Every finding on record at Care Pavilion Nursing and Rehabilitation Center

Based on review of facility policy, observations, and staff interview it was determined that the facility failed to ensure that drugs and biologicals were stored in a secure and safe environment for one of three medication rooms observed (first floor west).Findings include: Review facility policy on Medication Storage with the most recent review date of December 17, 2024, revealed that under section POLICY: Medications will be stored in a manner that maintains the integrity of the product, ensure the safety of the residents and is in accordance with the Department of Health guidelines medications will be stored in a manner that maintains the integrity of the product, ensure the safety of the residents and is in accordance with the Department of Health guidelines. Under section PROCEDURE #A. With the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorize personnel, as defined by facility policy. Observation of the first-floor west Medication room conducted on August 24, 2026, at 9:30 a.m. revealed that the medication door was propped open by an emergency box. Observation of the medication room revealed that there was a stack of medication blister packs with leftover tablets in them on top of the refrigerator. Observation of the medication refrigerator inside the first-floor west medication room, revealed that the medication refrigerator was not locked. Further inspection of the medication refrigerator revealed multiple vials of insulin and multiple injectable Ozempic (prescription medication), and PPD (used for intradermal Mantoux tuberculosis skin testing) vials inside the refrigerator. Interview on August 24, 2026, with licensed nurse Employee E4 confirmed that the door to the medication room was propped open by an emergency box. Follow-up observation of the first floor west medication room conducted on August 24, 2026, at 9:45AM with the DON (director of nursing) Employee E2, revealed that there was a stack of medication blister packs with leftover tablets in them on top of the refrigerator, medication refrigerator inside the medication room, was not locked, multiple vials of insulin and multiple injectable Ozempic and PPD vials inside the refrigerator. Interview with DON Employee E2 conducted at the time of the observation, confirmed that medication room was propped open by an emergency box. Further Employee E2 confirmed the above observation. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, observations, and interviews with staff and residents, it was determined that the facility failed to maintain an environment that was safe, sanitary, and comfortable for residents, staff and the public for three of three resident care areas observed (Main Lobby, Two East, Three East).Findings include:Review of facility policy titled, General Infection control - Housekeeping revised October 24, 2025, revealed it is the policy of the facility to promote a sanitary environment and reduce the transmission of infectious agents. Cleaning - the necessary first step of any disinfection process. Cleaning removes organic matter, salts, and visible soils, all of which interfere with microbial inactivation. The physical action of scrubbing with detergents and surfactants and rinsing with water removes substantial numbers of microorganisms. If a surface is not cleaned first, the success of the disinfection process can be compromised. Removal of all visible blood and inorganic and organic matter can be as critical as the germicidal activity of the disinfecting agent. 1. Routine Cleaning - of resident areas occurs while the resident is admitted . It focuses on the resident zones and aims to remove organic materials and reduce microbial contamination to provide a visually clean environment. Systems should be established to ensure that cleaning staff have reasonable access to perform routine cleaning. Scheduled basis (i.e., weekly) and when visibly soiled, clan low-touch surfaces. Observations on July 16, 2026, at 9:00 a.m. in the main floor lobby, revealed a strong odor of cigarette smoke. Interview with Resident R2 on July 16, 2026, at 10:17 a.m., revealed his/her previous room was not kept clean. Observations on July 16, 2026, at 10:30 a.m. of the second floor revealed a strong urine odor by the elevators and vending machines. Observation on July 16, 206, 10:40 a.m. revealed room [ROOM NUMBER] on the third floor was found to have mouse droppings, sticky floors, and dead flies around the room. A mouse was also observed running across the room. Interview with Resident R4 on July 16, 2026, at 10:45 a.m. the facility staff don't do a good job of cleaning. Continued observations on July 16, 2026, on the third floor revealed room [ROOM NUMBER] was found to have mouse droppings on the floors, sticky floors, and dead flies around the room. Further observations on July 16, 2026, on the third floor revealed room [ROOM NUMBER] was found to have mouse droppings on the floors, sticky floors, and dead flies around the room. Observations on July 16, 2026, in the third floor in the utility closet, roaches were present and food chunks were on the floor throughout the hallway. Interview with Employee E9 on Thursday July 16, 2026, at 10:50 a.m. confirmed condition of the facility and resident rooms. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of clinical records, facility policy, and staff interview, it was determined the facility failed to implement interventions to assess and treat a deteriorating sacral pressure ulcer. This failure resulted in actual harm to Resident R1 who developed sepsis requiring hospitalization for one of two residents reviewed (Resident R1). Findings include: Review of facility policy titled Skin Integrity revised 2023, revealed if the facility uses a wound care company, wound care documentation must be uploaded into the resident's electronic medical record (under the miscellaneous tab) and a corresponding progress note written by nursing stating wound care company was in and assessed the wound that day. Continued review of facility policy revealed the facility will notify the resident's physician and responsible party with changes/updates as appropriate and enter any new orders from the physician, as it applies to wound treatment and interventions as necessary. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including Parkinsonism (conditions that cause slowed movements and other movement-related symptoms), pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue) of sacral region stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue), and cognitive communication deficit. Review of Resident R1's nurse practitioner, Employee E2, wound note, dated June 23, 2026, revealed Patient seen today for follow up of sacral pressure ulcer which has deteriorated since the previous encounter. The patient continues to remain incontinent of stool, which has contaminated open wound. There is no periwound cellulitis (occurs when a bacterial infection spreads from a wound or skin break into the surrounding skin) present on evaluation today, however there is new undermining (skin at the edge of a wound appears intact, but the tissue underneath has separated from the deeper wound bed, forming a pocket or shelf-like area beneath the visible skin) present at this time. Given new undermining in setting of chronic pressure ulcer, discussed with nursing staff to obtain x-ray of the coccyx/sacrum as well as basic labs (Complete Blood Count (CBC)/ Basic Metabolic Panel (BMP)) for further evaluation of osteomyelitis (bone infection), with low threshold to begin oral vs intravenous antibiotics. Continued review of Resident R1's wound note, dated June 23, 2026, revealed the wound measurements are 2.3 centimeters (cm) length x 3.6 cm width x 0.9cm depth, with an area of 8.28 square (sq) cm and a volume of 7.452 cubic cm. Review of Resident R1's clinical record revealed x-ray was completed on June 25, 2026. Further review of Resident R1's clinical record failed to reveal documented evidence the recommended lab tests were completed. Review of Resident R1's wound nurse practitioner, Employee E2, wound note, dated July 1, 2026, revealed patient seen today for follow up of sacral pressure ulcer which has deteriorated since the previous encounter. The patient continues to remain incontinent of stool, which has contaminated open wound. There is no periwound cellulitis present on evaluation today, however undermining remains/wound now presents with mild odor. x-ray of the sacrum was obtained 6/25, read via radiology as: IMPRESSION: No acute bone abnormality. No acute osteomyelitis is noted. However, discussed with nursing staff and primary team directly that current wound presentation is consistent with early osteomyelitis. I spoke with primary team provider (Nurse Practitioner, Employee E1) with these concerns, for which primary provider mentions labs and antibiotics will be pursued at present time with close clinical monitoring for further deterioration. Continued review of Resident R1's wound dated, dated July 1, 2026, revealed the wound measurements of 2.8cm length x 3.6cm width x 1.1 cm depth, with an area of 10.08 sq cm and a volume of 11.088 cubic cm., indicating deterioration of the wound. Review of Resident R1's clinical record revealed no documented evidence antibiotics and labs were ordered and completed. Interview conducted on July 13, 2026, at 12:19 p.m. with facility Nurse Practitioner, Employee E1 revealed he/she does not recall the conversation with the Wound Nurse Practitioner, Employee E2. Interview conducted on July 14, 2026, at 10:50 a.m. with Wound Nurse Practitioner, Employee E2, revealed he/she contacted the primary team line and spoke with the facility Nurse Practitioner, Employee E1, regarding the presentation of Resident R1's wound. Wound Nurse Practitioner, Employee E2 stated Nurse Practitioner, Employee E1, confirmed the information would be relayed to appropriate doctor, antibiotics would be started and labs would be obtained. Review of Resident R1's clinical record revealed the resident was transported to the hospital on July 3, 2026, and admitted with a diagnosis of sepsis (life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs). Interview conducted on July 14, 2026, at 11:15 a.m. with the Director of Nursing (DON), Employee E3, confirmed no antibiotics were started or labs obtained as recommended for Resident R1's wound. The facility failed to implement interventions to treat a deteriorating sacral pressure ulcer. This failure resulted in actual harm to Resident R1 who develop sepsis, requiring hospitalization for further evaluation and treatment. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record reviews and interviews with staff, it was determined the facility failed to identify a full-thickness foot wound with exposed adipose (fat) tissue in a timely manner, for one of three residents reviewed for wounds. This failure resulted in actual harm to Resident R4 who developed an infection of the right big toe. (Resident R4) Findings include: Review of Resident R4's Significant Change MDS assessment (Minimum Data Set - mandatory periodic resident assessment tool), dated March 23, 2026, revealed the resident was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Disease (damage to the brain from interruption of its blood supply), and End Stage Renal Disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Continued review of Resident R4's MDS assessment revealed the resident was severely cognitively impaired, received hospice services and enteral tube feedings. Further review revealed Resident R4 was dependent for all activities of daily living, including toileting, bathing, dressing, hygiene, bed mobility, and transfers. Review of Resident R4's care plan, dated initiated October 21, 2025, revealed the resident was at risk for impairments to skin integrity related to impaired mobility. Interventions included to monitor/document location, size, and treatment of skin injuries and to report abnormalities, failure to heal, or signs/symptoms of infection to the physician. Review of Resident R4's Wound Consultant Report, dated May 27, 2026, revealed the resident was seen for follow-up of multiple wounds and initial evaluation of a right medial (inner) ankle arterial wound (wound caused by poor blood flow) and a right lower leg trauma wound. Both wounds were noted as granulation (healthy skin tissue) and had no signs of infection. The wound consultant recommended for both the right medial ankle and right lower leg wounds to be cleansed with normal saline and a xeroform (medicated gauze) dressing. Further review of the Wound Consultant Report dated May 27, 2026; revealed Resident R4 also had wounds requiring treatments to the sacrum, right medial (inner) knee, left medial knee, right proximal tibia (lower leg) and right ischium (hip). Review of Resident R4's Wound Consultant Report authored by wound physician, dated June 3, 2026, revealed the resident was seen for follow-up of multiple wounds and initial evaluation of a right hallux (big toe) trauma wound. The report notes the right hallux wound was a full thickness (severe injury extending through the skin layers into the subcutaneous tissue) wound with infection. Wound measurements were 3.8 cm (centimeters) length by 3.2 cm width by 0.3 cm depth, with an area of 12.16 square centimeters. The report noted adipose (fat) tissue was exposed and the wound probed to bone, indicative of osteomyelitis (bone infection). The report further noted the periwound (tissue surrounding the wound) had signs of infection. The wound consultant recommended for the wound to be cleansed with normal saline, treated with a honey dressing and covered with a border dressing every other day. Further review of the Wound Consultant Report from June 3, 2026, revealed Resident R4 also had wounds that required treatments to the sacrum, right medial knee, left medial knee, right proximal tibia, right ischium, right lower leg and right medial ankle. Review of Resident R4's Treatment Administration Records (TARs) for May and June 2026 revealed resident received wound care treatments every other day to the right tibia, left ankle, left knee and right knee; and daily treatments to the right ischium and sacrum. Continued review of TARs failed to reveal evidence of Resident R4 was prescribed or received any treatments to the right medial ankle and the right lower leg wounds. Further review of TARs failed to reveal evidence Resident R4 was prescribed or received any treatments to the right hallux wound. Continued review of Resident R4's clinical record, including progress notes, nursing assessments, skin assessments, care plan, hospice notes and dialysis notes failed to reveal evidence the right hallux wound was observed or assessed prior to the wound consultant report on June 3, 2026. Interview on June 10, 2026, at 8:53 a.m. with the facility's wound team, consisting of Employee E6, Licensed Nurse; Employee E7, Licensed Nurse; and Employee E8, Wound Consultant; revealed they were not aware of how, why, or when Resident R4 acquired the right hallux wound. Employee E6 stated the wound team assesses all wounds weekly and upload their reports into the clinical records. Employee E6 stated staff nurses are expected to complete an incident report and document in the notes any new skin impairments. Employees E6, E7 and E8 were not able to recall any specific clinical details regarding Resident R4's wounds and stated there are a lot of wounds in the facility. Resident R4 was not available for observation or assessment at the time of the survey. Continued review of Resident R4's TARs revealed Employee E9, licensed nurse, provided wound treatments to Resident R4 on May 27, 28, 29 and June 1, 2, 3, 4 and 5, 2026. Interview on June 10, 2026, at 9:17 a.m. Employee E9, Licensed Nurse, confirmed she provided regular care, including wound treatments, to Resident R4. Employee E9 stated she does not recall the resident having any toe wounds. Interview on June 10, 2026, at 9:35 a.m. Employee E4, Assistant Director of Nursing, revealed no incident reports had been completed related to Resident R4's right hallux wound. Continued interview revealed staff nurses are responsible for completing incident reports and notes for any new skin impairments. Interview on June 10, 2026, at 9:40 a.m. Employee E2, Director of Nursing revealed he was unaware of Resident R4's right hallux wound. The Director of Nursing confirmed a full-thickness wound with exposed adipose tissue would not become infected on the same day that it occurred and the wound would have occurred prior to its discovery on June 3, 2026. Follow-up interview on June 10, 2026, at 10:12 a.m. the Director of Nursing confirmed there was no documentation of the right hallux wound and no incident report prior to the wound being discovered as infected by the wound team on June 3, 2026. The Director of Nursing revealed the wound care team are expected to immediately enter treatment orders for all wounds after their assessments. The Director of Nursing confirmed there was no transcription or communication of treatment orders for Resident R4's right hallux wound. Further, the Director of Nursing stated he was not aware of the right hallux wound until it was brought to his attention by the survey team. 28 Pa Code 211.5(f)(i)(ii)(iii)(vii)(ix) Medical records 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of facility documentation and interviews with residents and staff, the facility failed to maintain an effective pest control program for seven of seven nursing units reviewed (1 East unit, 1 [NAME] unit, 2 East unit, 2 [NAME] unit, 3 East unit, 3 [NAME] unit, 4 [NAME] unit). Findings include: Interview on June 9, 2025, during entrance conference, the Nursing Home Administrator revealed that the facility recently contracted with a new pest control company due to ongoing pest issues. Interview on June 9, 2026, at 9:20 a.m. Resident R7, on the 1 [NAME] unit, stated that the mice and roaches problem has not gotten any better. Observation, at the time of the interview, Resident R7 opened a dresser drawer and showed that there were mouse droppings throughout the clothes and linens in the drawer. Interview on June 9, 2026, at 9:48 a.m. on the 1 East unit, a laboratory technician who requested to remain anonymous, stated that they come into the facility at 3:00 a.m. and always see mice, roaches and flies. The employee stated that they do not feel comfortable working at the facility because of the pests. Interview on June 9, 2026, at 9:50 a.m. Resident R8, on the 1 East unit, stated that mice run out from under the PTAC (heating and cooling) unit. Observation, at the time of the interview, revealed pink fiberglass insulation with open avoids and mouse droppings underneath the PTAC unit. Interview on June 9, 2026, at 10:10 a.m. Resident R9, on the 1 East unit, stated that a mouse had eaten through the packaging of her sandwich. Observation, at the time of the interview, revealed that Resident R9 had numerous opened and soiled food containers surrounding her in bed. The bedside tray table was heavily soiled with debris and a styrofoam cup on the tray table was completely encased in fruit flies. Numerous flies were observed flying around the resident. Multiple roaches were observed in a glue trap behind the resident's bed. Continued interview, Resident R9 and her roommate Resident R10, stated that they see mice everyday run across the room. Observation on June 9, 2026, at 10:50 a.m. room [ROOM NUMBER], on the 2 East unit, revealed numerous flies in the room. Observation on June 9, 2026, at 10:55 a.m. room [ROOM NUMBER], on the 2 [NAME] unit, revealed mice droppings along the baseboards in the room. Several open bags of clothes were noted on the floor with mice droppings noted in the clothes. Review of pest control report, dated May 27, 2026, revealed that cockroaches were observed near the reception desk and 3rd floor nurse stations. Rooms 351, 355, 356, 357, 359 and 370 were inspected and treated for roaches, mice and ants. A mouse was observed in room [ROOM NUMBER]. Rats were observed in the front of the facility. The pest control company recommended deep cleaning of all rooms and noted that floors have been neglected; debris, spills, mice droppings and urine odors were found throughout the listed rooms and hallways. Review of pest control report, dated June 5, 2026, revealed that excessive mice activity was observed on each floor. Rooms 301, 316, 162, 175, 201 and 318 were treated for roaches, mice and ants and that excessive mouse activity was found in each room. The pest control company met with maintenance and housekeeping staff and recommended that the facility would benefit from improved sanitation. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 10, 2026, at 12:00 p.m. 28 Pa Code 201.24(a) Responsibility of licensee

