used for her tracheostomy care. A bag of trach ties was noted on the floor, a basin was on the floor that contained a humidifier bottle that was dated [DATE]. A bag was on the floor next to dresser that had some trach supplies in it. During an interview completed on [DATE], at 9:50 am, Registered Nurse (RN) Employee E2 confirmed the above observations. During an observation and interview on [DATE], at 10:13 a.m. Resident R34 indicated staff do not empty the suction canister, they leave it filled, let it go to the top. Resident R34 indicated suctioning is used daily. During an observation and interview on [DATE], at 10:26 a.m. Resident R34 had a sterile tracheostomy care tray with sterile gloves opened located on the bedside table. Resident R34's personal belongings (stress balls) were observed on top of the opened tracheostomy care tray. Distilled water was observed on the floor. The resident stated the water was used for her tracheostomy care. A used, opened tracheostomy kit with a dirty spoon in it was observed behind Resident R34's television. Pipe cleaners were observed lying on the resident's tv stand without a bag. The resident's suction catheter tubing was unbagged lying on the bedside dresser. A 7.5 inner cannula was observed in the resident's top drawer in her dresser and a 5.00 disposable inner cannula was observed under the resident's tv on the dresser. There was oxygen tubing, not store in a bag, located behind the resident's tv. There were no emergency supplies, including ambu bag, obturator, or one size smaller inner cannula at the resident's bedside. During an interview on [DATE], at 10:52 a.m. RN, Supervisor, Employee E2 confirmed the above observations. Review of Resident R34's clinical record on [DATE], at 11:20 a.m. revealed the facility failed to enter an order to change Resident R34's inner cannula and neck ties and include the size of the resident's inner cannula. Resident R34's care plan was not updated, last revised [DATE], and failed to include how often to change/clean the inner cannula and the size of the resident's tracheostomy. During an observation on [DATE], 12:05 p.m. the crash cart located on 4th floor the following was observed. -The cart was unlocked -Oxygen tank failed to have regulator attached (as the checklist located on top of the cart indicated) -No tubing or Yanker connected to suction canister (as the checklist located on top of the cart indicated) -An expired 250 ml 0.9% Normal Saline Solution IV fluid bag (expired ,d+[DATE]) -Dressing kit tray expired [DATE] During an interview on [DATE], at 12:20 p.m. the DON confirmed the above findings. During interviews completed on [DATE], from 1:30 p.m. until 1:40 p.m. 4 of 4 licensed nurses failed to confirm they were educated on trach care, emergency care, how to obtain a trach culture, and how long to suction. During review of clinical records on [DATE], at 2:06 p.m. 2 of 2 residents failed to have an order for their inner cannula size, how often to clean/change the inner cannula and neck ties. 2 of 2 care plans failed to be individualized and have information related to how often trach care is performed (cleaning/changing inner cannula and neck ties) and the size of the resident's inner cannula. (Resident R32 and R34). The facility failed to implement their plan of correction. During an interview on [DATE], at 3:19 p.m. the Nursing Home Administrator and DON were notified the facility failed to implement their plan of correction. On [DATE], at 9:45 a.m. the NHA was asked if the facility was ready to verify education competency and if it was okay to re-interview staff. The NHA stated give us a minute and the DON said he already talked with staff. On [DATE], at 10:02 a.m. LPN, Employee E1 was interviewed to verify competency of the education the facility provided on Trach Care, Enhanced Barrier Precautions, and Care Plans. LPN, Employee E1 had the education provided by the facility available in front of him. LPN, Employee E1 failed to know what emergency supplies are readily available at the bedside. When asked what size inner cannulas should be available, LPN, Employee E1 stated 5, 7, 9 then stated Let me cheat for that one and then looked through the education provided from the facility and stated pretty sure size 5, 7, and 9. LPN, Employee E1 failed to indicate the size of the resident's inner cannula and a size smaller. LPN, Employee E1 asked what is an obturator? When asked what would you do if you were unable to reinsert trach tube if smaller cannula does is unsuccessful, LPN, Employee E1 stated Call, 911. and failed to know to cover the resident's stoma with sterile gauze and use a bag-valve mask over mouth and nose as the education provided by the facility revealed. LPN, Employee E1 failed to know how to obtain to culture of the tracheostomy and indicated a culture swab would be used to obtain it from the resident's inner cannula. The facility's education indicated a trach culture is obtained by using a suction catheter, then suctioning the airway secretions into a sterile container, then labeling the specimen with the resident info, date and time. The culture is then sent to the lab immediately. Review of Resident R34's clinical record on [DATE], at 10:40 a.m. failed to include an updated personalized care plan with interventions related trach care. Resident R34's care plan was not updated, last revised [DATE], and failed to include how often to change/clean the inner cannula and the size of the resident's tracheostomy. The facility failed have care plans for tracheostomy updated by the MDS Nurse to reflect current status on [DATE], as the facility plan of correction indicated. On [DATE], at 1:13 p.m. review of Resident R32 's clinical record revealed the resident returned to the facility on [DATE]. Orders and care plans were reviewed and updated to include individualized care for the resident's tracheostomy. Resident R34 's orders for trach care with size of trach tubes, emergency care, and suctioning were entered on [DATE]. The resident 's care plan was updated on [DATE], to include personalized center care for trach care, including size and suctioning. No other residents currently in-house were in need of trach care. On [DATE], at 1:22 p.m. review of the summary sheet provided for the electronic training (Carefeed) revealed 19 of 19 licensed nursing staff were educated. During in-person interviews conducted on [DATE], three of three licensed nursing staff members confirmed they were educated on trach care, suctioning, and what to do in an emergency, and how to obtain a trach culture. During phone interviews completed on [DATE], two of eight licensed nursing staff answered the phone and confirmed they were educated on trach care, suctioning, what to do in an emergency, and how to obtain a culture. Review of the facility assessment on [DATE], revealed it was updated to include trach care by the Administrator on [DATE]. An audit was completed by the DON on [DATE]. No new residents w [TRUNCATED]

Based on review of facility policy, facility documents, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of five residents (Resident R32), which resulted in actual harm requiring a transfer to the hospital for evaluation of head trauma that resulted in an acute minimally depressed right orbital floor fracture for one of five residents (Resident R32). Findings include: Review of facility policy Protection from Abuse last reviewed 9/18/24, indicated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. The facility shall have processes in place to include screening, reporting and response to allegations of potential or actual abuse and neglect. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of the facility policy Bed Safety and Bed Rails last reviewed 9/18/24, indicated consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. Review of facility's current Nurse Aide (NA) job description indicated the primary purpose of your (NA) job is to provide each of your assigned residents with routine daily nursing care and services in accordance with the residents assessment and care plans as may be directed by supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with federal, state, and local standards governing the facility. Review of the admission record indicated R32 was admitted to the facility on [DATE]. Review of Resident R32's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of respiratory failure (lungs have trouble loading your blood with oxygen), heart failure (heart doesn't pump the way it should), and diabetes (high sugar in the blood). Section GG Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed indicated resident is Partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). Review of Resident R32's physician order dated 3/24/25, indicated bilateral side rails. Review of Resident R32's care plan on 3/31/25, at 12:38 p.m. failed to include the use of side rails. Review of Resident R32's progress note dated 3/31/25, at 06:43 a.m. indicated resident fell out of bed while having care done aide with her resident has a big knot on right eye 911 called and sent to hospital at 645 am. Review of Resident R32's progress note dated 3/31/25, at 6:53 a.m. indicated resident fell out of bed during hygiene. Nurse Aid (NA) reports Resident went limp during care and rolled out of bed onto floor. Bed in high position prior to fall. Writer discovered Resident on floor next to bed moaning, complained of (c/o) left sided pain, pointed to hip. No internal or external rotation to either extremity noted. Redness noted to right elbow, purple hematoma noted to rt eye. Resident had difficultly remaining awake and alert during assessment, staff at bedside throughout entire event. MD notified; message left for Resident's daughter. Resident transferred to hospital for emergency evaluation. VS 96.7 82 20 170/83 pulse ox 99% on ordered O2. Review of Resident R32's progress note dated 4/1/25, at 1:50 a.m. indicated resident returned from hospital. No new orders at this time. Resident assisted into bed, call bell within reach. Bed in lowest position. During an interview and observation on 4/2/25, at 9:31 a.m. Resident R32 was in bed, no side rails observed to bed. Residents R32's eye was red, with bruising noted around her eye as well as her right neck. Upon asking resident R32 what happened she replied I have fallen out of bed, I have been asking for rails, I would be able to pull myself over and hold onto it. Upon further query Resident R32 stated they rearranged my furniture so there was nothing to hold onto. She rolled me away from her towards the window, I jerked like I was going to fall. They use one aid and roll me both ways I was dropped the bed was up. The residents bed side stand was noted to the left side of her bed against the walls as well as a stand on wheels closer to her bed and in reach of her left hand. Further interview completed Resident R32 stated I am waiting for my care as I have an appt at 12:00. This was not the first time rolling out I have fallen, no new intervention were put in place for me, I still don't have rails, they are rising me up for their backs. During an interview completed on 4/2/25 at 9:50 a.m. RN Employee E2 confirmed no side rails were on Resident R32's bed. During an interview completed on 4/3/25, at 10:00 a.m. upon asking Licensed Practical Nurse (LPN) Employee E11 concerning side rail placement she replied if I had someone that was ordered bed rails I would expect to see them as soon as possible, it has to be an order. During an observation and interview completed on 4/3/25, at 10:05 a.m. Resident had complaints of feeling dizzy, LPN Employee E11 stated that Resident R32 was not right at all and she is going to be sent out for a change in condition. During an interview completed on 4/3/25, at 11:58 a.m. LPN Employee E11 confirmed that Resident R32 was sent to the hospital for a change in her condition and stated that when the medics arrived for transfer resident was more alert and didn ' t want to go, but she did just have a head injury, you never know I take that very serious. During a telephonic interview completed on 4/3/25, at 10:54 a.m. upon asking Nurse Aid (NA) Employee E16 is she could recall the events that took place concerning Resident R32's fall from bed she replied, I do, I was changing her everything need to be changed. I had to position her on her side and there was no side rail she let go of her nightstand and [NAME]. She did not have rails she was holding on one the nightstand and her [NAME]. The [NAME] had wheels her nightstand was stationary one hand was on the [NAME] and one was one her nightstand. I just pulled her over and put her on her left side. I pull the sheet toward me and it helps the resident start to turn I turned her away from me. I did not witness her hitting her head because I was at the foot of the bed putting the bottom sheet on. We were having a conversation, I had to wake her up to complete care, she did not go limp she just got quite and then I heard a thump. I went out to get the nurse right away. I helped the medics making her more comfortable, she had no complaints of pain, she makes her needs know, she lets you know. During an interview completed on 4/3/25, at 11:39 a.m. upon asking Occupational Therapist (OT) Rehab director Employee E17 which way are resident should be turned in bed, she replied you are to roll them toward you. Upon asking Employee E 17 concerning side rails for Resident R32 she replied Ideally as soon as you get an order you should be able to put them on. It would be appropriate for a resident request. I don't remember ordering them or doing an assessment. The RN put them in (order) the order should have been placed when the assessment was completed. An RN can put them in and confirmed Resident R32 had an order for side rails. During a telephonic interview completed on 4/3/25, at 1:43 p.m. upon asking Registered Nurse (RN) Employee E12 about the process for side rails she replied I would expect them by the next morning, when I'm there no one from maintenance is there. We use an app to notify them, I do the assessment first, I can't always follow up, I did put in for Resident R32 and sent the request to maintenance. Review of Resident R32 ' s hospital records indicate on 4/3/25, at 2:08 p.m. a CT scan (imagining test that uses x-rays and a computer to create detailed images of bone) of the Maxillofacial (upper jaw bone part of facial and skull structure) or sinuses without contrast final result: 1. Acute minimally depressed right orbital floor fracture. 2. No acute cervical spine osseous abnormality. Orbital floor fracture Evident from CT head imaging on 3/31 Oral and Maxillofacial surgery consulted Review of nursing progress note dated 4/4/25, at 7:58 a.m. indicated Resident R32 was admitted to hospital with the diagnosis of altered mental status, ground level fall, encephalopathy (disease, damage or malfunction of the brain), and weakness. During an interview completed on 4/5/25, at 8:45 a.m. upon asking Nurse Aide (NA) Employee E18 which way a resident should be turned in bed, she replied I would ask them, or toward me. During an interview completed on 4/5/25, at 8:48 a.m. upon asking Nurse Aide (NA) Employee E19 which way are resident should be turned in bed, she replied towards you. During an interview completed on 4/5/25, at 8:55 a.m. upon asking RN Employee E2 concerning side rail placement she replied it should only take a day, it's through maintenance. During an interview completed on 4/5/25, at 9:00 a.m. upon asking Nurse Aide (NA) Employee E21 which way are resident should be turned in bed, she replied towards me. During an interview completed on 4/4/25, at 3:19 p.m. the Director of Nursing confirmed that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of five residents (Resident R32), which resulted in actual harm requiring a transfer to the hospital for evaluation of head trauma for one of five residents (Resident R32). 28. Pa Code 201.18(b)(1)(e)(1) Management. 28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1). This failure created an immediate jeopardy situation. Findings include: Review of the facility Wandering and Elopements policy last reviewed 9/18/24, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Elopement screenings will be completed on residents upon admission, change in condition, and as needed. When a resident is identified to be at risk for elopement, they will be care planned along with interventions identified to reduce the resident's risk for elopement. Residents being identified as being at risk will have the Resident Identification Form completed with a current picture. The completed form will be placed in the Elopement Risk Binder located at each nursing station and the front exit. If an employee observes a resident leaving the premises, he/she should attempt to prevent the resident from leaving, get help from other staff members in the immediate vicinity, and if needed instruct another staff member to inform the charge nurse or Director of Nursing (DON) that a resident is attempting to leave or has left the premises. When the resident returns to the facility the DON or charge nurse must examine the resident, contact the attending physician and report findings and conditions of the resident. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses of opioid abuse, alcohol abuse, psychoactive substance abuse, and cerebral infarction (commonly referred to as a stroke, occurs when the blood supply to the brain is interrupted, leading to a lack of oxygen and nutrients to brain cells.) Review of Resident R1's Elopement Risk Evaluation dated 2/21/25, indicated the resident was not an elopement risk. Review of Resident R1's care plan dated 2/24/25, indicated Resident R1 had a behavior problem with entering into other resident's rooms and defecating on the floors. Review of Resident R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE], completed by Social Service Director Employee E2 indicated the resident was cognitively intact. Review of Resident R1's Elopement Risk Evaluation dated 2/24/25, asked nine questions and it was indicated an answer of Yes for ANY of the above indicates Risk of Elopement, proceed with identification of resident as an elopement risk including but not limited to wander guard placement and facility notification. Proceed to the Care Plan and Initiate. The resident answered yes for two of nine questions. It was indicated the resident wanders and was recently admitted and was not accepting the situation. The facility failed to initiate a care plan for the resident's elopement risk. Review of a progress note dated 2/25/25, at 3:28 p.m. entered by Licensed Practical Nurse (LPN), Employee E1 stated Resident R1 was seen first while passing medications. Resident R1 was sitting in the common area and kept insisting that family is unaware of where Resident is at and needs to go tell them. LPN, Employee E1 looked in the resident's clinical record and there was not contact information for any family. The resident was last seen around 11:00 a.m. in the common area. Review of Resident R1's clinical record on 2/25/25, failed to indicate Resident R1 was reevaluated for a risk of elopement after displaying exit-seeking behaviors. Review of information submitted to the Department of Health on 2/26/25, indicated on 2/25/25, Resident R1 had an unauthorized LOA from the facility around 2:15 p.m. It was indicated the supervisor saw the resident walking away from the property and heading towards the bus stop, and immediately notified the DON. Resident R1 was dressed in street clothes with a winter coat. The resident was assessed for elopement and was determined not to be a risk. Staff members searched the area around the facility and called the resident's listed phone number. The number listed was a place he had been staying prior to hospitalization and has since been evicted. The police, physician, and appropriate agencies were notified. Review of Social Service Director, Employee E2's witness statement dated 2/25/25, indicated on 2/24/25, Resident R1 stated, he/she needed to get out to take care of a few things. On 2/25/25, around 2:50 p.m. was notified Resident R1 walked off the property and staff was looking for resident. Review of Nurse Aide, Employee E12's undated witness statement indicated Resident R1 asked to use NA, Employee E12's phone and called someone multiple times. It was indicated apparently it was a family member. Review of Medical Records, Employee E3's witness statement dated 2/26/25, indicated on 2/25/25, residents were being taking out for their 2 p.m. smoke break. Medical Records, Employee E3 started to light resident's cigarettes as they came out of the door and told them to keep the line moving towards the smoking area. On the way-out Medical Records, Employee E3 indicated there were people yelling and talking to each other. Resident R5 approached medical records, Employee E3 and stated, that man left out and walked off the property. Medical Records, Employee E3 asked what man, and he proceeded to say the man with the black coat with the fur around the hood. While heading outside Medical Record, Employee E3 seen Resident R1 walking down the driveway with Dietary Aide, Employee E4. Medical Records, Employee E3 stated she never seen him before and was unaware he was a resident. Medical Records, Employee E3 ran inside and told the Director of Nursing who was standing in the lobby and proceeded to do the elopement protocol. A review of a progress note dated 2/27/25, at 11:04 a.m. entered by the Director of Nursing indicated a case manager called to see if the facility had any whereabouts on Resident R1. It was indicated the DON told the case worker that the facility was not aware of where he had gone. The DON asked the case manager to contact the facility if she has any information on where the resident is and his condition. A review of the facility's investigation for Resident R1's elopement on 3/12/25, at 9:15 a.m. indicated the resident was last seen leaving the property at the end of the driveway. Resident R1 exited the facility at approximately 2:30 p.m. with a dietary aide. The resident was wearing black pants, a black puffy coat with the hood up, dark shoes, and dark rimmed glasses. The weather was 50 degrees Fahrenheit and cloudy. The facility does not have an alarm system for the doors. It was indicated the resident was assessed for an elopement risk but was not a risk. The facility failed to identify Resident R1 as an elopement risk. During an interview on 3/12/25, at 9:36 a.m. RN Supervisor, Employee E5 stated she worked 7 a.m. to 3 p.m. the day Resident R1 eloped, and indicated she didn't know Resident R1 well. RN, Supervisor, Employee E5 stated Resident R1 was seen sitting in the common area just before he eloped. RN Supervisor, Employee E5 stated It was almost time to smoke, the smokers went out, I stayed in my office, I guess he saw that as his opportunity. Sometime shortly after that staff began to search for the resident. RN Supervisor stated the elopement risk screening tool only uses nursing judgement to determine if a resident is an elopement risk. During an interview on 3/12/25, at 9:53 a.m. LPN, Employee E1 stated she worked 7 a.m. to 3 p.m. on 2/25/25. LPN, Employee E1 stated Resident R1 wasn't always nice and kept requesting to see his family. LPN, Employee E1 didn't see any family's contact information listed on Resident R1's clinical record. LPN, Employee E1 stated Resident R1 was homeless. Resident R1 went all day saying no one knows where he is at, and he needs to get out of here. LPN, Employee E1 stated she was unsure when to reevaluate residents for elopement risks. LPN, Employee E1 stated around 2 p.m. she was notified Resident R1 was missing. A search was conducted for Resident R1; however, he was not located. During an interview on 3/12/25, at 10:03 a.m. Social Services Director, Employee E2 stated the day before, Resident R1 eloped, he indicated he needed to make some phone calls and had to make a plan. Social Service Director, Employee E2 asked what Resident R1's plan was, and Resident R1 indicated he didn't have a plan. The next day Resident R1 took off and the elopement protocol was initiated sometime between 2 p.m. and 3 p.m. No one heard from him since. During an interview on 3/12/25, at 10:10 a.m. Nurse Aide, Employee E6 stated the front doors are always locked and someone must push the button to let anyone out. NA, Employee E6 stated if resident displays exit-seeking behaviors a nurse must be notified. During an interview on 3/12/25, at 10:17 a.m. Medical Records, Employee E3 stated she covers the smoking breaks at 10 a.m. and 2 p.m. During a smoke break on 2/25/25, the doors were open and shut, with people were coming in from outside. Medical Records, Employee E3 was outside, holding the door and told residents to go to the pavilion, and wait for her to light their cigarettes. During that time Dietary Aide, Employee E4 and Resident R1 came out and kept walking. Medical Records, Employee E3 indicated she didn't realize Resident R1 was a resident at the facility. Resident R5 said that man left, and indicated she thought Resident R5 was talking about Dietary Aide, Employee E4. Medical Records, Employee E3 asked Resident R5 if it was the guy sitting in the lobby. Medical Records, Employee E3 notified Receptionist, Employee E7 that Resident R5 told her a resident left and to complete a floor check and head count. Medical Records, Employee E3 stated once notified, Resident R1 was already gone. Medical Records Employee E3 asked Resident R5 why wouldn't you tell me when you saw him leaving, I would have run down parking lot. Medical Records, Employee E3 stated Resident R1 didn't even come over to the pavilion. She stated the police were notified but it took a long time to come, and the facility had to call again. Resident R1 never came out to smoke before. On 3/12/25, at 10:36 a.m. Resident R5 was unavailable for an interview and was out to the hospital. During an interview on 3/12/25, at 10:37 a.m. Nurse Aide, Employee E8 stated she was assigned to Resident R1 on 2/25/25. NA, Employee E8 works at the facility once a week, and was unfamiliar with Resident R1, however was aware Resident R1 was independent with care. NA, Employee E8 seen Resident R1 throughout the day, and didn't notice any exit seeking behaviors. NA, Employee E8 stated a nurse would have notified if a resident displayed exit-seeking behaviors. The last time NA, Employee E8 seen Resident R1 on 2/25/25, was around 1 p.m. Once notified Resident R1 was missing, NA, Employee E8 got in her car and started looking for Resident R1. During an interview on 3/12/25, at 10:42 a.m. the NHA and DON indicated Resident R1 walked out with Dietary Aide, Employee E4. The DON stated, it looked like they were together. It was indicated the Dietary Aide, Employee E4 did not have a conversation with Resident R1. Resident R1 had his hood up and walked out the door. Medical Records, Employee E3 was doing the smoking break that day. It was indicated they believe Resident R1 got on a bus, because if Resident R1 was on foot, he would have been found. The NHA and DON stated Resident R1 should not have been identified as an elopement risk. The DON stated, all the assessments we did, didn't show he was either. The DON and NHA confirmed the facility failed to identify Resident R1 was at risk for elopement and ensure Resident R1 was care planned for his risk and received adequate supervision to prevent elopement. During an interview on 3/12/25, 11:31 a.m. the DON stated since Resident R1 had two elopement risk assessments completed in the first few days. He indicated he was not sure an updated elopement assessment would have been completed on 2/25/25, the day the resident displayed exit-seeking behaviors and eloped. On 3/12/25, at 1:13 p.m. the NHA and DON were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 2/25/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. During an interview on 3/12/25, at 2:31 p.m. Receptionist, Employee E10 stated she works at the front desk Monday through Friday from 7a.m. until 3 p.m. Receptionist, Employee E10 stated the front doors are always locked and a staff member must push a button located behind the desk to open the doors. An elopement book is located at the front desk with residents' photos who are identified as an elopement risk. Staff must identify those who are leaving prior to unlocking the door. Whenever a resident is identified as an elopement risk, the binder is updated. It was indicated Receptionist, Employee E10 trains all staff to study the photos of residents to prevent anyone from eloping. On 3/12/25, at 5:13 p.m. an immediate action plan was received and accepted which included the following interventions: 1. Immediate action(s) taken for the resident(s) found to have been affected include: -Resident R1 is no longer a resident at the facility but was located post elopement by the housing director of the YMCA where the resident had lived prior to hospitalization s. Resident is safe according to his friends in the northside area where he has been a lifelong resident. This was verified by the Administrator on 3/12/25. 2. Identification of other residents having the potential to be affected was accomplished by: -All residents will be assessed for elopement risk by the Director of Nursing or designee by the end of the day on 3/13/25. -All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the end of the day on 3/13/15, by the DON or designee. -Residents admitted within the last 30 days and who are currently in-house will be added to the Elopement Binder by the NHA or designee by 3/13/25. 3. Actions taken/systems put into place to reduce the risk of future occurrences include: -The elopement assessment tool will be updated by the Director of Nursing or Designee by 3/13/25. -Education will be completed by all staff on Elopement Risks, Assessments, Care Plans, and Supervision of residents by the DON or designee by 3/13/25. -Policies and/or procedures will be updated to identify residents who are at risk for eloping by the NHA or designee by 3/13/25. -Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the NHA or designee by 3/13/25. -A new process will be implemented by the NHA or designees to ensure that residents sign out of the facility when going on a leave of absences (LOA). This process will have the RN Supervisor or designated nurse (RN or LPN) will complete an LOA approval form which is to be given to the receptionist before the receptionist can allow the resident to exit the facility by 3/13/25. 4. How the corrective actions(s) will be monitored to ensure the practice will not recur: -Audits will be implemented by 3/13/25, for LOA sign out compliance weekly for 4 weeks, then monthly for two months. -An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the NHA or designee by 3/13/25. -This plan of correction will be monitored at the QAPI meeting until such time is consistent substantial compliance has been met. On 3/13/25, at 12:43 p.m. it was confirmed 78/78 Residents were reassessed for an elopement risk. 13/78 Residents were identified as a risk, and 13/13 care plans were updated to include interventions to prevent elopement. 13/13 Residents were included in the elopement binder. On 3/13/25, at 12:46 p.m. it was confirmed the elopement tool assessment was updated to include residents who were recently admitted or readmitted in last 30 days. The new tools assesses if in last 90 days does the resident have history of elopement or attempt to leave the facility without informing the staff, has the resident been witnessed packing belongings with intent to leave facility, has the resident been exit seeking, has the resident been in non-resident care area, and/or unsupervised area. Residents who answer yes to questions 2-4 will be identified as an elopement risk. If triggered yes, the tool auto populates a care plan task to be completed. During in-person interviews completed from 3/13/25, at 10:31 a.m. until 3/13/25, at 12:05 p.m. 18/18 staff confirmed they were educated. Staff were educated on how and when to complete an elopement assessment, and what to do for residents that are displaying exit seeking behaviors. 91/120 Staff were educated on the elopement risks, assessments, care plans, and supervision of residents on 3/13/25. Staff were sent an alert that was signed and acknowledge for the elopement risk training and all staff must confirm they were educated prior to the start of their next shift. 90/120 Staff members signed the acknowledgement of elopement training. During phone interviews completed on 2/13/25, at 2:10 p.m. at 5 of 5 staff members confirmed they were educated on elopement risks. All staff must confirm they were educated prior to the start of their next shift and sign the education sheet in-person. Staff education was verified with dated sign-in sheets and review of all current staff utilized in the facility having signed and/or educated over the phone as indicated. Policies for elopement was reviewed on 3/12/25, no updates were made. Elopement books with 13/13 Identified residents were observed at 2 of 2 nursing stations and the front desk. The residents' photos and names were listed. The facility created LOA approval forms that are located at each nursing station. It is indicated the form must be filled out and given to Receptionist before the receptionist can allow the resident to exit. An audit was completed for residents with a LOA on 3/13/25. No residents went on LOA. The facility will continue to audit weekly. An Ad Hoc QA Meeting was completed on 3/13/25. Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 3/13/25, at 2:32 p.m. During an interview on 3/13/25, at 3:03 p.m., the NHA and Regional Clinical Operations Specialist, Employee E9 confirmed that the facility failed to make certain each resident received adequate supervision and failed to identify and implement interventions for a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1), resulting in Immediate Jeopardy. 28 Pa. CodeS 201.14(a) Responsibility of Licensee. 28 Pa. Code S 211.10(d) Resident care policies. 28 Pa. Code S 211.12(d)(5) Nursing Services.