Based on review of communication records, facility documentation and interviews with staff, it was determined that the facility failed to provide medical records in a timely manner to the Area Agency on Aging as required by law, for one of one records reviewed (Resident R2). Findings include: Service Access and Management, Inc, (SAM) works on behalf of the Philadelphia Corporation for Aging and has been designated by the Commonwealth of Pennsylvania Department of Aging as the Area Agency on Aging in Philadelphia. SAM is authorized to receive and investigate allegations of abuse, neglect, financial exploitation and abandonment of older Philadelphians in accordance with the Older Adults Protective Services Act. Review of Title 45 Code of Federal Regulations Section 164.512(c)(1) revealed that disclosures of protected health information are permitted when the entity reasonably believes an individual to be a victim of abuse, neglect or domestic violence. Review of electronic communication records revealed that on May 18, 2026, at 11:06 a.m. SAM sent a request for medical records for Resident R2, including most recent physician note, most recent assessment and investigative documents pertaining to an allegation of abuse. The electronic communication was addressed to Employee E1, Administrator, and Employee E5, Director of Social Work. Continued review of electronic communication records revealed that additional requests for Resident R2's records were made by SAM on May 20, 22 and 27, 2026. These requests were again addressed to Employees E1 and E5. An additional request noted that a representative from SAM spoke with Employee E2, Director of Nursing, on May 28, 2026. The request indicated that they were still waiting for physician notes and abuse investigation documents for Resident R2. The request was addressed to Employees E1, E5 and E10, social worker. During Entrance Conference on June 9, 2026, at 9:00 a.m. with facility administrative staff, evidence was requested regarding the provision of the medical records to SAM related to Resident R2. Employee E2, Director of Nursing, stated that he was not aware of the request. Interview on June 9, 2026, at 10:19 a.m. with Employee E5, Director of Social Work, stated that she made the Administrator and Director of Nursing aware of the request from SAM. Employee E5 stated that Employee E10 was the facility social worker responsible for Resident R2. Employee E5 stated that Employee E10 would be the one responsible for sending the clinical documents to SAM and that the Director of Nursing would be the one responsible for sending the abuse investigation documents to SAM. Follow-up interviews on June 9, 2026, at 12:25 p.m., 1:55 p.m. and 2:55 p.m. with Employee E5 revealed that she was unable to provide any evidence that the requested records for Resident R2 were sent to SAM at the time that they were requested. Employee E10 was unavailable for interview. 28 Pa Code 201.24(a) Responsibility of licensee28 Pa Code 211.5(b)(2)(i) Medical records28 Pa Code 211.12(d)(3) Nursing services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to investigate an injury of unknown origin to rule out abuse and neglect for one of three residents reviewed for wounds (Resident R4).Findings include: Review of facility policy Abuse dated reviewed June 1, 2025, revealed, Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Continued review revealed, Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person's the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Further review revealed, Investigation of injuries of Unknown Origin or Suspicious injuries must be immediately investigated to rule out abuse.Review of Resident R4's Significant Change MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 23, 2026, revealed that the resident was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (damage to the brain from interruption of its blood supply), and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Continued review revealed that the resident was severely cognitively impaired, received hospice services and tube feedings. Further review revealed that the resident was dependent for all activities of daily living, including toileting, bathing, dressing, hygiene, bed mobility and transfers.Review of Resident R4's care plan, dated initiated October 21, 2025, revealed that the resident was at risk for impairments to skin integrity related to impaired mobility. Interventions included to monitor/document location, size and treatment of skin injuries and to report abnormalities, failure to heal, or signs/symptoms of infection to the physician.Review of Resident R4's Wound Consultant Report authored by wound physician, dated June 3, 2026, revealed the resident was seen for follow-up of multiple wounds and initial evaluation of a right hallux (big toe) trauma wound. The report notes the right hallux wound was a full thickness (severe injury extending through the skin layers into the subcutaneous tissue) wound with infection. Wound measurements were 3.8 cm (centimeters) length by 3.2 cm width by 0.3 cm depth, with an area of 12.16 square centimeters. The report noted adipose (fat) tissue was exposed and the wound probed to bone, indicative of osteomyelitis (bone infection). The report further noted the periwound (tissue surrounding the wound) had signs of infection. Continued review of Resident R4's clinical record, including progress notes, nursing assessments, skin assessments, care plan, hospice notes and dialysis notes failed to reveal evidence the right hallux wound was observed or assessed prior to the wound consultant report on June 3, 2026.Interview on June 10, 2026, at 8:53 a.m. with the facility's wound team, consisting of Employee E6, Licensed Nurse; Employee E7, Licensed Nurse; and Employee E8, Wound Consultant; revealed they were not aware of how, why, or when Resident R4 acquired the right hallux wound. Employee E6 stated staff nurses are expected to complete an incident report and document in the notes any new skin impairments. Review of Resident R4's TARs revealed Employee E9, licensed nurse, provided wound treatments to Resident R4 on May 27, 28, 29 and June 1, 2, 3, 4 and 5, 2026.Interview on June 10, 2026, at 9:17 a.m. Employee E9, Licensed Nurse, confirmed she provided regular care, including wound treatments, to Resident R4. Employee E9 stated she does not recall the resident having any toe wounds.Interview on June 10, 2026, at 9:35 a.m. Employee E4, Assistant Director of Nursing, revealed no incident reports had been completed related to Resident R4's right hallux wound. Continued interview revealed staff nurses are responsible for completing incident reports and notes for any new skin impairments.Interview on June 10, 2026, at 9:40 a.m. Employee E2, Director of Nursing revealed he was unaware of Resident R4's right hallux wound. The Director of Nursing confirmed a full-thickness wound with exposed adipose tissue would not become infected on the same day that it occurred and the wound would have occurred prior to its discovery on June 3, 2026.Follow-up interview on June 10, 2026, at 10:12 a.m. the Director of Nursing confirmed there was no documentation of the right hallux wound and no incident report prior to the wound being discovered as infected by the wound team on June 3, 2026. The Director of Nursing revealed the wound care team are expected to immediately enter treatment orders for all wounds after their assessments. The Director of Nursing confirmed there was no transcription or communication of treatment orders for Resident R4's right hallux wound. Further, the Director of Nursing stated he was not aware of the right hallux wound until it was brought to his attention by the survey team.28 Pa Code 201.18(b)(1) Management28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and interviews with residents and staff, the facility failed to maintain clean, safe and homelike environment on three of seven nursing units reviewed (1 East unit, 2 East unit, 2 [NAME] unit). Findings include: Observation on June 9, 2026, at 9:48 a.m. of the 1 East unit revealed multiple missing and stained ceiling tiles in the hallway by the shower rooms. Observation on June 9, 2026, at 10:45 a.m. of the 2 East unit revealed multiple missing and stained ceiling tiles in the hallway by the shower rooms. room [ROOM NUMBER] had a large missing ceiling tile directly above the handwashing sinks and a ceiling tile that was caving in directly above the toilet. Observation on June 9, 2026, at 10:52 a.m. of the 2 [NAME] unit revealed that the PTAC (heating and cooling unit) in the dining/activity room was open underneath and the unit was being held up by a piece of wood. room [ROOM NUMBER] had food and debris all over the floor, the floors were heavily soiled with grime, the PTAC unit had an open exposed area, the tray tables were heavily soiled and the dresser was missing a bottom drawer. room [ROOM NUMBER] the floor was heavily soiled, with grime and debris crusted along baseboards and behind furniture. room [ROOM NUMBER] the floor was heavily soiled, with grime and debris crusted along baseboards and behind furniture; clothes were strewn across the floor and an oxygen tank was standing up in the room without a holder. room [ROOM NUMBER] beds B and C had full urine bottles on the beds and dresser, B bed and floor were soiled with feces, clothes were piled up on the floor with debris along the baseboards and behind the dressers and the PTAC unit had an open exposed area. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 10, 2026, at 12:00 p.m. 28 Pa Code 201.24(a) Responsibility of licensee

Based on observations, and resident interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for five of nine residents reviewed (Residents R1, R3, R4, R6 and R8).Findings include: During a tour of the facility on May 14, 2026, the following resident interviews were obtained on unit 1E: Interview with Resident R1 at 12:05 p.m. revealed that she does not like the food, she has ongoing issues with food being cold and some foods including chicken and sausage are undercooked and she is unable to eat. She says when there are things she cannot eat it is difficult to get a suitable replacement and she often is ordering food out or calling her family to bring her something to eat. She says that this is particularly bad in the evening at supper which is made worse by staff with bad attitudes that do not want to get her a replacement meal. Interview with Resident R3 at 11:35 a.m. revealed that she thought that the food was not very good, and that it was cold, she feels like the food could be better. Interview with Resident R4 at 11:39 a.m. revealed that the food is not great here, and it is not warm enough when it comes, and the chicken is always dry and the fish is sometimes undercooked. Interview with Resident R6 at 11:46 a.m. revealed that the food is horrible, it is cold and has no flavor at all, it is a mess. Interview with Resident R8 at 11:52 a.m. revealed that she was disappointed with the food, it is not aways warm, she wished it was better and that the portions were larger. Observations during a test tray conducted by the Food Service Director (FSD), Employee E5 on May 14, 2026, at 12:27 p.m. revealed that the cranberry juice was served at 66 degrees, and the cherry cobbler dessert was served at 79 degrees, both well above an acceptable range. The mashed potatoes, which were substituted for French fries, had an off flavor and the juice and dessert were too warm. Interview with the FSD on May 14, 2026, at 12:45 p.m. confirmed the results of the test tray. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on observations, staff interviews, and review of facility policy it was determined that the facility did not ensure professional standards of practices related to access to life-sustaining medical equipment for two of three nursing units reviewed (First Floor east unit and First Floor west unit). Findings Include: Review of facility policy titled, Cardiopulmonary Resuscitation (CPR) Certification Policy with a review date of [DATE] states, Policy- to ensure that a resident has the right to a dignified existence and self-determination including the right to formulate advance directives as well as to receive life sustaining treatment if desired. The Procedure reads, .4. If CPR is warranted, still will immediately initiate CPR. 5. A Code Blue will be announced over the intercom system and the code sheet will be initiated. 6. Any certified staff available to assist should respond to the designated area. 7. Crash Carts and emergency medical supplies and AEDS are available for use. A tour of the second-floor nursing unit was made on [DATE], at 10:40 a.m.An interview was held with the second-floor unit manager Employee E6 revealed the nursing crash cart was located on the unit by the nurses station. All contents were on the crash cart. Review of the facility Daily Emergency Code Cart Equipment Check form revealed clipboard with a form last dated [DATE]. Further review of the forms behind the other forms revealed February 2026, [DATE], and [DATE]. A tour of the first-floor east unit was taken at 10:55 a.m. During the tour, an interview was held with the first-floor east unit manager Employee E5 at 10:58 a.m. revealed the nursing crash cart was located on the unit by the nurses station. The crash cart did not contain an oxygen tank. Review of the Daily Emergency Code Cart Equipment Check form located on the chart revealed the form had not been completed since [DATE]. Employee E5 confirmed the date on the form. The licensed nurse Employee E5 confirmed that form was not filled out accurately due to there being no oxygen tank located on the crash cart. A tour of the first-floor west unit was taken at 11:15 a.m. During the tour, observation was made of the crash cart that was found without oxygen and items including masks, nasal cannulas, and suction tubing all scattered in disarray throughout the crash cart.An interview was held with the Director of Nursing Employee E2. Observation of the crash cart was made with the Director of Nursing Employee E2 and the Assistant Director of Nursing Employee E7 who confirmed the above findings at 11:25 a.m. The findings above were confirmed with the Director of Nursing Employee E2 at 2:05 p.m. The Director of Nursing stated that all carts have different procedures of holding documentation such as a binder versus a clipboard. The Director of Nursing Employee E2 confirmed that based upon the Daily Emergency Code Cart Equipment Check form that oxygen should be located on the crash cart. Employee E2 then explained that each crash cart is different and some do not allow for oxygen to be located on the cart. Employee E2 confirmed that in an emergency the nurse in charge would go to the crash cart first, and in the event of needing oxygen would need to then have to take an additional step to go to the oxygen storage room on the unit to obtain oxygen in an emergent situation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations of the physical environment for resident rooms and bathrooms, interviews with residents and staff, reviews of policies and procedures and the pest control operators' reports, it was determined that the facility was not maintaining an effective pest control program for two of four nursing unit (the first and third-floor nursing units). Findings include: A review of the facility's policy titled pest control dated April 1, 2022, revealed that it was the responsibility of the facility staff to ensure that the facility was maintaining an effective pest control program. The policy also indicated that the facility would maintain an on-going pest control program to ensure that the building was free of pests and rodents. The policy said that the facility's maintenance services was responsible for assisting with ensuring that the building was free of pests and rodents. Observations of resident rooms [ROOM NUMBERS] revealed problems with pest control. Interview with Resident R1 at 10:30 a.m., on April 8, 2026, confirmed the presence of common household pests (mice and cock roaches). Resident R1 who was alert and oriented and stated that there was a hole behind the toilet in the bathroom. The resident also reported that the ceiling in this bathroom was leaking water into his bathroom. Observations of the hole behind the toilet and brown stained ceiling tiles were confirmed the maintenance director at 10:35 a.m., on April 8, 2026. Further observations revealed that Resident R1 keeps dry foods (snack foods and soda) at the bed side unprotected from rodents and pests. Large boxes of dry foods were stored on the floor. Opened cans of soda were evident on the bureau. Resident R1 said that he would store the foods in a tight-fitting plastic container at the bedside if he was provided this food storage container. The opened cans of soda were to be stored in the nursing pantry refrigerator and labeled that was located on the first-floor nursing unit. Interview at 10:45 a.m., on April 8, 2026, with Residents R2 and R3 who were roommates living in room [ROOM NUMBER], revealed that they have seen mice in their bedroom. Observations of room [ROOM NUMBER] revealed the presence of food debris on the floor underneath both beds in this room. Resident R3 was observed to have dry foods (cereal, crackers, sugar packets) stored at the bedside. The resident reported that she did not have a container with a secure lid to store foods in room [ROOM NUMBER]. A review of the pest control operator's report dated March 5, 2026, revealed sanitation findings that need to be addressed. The pest control operator observed rodent droppings around every air cooling/heating unit in every resident bedroom. The pest control operator requested that the facility clean around the air cooling/heating units so that rodent activity could be monitored. A review of the pest control operators reports for March 12, 2026, for the first-floor nursing unit, revealed sanitation findings that need to be addressed. The pest control operator indicated that clutter of resident personal belongings was allowing for harborage of mice inside the resident room. The pest control operator asked the facility to store resident personal belongings (clothes, food) properly to prevent an excessive accumulation of items at their bed sides. Observation at 11:00 a.m., on April 8, 2026, of the third-floor resident rooms [ROOM NUMBERS] revealed problems with pest control and prevention of common household pests from entering the building to harbor and breed. Rodent droppings were evident in room [ROOM NUMBER]. The maintenance director, Employee E1, confirmed the mice droppings on the floor, in resident room [ROOM NUMBER]. Interview with the maintenance director at 11:15 a.m., on April 8, 2026, revealed that plans were to remove the front panel of the air cooling/heating unit in room [ROOM NUMBER] to inspect for entry ways for pests and rodents into the building. Further plans were to inspect the entire room [ROOM NUMBER] for holes/voids for pest entry into this room. Observations at 11:00 a.m., on April 8, 2026, of room [ROOM NUMBER] revealed Resident R4's personal belongings were stacked one on top of the other, in broken/torn cardboard boxes, next to the bed, in his room. This would allow places for rodents to live and breed. Resident R4 was agreeing to have his personal belongings stored in tight fitting containers in the basement storage area of the facility; so that he could access them as needed or requested. Interview with Resident R5 who also lives in room [ROOM NUMBER] revealed that the rodent issue in room [ROOM NUMBER] has been on-going. Resident R5 reported at 11:30 a.m., on April 8, 2026, that the mice are also seen by him in the bathroom in room [ROOM NUMBER]. Resident R5 reported that the toilet water pressure was not working properly in the bathroom making it difficult to flush the toilet after using it. Resident R5 said that the toilet would become full of water and overflow onto the floor with sewage. Observations of room [ROOM NUMBER] evidenced storage of foods (a variety of juices coffee with creamer, snacks and leftovers) at the bedside. The resident was not given the opportunity to use the nursing pantry refrigerator to store labeled and dated perishable food items. The resident in room [ROOM NUMBER] was not given a tightly sealed container for nonperishable food items for storage at the bedside if necessary. Interview with the maintenance director, Employee E1 at 11: 35 a.m., on April 8, 2026, confirmed the lack of proper food storage for room [ROOM NUMBER]. This improper storage and handling of foods provided nourishment for common household pests. A review of the pest control operator's report dated March 19, 2026, revealed that room [ROOM NUMBER] contained an accumulation of foods. The pest control operator indicated that this was food for common household pests (roaches and mice). The pest control operator asked the facility to properly store perishable and nonperishable foods or dispose of them daily. A review of the pest control operator's report of service dated March 27, 2026, revealed that resident room [ROOM NUMBER] on the third-floor nursing unit was found to have holes/voids in the floorboard of the closet in this room. The nursing staff noted that dead mice were in the floorboard of the closet. The pest control operator asked the facility to seal all voids in resident rooms. 28 PA. Code: 201.14(a) Responsibility of licensee 28 PA. Code: 201,18(b)(1)(d)(e)(1) (2.1) Management

Based on observations and interviews with staff it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.Findings include: An initial tour of the Food Service Department was conducted on December 1, 2025, at 9:40 a.m. with Employee E8, Food Service Director, (FSD) which revealed the following: Observation of the sink in the mop room revealed that it was clogged and full of dirty water. Observation of the trash can near the door revealed that it was not covered and contained kitchen waste which was open to the air. Observation of the drain collection funnel under the prep sink was full of trash that was dried and caked on thick. Observation of the fan guard in the prep room revealed a thick covering of grease and dust. Observation of the reach in refrigerator revealed personal drinks and orange colored soda and a black metal drink container with a sticker with a first name on it, and the door gaskets were dirty, torn and lose. Observation of the stainless-steel shelf in the prep room revealed that it was covered with crumbs, dust and dirt. Observation of the top of the coffee urn revealed dark brown grounds stuck to the stainless steel and dirt and dust and dried dark brownish black stains. Observation of the reach in refrigerator in the kitchen revealed that the door gaskets are dirty and torn apart. Observation of the air conditioning unit next to tray line, which was missing the cover, revealed a thick build-up of grease, dust and dirt blowing out over the kitchen area. Observation in the dish room revealed a chemical sanitizing low temperature machine. Testing of chemical sanitizing dish machine on revealed that no sanitizer was present in the final rinse confirming that the machine was not sanitizing the dishes that were being run through. The FSD could not get the machine to pump the sanitizing chemical into the rinse water and the machine. The FSD attempted to reach the rep from the chemical company to have them check the machine, but they could not come out the same day. The facility switched to serving residents on disposable dishware and silverware. Interview with the FSD on December 1, 2025, at 12:45 p.m. confirmed the above findings. Observation during a follow up visit to the kitchen on December 2, 2025, at 12:10 p.m. revealed the trash can in the corner with no cover and filled with trash, and the dish machine was still out of service. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures during test tray evaluation and for 15 of 35 residents reviewed (Residents R9, R42, R60, R63, R67, R72, R89, R144, R246, R288, R294, r299 R329, r315, and R339).Findings include: A review of Test Tray Evaluation Form, revealed that the standard temperature for hot foods, including entree and starch, on tray line was over 135 degrees and cold food, including milk and juice, was under 50 degrees. Interview with Resident R42 on December 1, 2025, at 10:15 a.m. revealed that the food is not what he ordered, that he supposed to be getting shakes and double portions. Interview with Resident R60 on December 1, 2025, at 10:18 a.m. revealed that the food is horrible and always cold. Interview with Resident R67 on December 1, 2025, at 10:21 a.m. revealed that she does not like food, it does not taste good. Interview with Resident R72 on December 1, 2025, at 10:25 a.m. revealed that the food is not warm enough. Interview with Resident R144 on December 1, 2025, at 10:30 a.m. revealed that the food that they bring is cold. Interview with Resident R246 on December 1, 2025, at 10:33 a.m. revealed that the food is cold. Interview with Resident R288 on December 1, 2025, at 10:37 a.m. revealed that the food is not good, that they don't bring us much for breakfast, only toast the other day, and the food is cold. Interview with Resident R294 on December 1, 2025, at 11:07 a.m. revealed that the food is cold. Interview with Resident R339 on December 1, 2025, at 11:07 a.m. revealed that the food is not what she wants, she wants the hot cereal and eggs, but they do not send this, and she has no allergies and is frustrated. Interview with Resident R9 conducted on December 1, 2025, at 11:06 AM revealed the food in the facility does not taste good and its always served cold. Interview on December 1, 2025, at 11:54 a.m. Resident R63 stated that foods are not cooked properly and that foods are served cold. Interview on December 1, 2025, at 12:30 p.m. Resident R89 stated the food is always cold and the that facility does not use anything to keep foods warm while the trays are being distributed. Interview on December 1, 2025, at 12:35 p.m. Resident R329 stated that the food doesn't taste good. Interview on December 2, 2025, at 9:54 a.m. Resident R315 stated that the food tastes fake, that the food is not cooked properly and that the coffee is undrinkable. Interview on December 2, 2025, at 9:54 a.m. Resident R299 stated that the food is cold, does not taste good and that the coffee is too strong, too bitter and undrinkable. Observations during a test tray conducted with the Food Service Director (FSD), Employee E8, on December 2, 2025, at 12:35 p.m. revealed that the fish, bow tie pasta, broccoli, pureed fish, mashed potatoes and pureed broccoli were all below acceptable 135 degrees, and the apple sauce and cranberry juice were above the acceptable 50 degrees. An interview with the FSD, on December 2, 2025, at 12:40 p.m. confirmed that these food items were outside the acceptable temperature and therefore not palatable, and a review of the Test Tray Evaluation Form revealed all foods and drinks except coffee and milk did not meet the standard of service temperature. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of facility documents and interview with staff, it was determined that the facility failed to ensure that residents were provided with education related to influenza vaccines prior to administering influenzas vaccines to residents for eight of eight residents reviewed. (Resident R8, R9, R14, R17, R20, R128, R260 and R284)Review of facility policy on Infection Prevention and Control Program revealed that under section Policy Statement: The infection prevention and control program is a facility wide effort involving all disciplines and individuals. Under section Policy Interpretation and Implementation. Coordination and oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist. #8. Immunization: a. Immunization is a form of primary prevention. b. Widespread use of influenza vaccine in the nursing facility is strongly encouraged Review of consents/declination forms for the influenza vaccines and review of clinical record for Resident R8, R9, R14, R17, R20, R128, R260 and R284, revealed no documented evidence that that Resident R8, R9, R14, R17, R20, R128, R260 and R284, were provided with education on influenzas vaccines prior to the administration of the vaccine. Interview with Director of Nursing Employee E2 conducted on December 6, 2025, confirmed that the facility did not provided education to residents related to influenza vaccines prior to administering the vaccines for Resident R8, R9, R14, R17, R20, R128, R260 and R284. Further interview with Employee E2 revealed that the facility did not have a process in place for educating residents on influenza vaccines prior to the administration of the vaccine. 28 Pa. Code 201.18(e)(1) Residents rights

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public for two of seven nursing units reviewed (3 [NAME] nursing unit, 3 East nursing unit.) and the boiler room. Findings include: Tour of the 3 East nursing unit on December 1, 2025, at 11:41 a.m. revealed the following: Resident room [ROOM NUMBER] the fan had fallen off of the wall, the dresser was missing a drawer, the bed remote had frayed wires, two holes in the floorboards were noted, a ceiling panel was loose and floor tiles were taped together.The dining room had five tables that were unsteady and wobbled when leaned on\.The cabinet in the dining room was covered in built-up debris and missing several handles. Tour of the 3 [NAME] nursing unit on December 1, 2025, at 11:02 a.m. revealed the following: Resident room [ROOM NUMBER] toilet was clogged, full of feces and unable to be flushed. Resident R45 stated that staff flush briefs down the toilet, which clogs it, and that it happens often. Also in resident room [ROOM NUMBER] there was a hole in the baseboard behind Resident R375's tube feeding pump. Resident room [ROOM NUMBER] the bathroom overhead light was not working. Resident room [ROOM NUMBER] the bathroom light had no cover and there was a large hole above the baseboard. Resident room [ROOM NUMBER] PTAC unit had wires sticking out from the underside of the unit, the drywall was torn apart next to the sink and the toilet lid cover was too large for the toilet so that the lid would not close properly; The pantry had two floor tiles missing, water was leaking from the water supply line to the floor, there were towels on the floor to absorb the water, and there was no refrigerator on the unit for the storage of resident foods; The medication storage room contained two oxygen tanks stored without holders; The PTAC unit in the dining room was being supported by five pieces of stacked wood pieces; Three tables in the dining room were unstable and wobbled when leaned on; Two windows in the dining room had no screen and one of them would not close all the way due to a missing piece of the window frame. The above findings were reviewed with Employee E12, Maintenance Director, on December 4, 2025, at 9:23 a.m. Observations during the initial tour of the building on December 1, 2025, at 10:05 a.m. revealed the following: Observations on the 2nd Floor [NAME] Unit revealed the fluorescent lighting in the ceiling was out and dark near rooms [ROOM NUMBERS]. Observations in the central bathroom on 2nd Floor [NAME] revealed an unlocked door and renovations inside the bathroom where all the floor tiles and baseboards had been removed leaving dangerous open holes in the floor where drain grates were removed. Observation in room [ROOM NUMBER] bed A revealed that the headboard of the bed was off and leaning against the wall. Observation in room [ROOM NUMBER] revealed that the baseboards were lose and there were holes in the wall above the baseboard near the sink and the walls were scuffed with dark marks. Observation in room [ROOM NUMBER] revealed that the walls were scuffed and dirty with black marks. Observation in room [ROOM NUMBER] revealed that the baseboards were lose and the walls were wavy and scuffed with dark marks. Observation in room [ROOM NUMBER] revealed that the baseboards were lose and the walls were scraped with dark marks. Observations on the 3rd Floor [NAME] Unit revealed PTECC/HVAC wall units in rooms [ROOM NUMBERS] that the bottom panel was missing or lose on the floor exposing dangerous sharp edges and internal parts. Observations on the 1st Floor East unit the door to the employee bathroom was broken and lose and the metal door frame was disconnected from the floor causing the entire unit to move when pushed on. Observations during a tour of the boiler room on December 3, 2025, at 11:50 a.m. with the Maintenance Director, Employee E12 and the Regional Maintenance Manager, Employee E13 revealed standing water covering most of the floor all the way to the doorway threshold entering the hall outside the kitchen. Interview with the Maintenance Director revealed that the hot water holding tank had been leaking and the facility was planning on replacing it. He was unsure how long the leaking had been going on. Observation of the 3 [NAME] nursing unit on December 1, 2025, at 11:02 a.m. revealed that the central shower room was undergoing renovations. The toilet, shower and bath fixtures had been removed from the room, and the flooring had been removed, exposing concrete flooring. There were multiple deep holes in the floor in the area where the toilet had been removed as well as in the center of the room. Multiple ceiling panels had fallen and were caved in. Continued observation of the 3 [NAME] shower room revealed that the construction area was unsecured. Interview on December 1, 2025, at 11:20 a.m. Resident R45 stated that a week ago he went into the 3 [NAME] shower room to use the toilet when he noticed that all of the fixtures were removed. The resident stated that now he has to use a shower room on another nursing unit. Interview on December 2, 2025, at 9:32 a.m. Employees E25 and E26, nurse aides, confirmed that the 3 [NAME] shower room was under construction and that the doors to the room have been left unsecured. The employees confirmed that residents have to use shower rooms on other units due to the construction. Interview on December 4, 2025, at 9:23 a.m. Employee E12, Maintenance Director, confirmed that the 3 [NAME] shower room was under construction for repairs and renovations due to leaks. Observation of the East Stairwell on December 5, 2025, at 10:33 a.m. revealed that the roof access door was open, which would allow weather elements and pests to enter the building. Continued observation of the East Stairwell and interview with the Nursing Home Administrator on December 5, 2025, at 10:45 a.m. confirmed that the roof access door should not be left open. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of resident records, review of facility policy, and staff interviews, the facility failed to monitor residents for changes in nutritional status and failed to implement appropriate interventions in response to identified nutritional changes for three of seven residents reviewed (Residents R38, R183 and R375). Findings include: Review of the facility's policy titled Nutrition (Impaired) Unplanned Weight Loss Clinical Protocol dated September 2017, revealed nursing staff are responsible for monitoring and documenting residents' weight and dietary intake over time, and any significant changes in weight, appetite, or food/fluid intake must be reported to the physician. The policy requires that the physician, in collaboration with nursing and the multidisciplinary team, assess the resident's nutritional status, review for possible medical causes of weight loss or gain-including disease, medication effects, or fluid imbalances-and authorize appropriate interventions based on identified causes, overall condition, prognosis, and resident wishes. Interventions, such as dietary modifications or the use of appetite stimulants, should only be implemented after a thorough evaluation and documentation of underlying causes. In this instance, the physician was not notified of the resident's weight loss, and the dietician failed to initiate any interventions or provide documented guidance. As a result, there was no physician-directed assessment or follow-up, representing a clear deviation from the policy, which mandates timely physician notification, collaborative evaluation, and cause-specific interventions to manage impaired nutritional status. Review of Resident R38's quarterly Minimum Data Set (MDS- A federal mandated assessment tool for all residents) dated October 18, 2025, revealed Resident R38 was admitted to the facility on [DATE]. The resident was wheelchair dependent and was assessed with the BIMS (Brief Interview of Mental Status) of 00 (sever cognitive impairment). Continued review of Resident R38 revealed that the resident is on a regular soft bite sized diet and self-fed independently. Resident R38's diagnosis' included hypertension (high Blood pressure), Parkinson's disease (neurodegenerative disease of the central nervous system effecting motor and non-motor systems) depression (mood disorder that causes persistent feeling of sadness and loss of interest). Review of Resident R38's clinical record revealed that this resident was ordered on October 8, 2025 a regular diet, soft bite size, level 6 texture (soft solid foods cut into small pieces) thin level 0(thin regular liquids) with instructions to weigh resident as indicated. Continued review of Resident R38's clinical record indicated resident had a 12.8-pound weight loss in one month and a 19.0-pound weight loss over two months with the following documented weights: - September 19, 2025, weight 143.4 lbs.- October 9, 2025, weight 137.2 lbs.- November 5, 2025, weight 124.4 lbs.- November 25, 2025, weight 122.2 lbs. Review of resident R38's documented dietary assessment dated [DATE], (a documented 6.2 lb. weight loss) revealed that Resident R38 was on regular soft and bite sized diet no reports of difficulties chewing or swallowing on current diet textures, intake is highly variable per documentation likely related to decreased appetite with advanced age. (She/he) is able to sell feed independently per OT (occupational therapy). No new labs to review this quarter. Weight history reviewed, weight remains stable and is risk for fluctuations on diet diuretic medication. Current weight 137 normal per age standards weight maintenance without significant loss gain is desired registered dietician will continue to monitor and reassess as needed. Review of Resident R 38's documented dietary assessment dated [DATE] , revealed no reports of difficulties chewing or swelling on current diet oral intake is variable per documentation with unusual eating patterns (she/he) is self-fed independent per OT(occupational therapy) no new labs to review she remains on vitamin D and calcium supplement for support residents current weight is 124.4 pounds normal per standards (a documented 12.8 lb. weight loss) (she/he) is trigger for a significant weight loss compared to one and two months ago, previously stabled. Some weight loss may be related to advanced age and variable intake, however unlikely greater than 10-pound weight loss occurred in one month. Reweight requested on 11/14/25. Weight fluctuations can also be anticipated related to heart failure diagnosis and resident on diuretic medication. Weight maintenance without significant weight loss is desired. Dieticians will continue to monitor and reassess as needed nursing to obtain re-weight as requested. Continued review of Resident's 38 clinical record revealed that a weight was not obtained until November 25, 2025, 11 days later. Review of the resident's progress notes revealed that the last two medical practitioner notes were completed by the Nurse Practitioner on November 1, 2025, and November 13, 2025. Both notes indicate that the resident was seen; however, there is no documentation that the resident was followed, assessed, or evaluated for significant weight loss. The notes state, I have reviewed records, including EMR (electronic medical records), vital signs, labs, and consults. Interview with Registered Dietitian, Employee E4 on December 2, 2025, at 11:10 a.m. revealed that she acknowledged the resident's significant weight loss but could not explain why the resident had not been reweighed and was unaware of any interventions initiated to address the weight loss. She stated that she would investigate the matter further and consult with Dietitian Employee E17 regarding appropriate follow-up and interventions. Interview with Registered Dietitian Employee E17 on December 2, 2025, at 3:00 p.m. revealed that she assessed the resident on November 13, 2025, acknowledged the resident's significant weight loss, and referred the resident to nursing for a reweight. She noted that the previous weight may not have been accurate and recognized that the resident was taking Furosemide, which could contribute to weight loss. Dietitian Employee E17 confirmed that the physician had not been notified of the weight loss. She planned to add a dietary supplement to the resident's orders and to reweigh the resident the following month. In our interview with the Director of Nursing (DON)Employee E2, on December 3, 2025, at 9:25 a.m. revealed that he reviewed the matter and found that the nurses reported that Resident R38 was refusing to be weighed, but documentation was not entered into the resident's clinical record in a timely manner. The resident's clinical record was later updated by the regional nurse employee E18 with late entries indicating that the resident had allegedly refused weights several times; however, there was no contemporaneous documentation of these refusals, and no discussion or notification to the physician occurred regarding the resident's weight loss or refusals. Review of Resident R375's care plan, dated November 5, 2025, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including malnutrition (lack of sufficient nutrients in the body), respiratory failure (not enough oxygen passes from your lungs to your blood), cerebral infarction (damage to the brain) and dysphagia (difficulty swallowing). Continued review of the care plan reviewed that the resident was at risk for malnutrition and that the resident required tube feedings. Further review of the care plan revealed a goal of weight stability. Review of Resident R375's weights revealed:On October 24, 2025, the resident weighed 165 pounds;On November 6, 2025, the resident weighed 165 pounds;On November 12, 2025, the resident weighed 144 pounds; [NAME] November 25, 2025, the resident weighed 106 pounds. Review of nutrition notes for Resident R375 revealed a note, dated November 19, 2025, which indicated that the resident is triggering for significant weight loss compared to previous admission weights, however, likely inaccurate as he did not lose 20 pounds over a few days. The note continued that weight maintenance and/or gain is desired. Interview on December 2, 2025, at 11:24 a.m. Employee E4, Registered dietician, confirmed that Resident R375's weights were inaccurate and that the resident needs to be re-weighed to confirm the weight loss. Review of the December 2025 physician order for R183 indicated that the resident was admitted into the facility on January 27, 2025 with diagnoses of anxiety, depression, dislocation of left hip, cocaine abuse; traumatic subdural hemorrhage; hypertension; seizures Review of the resident' initial nutritional assessment completed on January 29, 2025 indicated that the residents were also malnourished (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). Review of the December 2025 physician orders included a physician's order dated January 30, 2025, for the resident to have one- 4 ounce house shake provided to him to drink two times a day with his breakfast and lunch meals. During an interview with the Registered dietitian, (Employee E4) on December 5, 2025, the registered dietician reported that the purpose of the resident consuming the house shakes was to promote weight gain. Review of a nursing note dated April15, 2025 at 3:52 p.m. documented that the resident was discharged to the hospital on April 15, 2025, and subsequently re-admitted to the facility on [DATE]. Review of the resident's physician orders upon return from the facility on April 28, 2025, did not include the physician's orders for the resident to have one-4ounce house shake for breakfast and lunch meals. Continued review of the resident's clinical record indicated that there was no documentation that the resident had an admission weight obtained upon (his/her) return to the facility on April 28, 2025 or any documentation that a nutritional assessment was completed upon (his/her) return to ensure that the resident's weight was properly obtained and the resident was properly assessed by the registered dietician for his nutritional needs. During an interview with the Registered dietician. Employee E4 on December 5, 2025 at 11:05 a.m. the resident's clinical record was reviewed and the registered dietician confirmed that there was no admission weight taken upon the resident's return, and nutritional assessment completed on the resident upon his returned, as required. The registered dietician also confirmed that upon the resident's return from the hospital, the house shake to promote weight loss was discontinued. It was confirmed with the registered dietician at this time that there was no documentation information in the clinical record as to why the facility did not resume the physician's order for the resident's house shakes upon his return from the hospital on April 28, 2025. Review of the resident's weight taken on May 13, 2025 by nursing staff recorded the resident's weight at 125.lbs. Review of the resident's weight taken on June 6, 2025 was recorded as 108.0 (pounds) lbs., indicating that the resident had a significant weight loss of -13.67% over less than a 30 day period. The significant weight loss of the resident was confirmed with the dietician on December 5, 2025 at 11:05 a.m. Review of the dietician's nutritional assessment that was completed on June 7, 2025 after the significant weight loss indicated, the previous dietician prescribed house shake BID (twice a day) but that it was not noted in the chart order. Review of the clinical record provided no documentation that the resident was consuming the house shakes twice a day upon his return from the hospital on April 28, 2025 through June 6, 2025. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)Nursing Services

Based on review of facility documentation, clinical record review and interviews with residents and staff, it was determined that the facility failed to assist residents to access Alcoholics Anonymous (AA)/ Narcotics Anonymous (NA) resources for one of 42 residents reviewed (Resident R63). Findings include:Interview on December 1, 2025, at 11:54 a.m. revealed that Resident R63 wanted to attend AA/NA meetings and that none were available at the facility. Review of Resident R63's care plan, dated June 12, 2025, revealed that the resident had or had the potential for ineffective coping related to history of substance use disorder (medical condition in which there is uncontrolled use of a substance despite harmful consequences). Interventions included encouraging support available and listed resources such as Alcoholics Anonymous. Review of the Facility Assessment, dated April 16, 2025, revealed that 55% of the facility population had a history of mental illness, including diagnosis of substance use disorder. Interview on December 4, 2024, the Director of Nursing (DON) confirmed that the facility does not offer AA or NA meetings to residents. The DON stated that the facility offers a Peer Program. Review of peer review documentation revealed that AA/NA meetings are not offered as part of the program. 28 Pa Code 201.18(b)(1) Management