Based on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 24 of 24 residents that smoke. Findings include: Review of the facility policy Wandering and Elopements, last reviewed 4/1/24, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Residents will be screened regularly for risk for wandering and elopement. The resident's care plan will include strategies and interventions identified appropriate. Review of the facility policy Signing a Resident Out, last reviewed 4/1/24, indicated all residents leaving the premises must be signed out. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. Review of the facility policy Smoking Policy, last reviewed 4/1/24, indicated it is the facility policy to allow residents to smoke in approved areas and at approved times. It was indicated any fire lighting products is prohibited to be in a resident's possession for the safety of every resident. Smoking materials (cigarettes and lighters) are to be stored at the nurse's station/front desk. Each resident that smokes will be assessed for their own individual abilities and circumstances and care planned for this ability. Residents are strongly encouraged to wear a smoking apron while smoking. The designated smoking times are for 30 minutes increments and are everyday at 10:00 a.m., 2:00 p.m., and 7:00 p.m. Review of the facility policy, Safety and Supervision of Residents last reviewed 4/1/24, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Review of Resident R1's clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness, high blood pressure, and alcohol abuse. Review of Resident R1's Admission/Re-Admit Eval V10.6-2023 dated 5/25/24, indicated the resident had a history of elopement or an attempted elopement while at home and at the facility without informing staff. It was indicated the resident was identified as an elopement risk and a care plan for elopement must be initiated. Review of Resident R1's progress note dated 5/26/24, at 10:41 a.m. Registered Nurse, Employee E2 stated resident requires frequent orienting regarding why he's in facility. Review of Resident R1's progress note dated 5/30/24, Nurse Practitioner, Employee E3 indicated the resident was deemed per psychiatry not to have capacity to make decisions. The resident was recently admitted after being found down, seizures (a sudden, uncontrolled burst of electrical activity in the brain) requiring intubation (technique doctors use to keep airway open by inserting a tube into the windpipe to keep the airway open) and intensive care unit (ICU) management. Review of Resident R1's progress note dated 5/31/24, Registered Nurse Assessment Coordinator (RNAC), Employee E4 at 9:30 a.m. stated a licensed practical nurse (LPN) came down hall to tell this RN that resident is more confused thinks he just got here last evening and that he has address in Wilkinsburg that he needed to get today and would be leaving. Nursing Home Administration (NHA) was alerted, staff alerted to monitor his whereabouts every 10-15 minutes, front staff alerted with picture of resident. Staff will continue to monitor and intervene as necessary. Review of Resident R1's WEC: Elopement Risk Evaluation V10.1-10.2023 dated 5/31/24, at 10:15 a.m. indicated the resident was an elopement risk and the facility staff should proceed with identification of resident as an elopement risk including but not limited to wander guard placement and facility notification. It was indicated to proceed to care plan and initiate. Review of Resident R1's progress note dated 5/31/24, RN, Employee E5 at 12:44 p.m. indicated the resident was alert with obvious signs of intermittent confusion. The resident reported wanting to walk up the street to a nearby restaurant where a friend work so that he can alert her to his whereabouts. Review of Resident R1's progress note dated 5/31/24, LPN, Employee E6 at 2:06 p.m. indicated the resident attempted to go out the front doors. This write called to lobby to bring resident back to floor. Review of Resident R1's care plan dated 5/31/24, failed to identify the resident as an elopement risk and failed to initiate any interventions. Review of the facility's electronic bulletin message board dated 5/31/24, entered by the NHA stated PLEASE MAKE SURE ROUNDS ARE BEING DONE AND ALL RESIDENTS ARE ACCOUNTED FOR- WE MUST KNOW WHERE ALL RESIDENTS ARE AT ALL TIMES. NO ONE SHOULD BE ON THE SECOND OR FIRST FLOOR. PLEASE ALSO REVIEW THE UPDATED ELOPEMENT BINDERS. Review of Resident R1's progress note dated 6/1/24, RN, Employee E7 stated I was notified that resident eloped during smoke break stating that he was going to the store and never returned. Condition Pink was called, and the ground were searched. It was indicated a Condition Pink requires staff to stop what they ' re doing and assist on locating the missing resident in the facility. If the resident is not located then the DON and NHA is notified, as well as the resident's family, physician, police. Review of RN, Employee E7's witness statement dated 6/1/24, indicated she was notified that Resident R1 left the premises during smoke break. Receptionist, Employee E14 who staffs the front desk stated that he took everyone out for the break because that's what he always does. RN, Employee E7 stated she was informed the resident walked towards GetGo, I walked over there to see if resident was there, and no one had seen him. Review of Receptionist, Employee E14's witness statement dated 6/1/24, stated Staff took residents out for their 7 p.m. smoke break, while passing everyone a cigarette Resident R1 walked off. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/1/24, indicated the resident had an unplanned discharged to home/community and his return was not anticipated the same day of his elopement. Review of Resident R1's progress note dated 6/2/24, RN, Employee E8 at 5:23 a.m. stated Resident left facility alone, on 3-11 shift on 6/1/24. He has not called or returned. Review of Resident R1's Hospital Records dated 6/6/24, indicated emergency medical services (EMS) found Resident R1 lying supine on the ground, unresponsive in an alley in town in the pouring rain. Resident R1 was unresponsive except for deep painful stimuli. He had an obvious compound fracture (a break or crack in your bone that is visible through your skin), with active bleeding to the right foot at the bottom of the tibia/fibula (two bones that form your lower leg) where it met the ankle. A bystander indicated Resident R1 was possibly struck by a car. The patient had a minor abrasion to the right side of his forehead. Resident R1 became combative and started swinging and not making comprehensible sounds. Police assisted in restraining the resident, and he was sedated during transport to the hospital as a level one trauma. Review of Resident R1's Hospital Records dated 6/6/24, indicated Resident R1 was admitted to the hospital as level one trauma with open right distal tibia/fibula, left 12th rib fracture, and left anterior (at or near the front) shoulder dislocation after being found down in alley after being struck by vehicle. It was indicated the resident had surgery on his right leg. During an interview on 6/18/24, at 9:44 a.m. Front Desk Receptionist Employee E9 stated the duties of the receptionist include answering calls, opening the door, and to keep an eye on the residents, on the ones that escape. Front desk receptionist, Employee E9 stated no residents are allowed to leave the facility unattended and during smoke breaks a designated smoke monitor is always with them. It was indicated an elopement binder is located at the front desk. During an interview on 6/18/24, at 1:01 p.m. LPN, Employee E10 stated on admission everyone gets a smoking and elopement assessment. During an interview on 6/18/24, at 1:03 p.m. Nurse Aide, Employee E11 stated during smoke breaks, the person supervising is responsible for the residents. On the weekends the Registered Nurse Supervisor must do it on the weekends. NA, Employee E11 indicated anyone that wanders, staff must keep an eye on. During an interview on 6/18/24, at 1:10 p.m. LPN Employee E12 was asked how she knows if a resident is an elopement risk and stated it usually comes in their paperwork, but a lot of times you can't see paperwork until there is a problem. LPN, Employee E12 stated any new admission gets a screening, and if identified as an elopement risk it is usually given in verbal report, there are no wrist bands or stickers to identify them. There is no wander guard system here, so that is problematic. LPN, Employee E12 stated the front desk is not supposed to not let any residents out, they must call and assist resident back where they belong. LPN, Employee E12 stated my understanding is during the week on evenings someone is there, then at nighttime the supervisor should sit at desk. Review of the facility's list of accidents and incidents for the month of June 2024, reviewed on 6/18/24, failed to include Resident R1's elopement that occurred on 6/1/24. During an interview on 6/18/24, at 1:39 p.m. the NHA confirmed Resident R1's elopement was not on the list of accidents and incidents for June 2024 provided by the facility. During an interview on 6/18/24, at 1:42 p.m. the Director of Nursing (DON) stated she is unsure why Resident R1's elopement is not shown on the list of incidents and accidents. The DON brought in a folder a filled with variety of witness statements and provided seven witness statements, the DON kept the rest of folder indicating that the other statements are not pertaining to Resident R1. The DON stated This gentleman kept wanting to leave AMA (Against Medical Advice-a form of discharge from the facility in which a patient chooses to leave before the treating physician recommends discharge)-. He only had one family member, like an aunt. When I called her, she said he does this all the time. During an interview on 6/18/24, at 2:04 p.m. the Director of Nursing stated RN, Employee E7 was responsible for supervising residents when Resident R1 eloped from the facility during a smoke break on 6/1/24, and she was terminated from her attitude towards the incident. The DON, stated Resident R1 was alert and oriented although he is sickly. The DON stated the nurse wouldn ' t give him AMA, so since he didn ' t give it to him, he took himself out of here. The DON stated Resident R1 was not a smoker and sometimes residents who are not smokers go outside with smokers. During an interview on 6/18/24 at 2:16 p.m. the DON confirmed the facility failed to implement a care plan for Resident R1's elopement risk. During an interview on 6/18/24, at 2:34 p.m. the DON stated she was notified by Resident R1's family member that he was found at the hospital on 6/6/24. During an interview on 6/20/24, at 9:08 a.m. the NHA and DON indicated Receptionist, Employee E14 was the one monitoring residents during a smoke break on 6/1/24, when Resident R1 eloped. The DON indicated residents who do not smoke go outside with smokers. It was indicated Receptionist, Employee E14 no longer works at the facility because he quit showing up. Review of Resident R2's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the resident had diagnoses of anxiety, depression, and muscle weakness. Review of Resident R2's clinical record from 1/10/24, to 6/19/24, failed to include a smoking evaluation was completed. Review of Resident R2's care plan dated 6/12/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R2 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R2. Review of Resident R3's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of asthma, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances.) Review of Resident R3's clinical record from 6/13/24, to 6/19/24, failed to include a smoking evaluation was completed. Review of Resident R3's care plan dated 6/14/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R3 was observed smoking outside. Review of the facility's undated smoking list indicated Resident R3 was a smoker. Review of Resident R4's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R4's clinical record indicated a smoking assessment dated [DATE], indicated the resident requires supervision while smoking, a smoking apron, and the facility must hold cigarettes and lighter. No further smoking assessments were completed. Review of Resident R4's MDS dated [DATE], indicated the resident had diagnoses of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and encephalopathy (an abnormality of brain function or structure). Review of Resident R4's care plan last revised 3/18/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R4 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 5/29/23. Review of the facility's undated smoking list failed to include Resident R4. Review of Resident R6's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], indicated the resident had diagnoses of Human Immunodeficiency Virus (HIV), anemia (deficiency of healthy red blood cells in blood), and muscle weakness. Review of Resident R6's safe smoking evaluation dated 4/16/24, indicated the resident always requires supervision and a smoking apron. Review of Resident R6's care plan dated 4/16/24, indicated the resident is a smoker and must wear a smoking vest and supervision while smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R6 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 4/16/24. Review of Resident R7's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of alcohol abuse alcohol dependence with alcohol-induced persisting dementia and tobacco use. Review of Resident R7's clinical record from 6/17/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Review of Resident R7's care plan dated 6/17/24, failed to include a care plan for smoking. During an interview and observation on 6/18/24, at 10:11 a.m. Resident R7 was observed pulling his cigarettes and lighter out of his pocket. Medical Records Employee E13 stated he arrived last night and we have to get his cigarettes. Medical Records Employee E13 stated new people come all the time, smoker list changes. Medical Records, Employee E13 confirmed no current smoker list was being utilized. During an observation on 6/18/24, at 10:21 a.m. Resident R7 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R7. Review of Resident R8's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R8's care plan dated 1/29/24, indicated the resident is a smoker and requires supervision and a smoking apron while smoking. Review of Resident R8's MDS dated [DATE], indicated the resident had diagnoses of anemia, seizure disorder, and Wernicke's encephalopathy (a neurological disorder caused by the lack of thiamine (also known as vitamin B1, a water-soluble vitamin that enables the body to use carbohydrates as energy). Review of Resident R8's safe smoking evaluation dated 4/16/24, indicated the resident always requires supervision. During an observation on 6/18/24, at 10:21 a.m. Resident R8 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R8. Review of Resident R9's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of COPD, tobacco use, and cocaine abuse. Review of Resident R9's safe smoking evaluation dated 6/11/24, indicated the resident always requires a smoking apron and supervision. Review of Resident R9's care plan dated 6/15/24, failed to include a care plan that reflected the resident's smoking needs, and adaptive equipment needs for smoking safely. During an observation on 6/18/24, at 10:21 a.m. Resident R9 was observed smoking outside without an apron. The facility failed to implement safe smoking interventions as per his most recent smoking assessment completed on 6/11/24. Review of the facility's undated smoking list failed to include Resident R9. Review of Resident R10's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy, alcohol dependence, and anemia. Review of Resident R10's clinical record from 6/14/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Review of Resident R10's care plan dated 6/17/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R10 was observed smoking. Review of the facility's undated smoking list failed to include Resident R10. Review of Resident R11's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, muscle weakness, and polyneuropathy (damage to peripheral nerves). Review of Resident R11's clinical record from 6/6/24, to 6/19/24, failed to include a safe smoking evaluation was completed. Review of Resident R11's care plan dated 6/15/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R11 was observed smoking outside. Review of the facility's undated smoking list failed to include Resident R11. Review of Resident R12's clinical record indicated the resident was admitted to the facility on [DATE]. Review of Resident R12's MDS assessment dated [DATE], indicated diagnoses of seizure disorder, muscle weakness, and osteoarthritis (inflammation of one or more joints). Review of Resident R12's smoking evaluation dated 4/16/24, failed to indicate if the resident can smoke independently or with set up, may smoke unsupervised in designated areas, or be always supervised. The summary of the evaluation was left blank and not completed thoroughly. Review of Resident R12's care plan dated 9/7/23, indicated the facility must secure smoking materials and educate resident on facility policy and procedures for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R12 was observed smoking outside. Review of Resident R13's clinical record indicated the resident was admitted to the facility on [DATE], with diagnoses of high blood pressure, intellectual disabilities, and wheezing. Review of Resident R13's smoking evaluation dated 6/18/24, indicated the resident must be always supervised. The assessment was completed six days after the resident was admitted . Review of Resident R13's care plan dated 6/13/24, failed to include a care plan for smoking. During an observation on 6/18/24, at 10:21 a.m. Resident R13 was observed smoking outside. During an observation on 6/18/24, at 10:07 a.m. Medical Record, Employee E13 left residents (Resident R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13.) unattended outside to go back inside the lobby to get the water cart. During an interview on 6/18/24, at 1:03 p.m. Nurse Aide, Employee E11 stated during smoke breaks, They all need a smoking apron. That ' s the rule, they all are to have on an apron. During an interview on 6/20/24, at 9:13 a.m. the NHA and DON confirmed the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 16 residents who was identified as high risk for elopement (Resident R1). The facility failed to provide adequate supervision during smoking times for 11 of 11 residents observed (Residents R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, and R13), failed to complete safe smoking assessments, maintain an updated list of current smokers, implement care plans reflective of residents' smoking needs, and have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 24 of 24 residents that smoke On 6/20/24, at 10:41 a.