Based on observation, review of clinical record, review of facility policy and interview with staff and residents, it was determined that the facility failed to ensure that postal mail was delivered in timely manner for one of 42 residents reviewed. (Resident R128)Review of facility's undated policy on Mail and Package Handling revealed that under section Policy Statement: It is the policy of Care Pavilion Rehabilitation & Nursing to ensure that all residents and facility mail and packages are handled in a secure and respectful manner and distributed timely. Section Procedure: #1. Mail Arriving in Envelopes: All incoming mail that arrives in envelopes, including USPS, UPS, FedEx, and other courier deliveries, must be directed to the Business Office immediately upon receipt. #3. Resident Mail Handling: Once resident mail arriving in envelopes is sorted, the Business Office will deliver it directly to the Recreation Department for distribution. The Recreation Department is responsible for organizing and ensuring that each resident receives their mail in a respectful, timely and private manner. Review of Resident R128's clinical record revealed that Resident R128 was admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder, and Type 2 Diabetes Miletus. Review of Resident R128's MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated May 1, 2025, section C0500 BIMS (brief interview for mental status) score revealed that Resident R128's BIMS score was 14 suggesting that Resident R128 was cognitively intact. Interview with Resident R128 conducted on December 1, 2025, at 10:53 AM revealed that has not been getting (his/her) mails. Further, Resident R128 revealed that (he/she) has been expecting a mail from the Social Security Administration and that (he/she) has not received the mail yet. Further Resident 128 also revealed that (he/she) called the Social Security Administration office and spoke with a social security representation with facility social worker present to follow-up of the letter. Resident R128 was told by social security representation that they mailed (him/her) the letter two weeks ago. Resident R128 revealed that (he/she) never got it. Interview with Employee E31, Director of Therapeutic Recreation conducted on December 4, 2025, at 2:36 p.m. revealed that mail is delivered to the front desk and then it gets delivered to activities with no set time frame. Further, Employee E31 revealed that resident's mail is placed in boxes in their office and when the boxes are full, the mails are sorted out and that is when the mails and delivered to the residents. Further interview with Employee E31, Director of Therapeutic Recreation confirmed that resident's mail is not delivered to the residents as soon as it is received because there is no daily resident mail delivery schedule and there is no specific resident mail delivery day. 28 Pa. Code 201.2(a) Resident's right

Based on review of facility policies, personnel files and interviews with staff, it was determined that the facility failed to obtain criminal background checks as required for one of five personnel files reviewed for newly hired staff (Employee E19). Findings include: Review of facility policy Abuse dated June 1, 2025, revealed that the facility will screen employees prior to working with residents and that screening components include verification of references, certification and verification of license and criminal background check. Review of Employee E19's personnel file revealed that the employee was hired on October 1, 2025, as a nurse aide. Continued review revealed that a Pennsylvania Criminal Record Check was not completed until December 1, 2025, at 4:58 p.m., after the file was requested by state surveyors. Additionally, reference checks were not completed for the employee. Continued review of Employee E19's personnel file revealed that the employee had not resided in the state of Pennsylvania for at least two years and that the employee attested to having criminal charges in another state. Further review revealed that the facility did not obtain a Federal Criminal Record Check as required. Interview on December 4, 2025, at 12:36 p.m. Employee E20, Human Resources Director, confirmed that the State and Federal criminal record checks were not completed as required. 28 Pa Code 201.19(8) Personnel policies and procedures

Based on review of facility documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges as required for three of three months reviewed (August, September and October 2025). Findings include: During Entrance Conference with the Nursing Home Administrator on December 1, 2025, at 10:15 a.m. evidence of facility initiated transfer and discharge reports to the State Long-Term Care Ombudsman were requested. During an interview with Employee E15, Regional Director of Operations, on December 4, 2025, at 1:10 p.m. evidence of facility initiated transfer and discharge reports to the State Long-Term Care Ombudsman were requested again. Interview on December 4, 2025, at 1:20 p.m. the Nursing Home Administrator stated that the previous Director of Social Work left the facility in September 2025 and confirmed that the facility did not have evidence that notices were sent to the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges for August, September and October 2025, as required. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure proper supervision of residents during smoking hours which resulted in actual harm to Resident R1 who sustained first and second degree burn on face when nasal cannula ignited while smoking with oxygen in use for one of 38 residents reviewed (Resident R1). This deficiency was cited as past non compliance. Findings include: Review of undated Resident and Visitor Smoking Rules revealed the following: #1. No smoking is allowed indoors anywhere at Care Pavilion; including cigarettes, vape devices, etc. No smoking when oxygen is in use. #2. No smoking outside of the Walnut Street entrance/exit. #3. Residents and visitor smoking is only permitted in the designated outdoor smoking area (The Courtyard) during designated smoking times. Two designated staff members 'Smoking Monitors' are stationed in the smoking area at all times. #6. Residents are permitted to hold their own smokable tobacco products; however, they are not permitted to hold combustible devices such as lighters, matches, vape devices and other electronic smoking devices that contain a heating element. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease (condition where the kidneys have permanently lost most of their ability to function), and dependent on Renal Dialysis. Review of Resident R1's Medicare 5-day MDS (Minimum Data Set- federally required resident assessment completed at specific intervals) assessment dated [DATE], section C0500, BIMS Summary Score revealed a score of 12 indicating Resident R1 had a moderate cognitive deficit. Section GG0170 Mobility J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns was coded 04 (Supervision or touching assistance), K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space was coded 88 (Not attempted due to medical condition or safety concerns). Review of Resident R1's Smoking Evaluation dated July 22, 2025, revealed under section #2. Resident did not use oxygen, Cognitive: #3. did not have Dementia, #4. did not have poor memory, under section Behavior: #7. no history of unsafe smoking habits, under section Evaluation: #13. Smoking Decision: Independent smoking is allowed. Further, the next smoking assessment was completed on August 28, 2025, where the resident was coded as Resident is not allowed to smoke. Review of Resident R1's August 2025 physician orders revealed an order for oxygen at 4L (liters)/Min (minute)-6L/Min via NC (nasal canula) - PRN (as needed) dated August 21, 2025, for supplementary oxygen. Review of Resident R1's nursing notes dated August 27, 2025, time stamped 3:35 PM revealed: Resident ambulated to unit in distress, resident was bleeding from lip with visible burn marks to face. [Resident R1] explained that (he/she) lit cigarette while nasal cannula was inserted. [Resident R1] stated (he/she) did not want RP (responsible party) called, visibly upset. [Resident R1] stated (he/she) snuck outside to smoke with oxygen tank. Transportation called for resident to be transferred to ER (Emergency Room). Resident provided cold rag with ice and A&D applied. DON (Director of Nursing)/SW (Social Worker) /Administrator made aware . EMT (Emergency Medical Transport) arrived transported to local hospital, oncoming nurse made aware. Review of Resident R1's nurse's notes dated August 28, 2025, revealed that Resident R1 returned from local hospital via ambulance transport status post self-inflicted accidental from smoking to burns to face, nose and lip areas. Upon return 1st/2nd degree burns to be left open to air. Burn lesions on face left worse than right around nasolabial folds. nares, upper lip with redness/swealing no open blisters. Noted scant bleeding. Resident reports 8/10 pain. Denies inner damage to oral mucosa. Review of facility investigation revealed that on August 27, 2025, at approximately 3:30 pm, Resident R1 returned to the unit from the courtyard bleeding from his/her lips with visible burn marks to the side of his/her face. Resident R1 stated he/she left the unit to smoke while using 02 (oxygen) tank and nasal canula was on. Interview with facility Nursing Home Administrator (NHA), Employee E1 conducted on September 9, 2025, at 9:03 AM revealed Resident R1 was a dialysis resident who came back from on-site dialysis treatment. Nursing Home Administrator, Employee E1 revealed that resident uses a wheelchair. Resident R1 returned from dialysis with portable oxygen, went to the smoking area with oxygen in use, took another resident's cigarette but forgot (he/she) had O2 on. Further facility administrator revealed that at the time of the incident, there was a resident Bar-B-Q and there were a lot of activities occurring in the courtyard. Observation of the door leading to the courtyard conducted on September 9, 2025, at 9:08 AM revealed that the door was located immediately to the left of the reception desk. Further observation revealed that Smoking monitor, Employee E12 was at the door to the courtyard and was writing names of residents who were going into the courtyard. Further Employee E12 was assisting residents on wheelchairs and controlling the traffic of residents who were passing through the door. Interview with Smoking monitor, Employee E12 conducted on September 9, 2025, at 1:43PM revealed that at the time of the incident with Resident R1, at almost 3PM, his partner Employee E13 smelled marijuana and told him to check. Employee E12 then went to see the group where the smell was coming from when he saw a flash on Resident R1's face who was nearby and saw that Resident R1's face was burned on the face. Employee E12 then turned off Resident R1's oxygen and took Resident R1 to the nurse supervisor's office next to the front desk. Interview with Smoking monitor, Employee E13 confirmed that she was working at the time of the incident and that she was assigned to watch the door and Smoking monitor, Employee E12 was assigned to be by the gate on the other end of the courtyard. Further interview with Smoking monitor, Employee E13 revealed that while manning the door to the courtyard, she smelled marijuana and asked Smoking monitor, Employee E12 to check. After a while she heard a loud pop and heard one of the residents yelled fire or something and when she looked, she saw Resident R1 in the gazebo. Further Smoking monitor, Employee E13 revealed that Resident R1's face was bleeding and that Smoking monitor, Employee 12 was already there helping Resident R1. Additional interview with Smoking monitor, Employee E13 revealed that she was assigned to the door and was writing down names of residents who came through the door to the Smoking Courtyard. Employee E13 revealed that there was a Bar-B-Q going on at that time and there were a lot of residents in the courtyard and that she was very busy. She did not notice Resident R1 go into the courtyard and did not know how Resident R1 got in.Resident R1 was in the hospital at the time of investigation and was not available for interview.The facility failed to supervise Resident R1 who was on oxygen while smoking in the courtyard. This failure resulted in actual harm to Resident R1 whose oxygen nasal canula ignited while smoking causing Resident R1 to sustain first and second degree burns to his face. This deficiency was cited as past non-compliance.Review of facility Action plan/Follow up documentation revealed the following information.Resident was immediately assessed and noted with burns to his/her face. 911 (emergency transport) was called and resident was transferred out. Other residents that were present in the courtyard were assessed with no injuries noted. Fire Marshall assessed and reviewed incident at the facility. - date completed-8/27/25 House wide room sweeps of the facility were conducted in an attempt to recover lighters and matches from the residents. - date completed- 8/27/25Current list of residents that smoke was reviewed to determine if there were others that also wear O2. - date completed- 8/27/25Current residents that smoke had new smoking assessments completed- - 8/27/25Current residents that smoke had care plan reviews completed on or before 8/27/25.Signs were placed on the door to the smoking courtyard to alert staff and residents that O2 use is not permitted during smoking times.- date completed - 8/27/25Re-direction was completed with smoking monitors on smoking safety and updated smoking policy. - date completed- 8/27/25Dialysis staff educated regarding process for returning residents to nursing unit when the complete dialysis and not to allow resident to leave until a facility staff member comes to transport them back to their nursing unit. -9/5/25A new attendance sheet/safety check sheet was implemented with smoking monitors for each smoke break to ensure there are no safety concerns such as O2 use before initiating smoking. - 8/28/25Facility smoking times and schedules were reviewed for assigning units/times in an effort to decrease volume of resident at one time. -8/27/25A new Security Attendant safety check form and process was implemented for resident who leave the facility on independent LOAs. - 8/27/25Facility smoking policy was reviewed and revised to include resident that are on continuous O2 will not be permitted to smoke and will be offered smoking cessation alternatives. -8/27/25NHA or designee will complete 5 smoke break observations per week x4 weeks. Results will be reviewed during facilities monthly QAPI meeting to determine further need for auditing. -8/29/25DON or designee will complete weekly audits of 5 residents that smoke to ensure assessment, care plan and O2 use is assessed and care planned x4 weeks. Results will be reviewed during facilities monthly QAPI meeting to determine further need for auditing. -8/29/25 Review was conducted of clinical records, facility documentation, staff education, and facility audits. Residents and visitors smoking rules were revised and staff education completed. Interview with staff revealed that the staff was knowledgeable about the facility's rules of no oxygen allowed in the smoking courtyard. Dialysis staff were in-serviced related to returning residents to nursing unit once dialysis treatment was completed. It was determined that the plan of correction was implemented and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined the facility failed to protect Resident R271 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R137 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident 208 on January 31, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R137 was found pinning down and performing oral sex on Resident R271. (Resident R137 and Resident R271) Findings Include: Review of facility policy titled Abuse reviewed December 13, 2024, revealed sexual abuse is defined as non-consensual sexual contact of any type with a resident. It is the policy of the facility that residents will be protected from abuse while they are residing at the facility. Review of the Facility Assessment Tool (determines what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies) dated January 16, 2025, revealed more than half (55%) of the resident demographic was made up of psychiatric/ mood disorders. Continued review of the facility assessment revealed that approximately 50% of the residents living in the Memory Care unit (4th floor nursing unit) have behaviors toward others, wandering or exit seeking behaviors. Review of Resident R137's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 20, 2025, revealed resident was admitted to the facility on [DATE], and had moderate cognitive impairment. Further review of the MDS assessment revealed Resident R137 was independent for mobility (walking 10 and 50 feet) and noted diagnoses of Depression (major loss of interest in pleasurable activities) and alcohol dependence with alcohol-induced persisting Dementia (progressive degenerative disease of the brain). Review of Resident R137's comprehensive care plan dated January 16, 2025, revealed the resident displayed inappropriate sexual behaviors (verbal or physical) related to making inappropriate remarks. Resident R137 touches other residents and/or staff inappropriately. Review of Resident R137's clinical record revealed a nursing note dated January 31, 2025, at 3:24 p.m. that revealed [Resident R137] is engaged in inappropriate sexual behavior with staff and other residents. He attempted to touch the private parts of one staff and another resident. Additional review of Resident R137's comprehensive care plan revealed the care plan was revised on January 31, 2025, to include new interventions for every 15 minute checks. Review of Resident R208's quarterly MDS dated [DATE], revealed the resident was rarely/never understood and had short-term and long-term memory problem. Further review of the MDS assessment revealed Resident R208 had diagnoses of Manic Depression, Bipolar Disease (condition in which a person has period of depression and periods of extreme happiness), and Adjustment Disorder with mixed anxiety and depressed mood. Review of Resident R208's comprehensive care plan dated February 23, 2024, revealed the resident had an alteration in neurological status related to traumatic brain injury (TBI). Intervention dated February 23, 2024, included to cue and redirect Resident R208 as needed. Interview on February 13, 2025, at 11:15 a.m. with Licensed Nurse 4th floor Unit Manager, Employee E14, revealed this employee was unaware of who's private parts Resident R137 attempted to touch, and did not have an incident report (formal document that records unexpected events, accidents, or issues within a company. The document provides a detailed account of the incident, including where and when it happened, who was involved, and any contributing factors) for the incident of January 31, 2025. Interview on February 13, 2025, at 11:26 a.m. with Licensed Nurse, Employee E23, revealed on January 31, 2025, staff overheard screaming from Resident R208's room. When the nurse aide responded to the screaming, Resident R137 was observed attempting to touch Resident R208's penis. Continued interview with Licensed Nurse, Employee E23, revealed this incident was the first of witnessing Resident R137 act sexually inappropriate. Interview on February 13, 2025, at 11:40 a.m. with Nurse Aide, Employee E24, revealed on January 31, 2025, the employee responded to yelling in Resident R208's room and Resident R137 was observed pulling at Resident R208's pants saying [Resident R137] wanted to suck Resident R208's penis. Continued interview with Nurse Aide, Employee E24, revealed this incident was reported to the charge nurse. Review of Resident R271's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 8, 2024, revealed the resident was rarely/never understood. Resident R271 assessed with BIMS (Brief Interview of Mental Status) of 3, which indicated the resident had severe cognitive impairment. Further review of Resident R271's MDS assessment revealed Resident R271 had behaviors of wandering daily and diagnoses of Dementia and Psychotic Disorder (loss of contact with reality). Review of Resident R271's clinical record revealed a nursing progress note dated January 25, 2025, indicating the resident was observed by the nursing staff wandering into other residents' rooms. The nursing staff indicated the resident was redirected to his/her room several times. Further review of Resident R271's clinical record revealed a nursing progress note dated January 30, 2025, that indicated this resident was wandering around the nursing unit. Review of Resident R271's comprehensive care plan initiated at the time of admission to the facility on [DATE], revealed the resident had behavior problem related to Psychosis, wandering in other resident's rooms, and difficult to redirect. Interventions developed included to check in on the resident every 30 minutes and informed resident that behavior is not accetable and suggest appropiate ways to express self Review of Resident R271's clinical record revealed a nurse practitioner assessment dated [DATE], that indicated this resident had diagnoses of Psychosis (loss of contact with reality resulting in disorganized thinking) and Dementia. The nurse practitioner indicated being unable to obtain information from Resident R271 because of cognitive deficits. Continued review of Resident R271 clinical record revealed a nursing note dated February 12, 2025, that indicated this resident was wandering about the nursing unit and required redirection at all times. Interview on February 13, 2025, at 11:00 a.m. with Licensed Nurse, Employee E13, who was familiar with the care of Resident R271 confirmed this resident was significantly confused and wandered about the nursing unit ad lib (as desired). Interview on February 13, 2025, at 11:15 a.m. with Licensed Nurse 4th floor Unit Manager, Employee E14, confirmed, Resident R271 had been wandering into other residents' rooms since admission to the facility in August 2024. The nurse reported the other residents do not want Resident R271 wandering inside their bedrooms. This nurse also confirmed that besides every 30 minute checks, the care plan for Resident R271 had not been revised to include recreational needs for resident's with Dementia. Review of Resident R271's clinical record revealed a nursing progress note dated February 13, 2025, that indicated Resident R271 was sent to the emergency room of the hospital as a sexual assault victim. The nursing staff documented Resident R271 had a change in mental status as a result of the sexual assault. Review of Resident R271's hospital record revealed Resident R271 was sent to the hospital on February 13, 2025, because the resident was found on the floor receiving oral sex from another resident (Resident R137). Review of facility documentation revealed a statement by Nurse Aide, Employee E22, dated February 12, 2025, that indicated as Nurse Aide, Employee E22, was coming out of another resident's room; the employee witnessed the Resident R271 being pinned down by Resident R137. As Nurse Aide, Employee E22, entered the room Resident R137 was observed to have both of Resident R271's arms pinned to his/her side performing oral sex on Resident R271. Resident R271 was observed squirming and holding onto his/her brief. Nurse aide, Employee E22, promptly notified the charge nurse of the incident who subsequently responded to the incident and was able to get Resident R137 off Resident R271. Resident R271 was then escorted back to his/her room until the local police arrived. Interview on February 13, 2025, at 12:53 p.m. with Nurse Aide, Employee E20, revealed on February 12, 2025, at approximately 9:30 p.m. Nurse Aide, Employee E22, called for assistance and when Nurse Aide, Employee E20, responded she observed Resident R137 holding down Resident R271 and performing oral sex. Nurse Aide, Employee E20, revealed Resident R137 was completely unaware that staff were in the doorway observing the incident. Further interview revealed Nurse Aide, Employee E20, and Nurse Aide, Employee E22, went to get the charge nurse to assist and then went back to the resident's room before intervening. Interview on February 13, 2025, at 3:20 p.m. with Licensed Nurse, Employee E16, revealed approximately two weeks prior during an initial encounter with Resident R137, the resident asked Licensed Nurse, Employee E16, if Employee E16 had a big penis and if Resident R137 could suck his penis. Continued interview with Licensed Nurse, Employee E16, revealed that on February 12, 2025, at approximately 9:30 p.m., the employee was notified by Nurse Aides, Employee E20 and E22, that Resident R137 was performing oral sex on Resident R271. Licensed Nurse, Employee E16, promptly responded to the incident between Resident R137 and R271. Licensed Nurse, Employee E16, observed Resident R137 performing oral sex on and subsequently had to physically remove Resident R137 from Resident R271. Interview on February 13, 2025, at approximately 9:45 a.m. with the Director of Nursing, Employee E2, confirmed that revealed on February 12, 2025, around 9:30 p.m. Resident R137 was found/observed performing oral sex on Resident R271. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on February 13, 2025, at 12:02 p.m. for the facility's failure to protect a resident from sexual abuse (non-consensual sexual contact) by a resident who had a history of sexually inappropriate behaviors. This resulted in Resident R137 pinning down and performing oral sex on Resident R271 while Resident R271 was observed squirming and holding onto his/her brief. An Immediate Jeopardy template (document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on February 13, 2025, at 12:11 p.m. The facility submitted a written plan of action on February 13, 2025, at approximately 2:51 p.m. and implemented the plan of action which included: 1. Resident R271 and Resident R137 were immediately separated and monitored by staff on February 12, 2025. 2. Police were called and arrived at the facility shortly after the incident on February 12, 2025. 3. Both residents (Resident R271 and R137) were sent to the local hospital emergency room for evaluation on February 12, 2025 and remained at the facility as of February 13, 2025. 4. Both residents (Resident R271 and R137) responsible parties were made aware of transfer and incident on February 12, 2025. 5. Skin checks were completed on 4-west with no adverse findings on February 12, 2025. 6. Current residents with known sexual behaviors were audited for recent behaviors and appropriate care planned interventions to ensure the safety of other residents. 7. Social worker completed random resident interviews to ensure no unwanted sexual behaviors have occurred or were occuring. 8. Abuse policy education was initiated house wide for identifying and reporting sexual abuse and sexually promiscuous behaviors including examples of such behaviors. 9. Change in Condition policy education was initiated with the nursing staff: Resident's exhibiting behaviors will have a change in condition assessment completed and will be discussed in clinical meeting for further care plan review and intervention implementation. When a behavior is observed, the resident(s) will be put on 1:1 observation until they are able to be assessed by IDT (interdisciplinary team) and the supervisor/DON or designee will be made aware. 10. The Change in Condition policy was reviewed and revised. 11. The Abuse policy was reviewed and updated to include examples of sexual abuse, warning signs and soft signs (excessive clingyness, low self esteem, recurrent nightmares, or overly friendliness towards strangers) of sexual abuse. 12. Residents with documented behaviors will be audited weekly x 4 weeks to ensure interventions and care plans are in place. Results of auditing will be reviewed during QAPI meeting to determine further need for ongoing auditing. Review of clinical records confirmed Resident R271 and R137 were transferred to the hospital and responsible parties were notified of the transfer and incident. Both residents remained at the hospital as of February 14, 2025. Review of facility documentation confirmed the facility completed skin checks for all residents on 4-west with no adverse findings. Review of facility plan of action confirmed the facility completed the audits to ensure other residents with known sexual behaviors had appropriate care planned interventions to ensure the safety of other residents. Interview with the Director of Nursing, Employee E2, on February 14, 2025, at 11:47 a.m. revealed each nursing unit census was printed out and reviewed with the unit manager to identify residents with sexually inappropriate behaviors. Any identified residents had care plans reviewed and ensured proper interventions were in place to keep residents safe. Further interview with the Director of Nursing, Employee E2, revealed staff also identified residents with wandering behaviors as these residents are at an increased risk for abuse. Further review of facility documentation confirmed residents were interviewed to ensure no unwanted sexual behaviors occurred. Interviews conducted with 37 staff members from all departments were conducted on February 14, 2025. All staff members reported that they received education regarding the abuse policy for identify identifying and reporting sexual abuse and sexually promiscuous behaviors including examples of such behaviors. Licensed nursing staff, nursing assistants as well as ancillary staff from all departments, including maintenance, therapy, dietary, activities, and housekeeping were interviewed. Interviews with licensed nursing staff confirmed staff were educated on the change in condition policy and interventions to implement for a resident exhibiting behaviors. The Abuse and Change in Condition policies were reviewed for revisions. The Immediately Jeopardy was lifted on February 14, 2025, at 12:32 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility policies, facility documentation, review of clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from verbal abuse for one of 36 residents reviewed which resulted in an Immediate Jeopardy Situation (Resident R464). Findings include: The facility's Abuse Policy dated November 28, 2016, indicates: verbal abuse is defined as the user of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident, or within their hearing distance, regarding less of their age, ability to comprehend, or disability. Example or verbal abuse include, but not limited to threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Review of admission record indicated Resident R464 was admitted to the facility on [DATE]. Review of Resident R464's quarterly Minimum Data Set (MDS - a periodic assessment of care needs) dated November 2, 2023, indicated the Resident R464's Brief Interview for Metal Status (BIMS) cognition was intact. Continue review of Resident R464's clinical record revealed the diagnoses to inlcude: Major Depressive disorder, recurrent, and cognitive communication deficit. Review of Resident R464's care plan, dated initiated July 25, 2023, revealed that the resident had behaviors related to problem solving, putting them at risk for negative behaviors, reduced independence with activities of daily living and safely awareness when navigating the SNF environment. Goal included: resident will exhibit adequate problem solving to safely navigate the SNF environment Interventions included: Speech Therapy to address deficits through active treatment plan. Review of information sent to the Department on October 11, 2023, indicated that Resident R464 was verbally abused by a Nurse aide (NA), Employee E22. Review of Nurse aide, Employee E22's witness statement dated October 2, 2023, indicated that the employee delivered a breakfast tray to said resident and I didn't notice that he already had a table, so I brought in a table for him to use that's when the verbal abuse started and that's when he threatened to hit me then he tried to swing at me. Then I reported to my unit manger then he came back out the hallway to continue to verbally abuse and threats. Review of Unit Manager, Employee E23's witness statement dated October 4, 2023, indicated hearing verbal altercation after walking through the doorway leading to the back hallway. Observation was made of Resident R464 and NA, Employee E22 engaged in heated argument, both were yelling and using profanity towards each other. The Resident R464 was observed sitting in his manual wheelchair in front of the room and NA, Employee E22 was approximately 10-15 feet away. Employee E23 stepped into separate both parties by grabbing Nurse aide, Employee E22 and asking to go to the nurse's station, the two were still yelling at each other. Review of Housekeeper, Employee E24's witness statement dated October 4, 2023, indicated witnessed NA, Employee R22 calling Resident R464 that thing and using profound language toward Resident R464. Both NA, Employee E22 and Resident R464 were calling cuss words yelling and screaming at each other. Review of facility documentation sent to the Department on October 11, 2023 revealed: Verbal abuse that occurred 10/3/2023 [sic - occurred on 10/2/2024] between a CNA and resident will be substantiated based on the witness statements. The CNA has not worked since the incident [sic - Nurse Aide Worked on October 4, 2023] and will be terminated. Interview on January 4, 2023, at 1:42 p.m. the Administrator confirmed that the facility failed to prevent verbal abuse for one of 36 residents reviewed (Resident R464). On January 18, 2024, at 10:47 a.m. an interview with Employee E24, Housekeeper, revealed that on October 2, 2023, at approximately 7:30 a.m. approached NA, Employee E22 to inform her that room [ROOM NUMBER] where Resident 464 was resigning was scheduled for deep detail cleaning. Employee E22 responded that thing over there will not come out of the room. I don't know about that thing over there reference referring to Resident R464 who was in C bed. Resident R464 came to the door and responded to employee E22 who are you calling 'that thing'? Both Resident R464 and Employee E22 started verbal altercation by cursing at each other. Employee E22 observed stating to Resident R464 Fxxx you, you Bxxx, Mxx, Fxx. NA, Employee E22 was also observed by going toward Resident R464 by holding her right hand in the air and pointing with her thumb and index finger up and using cursing language. The unit manager, Employee 23, came to separate and pulled Employee E22 by her right hand and pulled her away to the nursing station. Housekeeper, Employee E24 as a mandated reporter did not report this verbal abuse to anyone as she assumed that Unit Manager, Employee E23 directly observed NA, Employee E22 cursing at the Resident R464 and interfered in the verbal altercation and would take the appropriate actions to report it to the administration. On January 18, 2024, at 11:08 a.m. an interview was held with Assistant Administrator (ANHA), Employee E13 who conducted the internal investigated of verbal abuse. It was revealed on October 2, 2023, at approximately 10:30 a.m. the unit manager Employee E23 came to her office and reported that NA, Employee E22 desires to go home as Resident R464 yelled at her and E22 was unable to perform her responsibilities. No other information was shared with Employee E13 for her to take action to investigate the matter of potential verbal abuse. The next day or two later I went to speak to Resident R464 who reported that they got into a verbal altercation about tray and his wheelchair being moved and he couldn't get to his wheelchair. I asked if he felt safe and he stated yes and that's when we started the investigation and suspended NA, Employee E22. Investigation began on 10/4/23. ANHA, Employee E13 confirmed that Unit Manager, Employee E23 and Housekeeper, Employee E24, failed to report verbal abuse immediately and there was a delay in conducting the investigation and suspending the NA, Employee E22 who was the alleged perpetrator. ANHA, Employee E13 confirmed facility inaccurately reported to the Department that the verbal abuse occurred on October 3, 2023, as the verbal abuse occurred on October 2, 2023. ANHA, Employee E13, confirmed according to the punch report Employee E22 worked on October 2, 2023, from 7:09AM-3PM. Was off on October 3, 2023, and returned to work on October 4, 2023, at 7:02AM-10:15 AM. Facility did not suspend the alleged perpetrator immediately and allowed her to perform her responsibilities. ANHA, Employee E13 clarified that based on the record Employee E22 left the building on October 2, 2023, at approximately 10:00 a.m. as being upset and unable to perform her responsibilities. However, the human resource department edited the timecard and paid her until end of her shift which ended at 3:00 p.m. Surveyor reviewed the re-training sign in sheets for recognizing and reporting elderly abuse, which was dated October 3, 2023, with re-training approximately 173 staff. ANHA, Employee E13 was questioned why the facility did not recognize the abuse until October 4, 2023, why there was a re-training conducted of all staff on October 3, 2023, and there was no clear answer provided by ANHA, Employee E13. On January 18, 2024, at 12:04 p.m. a telephone attempt was made to interview unit manager, Employee E23 who was no longer working for the facility and there was no response. Voice message was left. On January 18, 2024, at 2:10 p.m. interview was conducted with Resident R271 who a roommate for Resident R464 was recalled the situation which occurred on October 2, 2023 and reported the incident woke me up as the [Resident R464] was using profanity toward NA, Employee E22. Resident R271 did not hear NA, Employee E22 curse at the Resident 464 besides might of said yea you too, I can't recall if she called him any names. On January 18, 2024 at 2:35 p.m. Resident R86 which room was located near Resident's R464 was interviewed who overheard the verbal altercation and remember coming toward her doorway to observe the situation. Resident R86 reported Resident R464 asked for assistance as he/she was really disabled. NA, Employee E22 started using profound language toward Resident R464. Resident R464 started cursing and NA, Employee E22 as it became uncontrollable. I came out of the room to observe it and hear it. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from verbal abuse from a nursing aid staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on January 18, 2024, at 12:36 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 1. Resident R464 had a skin check performed with no findings. Resident R464 continued schedule skin checks per clinical record review. 2. Per nursing notes no distress was noted 3. The alleged perpetrator was suspended on 10/4/2023 and terminated on 10/11/2023 based on investigation. 4. On 10/11/2023 resident was offered emotional support by social services. 5. Resident was monitored post incident for ongoing support. 6. Other residents on the assignment were interviewed to ensure that no other residents were affected. completed on 10/4/2023 7. 100% Unit Managers and CNAs were educated on recognizing and reporting abuse completed on 10/13/2023 8. 100% of housekeeping staff will be educated on recognizing and reporting abuse completed on 10/13/2023. 9. Weekly audits will be completed weekly x3 to identify abuse for 2 months to identify on each shift. 10. Weekly audits of grievances will be completed by administration to ensure residents have not experienced abuse of any kind. 11. During QAPI the facility will review the audits and reportable events to determine if there have been allegations of abuse. 12. Facility will report allegations of abuse through the event reporting system. Review of facility documentation revealed that the corrective action plan was immediately initiated. Interviews were initiated to screen residents for abuse. Residents were interviewed by facility staff. Facility in-services for staff were promptly initiated and included abuse and neglect and reporting requirements. Examples of verbal abuse reviewed included screaming, yelling, cursing, etc. Interviews were conducted on January 18, 2024 between 10:47 a.m.-2:55 p.m. & 3:06 p.m.-5:10 p.m. with staff from various departments. All staff reported that they received the in-service training. It was confirmed during the interviews that they were able to recognize signs of resident abuse, that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process. Interviews conducted on January 18, 2024, between 2:18 p.m.-2:52 p.m. & 3:06 p.m.-3:13 p.m. with residents from all nursing units reported that they had no concerns related to staff or care. Residents denied any concerns of abuse and reported that they felt safe at the facility. The Immediate Jeopardy was lifted on January 19, 2024, at 9 :30 a.m. 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 observations, review of clinical records, review of facility policies, review of documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise a resident who was assessed to be at risk for elopement for one of eight residents reviewed, resulting in Resident R1 exiting the secure dementia unit, eloping from the facility, and missing for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy. (Resident R1) Findings include: Review of facility policy title, Elopement revised on March 1, 2023, revealed, elopement is defined as, when a resident leaves the premises or a safe area without authorization and or necessary supervision and elopement risk prevention protocol should be followed. Included in the purpose of the policy was to provide prompt and appropriate intervention(s) should an elopement occur and to train and maintain staff awareness of the importance of resident safety and security. Review of facility's documentation related to fire drill performance stated perform a drill during the third shift. Test the system by activating a smoke detector, pull station, or other trigger in the proper zone. Maintenance staff should verify activation at the fire department/monitoring company. Staff in the zone of origin should systematically inspect each room to find the fire and ensure doors are closed. Notify residents of the drill, if applicable document who the residents were that were involved in the evacuation, and where they were evacuated to. Verify operation of the alarm system (during drill). Conduct a walk-through inspection checking the following items: magnetic outside courtyard gate releases, areas of the building will include: dining rooms, kitchen, laundry, shower room and therapy/gym. Review of Resident R1's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 15, 2022, revealed that the resident was admitted to the facility on [DATE], with the diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (high blood pressure), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), long term use of insulin and alcohol use with unspecified alcohol-induced disorder. Continued review of the MDS revealed that the resident was independent in making decisions regarding tasks of daily life and that the resident had wandering behaviors. Review of nursing notes revealed a note, dated September 8, 2022, at 9:17 p.m. which indicated that Resident R1 was admitted to the facility and that due to having a history of elopement a Wanderguard (devise that is place on resident's wrist or ankle which prevent doors to the unit to be open for exit) was placed on the resident's leg. Review of Resident R1's Elopement Risk Assessment, dated October 27, 2022, and September 3, 2023, revealed that the resident was identified by the facility as being at risk for elopement. Review of nursing note dated April 14, 2023, at 2:24 p.m. indicated that Resident R1 attempted to elope from the building at 10:00 a.m. The resident asked his aide to accompany him to the vending machine to buy some snacks and while the resident was at the lobby, he ran through the front door that was open and took off. Aide alerted bystanders who helped to run after him and caught up with him at the parking lot. The resident was subsequently redirected back to the secure dementia unit. Review of Resident R1's care plan last revised August 31, 2023, revealed that a care plan for the risk of elopement related to impaired safety awareness. Resident wanders seeking exit from the unit. The interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book; identified patterns of wandering and a Wanderguard alert. Further review of Resident R1's clinical records revealed a physician order dated May 23, 2023, for frequent monitoring; every shift for elopement. Interview on September 18, 2023, at 11:11 a.m. with Employee E3, nurse aide, revealed that she was the assigned nurse aide to care for Resident R1 on September 14, 2023, during the 11-7 shift. Employee E3 stated that when the fire drill alarm activated, around 12:30 a.m., she was called down to the first floor to participate in the fire drill and sign paperwork, along with nurse aide, Employee E4. After signing the fire drill documents, Employee E3 proceeded to assist her assigned residents with personal care and failed to ensure Resident R1 was in his room and to head count her assigned residents after the fire drill. After the fire drill, Employee E3 proceeded to provide care to resident starting from room [ROOM NUMBER], not accounting for Resident R1. Interview conducted with the Charge Nurse on the locked dementia unit, Employee E5, on September 18, 2023, at 3:54 p.m. Employee E5 confirmed that she failed to supervise the exit door on the high side (rooms 417-424) because multiple residents on the unit verbalized exit seeking behaviors. I was all over the place; it got hectic; and I couldn't just stand at the door. Further interview revealed that the Charge Nurse, Employee E5, was notified by nurse aid, Employee E3, that Resident R1 was missing at approximately 5:00 a.m., four and a half hours after Resident R1 eloped. Further interview conducted on September 18, 2023, with nurse aide, Employee E6, at 5:30 p.m. revealed that because the nurse aides, Employee E3 and E4, were called down to participate in the fire drill, the dementia locked unit only had two employees to supervise all of the residents on the floor. Nurse Aide, Employee E6, secured the exit door on the low side (rooms 401-408) during the drill. Interview with the facility receptionist, Employee E11, conducted on September 19, 2023, at 12:44 p.m. revealed that she had seen the resident during the fire drill on the first floor. Employee E11 stated, I saw the resident, I told my coworker to get that door (the door to the outside smoking area). He stood there and the resident turned around and went towards the west side . I didn't see him afterwards; we were signing papers. Review of facility provided documentation, Camera Timeline and Pictures revealed that on September 15, 2023, at 12:34:35 a.m. the resident was headed towards the admission office, failed to open the office door, and then headed towards the reception area but never came insight of front desk. At 12:35:36 resident was seen walking back in sight past elevators. At 12:35:48 the resident went down the hallways towards the ATM (automated teller machine). At 12:36:27 a.m. the resident was headed toward smoke room hallway and exited outside through the exit door at 12:36:41 a.m. An interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, conducted on September 18, 2023, at approximately 1:20 p.m. confirmed that lack of supervision on the Fourth-floor secured dementia unit resulted in Resident R1 escaped from the fourth-floor unit through the unsupervised exit door (which was located approximately five steps from his room). Failing to secure the exit doors on the First floor resulted in Resident R1's escape out of the facility through the indoor smoke room hallway exit door. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. Resident R1 went missing from September 15, 2022, at 12:36 p.m. and is still yet to return. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on September 18, 2023, at 1:54 p.m. On September 18, 2023, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility's plan of correction included the following: 1. Upon notification that a resident had eloped from the facility, the facility initiated a search for the resident at 5 a.m. on September 15, 2023. The facility notified the following: police, family member, searched/called shelters, local hospitals and public transportation. 2. Facility immediately concluded resident head count and confirmed that all other residents were accounted for. 3. On September 15, 2023, the facility audited 100% of the residents at risk for elopement that have an order for a wanderguard which equaled 33 residents. This audit included a review of the residents Elopement User Defined Assessment, orders, and care plan. 4. On September 15, 2023, the facility verified that 100% of photos of wandering residents remain posted in ancillary departments and at nurses' stations for staff awareness were current. 5. On September 15, 2023, the facility revised its fire drill policy and procedure to include the following: o Following drill head count to be completed and reported to Maintenance. o Added question to ensure elevators/ stairwells are monitored during drill. o Do not set audible alarm for 11-7 drills. o Only send one nursing assistant to fire drill from the dementia unit. 6. On September 15, 2023, the facility-initiated elopement and fire drill education which carried out through the weekend. As of September 18, 2023, 33% of facility staff were reeducated on the elopement and fire drill policies. This education will continue at the start of each shift until the facility receives 100%. Any staff that we are unable to reach will be educated prior to working. 7. The facility added a screamer alarm on the exit door near smoking room which is activated 24/7 and is not connected to the wanderguard system so it will alarm regardless of fire alarm when offline. 8. The facility will complete elopement and fire drills weekly starting on September 18, 2023, for 2 months. During the fire drills, audits will be completed to ensure new protocols are being followed including supervision of exit doors and head counts following drills to ensure prompt accountability of all residents in the facility. The facility conducted its first drill on September 18, 2023, at 5:00am. 9. All audits will be reported to Quality Assurance Performance Improvement Committee. After the initial audits are completed, the committee will review the audits findings and determine the frequency of future audits. A review was conducted of the education, competencies and drills provided to facility staff related to resident elopement. Interviews were conducted on September 19, 2023. Facility staff were able to verbalize proper unit procedures during a fire drill. Facility staff demonstrated verbal understanding of key concepts from recent training, including the importance of securing the exit doors, conducting a head count, and sufficient supervision during the fire drill. Staff were able to define elopement and identified the importance of notifying authorities right away. Facility audits were reviewed and residents who were identified by the facility as being at risk for elopement had appropriate elopement prevention measures in place. Review of audits and a tour of the facility's screamer (an activating alarm when the door opens) system was conducted on September 19, 2023, at 5:06 p.m. and alarms were functioning appropriately. Review of facility documentation revealed that the corrective action plan was immediately initiated on September 18, 2023. The facility's action plan was accepted on September 19, 2023, at 5:32 p.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility's documentation, review of clinical records, review of hospital records and staff interview, it was determined that facility failed to ensure that the appropriate assistive device for ambulation and safe use and to provide supervision to Resident R1 to prevent from utilizing his cane to harm other residents. This failure resulted in actual harm to Resident R2 who was hit by Resident R1 on the head and requiring transfer to the hospital and a diagnosis of head injury for one of three residents reviewed. (Resident R1 and Resident R2) Findings include: Review of Residents R1's clinical records revealed the diagnoses of Alzheimer's disease (irreversible, progressive disease of the brain), dementia with agitation, and altered mental status. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated June 7, 2023, revealed a BIMS (Brief Interview of Mental Status) score of 13 which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident required limited assistance with ambulation and used a cane as a mobility device. Review of Resident R2's quarterly MDS dated [DATE], revealed that the resident was assessed with a BIMS score of 3, which indicated that the resident was cognitively impaired. Further review of the MDS revealed that the resident required limited assistance with ambulation. Review of a psychiatric evaluation dated April 4, 2023, revealed that Resident R1 was seen for confusion and agitation. Review of Resident R1's nursing notes dated April 6, 2023, at 9:15 a.m. revealed this morning charge nurse reported that (Resident R1) hit (Resident 3) on his left arm with stick. According to charge nurse, Resident R1 admitted to hitting him too. Stick was removed from him by charge nurse. Review of Resident R1's care plan dated April 7, 2023, revealed that the resident was identified with a potential to be physically aggressive to others related to poor impulse control. The only intervention listed was Administered medications as ordred. Monitor/document side effects and effectiveness. On April 9, 2023, quarterly care conference was held with interdisciplinary team, R1 and R1's son. Per facility's social worker, no new behaviors and no changes in R1's condition noted in documentation. There was no evidence that the Resident R1's care plan was updated with interventions to address the resident's use of a cane to hit another resident. Review of Social Services note dated April 6, 2023, at 1:41 p.m. revealed [Resident R1] was noted to be involved in an altercation with another resident. Interviewed him and found him in 4W lounge, very friendly. Asked if anything had happened recently, and he immediately said that something had, that he had hit someone with his cane, but couldn't remember who it was. At that moment, the other resident named in the incident walked by and (Resident R1) said to him, Who did I hit with my cane? The other resident said, You know who you hit. It was me. (Resident R1) immediately apologized, said it was just a reflex and both men stated their ongoing friendship. Both appeared in no distress. SS to provide 1:1 visits to provide ongoing emotional support and to monitor for changes. Review of nursing note dated April 6, 2023, at 3:26 p.m. revealed that physical therapy consult initiated for resident to be evaluated for assistive device due to previous walking stick being removed due to resident hitting another resident in the arm with walking stick. Review of physical therapy note from April 12, 2023, revealed that Skilled interventions to address Gait Training focused on anticipatory responses with single point cane (SPC) that he owns MI (Modified Independent). Resident states he was defending himself against another resident. Resident refused to give up SPC. Rolling walker (RW) put in room and nursing communication completed with nursing staff stating they will wean off SPC. There was no documented evidence of steps and intervention implemented in weaning Resident R1 from the use of a cane. There was no evidence that nursing staff encourage and/or aide Resident R1 in using the rolling walker for ambulation in place of the single point cane. Review of Resident R1's physician documentation dated April 17, 2023, stated Ambulatory dysfunction uses a cane at baseline continue supportive care. Additional review of nursing notes from June 30, 2023, revealed that at approximately 7:40 p.m. Resident R1 had another physical altercation with Resident R2. Resident R1 hit Resident R2 on left temporal area with his cane resulting in deep facial laceration. Resident R2 was sent to emergency roiagnom on [DATE], at 8:00 p.m. for head injury and facial laceration including left upper staples. Review of Resident R2's annual MDS dated [DATE], revealed a BIMS score of 9 which indicated that the resident had moderate cognitive impairment. Continued review of the MDS revealed that the resident required limited assistance with ambulation and utilized a walker and wheelchair for mobility. Review of Resident R2's care plan initiated October 14, 2022, revealed that the resident had the potential to be physically aggressive to others related to dementia and poor impulse control. Interventions included to administered medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what behavior and document what de-escalates behaviors; give the resident as many choices as possible about care; psychiatic/psychogeriatric consult as indicated. Review of Resident R2's hospital discharged summary dated June 30, 2023, confirmed the resident's diagnosis of head injury and facial laceration. Interview with the Director of Nursing and Nursing Home Administrator on July 7, 2023, at 1:00 p.m., revealed that this incident occurred in lounge room. Nurse aide, Employee E4, was assigned to supervise residents in lounge area during that time but was not present during incident. Additional interview with Director of Nursing revealed from now on we will have our own staff assigned on lounge duty instead of agency nursing staff. The facility failed to ensure that the appropriate assistive device for ambulation and supervision was provided to Resident R1,with a history of aggressive behaviors. This failure resulted in actual harm to Resident R2 who was hit by Resident R1 on the head, requiring transfer to the hospital and repair to a laceration on the head. Refer to 744. 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.12(c) Nursing services 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, review of a facility reported incident, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to provide appropriate supervision for one of eight residents reviewed (Resident R1) which resulted in Resident R1 eloping from the facility during a smoking break at 2:30 a.m. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled, Elopement revised October 24, 2022, revealed it is the policy of the facility to provide a safe and secure environment for all residents. The purpose of the policy is to assure the safety and security of all residents. CMS (Center for Medicare and Medicaid Services) defines elopement as when a resident leaves the premises of a safe area without authorization and or necessary supervision. Further review revealed, Staff education regarding responsibility to identify, report and intervene related to wandering/elopement risk such as but not limited to: anticipate resident needs based upon wandering triggers and patterns; acknowledge resident's behavior as an attempt to communicate needs; and encourage verbalization, identify etiology and recognize feelings. Review of facility Smoking Safety Policy, revised October 22, 2022, revealed, It is the facility policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices. Further review revealed, New admissions shall be informed upon admission that we enforce a smoking safety policy and procedure through admission agreement. They will be informed to not give smoking paraphernalia to any residents including their loved one. All smoking materials are to be delivered to the staff for proper storage. Staff members and volunteer workers should not purchase or give smoking paraphernalia to any residents unless it is coordinated via the activities department. Review of Resident R1's admission documentation revealed that the resident was admitted to the facility on [DATE]. Further review revealed a guardian certificate indicating that the Court adjudicated (Resident R1), a totally Incapacitated Person and appointed a permanent plenary guardian of the person and estate on June 29, 2021. Review of Resident R1's Minimum Data Set (MDS-a mandatory periodic assessment of resident care needs) dated April 21, 2023, revealed that the resident was admitted to the facility with the following diagnoses: schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), other abnormalities of gait and mobility; Type 2 diabetes mellitus (failure of the body to product insulin) with diabetic chronic kidney disease; Type 2 diabetes mellitus with hyperglycemia (high blood sugar levels); adjustment disorder with mixed anxiety and depressed mood; heart failure, chronic kidney disease stage 3, and tobacco use. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating that the resident was cognitively intact. Review of Resident R1's care plan, initiated on April 14, 2023, revealed Resident R1 was an elopement risk related to impaired safety awareness, new admission/adjustment and wandering aimlessly. Further review of care plan revealed, the resident was a smoker. The resident has a habit of smoking in her room. The resident was educated on the risk of smoking and the facility policy. Review of Resident R1's nursing notes dated, June 2, 2023, revealed when the charge nurse came on the floor at the start of the shift, Resident R1 was walking around the unit eating snacks. At approximately 2:38 a.m., Resident R1 stated, 'I want to go outside to smoke.' Resident has a habit of smoking in the room. Resident has an order that resident is allowed to go on LOA (leave of absence) with family after the approval by the guardian. The care nurse took the resident to the outside courtyard to go smoke. At 3:02 the charge nurse received a call from the front desk that the resident ran off from the care nurse that took her outside to smoke. 911 (Emergency Medical Services) was called immediately. A police report was taken. The DON (Director of Nursing), ADON (Assistant Director of Nursing), Administrators, Medical Director and unit manager were notified. Also, a message was left for the guardian. Review of the facility investigation report dated June 2, 2023 revealed that Resident R1 was admitted to the facility on [DATE], as a transfer because she was a smoker at a sister facility and they did not allow smoking. Upon admission, an elopement assessment was completed that yielded a score of 15 (10 or greater is categorize at high risk for elopement). Since the resident was being transferred from a sister facility, we felt confident of resident's history and did not implement interventions for risk for elopement. The resident never showed signs of exit seeking . Resident has a history of two smoking violations that resulted in an intervention of smoking breaks outside the routine designated smoking hours .During the 11-7 shift, a nursing assistant took two residents out for an additional smoke break to the courtyard. [Resident R1] did not have a cigarette so the nursing assistant knew her car was parked right out of the courtyard so she left to get a cigarette from her car. When she returned, the resident was not in the courtyard. The nursing assistant returns the other resident inside the facility for safety and notifies supervisor. Nursing assistant initiates a perimeter search. Nursing assistant goes to her car to initiate search of neighborhood. Interview on June 7, 2023, at 5:00 p.m. with Employee E5, nursing assistant who worked 11-7 shift on June 2, 2023, revealed the resident kept asking me, 'Can you take me out to smoke? You promised.' This resident is often up all night. The other resident I took out to the courtyard sits in the lobby by the door at night. He is a smoker and asked to go out to smoke. She (Resident R1) never showed signs that she was trying to elope. I took her out many times to smoke at night. Interview on June 7, 2023, at 3:00 p.m. with Licensed nurse, Employee E4, who worked 11-7 shift on June 2, 2023, revealed, This was a younger resident who was up at night and wanted to smoke. Resident R1 was not a problem. Resident R1 was pleasant and walked back and forth in the hallway. I was afraid if she didn't get out to smoke that she would smoke in her room. Her roommate is on oxygen. Interview on June 8, 2023, at 1:30 p.m. with the front desk receptionist. Employee E6, who worked 11-7 shift on June 2, 2023, revealed I saw the nursing assistant exit the building at 2:30 a.m. with two residents. I did not see anyone exit the courtyard. Within minutes, the nursing assistant came into the building and announced that the other resident ran off from the courtyard. Please notify staff. Nursing assistant stated she was initiating a search of the parking lot. I notified house supervisor and second floor nurse. Interview on June 7, 2023, at 2:00 p.m. with Registered Nurse Supervisor, Employee E3, who worked 11-7 shift on June 2, 2023, revealed I received a call from the front desk that a resident had left the facility. I hurried out to my car and began driving toward 63rd and Market Streets. I arrived at 69th Street, a transportation hub, and saw the resident. I called 911 (Emergency Medical Services) to say I had located the resident. I approached the resident and asked if she would return to the facility with me. She was with a young man. Resident replied that she is not returning to the facility. Police arrived and spoke with resident. I explained to the police that this resident has a guardianship and that our facility was responsible for her care. By now, there were about five police officers there. They agreed that we could not detain the resident. The police stated that they don't have the right to hold her. The police insisted that I leave. I returned to the facility. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident while smoking on an outside patio at approximately 2:30 a.m. which resulted in the resident eloping from the facility. The resident was located by facility staff at a nearby public transportation hub a mile away from the facility in the middle of a major city. The failure of not properly supervising a resident during an unapproved smoking placed the resident at risk for injury resulting in an Immediate Jeopardy situation. The Nursing Home Administrator and Director of Nursing were notified of the Immediate Jeopardy situation June 7, 2023 at 5:44 p.m. and an immediate action plan was requested. The Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 7, 2023, at 5:44 p.m. On June 7, 2023, the facility initiated an immediate action plan to address the failure to provide appropriate supervision which placed Resident R1 and other residents of the facility at risk for harm. The facility's immediate action plan included the following: 1. Upon notification that a resident had left the facility unattended, the facility immediately conducted a resident head count and confirmed that all residents were accounted for on June 2, 2023. 2. The facility completed a new elopement risk assessment on all residents. 3. Nursing Administration reviewed residents with a score of 10 or higher to identify if they were a risk for elopement with appropriate interventions. 4. The facility educated the nurse that completed the resident's elopement assessment on interpretation of policy and elopement risk. 5. Facility completed a new smoking assessment on all residents that smoke. New smoking assessments were completed on 100% of the residents that are known to smoke. 6. The facility's smoking policy was updated that when exceptions are made for care planned interventions, smoking will only be allowed to occur in the smoking room within the facility. 7. The facility will continue with plan to reroute staff and LOA residents to alternate exit door and lock the Courtyard. 8. The facility completed audits on smoking assessments to ensure accuracy with 100% of current known smoking residents audited. 9. The facility initiated audits at 2:00 p.m. to ensure compliance with the new smoking policy, completed hourly through June 5, 2023 with zero issues noted. 10. On June 3, 2023, residents at risk for elopement had care plans with current interventions in place. 11. On June 4, 2023, the facility verified that photos of wondering residents remained posted in ancillary departments and at nurse's stations and were current. 12. On June 5, 2023, the facility staff were educated on elopement policy including elopement interventions and completion of elopement assessment. Education was initiated on June 2, 2023, with 100% completion on June 5, 2023. 13. Staff were educated on revised smoking policy. Education was initiated on June 2, 2023, with 100% completion on June 5, 2023. 14. All new hire education was reviewed and verified for completeness prior to new employees beginning work schedule. 15. The facility completed elopement drills every shift that were initiated on June 2, 2023 and continued throughout the weekend on June 3, 2023 and June 4, 2023 with zero issues noted. 16. On June 7, 2023, the facility initiated education on behaviors exhibited by residents who are at high risk for elopement. 17. The facility will continue with receptionist coverage at the front desk 24/7. The facility will continue elopement drills monthly with rotation of shifts per policy. 18. The facility will continue with routine elopement assessments per facility policy and will continue assessing new and readmissions for elopement risk. 19. The facility will continue routine smoking assessments per facility policy and will continue assessing new and readmissions for smoking. 20. Facility added audits of smoking area to security rounds check list. All audits will be reported to Ad HOC QAPI (Quality assurance Program Improvement) committee. Review of facility documentation revealed that the corrective action plan was immediately initiated on June 8, 2023. Education was completed and audits were initiated to ensure the provision of appropriate supervision with 100% compliance. Review of facility plan of action confirmed that the facility completed a list of all residents who were at risk of elopement. New assessments were completed. Facility completed elopement drill for the facility staff. Audits were reviewed. A list of residents with orders for be allow to have a leave of absence (LOA) was verified and appropriate LOA forms and instructions were updated. Interviews on June 8, 2023, with 58 staff members of the 7-3 and 3-11 shifts were conducted regarding re-education of smoking policy and elopement policy with 100% compliance. Licensed nursing staff, nursing assistants as well as ancillary staff from all departments, including maintenance, therapy, dietary, admissions, social services were interviewed. The Action Plan was accepted on June 7, 2023, and the Immediate Jeopardy situation was lifted on June 8, 2023 at 5:30 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services