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested. On 6/20/24, at 3:05 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Elopement: -All residents are being assessed to identify if they are an elopement risk or not. If identified as a risk, an elopement risk assessment will be completed by the director of nursing or designee by the end of the day 6/20/24. -All care plans will be reviewed and updated by the end of the day on 6/20/24. -Assessment and care plans for residents who are elopement risks will be completed by the Director of Nursing or Designee by the end of the day on 6/20/24. -Newly admitted residents are screened for elopement risk upon admission and care plans and assessments done accordingly. -Education began to re-educate all staff on wandering and elopement as well as Safety and Supervision of residents. Education will be conducted by the Director of Nursing or Designee prior to the start of their next scheduled shift. -Additionally, education sent to all active staff member via alert send out (Care feed) and sign off sheet will be signed prior to the start of employee's next shift. -Policies and/or procedures have been reviewed to ensure that staff identify all roles and responsibilities regardingsupervision and surveillance of residents as well as what to do if a resident is identified as missing. -Resident R1 is no longer a resident at the facility but was located post elopement/AMA. Facility has talked with the family and the hospital and Resident R1 is safe. -Elopement Risk Binder update, and staff will be educated on those identified by the end of the day on 6/20/24. -All staff will be in-serviced on the policy for wandering and elopement and supervision starting 6/20/24. -Registered Nurse (RN) Supervisor and or/designee to audit for safe wandering throughout facility weekly for 4 weeks and then monthly for 2 months. -Findings of this audit will be discussed with the Resident Council. -The plan of correction will be monitored at the monthly Quality Assurance meeting until such 0time consistent substantial compliance has been met. Smoking: -All residents who smoke will be identified by the end of the day on 6/20/24. -Smoking assessments will be reviewed and completed/update as needed for identified smokers by the Director of Nursing or Designee by the end of the day 6/20/24. -Resident care plans and assessments will be reviewed and revised by the Director of Nursing or designee by the end of the day on 6/20/24. Revisions will be made to reflect all current supervision and safety interventions for smoking. -Education will begin immediately for all staff on the smoking policy and supervision. Education will be conducted by the Director of Nursing or Designees prior to the start of their next scheduled shift by the end of the day on 6/20/24. -Policies and/or procedures have been reviewed. -Facility will ensure that all residents are assessed for proper smoke equipment and supervision by end of the day on 6/20/24. -All smoking equipment such as lighters and cigarettes/cigars will be stored properly/safely by the end of the day on 6/20/24. -All smokers will be assessed for any injuries they may have incurred while smoking by the end of the day on 6/20/24. -All staff will be in-services on the facility policy for Resident Smoking and Supervision during times starting 6/20/24. -Nursing staff or designee will observe residents while smoking daily to ensure appropriate supervision and implementation of safety interventions as documented on the plans of care daily for 4 weeks and then monthly for 2 months. -The facility will designate a smoke monitor each smoking time by the end of day on 6/20/24. -The management team will oversee assigned caregivers/smoke monitors and residents during designated smoking times to ensure appropriate supervision and interventions are implemented and the plans of care are followed. -The Director of Nursing (DON), or designee, will complete random weekly chart audits for four (4) consecutive weeks. All care plans for residents will be reviewed to ensure that appropriate interventions have been put in place to reduce risk of smoking accidents. -Findings of this audit will be discussed with Resident Council. -This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. During an observation on 6/21/24, at 10:03 a.m. the supervised smoking was observed. Facility staff were present with tackle box containing cigarettes, lighters, and smoking aprons. During an interview on 6/21/24, at 10:58 a.m., Medical Records Employee E13 indicated all residents are encouraged to wear protective aprons, however they have the right to refuse and there is an updated list of all residents that are required to wear aprons. Review of facility's immediate action plan was verified and completed on 6/21/24, at 1:01 p.m. as follows: Elopement: All residents are being assessed to identify if they are an elopement risk or not. If identified as a risk, an elopement risk assessment will be completed by the director of nursing or designee by the end of the day 6/20/24. -77/77 Residents were assessed for elopement risk. 15/77 residents were identified as an elopement risk. All care plans will be reviewed and updated by the end of the day on 6/20/24. -15/15 resident care plans were reviewed and revised as needed for elopement risk and interventions related to risk of wandering. Assessment and care plans for residents who are elopement risks will be completed by the Director of Nursing or Designee by the end of the day on 6/20/24. -77 residents were assessed for risk of elopement and 15/77 residents who were identified as a risk were care planned for interventions. Newly admitted residents are screened for elopement risk upon admission and care plans and assessments done accordingly. -1/1 newly admitted resident was screened for elopement risk and care plan was not needed to be update because he was not identified as an elopement risk. Education began to re-educate all staff on wandering and elopement as well as Safety and Supervision of residents. Education will be conducted by the Director of Nursing or Designee prior to the start of their next scheduled shift. -106/106 staff were educated on the wandering and elopement as well as safety and supervision of residents. Staff were educated where to find Elopement binder of all residents identified as elopement risk and what code is called if resident is discovered missing. 17/17 Staff interviewed in-person confirmed they were educated on the Safety and supervision of residents. 6/6 interviews conducted via phone confirmed staff were educated on importance of supervising residents. 62/106 staff confirmed they received the education prior to the start of their shift. The facility will ensure staff sign off that they were educated prior to the start of their shift. Additionally, education sent to all active staff member via alert send out (Care feed) and sign off sheet will be signed prior to the start of employee's next shift. -106/106 staff were provided education regarding where to find elopement risk binder, code pink, and what to do if resident goes missing on 6/20/24, via alert send out. Staff were provided with policies on wandering and elopements, safety, and supervision of residents, and signing residents out. Policies and/or procedures have been reviewed to ensure that staff identify all roles and responsibilities regarding supervision and surveillance of residents as well as what to do if a resident is identified as missing. -106/106 staff were provided education regarding where to find elopement risk binder, code pink, and what to do if resident goes missing. Staff were educated on wandering and elopements, safety, and supervision of residents, and signing residents out. Resident R1 is no longer a resident at the facility but was located post elopement/AMA. Facility has talked with the family and the hospital and Resident R1 is safe. -Resident R1 will not be returning to facility. Elopement Risk Binder update, and staff will be educated on those identified by the end of the day on 6/20/24. -Review of Elopement Binder on 6/21/24, at 12:22 p.m. revealed a total of 15 residents were identified as an elopement risk. A picture of the resident and their first and last name is listed in the binder. An elopement binder is located at each nursing station and the front desk. All staff will be in-serviced on the policy for wandering and elopement and supervision starting 6/20/24. -106/106 staff were in-serviced on the policy for wandering and elopement and supervision on 6/20/24. Registered Nurse (RN) Supervisor and or/designee to audit for safe wandering throughout facility weekly for 4 weeks and then monthly for 2 months. -Facility will began monitoring for safe wandering on 5/30/24, on the 3rd and 4th floor. No residents were observed wandering. F [TRUNCATED]

Based on review of facility policy, observations, clinical record reviews, facility documentation, and interviews, it was determined the facility failed to implement interventions to prevent pressure ulcer and injury (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin.) development for residents who were admitted without PU/PIs, but who had multiple co-morbidities; and failed to provide ongoing skin assessments for four of four residents (Resident R5, R63, R68, and R231) that resulted in deterioration of one or more PU/PIs for two of four residents (R5 and R63) and infection for one of four (R68), which resulted in an immediate jeopardy situation for four of 74 residents. Findings: Review of the facility's Pressure Injury Risk Assessment policy dated 1/18/23, stated the purpose of this procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. It was indicated a pressure ulcer risk assessment using the facility's approved tool must be conducted. When a comprehensive skin assessment is completed, the findings are documented on the facility's approved skin assessment tool. If a new skin alteration is noted, a (pressure or non-pressure) form related to the type of alteration in skin must be completed. It stated a care plan and interventions based on risk factors identified in the assessments, the condition of the skin, and the resident's overall clinical condition, and the resident's stated wishes and goals must be developed. Review of the facility's Pressure Injuries Overview policy dated 1|/18/23, stated the purpose of this policy was to provide information regarding the definitions and clinical features of pressure injuries. It was indicated avoidable means a resident developed a pressure ulcer of injury and that one or more of the following was not completed: -Evaluation of the resident's clinical condition and risk factors. -Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice. -Monitoring or evaluation of the impact of the interventions; or -Revision of the interventions as appropriate. Review of the facility's Wound Care policy dated 1/18/23, stated the purpose of this policy was to provide guidelines for the care of wounds to promote healing. It stated a physician order must be verified and the care plan must be reviewed to assess for any special needs of the resident. The following should be recorded in the resident's medical record: -The type of wound care given. -The date and time the wound care was given. -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -If the resident refused the treatment and the reason(s) why. Review of Resident R5's clinical record indicated an admitted [DATE], with diagnoses that included malignant neoplasm of the skin (skin cancer), diabetes, muscle weakness, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life.) Review of Resident R5's physician order dated 12/22/21, indicated Resident R5 may be seen by a wound specialist. Review of Resident R5's physician order dated 3/9/22, indicated a weekly skin assessment must be completed every Wednesday. Review of Resident R5's Braden Scale for Predicating Pressure Sore Risk assessment dated [DATE], identified the resident was at risk with a score of 15. No further Braden Scale Assessments were completed until 6/4/23. The facility's Braden Scale for Predicting Pressure Score Risk assessment instructions indicated assessments are completed when admitted and every quarter. Review of Resident R5's MDS dated [DATE], Section M Skin Conditions, indicated the resident was at risk for developing PU/PIs and the resident did not have one or more unhealed PU/PIs. Review of Resident R5's care plan from 4/7/23 through 5/29/23, failed to include a care plan for pressure ulcers. Review of Resident R5's NG-Weekly Skin Inspection assessment dated [DATE], failed to indicate any abnormalities observed on the resident's skin. It was documented the resident had no skin issues. Review of Resident R5's progress note dated 4/26/23, entered by Licensed Practical Nurse (LPN), Employee E4, indicated the resident had developed a new reddish, purple bruise on left hip that measured 5 cm x 2.5 cm and two new dime-sized reddish, purple areas on the side of left foot. It was indicated the registered nurse supervisor was notified, and that care was provided in accordance with the resident's care plan. Review of Resident R5's care plan dated 4/26/23, failed to include care interventions related to the resident's pressure injury. Measurements for the left foot pressure injury were not documented. Review of the resident's clinical record on 4/26/23, failed to include documentation of the findings on the facility's approved skin assessment tool. Review of Resident R5's progress note dated 4/26/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, indicated she was requested by facility staff to have Resident R5's newly discovered deep tissue injuries (DTIs- persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues) to the left hip, left foot, and sacrum evaluated. It was indicated Resident R5 was malnourished, incontinent of urine and feces, and had bilateral lower extremity contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.) It was also indicated Resident R5 was on a regular mattress. The following wounds were documented for Resident R5: -Newly discovered left hip acute DTI that measured 1.9 cm x 3.3 cm. -Newly discovered left lateral foot acute DTI that measured 2.1 cm x 1.6 cm. -Newly discovered left proximal lateral foot acute DTI that measured 1cm x 1cm. -Newly discovered sacral acute DTI that measured 1 cm x 0.7 cm. Review of wound care consultant, NP, Employee E5, progress note dated 4/26/23, indicated Resident R5's DTIs were ordered skin prep and left open to air. Additional orders as of 4/26/23, included pressure relief and offloading, the facility's pressure ulcer prevention protocol, and a pressure redistribution mattress. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's physician orders from 4/26/23 through 5/2/23, failed to include the ordered treatment for Resident R5's left hip, left foot, and sacral PU/PIs. Review of the clinical record revealed no evidence that the physician orders were completed. Review of Resident R5's physician order dated 4/27/23, indicated to turn and reposition as tolerated. Review of Resident R5's April 2023 electronic Treatment Administration Record (eTAR), failed to include documentation that Resident R5 was turned and repositioned as ordered. During an interview on 5/31/23 at 8:32 a.m., the DON, confirmed the order for Resident R5 to be turned and repositioned was entered incorrectly, and there was no way to confirm the resident was turned and repositioned as ordered. Review of Resident R5's NG-Weekly Skin Inspection assessment dated [DATE], failed to indicate any abnormalities observed on the resident's skin, and it was documented the resident's skin was clear and intact. Review of Resident R5's clinical record indicated the facility staff failed to complete weekly skin assessments from 5/1/23-5/31/23. Review of Resident R5's progress note dated 5/3/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute DTI that measured 1.5 cm x 3 cm. -Left lateral foot acute DTI that measured 1.7cm x 1.3 cm. -Left proximal lateral foot acute DTI that measured 1 cm x 1 cm. -Sacral acute stage two pressure injury that measured 1 cm x 0.7 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/3/23, indicated Resident R5's DTIs were ordered skin prep and left open to air. Additional orders as of 5/3/23, included pressure relief and offloading, the facility's pressure ulcer prevention protocol, and a pressure redistribution mattress. It was indicated the plan of care and education was discussed with facility staff. A further review of Resident R5's physician orders from 5/3/23 through 5/19/23, failed to include the ordered treatment for Resident R5's left hip, left foot, and sacral PU/PIs. Review of Resident R5's physician orders dated 5/16/23, indicated she was admitted to hospice. Review of Resident R5's progress note dated 5/17/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute DTI that measured 2.9 cm x 3.9 cm. with sloughing of the epithelium (the protective layer of the skin). The wound worsened. -Left lateral foot acute DTI that measured 1.7 cm x 1.3 cm with no measurable depth. -Left proximal lateral foot acute DTI that measured 1cm x 1 cm with no measurable depth. -A newly discovered left medial foot DTI that measured 1.2 cm x 1.2 cm with no measurable depth and had eschar (a collection of dry, dead tissue within a wound). -Sacral acute stage pressure injury that received an outcome of resolved. Review of wound care consultant, NP, Employee E5, progress note dated 5/17/23, indicated Resident R5 was ordered Medihoney (wound gel that helps speed the healing time of existing wounds and reduces pain) to the left hip and covered with a foam dressing and changed daily. On 5/17/23, wound care consultant, NP, Employee E5, ordered skin prep to be applied over the Resident R5's left foot DTIs. Additional orders as of 5/17/23, included the facility's pressure ulcer prevention protocol, side to side offloading every two to three hours while in bed, offloading heels, and a pressure redistribution mattress. On 5/17/23, wound care consultant, NP, Employee E5, also ordered Resident R5 soft heel boots (designed to offload pressure from the heel of a non-ambulatory individual to help prevent the development of pressure ulcers) that were always to be worn, aside from ambulation. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's clinical record indicated the facility failed to update Resident R5's physician orders. A further review of Resident R5's physician orders from 5/17/23 through 5/19/23, failed to include the ordered treatment for Resident R5's left hip and left foot PU/PIs. Review of Resident R5's physician order dated 5/19/23, failed to include the ordered treatment wound consultant, Employee E5, ordered to the residents left foot on 5/17/23. It indicated skin prep was to be applied to the left hip and covered with foam dressing, daily, starting 5/20/23. It was indicated this order was discontinued on 5/30/23. A further review of the physician order dated 5/19/23, indicated the resident's right hip was to be cleansed with Dakin's, patted dry, Medihoney and alginate applied, and covered with foam dressing, daily, starting 5/20/23. It was indicated this order was discontinued on 5/30/23. A further review of Resident R5's physician orders from 5/19/23 through 5/29/23, failed to include the ordered treatment for Resident R5's left lateral, proximal, and medial foot PU/PIs. Review of Resident R5's May 2023 eTAR, failed to include documentation that Resident R5 was turned and repositioned as ordered. A further review of Resident R5's May 2023 eTAR, failed to include documentation from 5/1/23 through 5/30/23, that care was provided as ordered to the resident's left hip, left foot, and sacral PU/PIs. During an interview on 5/31/23 at 8:32 a.m., the Director of Nursing (DON), confirmed the orders for Resident R5 were entered incorrectly for the left and right hip from 5/19/23 through 5/30/23, and there was no way that confirmed the resident received treatment to her PU/PIs as ordered. During an interview with Resident R5's family at bedside on 5/30/23 at 9:49 a.m., it was indicated Resident R5 was recently admitted to hospice on 5/16/23 and was given pressure relieving boots on 5/17/23. It was stated Resident R5's pressure relieving boots went missing after the first day she received them and Resident R5's feet have not been offloaded. During an observation, it was observed Resident R5's feet were not offloaded. Resident R5's granddaughter stated she visits daily and expressed concern with the treatment of Resident R5's pressure ulcers. Resident R5's dressing to her left hip was dated 5/28/23, with a large amount of drainage noted on the dressing. During an interview on 5/30/23 at 10:07 a.m., Registered Nurse (RN), Employee E6, confirmed Resident R5's dressing was dated 5/28/23 and was not changed on 5/29/23 and 5/30/2023. Registered Nurse, Employee E6, also confirmed Resident R5 did not have soft heel protector boots in place and stated they have been missing for over a week. During this interview, RN, Employee E6, confirmed that all weekly skin assessments are documented in the clinical record using the facility's skin assessment tool and if a resident refused, it is documented in the clinical record. During an observation of Resident R5's left hip wound dressing change on 5/30/23 at 11:05 a.m., RN, Employee E6, incorrectly applied the prescribed Medihoney to the wound. RN, Employee E6, confirmed she only applied the Medihoney to the border of the wound. During the dressing change RN, Employee E6, failed to wash her hands in between removing the old dressing and applying a new one. During an interview with the Director of Nursing (DON) on 5/30/23 at 11:53 a.m., the DON, stated that Resident R5's wounds were not considered pressure ulcers although documented in the clinical record as PU/PIs by wound care consultant, NP, Employee E5. During an interview and observation on 5/31/23 at 12:35 p.m., RN, Employee E7, confirmed Resident R5's heels were not offloaded and stated she was aware that Resident R5 should have had pressure relieving boots on. RN, Employee E7, stated I was the one that recommended the boots. Review of Resident R5's progress note dated 5/31/23, entered by wound care consultant, NP, Employee E5, documented the following for Resident R5: -Left hip acute unstageable full-thickness skin and tissue loss (extends beyond the first two layers of the skin and may reveal subcutaneous (fatty) tissue, muscle, tendon, or even bone) pressure injury that measured 5.3 cm x 6.5 cm that had a small amount of serous drainage (a thin, watery, and clear type of fluid that comes out of a wound that had tissue damage.) It was indicated the wound deteriorated. -Left lateral foot acute DTI that measured 1.9 cm x 1.2 cm. -Left proximal lateral foot acute DTI that measured 1cm x 1cm. -Left medial foot DTI that measured 1.2 cm x 1.2 cm with eschar. -Sacral pressure ulcer that received a status of not healed. No documentation of the sacral wound measurements or description of wound bed were provided. -A newly discovered right hip DTI that measured 4.1 cm x 5.4 cm that had a purple base and two small blisters filled with serous drainage. It was documented no drainage was observed. Review of wound care consultant, NP, Employee E5, progress note dated 5/31/23, documented Resident R5's left hip was ordered to be cleansed with 0.125% Dakin's Solution (wound cleanser), Medihoney and calcium alginate applied to the wound bed, and covered with a foam dressing, changed daily. On 5/31/23, wound care consultant, NP, Employee E5 ordered Resident R5 skin prep to be applied over the resident's right hip and left foot DTIs and left open to air. On 5/31/23, wound care consultant, NP, Employee E5, ordered Resident R5's sacral pressure ulcer to be cleansed with normal saline (wound irrigation solution) and zinc (helps fight infection and heal wounds) and a foam dressing was applied, and the dressing was to be changed daily. Additional orders as of 5/31/23, included the facility's pressure ulcer prevention protocol, side to side offloading every two to three hours while in bed, offload heels, and a pressure redistribution mattress. On 5/31/23, wound care consultant, NP, Employee E5, also ordered Resident R5 soft heel boots (designed to offload pressure from the heel of a non-ambulatory individual to help prevent the development of pressure ulcers) that were to be always worn aside from ambulation. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R5's clinical record indicated the facility failed to update Resident R5's physician orders for Resident R5's left lateral, medial, and proximal foot DTIs as of 6/1/23. During an observation on 6/1/23 at 8:37 a.m., Resident R5 was observed lying in bed without pressure relieving boots and her heels were not offloaded. During an interview on 6/1/23 at 2:07 p.m., the DON confirmed the facility failed to implement pressure ulcer interventions and treatments as ordered to prevent the newly developed and deteriorated pressure ulcers for Resident R5. Review of Resident R63's clinical record indicated an admitted [DATE], diagnoses included osteoarthritis (Inflammation of one or more joints), viral hepatitis (an infection that causes liver inflammation and damage.), and anemia (deficiency of healthy red blood cells in the blood). Review of Resident R63's physician order on admitted d 2/23/22, indicated Resident R63 may been seen by a wound specialist. Review of Resident R63's physician order dated 2/23/22, indicated a weekly skin assessment must be completed every Wednesday. Review of Resident R63's Braden Scale for Predicating Pressure Sore Risk assessment dated [DATE], did not identify the resident as a risk at the time of admission, with a score of 19. No further Braden Scale Assessments were completed as of 5/30/23. The facility's Braden Scale for Predicting Pressure Score Risk assessment instructions indicated assessments are completed on admission for four weeks and then quarterly thereafter. Review of Resident R63's MDS dated [DATE], indicated the above-mentioned diagnoses were current. Review of Resident R63's MDS dated [DATE], Section M Skin Conditions, indicated the resident was at risk for developing PU/PIs and the resident had a stage three pressure ulcer. Review of Resident R63's care plan from 3/22/23 through 5/29/23, indicated the resident was at risk for alteration in skin integrity related to incontinence, decreased physical mobility. Interventions included for the resident to be repositioned, observe for skin conditions and report abnormalities, pressure reduction device on bed and chair, and to provide barrier cream to perineal area and buttocks after each incontinent episode and as needed. The facility staff failed to update the resident ' s care plan to include care interventions to treat the resident ' s pressure ulcer. Include that the care plan still says at risk when resident had an actual PU Review of Resident R63's progress note dated 3/22/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, documented the resident was complaining of mild pain and burning. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage two pressure ulcer that measured 3.1 cm x 2.1 cm x 0.1 cm. There was a small amount of serous drainage noted. Review of Resident R63's March 2023 eTAR indicated the resident's treatment order to the coccyx pressure ulcer was to be cleansed with normal saline, Medihoney and have calcium alginate applied, and dressed with a border gauze daily and as needed for soil and dislodgement was left blank and not signed off for completion on 3/23/23 and 3/24/23. A further review of Resident R63's progress note dated 3/23/23 and 3/24/23 failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's progress note dated 3/27/23, documented that a dressing was performed and moderate amounts of pale yellow and greenish drainage from three small dime sized openings was observed. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 3/27/23-4/10/23. Review of Resident R63's April 2023 eTAR, indicated the resident's treatment order to the coccyx pressure ulcer was to be cleansed with normal saline, Medihoney and have calcium alginate applied, and dressed with a border gauze daily and as needed for soil and dislodgement was left blank and not signed off for completion on 4/2/23 and 4/7/23. A further review of Resident R63's progress note dated 4/2/23 and 4/7/23, failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. The facility failed to document size wound size, stage, and description. Review of Resident R63's progress note dated 4/12/23, entered by wound care consultant, Nurse Practitioner (NP), documented the following for Resident R63's left buttock pressure ulcer: -Left buttock acute stage two pressure ulcer that measured 2.1 cm x 3.8 cm x 0.2 cm. There was a small amount of serous drainage noted and slough. The wound deteriorated and increased in size. Review of wound care consultant, NP, Employee E5 progress note dated 4/12/23, indicated Resident R63's left buttock pressure ulcer was ordered to have it cleansed with normal saline and Santyl applied to base with a calcium alginate and bordered gauze dressing daily and as needed. Additional orders as of 4/12/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's physician orders from 4/12/23 through 5/25/23, failed to include the order to change the resident's left buttock pressure ulcer as needed, which was ordered by wound care, NP Employee E5. Review of Resident R63's April 2023 eTAR, indicated the resident's treatment order to the left buttock pressure ulcer was to be cleansed with Dakin's, Santyl and have calcium alginate applied, and dressed with a border gauze daily was left blank and not signed off for completion on 4/20/23. A further review of Resident R63's progress note dated 4/20/23, failed to include a reason Resident R63's dressing was not changed as ordered. Review of Resident R63's April 2023 eTAR, failed to include an order to offload the resident from side to side with a wedge. Review of the resident's clinical record failed to include documentation the resident was offloaded as ordered. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 4/13/23-5/8/23. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. Review of Resident R63's progress note dated 5/10/23, entered by wound care consultant, NP, Employee E5, documented three wounds measured as one which indicated a new wound developed. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage three pressure ulcer that measured 1.6 cm x 3.9 cm x 0.1 cm. There was a small amount of serous drainage noted. The wound had slough. A debridement was performed at bedside that removed the slough. Post debridement measurements remained the same, and measured 1.6 cm x 3.9 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/10/23, indicated Resident R63's left buttock pressure ulcer was ordered to have it cleaned with normal saline and Santyl applied to the base with a calcium alginate, and it covered with bordered gauze, daily and as needed. Additional orders as of 5/10/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's clinical record indicated the facility staff failed to complete weekly skin assessments from 5/8/23-5/24/23. Review of Resident R63's progress note dated 5/24/23, entered by wound care consultant, Nurse Practitioner (NP), Employee E5, documented left buttock and sacrum have separated enough now considered two different wounds. The following pressure ulcer was documented for Resident R63: -Left buttock acute stage three pressure ulcer that measured 1 cm x 0.5 cm x 0.1 cm. There was a small amount of serous drainage noted. -Sacral chronic stage three pressure ulcer that measured 1.4 cm x 1.4 cm x 0.1 cm. Review of wound care consultant, NP, Employee E5, progress note dated 5/24/23, indicated Resident R63's left buttock wound was to be cleaned with normal saline and calcium alginate applied to the wound base, and covered with a border gauze daily and as needed. As of 5/24/23, the resident's sacral pressure ulcer was ordered to have it cleansed with normal saline and Santyl applied to base with a calcium alginate and bordered gauze dressing daily and as needed. Additional orders as of 5/24/23, included side to side offloading every two hours with wedge. It was indicated the plan of care and education was discussed with facility staff. Review of Resident R63's physician orders from 5/24/23 through 5/30/23, failed to include an order to change the resident's left buttock pressure and sacral pressure ulcer as needed, which was ordered by wound care, NP Employee E5. Review of Resident R63's NG-Weekly Skin Inspection assessment dated [DATE], failed to document any abnormalities observed on the resident's skin, however it was documented in the comments section that the resident had area to buttocks, wound care orders in place, will continue to monitor. The facility failed to document size wound size, stage, and description. Review of Resident R63's Corner View Skin Observation Tool (Licensed Nurses) dated 5/27/23, indicated the resident had a left rear thigh nickel size greenish yellow pus-filled cyst. No measurements were documented. Resident R63's left buttock's pressure ulcer was not documented. The instructions state to Document any open area. If NO open area; no documentation required. Complete Braden Scale. Review of Resident R68's assessments dated 5/27/23, failed to include a completed Braden Scale assessment. Review of Resident R63's progress note dated 5/30/23, indicated