Based on a review of clinical records, review of facility documents and resident and staff interviews it was determined that the facility failed to make certain that a resident was free from accident hazards and was provided a safe transfer resulting in actual harm when a resident was hit in the head / face with a Hoyer Lift causing a subdurral Hematoma, a cut lip and Headaches for one of forty residents reviewed (Resident R167). Findings Include: Review of Resident R167's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include Hemiplegia and Hemiparesis (Muscle weakness or partial paralysis on one side of the body) following Cerebral Infarction (stroke) affecting the Right Dominant side. Review of the Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) for Resident R167 dated September 26, 2022, revealed for transfers the resident required a two person physical assist and the Resident was determined to be cognitively intact. Interview with Resident R167 during a group resident council meeting on April 26, 2023 at 10:45 a.m. revealed the resident stated: I had an accident where I was hit by a Hoyer lift several months ago. I have been having headaches since, I was still supposed to see a neurologist, but I have not yet. Review of Resident R167's clinical record revealed on October 20, 2023, there was an incident that occurred where Resident R167 was injured by a Hoyer lift and was sent to the hospital. Further review of the resident's clinical record revealed documentation of ongoing headaches experienced by the resident. Review of facility documentation submitted to the Department of Health on October 21, 2023 revealed: revealed: Resident returned to the facility on ,d+[DATE] with diagnosis of a subdural hematoma tracking along the right falx and along the undersurface of the right temporal lobe ( head injury strong enough to burst blood vessels), and laceration to his upper left lip. Clinical record review revealed a discharge summary from a hospital stay from November 5 through November 6, 2022, which revealed: follow up with neurosurgery at [hospital] as soon as possible. Follow up in 1-2 weeks with CAT scan of your head prior to resuming aspirin and Plavix. Further interview with Resident R167 at 2:10 p.m. on April 27, 2023, revealed: the resident stated that while the staff was using the Hoyer lift they placed the Hoyer improperly. He stated that the hoyer lift was at the end of his bed rather than bedside like it usually is. The resident stated that while one staff was lowering him into his chair from his bed the second staff pulled back on the Hoyer sling which made the sling tilt over and hit him in the face. Resident R167 reports the second staff to be Nurse Assistant, Employee E19. Interview with Director of Nursing (DON) Employee E2, on April 27th at 1:20 p.m. reports staff competencies on hoyer lift training on file from 2018. No staff competencies on file from 2019-2022 prior to the incident that occurred in October 2022. Director of Nursing (DON) Employee E2 reports NHA an outside agency completed the trainings with the employees, but they are not able to access the documentation from 2019-2022. Documentation was not able to be provided. Interview with the Administrator, Employee E1, on April 27, 2024, at 2:30 p.m. revealed that no full witness statements was taken for Resident R167. The Administrator, Employee E1, confirmed that the only interview consisted of a statement in the incident report, incident description where the resident stated: An accident while trying to be transferred into his w/c. Employee E1, Administrator, confirmed that no other statement was taken for Resident R167 at the time of the incident or after. Interview with the Administrator, Employee E1, on April 27, 2023, at 2:17 p.m. revealed Nursing Assistant, Employee E19, was terminated for verbal abuse and neglect on April 3, 2023. Interview on May 4, 2023 at 11:00 a.m. with Employee E7, Nurse Aide, revealed: I was asked to assist Employee E19, Nurse Aide, with getting her resident out of bed into the wheelchair. I have worked here for twenty-two years. I know the correct way to position the hoyer lift. The correct way is to do it from the front. She positioned it from the side. Employee didn't do anything wrong but possibly she pulled the resident back too hard. That caused the resident to shift and I told her to pull the emergency release so he wouldn't fall. At that point, the hook hit his lip. I guess the bar with the scale attached could have hit him in the head but I didn't see that. We reported this to the charge nurse immediately. We provided statements. Then the Administrator asked us to demonstrate exactly what we did. We did not widen the base of the lift for stability. We were re-educated to widen the base when we are setting up the hoyer lift. The facility failed to make certain that a resident was free from accident hazards and was provided a safe transfer resulting in actual harm when a resident was hit in the head / face with a Hoyer Lift causing a subdurral Hematoma, a cut lip and Headaches 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of clinical records, review of facility documents, and interviews with staff and residents, it was determined that the facility failed to ensure that a resident was free from verbal abuse and neglect related to failing to provide goods or services that a resident requires by not ensuring that a resident received treatment and care following an Acute Care Hospital's discharge recommendations for a follow up appointment with a Neurologist which caused harm to Resident R167 related to the resident experiencing prolonged headaches for one of forty residents reviewed (Resident R167). Findings include: Review of Facility Policy Freedom From Abuse, Neglect and Exploitation, dated 2021, revealed: Purpose- To keep residents free from abuse, neglect and corporal punishment of any kind by any person. Types of Abuse . 5. Neglect a. Neglect may be occurring, if the facility is aware, or should have been aware of, goods or services that a resident requires but the facility fails to provide them to the resident. b. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Review of Resident R167's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include Hemiplegia and Hemiparesis (Muscle weakness or partial paralysis on one side of the body) following Cerebral Infarction (stroke) affecting the Right Dominant side. Review of the Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) for Resident R167 dated September 26, 2022, revealed for transfers the resident required a two person physical assist and the Resident was determined to be cognitively intact. Interview with Resident R167 during a group resident council meeting on April 26, 2023 at 10:45 a.m. revealed the resident stated: I had an accident where I was hit by a Hoyer lift several months ago. I have been having headaches since, I was still supposed to see a neurologist, but I have not yet. Review of Resident R167's clinical record revealed on October 20, 2023, there was an incident that occurred where Resident R167 was injured by a Hoyer lift and was sent to the hospital. Further review of the resident's clinical record revealed documentation of ongoing headaches experienced by the resident. Review of a report submitted to the Department of Health on October 21, 2023 revealed: Resident returned to the facility on [DATE], with diagnosis of a subdural hematoma tracking along the right falx and along the undersurface of the right temporal lobe ( head injury strong enough to burst blood vessels) , and laceration to his upper left lip. Further interview with the Resident R167 at 2:10 p.m. on April 27, 2023, revealed: the resident stated that while the staff was using the Hoyer lift they placed the Hoyer improperly. He stated that the hoyer lift was at the end of his bed rather than bedside like it usually is. The resident stated that while one staff was lowering him into his chair from his bed the second staff pulled back on the Hoyer sling which made the sling tilt over and hit him in the face. Resident R167 reports the second staff to be Nurse Assistant, Employee E19. Resident R167 reports the second staff Nursing Assistant, Employee E19, had been verbally abusive in the past saying keep my name out your mouth. Interview with Administrator, Employee E1, on April 27th at 2:17 p.m. revealed Nursing Assistant, Employee E19, was terminated for verbal abuse and neglect on April 3rd, 2023. Review of facility submitted information from October 20th, 2023, revealed resident R167, returned to the facility on ,d+[DATE] with diagnosis of a subdural hematoma tracking along the right falx and along the undersurface of the right temporal lobe, and laceration to his upper left lip. Clinical record review revealed a discharge summary from a hospital stay from November 5 through November 6, 2022, which revealed: follow up with neurosurgery at [hospital] as soon as possible. Follow up in 1-2 weeks with CAT scan of your head prior to resuming aspirin and Plavix. Interview with Unit Clerk, Employee E18, on April 27th at 12:55 p.m. revealed neurology appointment had not yet been held but is scheduled for June 15th, 2023. When questioned of an appointment held sooner, Employee E18 stated this was the soonest they could get Resident 167 an appointment. After asking for additional documentation relating to attempting to find an appointment for Resident R167, the facility could not provide any documentation. The facility failed to ensure that a resident was free from verbal abuse and neglect related to failing to provide goods or services that a resident requires by not ensuring that a resident received treatment and care following an Acute Care Hospital's discharge recommendations for a follow up appointment with a Neurologist which caused harm to Resident R167 related to the resident experiencing prolonged headaches. 483.13 Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise a resident who was assessed to be at risk for elopement for one of eight residents reviewed, resulting in Resident R1 exiting the secure dementia unit, eloping from the facility and missing for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. Findings include: Review of facility policy, Clinical Services: Elopement Prevention dated February 20, 2020, revealed, Elopement is defined as when a resident/patient leaves the premises of a safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 16, 2022, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (high blood pressure), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), long term use of insulin and alcohol use with unspecified alcohol-induced disorder. Continued review revealed that the resident was independent in making decisions regarding tasks of daily life and that the resident had wandering behaviors. Review of Resident R1's Admission Elopement Risk assessment, dated September 8, 2022, revealed that the resident was identified by the facility as being at risk for elopement. Review of Resident R1's care plan, dated initiated September 8, 2022, revealed that the resident was placed on the facility's Center Watch Program (resident's name included in a book at the front desk of residents at risk for elopements, staff education on who was at risk of elopement). Review of nursing notes revealed a note, dated September 8, 2022, at 9:17 p.m. which indicated that Resident R1 was admitted to the facility and that due to having a history of elopement a Wanderguard (devised that is place on resident's wrist or ankle which prevent doors to the unit to be open for exit) was placed on the resident's leg. Continued review of Nurses Notes revealed a note, dated October 6, 2022, at 3:00 p.m. which indicated that Resident R1 was moved to the fourth floor, which is the facility's secure (locked) dementia care unit. Continued review of Nurses Notes revealed a note, dated October 27, 2022, at 3:33 p.m. which indicated that Resident R1 left the facility's secure dementia unit at 1:45 p.m. and was found in a lounge area on the facility's first floor. Another note, written at 4:20 p.m. indicated that the resident was exit seeking and told staff that he exited the unit via the stairwell. The resident was subsequently redirected back to the secure dementia unit. Review of facility documentation revealed that the facility inspected and adjusted the locking mechanism on the stairwell door after the incident. Review of resident's care plan dated October 27, 2022, revealed that a care plan for the risk of elopement related to impaired safety awareness. Resident wanders seeking exit from the unit. The interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or book. Identified patterns of wandering- us wandering purposeful, aimless or escapist? Is resident looking for something? Wanderguard alert. Further review of nurses notes revealed a note, dated December 21, 2022, at 1:11 p.m. which indicated that when nursing staff went to get Resident R1 to obtain his weight, the resident was unable to be found on the unit and a search was initiated. The resident had not expressed any exit seeking behaviors that morning. Interview on January 3, 2023, at 2:43 p.m. with Employee E10, nurse aide, revealed that she was the assigned nurse aide to care for Resident R1 on December 21, 2022, during the day shift. Employee E10 stated that when lunch trays arrived on the unit between 12:00 p.m. and 1:00 p.m. she began to distribute the trays to the residents. Employee E10 stated that it was at that time when she realized that she was unable to find Resident R1. Employee E10 stated that she checked his room, bathroom and the lounge area, then immediately notified the charge nurse that she was unable to find the resident. Employee E10 stated that she continued to conduct her search, that she heard the door alarm and checked the stairwell from the secure dementia unit down to the lobby and could not find the resident. Employee E10 stated that Resident R1 had his typical morning routine that day and did not exhibit any unusual behaviors prior to his elopement. Interview on January 3, 2023, at 4:54 p.m. with Employee E14, smoke aide, revealed that on December 21, 2022, while he was on break in the facility's indoor smoking lounge, he noticed someone walk past the lounge. Employee E14 stated that he did not know who the person was, that he did not look like a resident or a staff person and that he assumed it was a visitor. Employee E14 stated that he escorted the unknown person out of the smoking lounge and into the hallway. Employee E14 confirmed that he did not tell anyone or find anyone to assist the person and stated that he just redirected the unknown person down the hallway. Employee E14 continued that approximately fifteen minutes later he heard a code yellow [elopement] announcement. Employee E14 stated that he proceeded to the lobby area and reviewed the camera footage. Employee E14 confirmed that the unknown person he had previously directed down the hall was identified as Resident R1 on the camera footage leaving the facility. Interview on January 3, 2023, at 4:19 p.m. with Employee E13, receptionist, revealed that on December 21, 2022, she received a call from the fourth floor unit asking her if she had seen a resident. Employee E13 stated that when staff from the unit called her, they provided a description of the resident but not his name. Employee E13 continued that five minutes later the fourth floor unit called again and asked her to call a code yellow [elopement]. Employee E13 stated that she announced the code yellow, that a search was initiated and that she began reviewing camera footage. Employee E13 stated that she identified Resident R1 leaving out the door on the camera footage and immediately informed the Nursing Home Administrator (NHA). Employee E13 stated that she did not remember seeing Resident R1 leave through the door, that at the time she was receiving her lunch from staff and pushing the button to open the door to allow x-ray technicians to enter the building. Employee E13 stated that she never laid eyes on him when Resident R1 entered the lobby area and exited through the parking lot door. Employee E13 stated that she knew Resident R1 was an elopement risk, that his information and picture was maintained in a book at the desk and that she had recently received training on elopement prevention, including participation in elopement drills, how to call a code yellow as well as step-by-step procedures and protocols. Observation of camera footage from December 21, 2022, was reviewed with Employee E3, assistant administrator, on January 3, 2023, at 3:28 p.m. The camera footage revealed that Resident R1 walked out of the lobby parking lot doors while multiple people went through the doorway, including facility staff and contracted technicians bringing in a portable x-ray machine, at 12:18 p.m. The receptionist was seen pressing the buzzer to allow the x-ray technicians to enter the building while looking away from the door, distracted and talking with facility staff. A wall panel of the Wanderguard system behind the receptionist desk showed that the light activated at the lobby parking lot door. Interview with Employee E3 at the time of the observation revealed that prior to the resident exiting the building, the lights on the Wanderguard panel activated for the stairwell, then the Walnut lounge corridor (on the first floor before the lobby area) before lighting at the lobby parking lot doors. Review of hospital records for Resident R1 revealed that he was brought to the emergency department on December 22, 2022, at 3:08 p.m. Hospital nursing notes indicated that the resident was brought to the hospital by emergency responders that were called by a passerby. Resident R1 reported to hospital staff that he was walking on the street and that his leg gave out. The resident denied any injuries and was noted to be alert and oriented but forgetful. Hospital staff noted that the resident was wearing a Wanderguard, that the resident did not know what it was or its function and that the hospital was able to identify the resident from paperwork found in his coat pocket. Continued review revealed that the hospital informed the facility that the resident was in their emergency department on December 22, 2022, at 4:13 p.m. Resident R1 was subsequently returned to the facility. Interview on January 3, 2023, at 10:15 a.m. the Nursing Home Administrator (NHA) confirmed that the facility was unable to determine how Resident R1 got through the stairwell door to leave the secure dementia unit. The NHA also confirmed that the facility was unable to determine where Resident R1 was found in the community before being transported to the hospital by emergency responders. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. Resident R1 went missing from December 21, 2022, at 12:18 p.m. until he was brought to the hospital on December 22, 2022 at 3:08 p.m., a period of almost 27 hours. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on January 4, 2022, at 2:26 p.m. On December 21, 2022, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following: 1. Resident was placed on a 1:1 upon return to the facility. His care plan was updated to reflect his current elopement status. Resident was evaluated at the emergency department and returned to the facility on [DATE], approximately 8:15 p.m. with no new orders and free of injury. Resident was placed on secure unit after return from emergency department. Wanderguard remains on resident's right arm. Social services assessed resident for psycho-social status, and resident's medications were reviewed and approved by primary care physician. 2. All residents who were identified as a high risk for elopement were audited to ensure the assessment was completed, care plans reflect the resident's status, Wanderguard placement occurred, and orders reflect Wanderguard usage and placement. Any discrepancies were corrected to ensure compliance. No other residents affected. Residents at risk for elopement audit was initiated on December 22, 2022 and completed on December 23, 2022. 3. The facility will review new admissions to ensure that elopement assessment is complete and accurate weekly for eight weeks. 4. Monthly audits will continue for two months to ensure accuracy of elopement assessments, care plans, and protocol is in place for residents who have been identified as a high elopement risk. 5. The elopement policy was reviewed, and staff were re-educated on the elopement protocol (elopement policy, signs of resident exhibiting wandering/exit seeking behaviors). Education was initiated on December 21, 2022 and completed on December 25, 2022. 