the resident's dressing was changed due to soilage and moderate amount of greenish yellow drainage was observed. Review of the clinical record failed to include interventions that addressed the signs and symptoms of infection of Resident R63's pressure ulcer. During an interview on 6/1/23 at 2:07 p.m., the DON confirmed the facility failed to follow physician orders, complete timely assessments, and update the resident's care plan to include PU/PIs for Resident R63. As a result of the facility's extensive noncompliance in multiple areas of pressure ulcer care, Resident R63 developed recurrent and/or multiple, avoidable Stage III pressure ulcer(s), and signs and symptoms of infection. Review of Resident R231's MDS dated [DATE], indicated an initial admitted [DATE] and a reentry date of 11/25/22. It was indicated the resident had peripheral vascular disease, diabetes, and a hip fracture. Review of Resident R231's MDS dated [DATE], Section M, Skin Conditions, indicated the resident was at risk for developing PU/PIs and indicated the resident did not have a pressure ulcer. Review of Resident R231's Census List from 12/1/22 through 5/24/23, indicated the resident had multiple transfers to the hospital. The resident went on an unpaid hospital leave on 12/31/22 and returned to the facility on [DATE], then went on an unpaid hospital leave on 1/23/23, was discharged on [DATE], and returned to the facility on [DATE]. The resident then went on an unpaid hospital leave on 3/29/23 until 4/10/23, and on 5/11/23 and returned 5/24/23. Review of Resident R231's NG-Admission/Readmission Evaluation dated 12/1/22, indicated the resident was at risk for developing pressure ulcer with a score of 14, and it was documented there was skin breakdown present. It was documented in the comment section, that there were areas to the right outer foot, left heel, and lower extremity. The facility failed to document measurements and the types of wounds with staging and a description. Review of Resident R231's clinical record indicated the facility staff failed to complete weekly assessments from 12/1/22-12/13/22. Review of Resident R231's NG-Weekly Skin Inspection assessment dated [DATE], documented the resident had mushy areas to the left heel. No documentation was provided on the resident ' s right outer foot or lower extremity. Mushy is a descriptive term that is an indicator of a DTI. Review of Resident R231's clinical record indicated the facility staff failed to complete weekly assessments from 12/15/22-12/28/22. Review of Resident R231's NG-Weekly Skin Inspection assessment dated [DATE], documented the resident had mushy area to the left heel. No documentation was provided on the resident ' s right outer foot or lower extremity previously documented on 12/1/22. Review of Resident R231's progress note dated 12/28/22, entered by wound care consultant, NP, Employee E5, the resident was being seen for the first time as a consultation for evaluation of the resident ' s wounds. It stated the resident was bedridden and complained of moderate pain with wound care. The following was documented for Resident R231: -Left heel full thickness venous ulcer (A sore caused by poor circulation in the veins. They usually develop on the inside of the leg, just above the ankle.) that measured 3.5 cm x 3.7 and the depth could not be determined due to the presence of eschar. There was a small amount of serous-sanguineous drainage (discharge that contains both blood and a clear yellow liquid known as blood serum) present. PU/PIs are usually located over a bony prominence, such as the sacrum, heel, or ankle. PU/PIs on the sacrum and heel are most common. Review of wound care consultant, NP, Employee E5, progress note dated 12/28/22, indicated Resident R231's left heel was ordered to have it cleaned with normal saline and Medihoney applied to the base with a calcium alginate, and it covered with ABD gauze and wrapped in Kerlex. Additional orders as of 12/28/22, included pressure relief and offloading. Review of Resident R231's progress note dated 12/31/22, indicated the resident was admitted to the hospital with hyperglycemia. Review of Resident R231's progress note dated 1/17/23, indicated the resident returned from the hospital. It was documented the resident had bilateral heel pressure ulcers that were unstageable due to the presence of eschar. A right foot pressure ulcer, unstageable due to eschar, and a pressure ulcer on the scrotum. It was documented the resident was on IV antibiotics due to osteomyelitis. Review of Resident R231's Census List from 1/23/23 through 3/16/23, indicated he was hospitalized on [DATE], was discharged from the nursing home facility on 2/7/23, and returned to the nursing home facility on 3/16/23. Review of Resident R231's clinical record indicated a readmitted [DATE] wit [TRUNCATED]

Based on observations, review of facility policies, and staff interviews, it was determined that the facility failed to maintain a sanitary kitchen, store food in proper conditions, maintain kitchen equipment, and prevent potential food borne illness due to potential food contamination from damage from a water leak and leaking ceiling in the kitchen, for all residents creating an Immediate Jeopardy (IJ) situation for one of one kitchens. Findings include: Review of the facility policy Food Safety and Sanitation last reviewed on 8/2/21, with previous review date of 4/28/21, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. Food that is stored is protected from contamination and growth of any pathogenic organisms. Foods are refrigerated and stored at or below 41 degrees Fahrenheit. All time and temperature control for safety (TCS) leftovers are labeled, covered and dated when stored. The leftover food is used with 72 hours (or discarded). Review of the facility policy General sanitation of Kitchen last reviewed 8/2/21, with a previous review date of 4/28/21, indicated that staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. Staff will be held accountable for cleaning assignments. Freezers will be defrosted as needed or per manufacturer's recommendations. Refrigerators will be washed thoroughly inside and outside and sanitized at least once a month or as needed. Dietary Employee E3 stated that the facility did not have a Dietary Manager as he walked out last week. During observations and subsequent further interview on 8/31/21, from 9:44 a.m. through 10:22 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) the condition of the fifth floor kitchen area was reviewed with the NHA and the DON and the NHA confirmed at this time we know the roof leak is the issue and caused the damage in the kitchen and through the facility. The kitchen ceiling leaking and having debris falling out of it potentially contaminating food, the windows being propped open allowing possible insect contamination, the food storage with fans leaking onto foods and outdated or undated foods had the potential food borne illness and contamination, the falling water damaged ceiling tiles in the hall and dish area had the potential for food contamination or staff injury. The storage of cleaning products with items used for cooking of foods had the potential of food contamination. The soiled sugar and flour bins had the potential for food contamination, the ice machine air gap pipe being disconnected allowed contamination of the facility ice machine, as indicated that it was the only ice machine in the building and the ice cream freezer being unclean and ice build- up had the potential for contamination. The NHA stated that the Dietary Manager had quit last week, the new manager was to start after Labor Day. A Dietary Supervisor would be in later. During an observation of the Main Kitchen on 8/31/21, at 8:50 a.m., the following was observed with Maintenance Employee E1 and the Assistant Director of Nursing Employee E2: The Fifth Floor entrance hall to the Main Kitchen had large areas where ceiling tiles appeared to have been ripped and wet, exposing brown substances and pipes. The floors were wet and uneven. To the right of this area was the doorway to the dish room which was very wet. The room adjacent to this was the cart room which had ceiling tiles missing, the floor was very soiled and wet, the wall below the area where staff would place soiled trays to be put into dish machine was missing the covering exposing plaster and glue. The ice machine air gap pipe was lying unattached with black substance covering it and a block of ice was on the floor and water was leaking from the pipe onto floor. The Main Kitchen area had a large piece of taped plastic with loose edges covering the ceiling outside of the deep freezer in the main throughway of the kitchen, the loose edges exposed plaster with a black substance, a gray bucket had been placed under the area catching tan liquid. At the main entrance of the kitchen there were two metal carts with cooking pans and next to the clean pans was a bucket of bleach, a bucket of unmarked dirty water and a can of bleach cleaner. Beside the two carts were two large white bins that were labeled sugar and flour with food debris and black substances covering the lids. The serving area of the kitchen contained five windows, two had air conditioners in them, the other three had been propped open with spray cans and the other with plate covers. Two of the propped open windows did not have screens allowing pests to enter. The Deep Freezer had multiple areas of ice buildup on the floor and ceiling, the cooling fans had dust and ice buildup. Refrigerator One beside the Deep Freezer had a five-gallon bucket of pickles at the entrance that had mold on the inside and outside. There was a pan of a tan substance, a pan of a brown substance, and a pan of fried meat that was gray in color, all were undated. There were three bottles of undated dressing and two small containers of unknown undated substances on the top shelf under the cooling fans, which had a black substance on them. The floor of Refrigerator One was soiled with debris. Refrigerator Two of the Main Kitchen had a soiled floor with food debris, the cooling fans had a black substance on them. The cooling fans were leaking onto two trays of cups of fruit stored underneath. The ice cream freezer near the tray line area had ice buildup with a foiled piece of ice cream stuck to the bottom. During an interview on 8/31/21, at 8:52 a.m. Dietary Employee E3 stated that this place has been like this for months .That's the problem they need to stop worrying about the little problems and take care of the big ones. During an interview on 8/31/21, at 9:30 a.m. with the Nursing Home Administrator (NHA), The Director of Nursing and the Regional Nurse confirmed the above observations. The NHA indicated that the elevator and the condition of the building was due to a pipe clogged with a wipe that leaked back into all the sinks and toilets in the building. A review of facility provided documents dated 7/19/21, indicated that the building had a leak from the kitchen on 7/19/21, which, according to the document, had been resolved. Immediate Jeopardy to the health and safety of the residents was identified and the IJ template was provided to the Nursing Home Administrator on 8/31/21, at 4:15 p.m. due to the unsanitary conditions in the kitchen and potential for foodborne illness and food contamination. The facility's corrective action plan included: 1. The sugar and flour bins cleaned. 2. Education of the dietary staff by the Dietary manager/ designee to keep bins clean. 3. The kitchen will be deep cleaned by the dietary department and housekeeping department staff monthly. 4. The dietary manager/designee will monitor for cleanliness daily. 5. the identified Freezer has been defrosted and cleaned including cleaning of fans. 6. the dietary staff will be educated on defrosting/cleaning freezer. 7. The dietary manager/ designee will monitor freezers cleanliness and defrosting weekly. 8. The identified area with broken missing tiles tape replaced to prevent debris from falling 9. Re-education of maintenance and Dietary staff on keeping debris from falling into food. 10. The maintenance director will monitor for missing ceiling tile and replace daily for two weeks then weekly for four weeks. 11. The outdated food has been removed and discarded. 12. The dietary staff have been educated on dating food prior to placement in refrigerator/freezers. 13. The dietary manager/designee will monitor all food for date daily for two weeks, then three times a week for two weeks, then weekly for a month. 14. The drainage pipe to the ice machine has been reconnected. 15. The maintenance director has been educated on making sure the drainage pipe does not drain onto floor. 16. The ice machine will be audited by the maintenance director/ designees to ensure the draining pipe is not disconnected and draining onto the floor daily for two weeks then weekly for two weeks, then monthly. 17. The two windows identified as being propped open, have been closed. 18. The dietary staff have been educated by the dietary manager/ designee not to prop open windows. 19. The dietary manager/ designee will monitor for propped open windows daily for two weeks, then three times a week for two weeks, then monthly. 20. The bleach cleaning solutions have been removed from the cooking area. 21. the dietary staff have been educated that cleaning solutions cannot be stored in cooking areas. 22. The dietary manager/designee will audit for cleaning solutions in cooking areas daily for two weeks, then three times a week for 2 weeks, then weekly for month. 100% of dietary and maintenance staff will be educated by Thursday 9/2/21. Any staff that has not been educated by Thursday will not be permitted to work until education is complete. During an interview on 9/1/21, at 9:44 a.m. the Dietary Supervisor Employee E4 stated that he had been cleaning up the kitchen all morning and had retrained the staff that came in regarding cleaning kitchen work areas, refrigerators and freezers, , proper food storage and labeling not storing cleaning products near any items used to prepare food, and not propping windows open. Dietary Supervisor Employee E4 stated this roof has been leaking for 6 months, the boiler room is above us that's where the leak is above that. During an observation 9/1/21, at 9:44 a.m. and subsequent interview with the Dietary Supervisor Employee E4 of the kitchen area, the plastic ceiling had holes placed in the plastic for water to directly go into bucket as stated by the Dietary Supervisor Employee E4. The tape around the edges were still loose continuing to allow debris to fall. No seal of leaks. Observation of the refrigerator and freezers showed areas had been cleaned and undated and outdated food had been removed. The windows had no longer been propped, the bleach and bucket had been removed from the metal pan areas and the sugar and flour bins had been cleaned. During an observation of the facility and subsequent interview on 9/1/21, from 9:44 a.m. through 2:18 p.m., with the NHA, due to inclement weather which caused more water to enter the building the following occurred: The Third Floor Activity Room had been made into a kitchen area where dietary staff were plating food for residents and placing it onto delivery carts. One Dietary staff person was using a mixer to provide pureed food items. During an interview on 9/1/21, at 2:18 p.m. The NHA was asked about the plan for the facility to address the ongoing problem with the roof leaking. An amendment was made on 9/1/21, at 2:18 p.m. to include: 1. A pump had been placed on the roof to remove water until roofing company can get onto roof to evaluate repairs needed, which was going to occur on 9/2/21. During an interview on 9/1/21, at 3:43 p.m. the Roofing Company Manager stated that he was coming in to start repairs on 9/2/21, in the morning that he anticipated being completed by 9/3/21. 2. Main kitchen closed. 3. Facility emergency food menu activation. 4. Temporary relocation of the kitchen to the third floor activity room. 5. This area will serve as a preparation area and loading of food carts. 6. The dietary manager/ designee will be present to alert staff. 7. The facility will notify the residents and family members of the kitchen's temporary closure. 8. The dietician will review the emergency menu to ensure dietary needs for residents is met. 9. The emergency menu will be posted throughout the facility. 10. Meals will be served on paper products. 11. The maintenance director will assess the damage to the roof the morning of 9/1/21. 12. The Simon Roofing Company on site to assess repairs needed. 13. Once the roof leak is repaired, the ceiling in the kitchen will be replastered and painted. 14. The entire kitchen will be deep cleaned. 15. The kitchen will be re-opened on 9/8/21. The contingency plan for food service should the above not occur will be to continue a weekly review of the emergency food menu for food ordering, preparation, transportation and food service process to ensure resident satisfaction. Following verification of implementation of facility corrective plan on 9/2/21, at 1:35 p.m., the Immediate Jeopardy was lifted. The facility failed to maintain a sanitary kitchen for the service of meals that are safe, free from potential of contamination and food borne illness for all of the residents creating an Immediate Jeopardy (IJ) situation for the main kitchen. Refer to F835 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.6(a)(b)(c)(d)(f) Dietary services.

Based on a review of facility policies, clinical record reviews, psychiatric notes, and staff interviews, it was determined the facility failed to ensure residents were free of significant medication errors, causing harm, and requiring hospitalization for one of twenty-two residents (Resident R1). Findings include: Review of the facility policy, Medication and Treatment Orders dated 4/28/21, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility policy, Adverse Consequences and Medication Errors dated 4/28/21, indicated a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician orders, manufacturer's specifications, or accepted professional standards, and principals of the professional(s) providing services. An example of a medication error is wrong dose. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individuals mental or physical condition or functional or psychosocial status. When a resident receives a new medication, the medication order is evaluated for the following: the dose is in agreement with current clinical practice. Resident R1 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1's MDS (Minimum Data Set - periodic assessment of a care needs) dated 4/20/21, indicated a BIMS score (Brief Interview for Mental Status, a mandatory periodic interview and screening tool used to assess cognitive function and determine interventions) equaled 11, indicating Resident R1 had a moderate cognitive impairment. Resident R1's care plan dated 7/21/21, addressed behavioral symptoms of hallucinations, delusions, fear, anxiety, and depression with interventions of psychiatric services and medications. The care plan also addressed the resident's use of [CONDITION(S)] medications (medications that affects how the brain works and causes change in mood, awareness, thought, feelings or behavior) for management of [CONDITION(S)] and bi-polar disorder with interventions to include medication administration as prescribed the physician, [CONDITION(S)] medication dose reduction, and monitoring for adverse reactions such as fatigue and behavioral symptoms not usual to the resident. Resident R1's MAR (Medication Administration Record) for June 2021, included medications of [MEDICATION(S)] for [CONDITION(S)], [MEDICATION(S)] for bi-polar disorder, [MEDICATION(S)] for bi-polar disorder. Review of a psychiatric note dated 6/28/21, documented Resident R1 was seen on 6/25/21, at 4:40 p.m. by the attending PhD, Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced education and clinical training in a health care specialty area) for a routine follow up appointment for the management of [CONDITION(S)], bi-polar disorder, and anxiety. Resident R1 reported sleeping a lot. Medications were reviewed due to hypersomnolence (excessive sleeping). Resident R1 was currently receiving [MEDICATION(S)] 400 milligrams (mg) twice a day at 9:00 a.m. and 9:00 p.m. Under the 'Treatment Plan and Other Recommendations' section of the document, [MEDICATION(S)] was decreased to 350 mg at 9:00 a.m. and 400 mg at 9:00 p.m. for 7 days, and then was to decrease to 300 mg at 9:00 a.m. and 400 mg at 9:00 p.m. Review of Resident R1's medical record indicated, LPN (licensed practical nurse) Employee E1 transcribed the new decreased order of [MEDICATION(S)] 300 mg at 9:00 a.m. and [MEDICATION(S)] 50 mg at 9:00 a.m. effective 6/27/21 into the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A medication error occurred when the additional dose of 400 mg of [MEDICATION(S)] was administered on 6/27/21, at 9:00 a.m., 6/28/21, at 9:00 a.m., 6/29/21, at 9:00 a.m., and 6/30/21, at 9:00 a.m. Review of Resident R1's progress notes documented on 6/30/21, at 15:45 (3:45 p.m.) the resident was not responding, Staff respond team at bedside. Call to 9-1-1. At 15:54 (3:54 p.m.) Resident R1 was transported via ambulance to a local hospital's emergency department. Resident R1's hospital clinical summary documented the resident was admitted on [DATE], at 4:39 p.m. diagnosed with altered mental status resulting from an accidental medication error, and discharged back to the facility on [DATE], at 6:43 p. m. Resident R1's hospital psychiatric consult on 7/1/21 documents [she] is able to state that she presented (said of the patient at examination) due to a medication error; she states they are trying to kill me there . They have [sic] me an extra dose. During an interview on 7/28/21, at 4:20 p.m. the Director of Nursing (DON), confirmed the facility failed to ensure residents were free from significant medication errors and Resident R1 received an additional 400 mg of [MEDICATION(S)] on 6/27/21, 6/28/21, 6/29/21, and 6/30/21, that resulted in harm and hospitalization . 28 Pa. Code: 201.14(a) Responsibility of Licensee 28 Pa. Code: 211.12(d)(1)(5) Nursing Services Previously Cited: 12/11/20; 7/24/20; 1/10/20 28 Pa. Code: 211.9(a)(1) Pharmacy Services

Based on review of clinical records, facility policies, documentation, and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program to mitigate or potentially control the spread of the coronavirus, failed to consistently educate staff on infection control practices pertaining to the COVID-19 pandemic for 34 of 52 nursing staff and 51 of 53 non-nursing staff, failed to follow CDC (Center for Disease Control) guidelines to actively monitor all residents for 39 of 41 residents diagnosed with [REDACTED]., R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R18, R19, R21, R22, R23, R25, R26, R28, R29, R33, R34, R36, R37, R40, and R41).These failures placed the facility in an Immediate Jeopardy situation for 19 of 68 residents (Resident R1, R4, R6, R9, R10, R11, R13, R14, R15, R17, R20, R21, R25. R29, R31, R33, R38, R39, and R40). Findings include: Review of the CDC guidance Preparing for COVID-19: Long-term Care Facilities, dated [DATE], indicated to actively monitor all residents at least daily for fever. Review of the facility titled, Policies and Practices - Infection Control, dated [DATE], indicated that the facility will provide a safe, sanitary environment to prevent the development and transmission of communicable diseases and infections. The policy further stated that all personnel will be trained on infection control practices upon hire and periodically thereafter. During an interview on [DATE], at 12:30 p.m. the Director of Nursing provided a list of current employees and confirmed that the facility provided three additional trainings to their staff pertaining to the Covid-19 pandemic: Covid Response Plan, Personal Protective Equipment (PPE) Powerpoint, and Taking Temperatures(for nursing staff). During an interview on [DATE], at 1:30 p.m. the Nursing Home Administrator provided literature used in orientation pertaining to infection control. This literature did not include the Covid Response Plan, PPE Powerpoint, or Taking Temperatures. During a review of the signed education rosters for the COVID Response Plan, PPE Powerpoint, and Taking Temperatures, the following was revealed for nursing staff: Nurse Supervisor Employees E52 did not receive education in Taking Temperatures and on Personal Protective Equipment and Nurse Supervisor Employee E53 did not receive education on the Covid Response Plan and on Personal Protective Equipment. Registered Nurse (RN) Employees E54 and E55 did not receive education in Taking Temperatures and on Personal Protective Equipment and RN Employee E54 did not receive education on the Covid Response Plan. Clerical Nurse Employee E56 did not receive education on Personal Protective Equipment. Licensed Practical Nurse (LPN) Employees E57, E60, E61, and E63 did not receive education on Taking Temperatures. LPN Employees E57, E58, E62 and E63 did not receive education on the Covid Response Plan. LPN Employees E57, E59, E60, E61, and E63 did not receive education on Personal Protective Equipment. Nurse Aide Employees (NA) E65, E67, E68, E70, E71, E72, E73, E74, E75, E76, E77, E78, E79, E81, E82, E83, E84, and E85 did not receive education on Taking Temperatures. NA Employees E66, E69, E72, E73, E75, E76, E79, E82, E83, E84, and E85 on the Covid Response Plan did not receive education. NA Employees E64, E65, E66, E67, E68, E70, E71, E72, E73, E74, E75, E76, E77, E79, E80, E81, E82, E83, E84, and E85 did not receive education on Personal Protective Equipment. During a review of the signed education rosters for the COVID Response Plan and the PPE, the following was revealed for non-nursing staff: The Nursing Home Administrator did not receive education in the COVID Response Plan. Activities Department Employees E1, E2, and E3 were not educated in the Covid Response Plan and on Personal Protective Equipment. Dietary Department Employees E4, E5, E6, E7, E8, E9. E10, E11, E12, E13, E14, and E15 were not educated in the Covid Response Plan and Employees E4, E5, E6, E7, E8, E9. E10, E11, E14, and E15 were not educated on Personal Protective Equipment. Environmental Services Department Employees E17, E18, E19, E20, E21, E22. E23, E24, were not educated in the Covid Response Plan and Employees E16, E17, E18, E20, E21, E22, E23, and E24 were not educated on Personal Protective Equipment. Laundry Department Employees E25, E26, E27, E28, and E29 were not educated in the Covid Response Plan and on Personal Protective Equipment. Maintenance Department Employees E30 and E31 were not educated in the Covid Response Plan and on Personal Protective Equipment. Office/Clerical Department Employees E32, E33, E34, E35, E36, E37, E39, E41, E42, E43, E44, and E45 were not educated in the Covid Response Plan and Employees E33, E34, E35, E36, E37, E38, E39, E40, E41, E42, E43, E44, and E45 were not educated on Personal Protective Equipment. Social Services Department Employees E46 and E47 were not educated in the Covid Response Plan and on Personal Protective Equipment. Therapy Department Employees E48, E49, E50 and E51 were not educated in the Covid Response Plan and Employees E50 was not educated on Personal Protective Equipment. During a telephone interview on [DATE], at 4:57 p.m. NA Employee E70 confirmed that she was not provided education during March, April, or [DATE] on taking temperatures or on the proper use of personal protective equipment. NA Employee E70 further confirmed that she did not always wear an N95 mask when caring for the residents who were COVID-19 positive which potentially contributed [MEDICAL CONDITION] spread. During a telephone interview on [DATE], at 5:21 p.m. Environmental Service Employee, (EVS) Employee E22, confirmed that he was not provided education during March, April, or [DATE] on signs and symptoms of COVID-19 or on the proper use of personal protective equipment. EVS Employee E22 further confirmed that he did not always use proper PPE when handling the residents' laundry which potentially contributed [MEDICAL CONDITION] spread. During a telephone interview on [DATE], at 6:26 p.m. NA Employee E79 confirmed that she was not provided education during March, April, or [DATE] on taking temperatures, signs and symptoms of COVID-19, or on the proper use of personal protective equipment. NA Employee E79 further confirmed that she did not fully understand the importance of taking the residents' temperatures during the early part of the pandemic which potentially contributed [MEDICAL CONDITION] spread. During a telephone interview on [DATE], at 6:40 p.m. NA Employee E75 confirmed that she was not provided education during March, April, or [DATE] on taking temperatures, signs and symptoms of COVID-19, or on the proper use of personal protective equipment. NA Employee E75 further confirmed that she had not always taken the residents' temperatures daily on her shift which potentially contributed [MEDICAL CONDITION] spread. During an interview on [DATE], at 3:10 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to educate their staff pertaining to the Covid-19 pandemic. During a telephone interview on [DATE], at 2:30 p.m. the Director of Nursing indicated that the facility nursing staff were provided direction to monitor for temperatures daily, starting on [DATE]. Review of Resident R1's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R1 was diagnosed with [REDACTED]. Review of Resident R1's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 29, 30, and [DATE], 5, and 11. Review of Resident R2's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R2 was diagnosed with [REDACTED]. Review of Resident R2's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], and [DATE]. Review of Resident R3's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R3 was diagnosed with [REDACTED]. Review of Resident R3's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27, 28, 29, 30, 31 and [DATE], 5, 7, 10, 14. Review of Resident R4's admission record indicated she was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R4's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE] ,23, 28, 29 and [DATE], 5, and 11. Review of Resident R5's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R5 was diagnosed with [REDACTED]. Review of Resident R5's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 28, 29 and [DATE], 5, and 11. Review of Resident R6's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R6 was diagnosed with [REDACTED]. Review of Resident R6's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 22, 26, 27, 28, 29, 30, 31 and [DATE], 5, and 11. Review of Resident R7's admission record indicated she was admitted to the facility on [DATE], A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R7's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27, 28, 29, 30 and [DATE], 5, and 11. Review of Resident R8's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R8 was diagnosed with [REDACTED]. Review of Resident R8's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 22, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R9's admission record indicated she was admitted to the facility on [DATE], A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R9's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27 and [DATE]. Review of Resident R10's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R10's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27, 28, 29, 30 and [DATE], 5, and 11. Review of Resident R11's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R11's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 22, 23, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R12's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R12's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 26, 29, 30, 31 and [DATE], and 11. Review of Resident R13's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R13's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 28, 29, 30 and [DATE], and 11. Review of Resident R14's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R14's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27, 28, 29 and [DATE], and 15. Review of Resident R15's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R15 was diagnosed with [REDACTED]. Review of Resident R15's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 28, 29 and [DATE], 5, and 11. Review of Resident R16's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R16's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 28, 29 and [DATE], 5, and 11. Review of Resident R17's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R17 was diagnosed with [REDACTED]. Review of Resident R17's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 24 and [DATE], and 9. Review of Resident R18's admission record indicated he was admitted to the facility on [DATE]. A review of the Admission MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R18's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 28, 29, 30, 31 and [DATE], 3, 4, 5, and 11. Review of Resident R19's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R19's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 23,26, 28, 29 and [DATE], 5, 11, and 12. Review of Resident R20's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R20 was diagnosed with [REDACTED]. Review of Resident R20's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], and 27. Review of Resident R21's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R21 was diagnosed with [REDACTED]. Review of Resident R21's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 23,26, 27, 28, 30, 31 and [DATE], 5, and 11. Review of Resident R22's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R22's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 23, 26, 27, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R23's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R23 was diagnosed with [REDACTED]. Review of Resident R23's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 22, 23, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R24's admission record indicated he was admitted to the facility on [DATE]. A review of the Admission MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R24 was diagnosed with [REDACTED]. Review of Resident R24's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 25, 27, 28, 29, 30 and [DATE], 5, and 10. Review of Resident R25's admission record indicated she was admitted to the facility on [DATE] A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R25 was diagnosed with [REDACTED]. Review of Resident R25's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 23, 26, 27, 28 and [DATE], 3, 4, 5, and 7. Review of Resident R26's admission record indicated he was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R26 was diagnosed with [REDACTED]. Review of Resident R26's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 26, 28, 30, 31 and [DATE], and 11. Review of Resident R27's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R27's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 27, 29, 30, 31 and [DATE], and 11. Review of Resident R28's admission record indicated she was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R28's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 27, 28, 29 and [DATE], 9, and 10. Review of Resident R29's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R29's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 23, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R30's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R30's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 22, 23, 26, 27, 28, 29, 31 and [DATE], 5, and 11. Review of Resident R31's admission record indicated he was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R31 was diagnosed with [REDACTED]. Review of Resident R31's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 20, 22, 23, 24, 27, 29, 30 and [DATE], 4, and 5. Review of Resident R32's admission record indicated he was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R32's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], (hospital transfer date) failed to reveal temperatures documented on [DATE], 23, 26, 27, 28, 29, 30 and [DATE], and 5. Review of Resident R33's admission record indicated he was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R33's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. Review of Resident R34's admission record indicated she was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R34 was diagnosed with [REDACTED]. Review of Resident R34's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 25, 28 and [DATE], and 11. Review of Resident R35's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R35's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 23, 27, 28, 29, 30 and [DATE], and 9. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R36's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 27, 28 and [DATE], 9, and 11. Review of Resident R37's admission record indicated he was admitted to the facility on [DATE]. A review of the Admission MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident R37 was diagnosed with [REDACTED]. Review of Resident R37's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], (hospital transfer date) failed to reveal temperatures documented on [DATE], 29 and [DATE], and 5. Review of Resident R38's admission record indicated he was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R38's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], (hospital transfer date) failed to reveal temperatures documented on [DATE], 28, 29 and [DATE], 5, and 11. Review of Resident R39's admission record indicated she was admitted to the facility on [DATE]. A review of the Quarterly MDS dated [DATE], included [DIAGNOSES REDACTED]. Review of Resident R39's nursing progress notes and Vitals Summary for temperature from [DATE], to [DATE], failed to reveal temperatures documented on [DATE], 19, 21, 22, 23, 26, 27, 28, 29, 30, 31 and [DATE], 4, 5, and 11. During an interview on [DATE], at 2:45 p.m. the Director of Nursing confirmed that the facility failed to monitor for temperatures daily. Review of resident room locations indicate that Resident R27 resided in a room identified as Covid-19 positive, and Resident R30 resided in that room together from [DATE] through [DATE], when Resident R30 was transferred to the hospital. Clinical record review indicated that Resident R30 became febrile with a temperature of 100.0 degrees on [DATE], after a three day absence of temeperatures having been taken. Resident R27 became febrile on [DATE], with a temperature of 100.3. Review of resident room locations indicate that Resident R9 resided in a room identifed as Covid-19 positive, and Resident R17 resided in that room together from [DATE] through [DATE]. Clinical record review indicated that Resident R17 became febrile with a temperature of 101.8 degrees on [DATE], after a three day absence of temeperatures having been taken. Resident R9 became febrile on [DATE], with a temperature of 100.8. During an interview on [DATE], at 2:55 p.m. the Director of Nursing confirmed that if the temperatures for Residents R27 and R30, and for Residents R9 and R17 had been assessed daily, initial signs and symptoms could potentially have been noted earlier, [MEDICAL CONDITION] spread could potentially have been lessened. Line listings of Covid-19 infections were provided by the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Residents R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R18, R19, R21, R22, R23, R25, R26, R28, R29, R33, R34, R36, R37, R40, and R41 did not have the required data completed for the following areas: Dementia/Neurologic Condition [MEDICAL CONDITION] Diabetes Condition Specifics Symptom Onset Date First Symptom Documented Any indicators the ,[DATE] days prior Specific Exposure Fever Lowest O2 sat Highest Temp Myalgia Fatigue Headache Sore throat Shortness of Breath Cough Chills Rhinorrhea Nausea/ Vomiting Not Yet tested Transferred out of LTCF Date of transfer out hospitalized hospitalization Date Supplemental Oxygen Intubated deceased Date Resolution of Symptoms During an interview on [DATE], at 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to report complete and accurate information on Covid-19 positive residents. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that Immediate Jeopardy existed for the 19 of 68 residents in the facility on [DATE], at 3:15 p.m. and a corrective action plan was requested. On [DATE], at 6:4

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to provide medication necessary to avoid physical harm for one of six residents reviewed (Residents R1). Finding include: Review of facility policy, Abuse and Neglect - Clinical Protocol, updated 2/10/16, defined neglect as failure to provide goods and services necessary to avoid physical harm. Review of Resident R1's admission Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 6/16/16, indicated that the resident was admitted to the facility on [DATE], was non-interviewable and had [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED] A review of Resident R1's Medication Administration Record (MAR - record of each medication given to a resident), dated 6/1/16 - 6/30/16, 7/1/16 - 7/31/16, and 8/1/16 - 8/31/16, indicated that the [MEDICATION NAME] order was not transcribed put into written form to the MAR and the medication was not administered as per physician's orders [REDACTED]. Review of a nurses' note for Resident R1 dated 8/31/16, but not timed, indicated that Resident R1, was very lethargic (tiredness, lack of energy). The physician was called regarding the change in condition and ordered a stat (Latin abbreviation indicating an order to be completed immediately) Basic Metabolic Panel (BMP - a blood test). Review of Resident R1's BMP dated 8/31/16, indicated that the resident's blood glucose level was 806 milligrams per deciliter (MG/DL), a critical value (a normal value is considered to be between 65-99 MG/DL.) Review of a nurses' note for Resident R1 dated 9/1/16, at 1:30 a.m. indicated that on 8/31/16, at 11:00 p.m. the lab notified the facility that the resident's blood glucose level was 806, the, resident was confused and lethargic, doctor was called, resident will be sent out to hospital for evaluation. Review of the hospital records physician's notes for Resident R1 dated 9/1/16, indicated, patient seen on 9/1/16 and according to the patient's nurses at the skilled nursing facility, he/she began not acting him/herself approximately 2 days ago, was noted to have increased confusion as well as some fatigue. Patient then had some lab work performed which showed a capillary blood glucose of 800, nursing had been unaware that he/she was on insulin. Because of the patient's altered state and laboratory findings, he/she was deemed appropriate for admission to ICU. (Intensive Care Unit - a hospital unit for the seriously ill). Review of the hospital discharge summary for Resident R1 dated 9/6/16, indicated, admitted to ICU (9/1 - 9/2) with Hyperosmolar Hyperglycemic State (serious condition caused by extremely high blood sugars). Patient has history of Diabetes Type II on insulin, but had not been receiving their insulin at the skilled nursing facility. During an interview on 9/15/16, at 3:30 p.m. both the Nursing Home Administrator and the Director of Nursing confirmed that the facility neglected to follow a physician's insulin order which resulted in Resident R1's blood glucose level reaching a critically high value and the resident's admission to the ICU. 42 CFR 483.13(c) Prohibit Mistreatment/neglect/misappropriation. Previously cited 5/27/16. 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 6/3/16, 5/14/15. 28 Pa. Code 211.12(d)(1) Nursing Services. Previously cited 6/3/16, 5/27/16, 5/14/15. 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15.

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to administer a significant medication resulting in harm to one of six residents reviewed (Resident R1). Findings include: Review of the facility's policy, Administering Medications, updated 2/10/16, stated that medications must be administered in accordance with the physician's orders [REDACTED]. Review of Resident R1's admission Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 6/16/16, indicated that the resident was admitted to the facility on [DATE], was non-interviewable and had [DIAGNOSES REDACTED]. Review of the hospital discharge records dated 5/31/16, indicated that Resident R1's discharge medications included [MEDICATION NAME] (a medication to reduce blood sugar) 10 Units subcutaneously (injection beneath the skin) daily, at bedtime. Review of Resident R1's admission order dated 5/31/16, indicated the [MEDICATION NAME] order was transcribed indicated that [MEDICATION NAME] (a medication to reduce blood sugar) order 10 Units subcutaneously (injection under the skin) every night at 9:00 p.m. to the resident's May 2016 Medication Administration Record (MAR - record of each medication given to a resident), and verified by the physician on 6/1/16. Review of Resident R1's MAR dated 6/1/16 - 6/30/16, 7/1/16 - 7/31/16, and 8/1/16 - 8/31/16, indicated that the [MEDICATION NAME] order was not transcribed and the medication was not administered as per physician's orders [REDACTED]. Review of a nurse's notes for Resident R1 dated 8/31/16, and not timed, indicated that Resident R1, was very lethargic, (tiredness, lack of energy). The physician was called regarding the change in condition and ordered a stat (Latin abbreviation indicating an order to be completed immediately) Basic Metabolic Panel (BMP - a blood test). Review of Resident R1's BMP dated 8/31/16, indicated that the resident's blood glucose level was 806 milligrams a deciliter (MG/DL), a critical value (a normal value is considered to be between 65-99 MG/DL.) Review of nurses' note for Resident R1 dated 9/1/16, 1:30 a.m. indicated that on 8/31/16, at 11:00 p.m. the lab notified the facility that the resident's blood glucose level was 806, the, resident was confused and lethargic, doctor was called, resident will be sent out to hospital for evaluation. Review of the physician's notes included in the hospital records for Resident R1 dated 9/1/16, indicated, patient seen on 9/1/16 and according to the patient's nurses at the skilled nursing facility, he/she began not acting him/herself approximately 2 days ago, was noted to have increased confusion as well as some fatigue. Patient then had some lab work performed which showed a capillary blood glucose of 800, nursing had been unaware that he/she was on insulin. Because of the patient's altered state and laboratory findings, he/she was deemed appropriate for admission to ICU. (Intensive Care Unit - a hospital unit for the seriously ill). Review of the hospital discharge summary for Resident R1 dated 9/6/16, indicated, admitted to ICU (9/1 - 9/2) with Hyperosmolar Hyperglycemic State (serious condition caused by extremely high blood sugars). Patient has history of Diabetes Type II on insulin, but had not been receiving their insulin at the skilled nursing facility. During an interview on 9/15/16, at 3:30 p.m. both the Nursing Home Administrator and the Director of Nursing confirmed that the facility utilized hospital discharge orders as facility admission orders [REDACTED]. 42 CFR 483.25(m)(2) Residents Free of Significant Med Errors. Previously cited 5/14/15. 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15. 28 Pa. Code 211.12(d)(1) Nursing Services. Previously cited 6/3/16, 5/27/16, 5/14/15. 28 Pa. Code 211.12(d)(5) Nursing Services. Previously cited 6/3/16, 3/28/16, 5/27/16, 5/14/15.