6. Staff education percentages: Nursing 100%, Dietary 92% (waiting for PRN staff), Medical Records 100%, Therapy 100%, Activities 100%, Administration 100%, Housekeeping 100%. Any staff who were not educated will receive education prior to working their first shift of work. Agency staff will be educated on elopement policy prior to working shifts at facility. 7. The facility conducted elopement education and drills (Code Yellow) on December 25, 2022 and December 26, 2022 for post incident. Elopement drills will be completed monthly each shift to ensure compliance. 8. Receptionists desk were educated on front desk monitoring, ensuring the front desk staff are not distracted when unlocking doors to let staff/residents in or out, residents must have unescorted leave of absences to exit independently, and to be cautious during change of shift related to the volume of staff going in and out. Education completed December 25, 2022. 9. Elopement competencies for all departments initiated on December 23, 2022, and completed on December 25, 2022. Ongoing competencies will be completed monthly for two months to ensure staff retained the education and is competent related to elopement policy on twenty percent of staff monthly. 10. Door audits were completed post incident on December 21, 2022, and December 22, 2022. All door Wanderguards were functioning. Ongoing audits weekly. Observation on January 3, 2023, at 8:53 a.m. revealed Resident R1 was in the lounge area in the facility's secure dementia unit with 1:1 supervision provided by nurse aide staff. Interview, at the time of the observation, Resident R1 stated that he wants to leave the facility but does not have any place to live. Resident R1 confirmed that he left the faciity on [DATE], and reported that he went to a friend's house, that he was drinking coffee on a street corner, got sick and that someone called an ambulance. Resident R1 would not state where he went or provide any other details from his misadventure. Resident R1 stated that he continues to feel frustrated with his situation and that he still wants to leave the facility. A review was conducted of the education, competencies and drills provided to facility staff related to resident elopement. Interviews were conducted on January 3 and 4, 2023. Facility staff were able to verbalize what they would do if they found a resident with exit seeking behaviors or if they were unable to find a resident. Facility staff demonstrated verbal understanding of key concepts from recent training, including reporting any usual activity, paying attention to alarms, watch doors, ensure stairwell doors fully close, monitor surroundings and cover keypads when entering codes to unlock doors. Facility audits were reviewed and residents who were identified by the facility as being at risk for elopement had appropriate elopement prevention measures in place. Review of audits and a tour of the facility's Wanderguard system was conducted on January 3, 2023, at 3:42 p.m. and alarms were functioning appropriately. Review of facility documentation revealed that the corrective action plan was immediately initiated on December 21, 2022. The facility's action plan was accepted on January 4, 2023, at 4:37 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to adequately supervise one of five residents reviewed (Resident R1), resulting in Resident R1 eloping from the facility and missing during the overnight hours for approximately 24 hours. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy title Clinical Guideline; Elopement revised April 2021, stated that the procedure is to identify residents who are at risk for elopement. And that new admissions who are at risk for elopement will have interventions put into place immediately until further evaluation is complete. Review of Resident R1's clinical record revealed the resident was admitted on [DATE], with diagnosis including but were not limited to Alzheimer's Disease (a gradually progressive type of brain disorder that causes problems with memory, thinking and behavior). Review of Resident R1's physician's notes dated September 16, 2022 revealed that the resident had poor insight, cognitive impairment with behavioral symptoms, unsteady gait and expressed that he would like to leave the building. The resident was to continue to participate in rehabilitation therapy due to ambulatory dysfunction. Review of Resident R1's clinical record revealed an Elopement Evaluation completed on September 16, 2022, which stated that the resident was at risk for elopement. Review of Resident R1's clinical record revealed that there was no care plan developed for being at risk for elopement, and no interventions were put into place prior to September 19, 2022. Review of Resident R1's nursing note dated September 19, 2022 at 10:01 p.m. revealed that the resident is loa (leave of absence) did not have permission to leave the premises. Review of Resident R1's nursing note dated September 20, 2022, 2:15 p.m. revealed that the resident left the faciity on September 19, 2022, at approximately 2:40 p.m. without permission, and was returned by Philadelphia Police Officers on September 20, 2022, at approximately 2:15 p.m. Review of facility documentation revealed and investigation of Resident R1's elopement which contained statements from facility staff on duty during the elopement. Review of a statement from Nurse Aide, Employee E10, who stated she was coming back into the facility around 3:05 p.m. on September 19, 2022, when she was asked by the Receptionist, Employee E9, to ask Resident R1 to come inside. Nurse Aide, Employee E10 told the Receptionist, Employee E9 that the Resident R1 said he would come in, but he stopped to talk to another resident. Nurse Aide, Employee E10 then asked the Smoking Monitor, Employee E11, to watch Resident R1. Continue review of written statements collected during facility investigation revealed a statement from the Smoking Monitor, Employee E11. The statement stated I was outside when the current receptionist told me that a resident needed to watched. I was ordered to make sure he does not leave the park to go outside the gate. I made sure he didn't leave that way successfully. But afterwards sadly we found out he left through the stairs in the park. At 3:20 I wet to go to the park to check where the resident was. I didn't find him and another nurse told me she couldn't find him either. We both tried to look for him for about 9 minutes until the nurse said I'll tell the front desk. It was about 2:40 when I was told about him but beyond that time. I was outside by myself so I supposed I lost sight of him while focusing on the other residents. Interview with the Smoking Monitor, Employee E11, on October 6, 2022, at approximately 2:35 p.m. confirmed that he was asked by the receptionist, Employee E9, to keep and eye on Resident R1. Further during interview it was confirmed that he in fact lost sight of the resident and did not see him leave the area because he was watching in the direction of the parking lot and he stated that he later was told that the resident went the other direction towards the stairs. Interview with the Receptionist, Employee E9, on October 3, 2022, at approximately 1:10 p.m. revealed that she was on duty when the resident eloped. She stated that she had pictures of residents who are elopement risks behind the desk, but that at the time of Resident R1's elopement on September 19, 2022, his picture was not in the book. Interview with the Nursing Home Administrator, on October 3, 2022, confirmed that Resident R1 had left the facility without permission in the afternoon on September 19, 2022, and did not return until the afternoon of September 20, 2022, when Philadelphia Police Officers returned him to the facility. Review of written statement from the Nursing Home Administrator (NHA) revealed that he spoke with a Philadelphia police officer who confirmed that the location where the resident was found on September 20, 2022, at 11:03 a.m. The location provided by the police officer was 4.4 miles from the facility, which required crossing over an overpass with a major river under it. Continue review of the statement from the NHA revealed that [Resident R1] was taken to the police district, identified and the facility was notified that he was found. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was assessed as an elopement risk on September 16, 2022. The resident went missing on September 19, 2022, at 2:40 p.m. and was not returned to the facility until September 20, 2022, at 2:15 p.m., a period of 24 hours. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 5, 2022, at 12:16 p.m. On October 5, 2022, at 6:23 p.m. the facility's action plan was accepted. The action plan included the following: 1. Resident was placed on a 1:1 upon return to the facility on 9/20/22. His care plan was updated to reflect his current elopement status. Resident was evaluated at the emergency department and returned to the facility on 9/20/2022 approximately 10:25 p.m. with no new orders and free of injury. Resident was placed on secure unit after return from emergency department. Wander guard was placed on resident's right arm. Social services assessed resident for psycho-social status, and resident's medications were reviewed and approved by primary care physician. 2. 25 residents who were assessed as an elopement risk were audited on 9/20/22, to ensure the assessment was completed, care plans reflect the resident's status, wander guard placement occurred, and orders reflect wander guard usage and placement. Any discrepancies were corrected to ensure compliance. Door alarms were audited for alarm and wander guard functioning. 3. The elopement policy was reviewed on 9/19/22, and staff were re-educated on the elopement protocol (elopement policy, signs of resident exhibiting wandering/exit seeking behaviors) immediately on 9/19/2022. The facility conducted elopement education and drills (Code Yellow) starting on 9/19/2022, for all shifts. Education provided to clinical staff regarding hospital record review and with new and re-admissions to ensure any new behaviors were captured and care planned. admission department educated on reviewing new admissions for appropriate unit selection and for communication of risk identification. 4. Outside smoke times will be limited to ensure proper supervision. IDT (Interdisciplinary Team) changed resident smoke times per unit to limit the volume of residents being supervised outside. Resident Council will be held on 10/6/22, and the change in smoke times will occur on 10/7/22. Staff assigned to supervise residents will be educated by 10/7/22, on proper monitoring of residents while outside to ensure resident safety. 5. Elopement Policy education was implemented, and the current percentage of completion is a follows: Nursing 70%, Dietary 30%, Medical Records 100%, Therapy 10%, Activities 88%, Administration 64%, Housekeeping 93%. This education will be ongoing. 6. The facility will conduct monthly audits to ensure elopement risk residents are clearly communicated throughout the facility. 14 new admissions were audited to assess if resident's hospital records indicated elopement risks and interventions are in place. Monthly elopement audits will occur to ensure all resident who are assessed to be an elopement risk have appropriate interventions in place, care planned, and orders reflect the plan of care. Door alarm functioning audits will occur monthly. The facility will review all audits monthly during the QAPI Meeting and make necessary changes based off the outcomes of the audits. Resident R1 was observed on Ocotber 6, 2002 and October 7, 2002, in the locked, secure unit with staff supervision. A review was conducted of the education provided to facility staff related to resident elopement. Interviews were conducted with facility staff on October 6, 2022 and October 7, 2022. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors. It was confirmed that smoking times were established for each unit to limit the number of residents requiring supervision outside. Following the verification of the immediate action plan, the Immediate Jeopardy was lifted on October 7, 2022, at 2:10 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services

Based on review of clinical and hospital records, review of facility policies and facility documentation and interviews with staff, it was determined that the facility failed to notify the physician in a timely manner of a resident's change in medical condition, failed to conduct ongoing neurological assessments according to the plan of care and failed to secure appropriate emergency transportation to transfer an unresponsive resident to the hospital for one of 21 residents reviewed (Resident R15). This failure resulted in actual harm to Resident R15 who developed further [MEDICAL CONDITION] activity and became unresponsive and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, Physician's Services, dated revised 3/4/2020, revealed that the facility must provide or arrange for the provision of physician 24 hours a day in case of emergency. Further review of the facility policy indicated . The facility will notify the physician if there is a change in the patient's/resident's condition.and In case of emergency, the facility will contact the attending physician or designee. If unable to reach either physician, the Medical Director will be called for orders. Review of an undated facility policy, Neurological Checks, revealed that Neurological exam also known as neuro-checks is a neurological exam and evaluation of a person's nervous system that can be performed quickly and is non-invasive. The purpose of this policy is to guide the nurse in performing neurological checks, usually performed after a head injury or suspicion of a head injury from falls or blows to head, but may be performed for other reasons in which there is concern for vascular events including but not limited to cardiovascular accident ([MEDICAL CONDITION] or stroke), [MEDICAL CONDITION] activity or brain infections. Fluctuations found by the neuro-checks changes over time may indicate brain swelling that can impact the twelve (12) cranial nerves and their function. Identifying those changes early and getting the resident to a higher level of care faster may prevent damage for a better outcome. Further review of policy revealed that Frequency of Neuro-checks a. For stable or unchanging neuro-checks use the following schedule: i. Every 15 minutes times 4 ii. Every 30 minutes times 4 iii. Every 60 minutes times 4 iv. Daily times 4 days b. For unstable or changing neuro-checks contact physician for orders and prepare for possible transfer . Other signs and symptoms to monitor and report that may be associated with head injuries a. Nausea/vomiting b. Dizziness c. Restlessness d. Confusion or dullness of thought (different from baseline) e. Increased sleepiness or inability to arouse resident as baseline i. In the event the resident is easily aroused/alert (at baseline) but changes but is now hard to wake, non-responsive or unable to open eyes, transfer the resident to higher level of care immediately f. Uneven breathing patterns or difficulty breathing i. In the event the resident having difficulty breathing (from baseline) transfer to resident to higher level of care immediately Review of the clinical record for Resident R15 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record for Resident R15 revealed no documentation of [MEDICAL CONDITION] activity from the date of the resident's admission on July 10, 2020, through October 29, 2020. Review of Resident R15 revealed nursing progress notes dated October 30, 2020, at 6:21 a.m., indicated that Resident R15 had experienced a random [MEDICAL CONDITION] from 3:38 a.m. to 4:42 a.m., a period of one hour and four minutes. Review of Employee E20's, licensed nurse, progress note dated October 30, 2020, indicated that Resident R15 was drooling from the mouth, had jerking of the right leg and right arm and repeated blinking of the left eye during the time of the [MEDICAL CONDITION] activity. Interview with Employee E2, Director of Nursing, on January 22, 2021, at 1:30 p.m., confirmed that Resident R15 had not experienced any [MEDICAL CONDITION] activity prior to the [MEDICAL CONDITION] noted by nursing staff on October 30, 2020, at 3:38 a.m. Interview with Employee E20, licensed practical nurse, on January 26, 2021, at 3:00 p.m., confirmed that Resident R15 had intermittent [MEDICAL CONDITION] activity on October 30, 2020, between 3:38 a.m. until 4:42 a.m. The nurse reported staying with Resident R15 until the end of the [MEDICAL CONDITION] activity. Further interview with Employee E20 revealed that the employee had not notified the night shift nursing supervisor or a registered nurse of Resident R15's [MEDICAL CONDITION] activity and that she did not notify the resident's physician of the resident's [MEDICAL CONDITION] activity until 6:21 a.m. on October 30, 2020, over two and a half hours after the [MEDICAL CONDITION] first started. Employee E20 further indicated that the physician did not respond to the nursing facility's call until 7:54 a.m., over four hours after Resident R15, first experienced [MEDICAL CONDITION] activity. Review of emedicall (a secured web based medical communications method between nurses and practitioners) physician orders for Resident R15 dated October 30, 2020, at 6:20 a.m. confirmed that the nurse notified the physician/designee of Resident R15's [MEDICAL CONDITION] activity. Review of emedicall return communication for Resident R15 revealed that the nurse practitioner responded to the nurse's message at 7:54 a.m. Additional review of Resident R15's clinical record dated October 30, 2020, at 7:22 a.m., revealed that the resident had an abnormal pulse oximeter (Pulse Ox- measurement of percentage of oxygen level in the bloodstream) reading of 90% (normal oxygen levels are at least 95%) and an elevated pulse rate of 122 (normal heart rate 60 - 80 beats per minute). Continued review of Resident R15's clinical record revealed no documentation that the physician had been notified of the change in the resident's vital signs. Further nursing documentation on October 30, 2020, at 8:40 a.m., revealed that Resident R15 was observed with a blank stare and drooling from the mouth. Resident was noted as not responsive verbally which was not resident's baseline (normal). Resident was also noted with rhonchi (an abnormal respiratory sound which is often caused by thick secretion on the larger airways.) throughout the lung field. Resident had a pulse oximeter reading of 90%. Review of emedicall communication for Resident R15 on October 30, 2020, revealed that the nursing staff had notified the resident's physician of the residents change in condition at 8:49 a.m. and that the nurse practitioner ordered the resident be sent to the hospital. Further review of Resident R15's clinical record revealed no documented evidence that nursing staff had clarified with the nurse practitioner the type of transport service for an unresponsive resident. Review of nursing progress note by Employee E21, licensed nurse, dated October 30, 2020, at 10:19 a.m. revealed that Resident R15 was transferred to the hospital by private ambulance company. Resident R15 was picked up at 10 a.m., one hour and forty minutes after the resident was found unable to verbally respond. Interview with Employee E21, licensed nurse, on February 10, 2021, at approximately 2:30 p.m. revealed that she assessed Resident R15 right after she received report from the 11 p.m. to 7 a.m. staff. She noted that the resident had a fever and she was not at her baseline. The doctor ordered that the resident be sent to the hospital. Employee E21 stated Resident R15's condition stayed the same until the resident was transferred to the hospital. Employee E21 also stated the ambulance transferred the resident to the hospital around 10:00 a.m. and that she did not call the physician or 9-1-1 when it took over an hour for the regular ambulance service to arrive at the facility. Review of ambulance transport records confirmed that Resident R15 had arrived at the hospital on October 30, 2020, at 10:35 a.m., over six hours and 57 minutes after the first onset of the resident's [MEDICAL CONDITION] activity. Interview with Employee E2, Director of Nursing, on January 22, 2021, at 1:00 p.m., confirmed that the facility did not send Resident R15 by emergency transport or 9-1-1, as the physician did not order emergency transportation for the resident. Review of Resident R15's care plan dated July 10, 2020 revealed that the resident had [MEDICAL CONDITION] disorder. Care plan interventions included post [MEDICAL CONDITION] treatment, turn on side with head back, hyper-extend to prevent aspiration. Keep airway open. After [MEDICAL CONDITION] take vital signs and neuro-check. Monitor for [MEDICAL CONDITION], headache, altered level of consciousness, paralysis, weakness, pupillary changes. Review of entire clinical record for Resident R15 did not reveal any evidence that the facility conducted a complete and on-going neurological exam (neuro checks) according to the resident's plan of care on October 30, 2020, from 3:38 a.m. to 10:00 a.m. over a period of 6 hours and 22 minutes. Interview with Employee E2, Director of Nursing, on February 10, 2020, at approximately 4:00 p.m. confirmed that the nursing staff did not perform a complete and on-going neurological examination on Resident R15 according to the plan of care on October 30, 2020, from 3:38 a.m. to 10:00 a.m. Review of Resident R15's clinical record also revealed no documented evidence that the staff taken additional set of vital signs other than the vital signs documented at 7:21 a.m. on October 30, 2020. Interview with Employee E2, Director of Nursing, on February 10, 2021, at 2:25 p.m. revealed active [MEDICAL CONDITION] activity would be considered a medical emergency and that staff should call the physician immediately, if unanswered, the medical director should be contacted. The Director of Nursing further stated that unresponsiveness for residents who are normally responsive should be considered a medical emergency as well and staff should use clinical judgement to call 9-1-1 or call the physician. A review of Resident R15's hospital records dated October 30, 2020, at 10:43 a.m., indicated that Resident R15 was admitted to the hospital emergency room with unresponsiveness. The hospital record further indicated that Resident R15 was witnessed having a generalized tonic, clonic shaking ([MEDICAL CONDITION] activity) and his gaze was deviated to the left without return to baseline upon arrival in the emergency department. The resident was subsequently intubated (insertion of an artificial airway) for airway protection. The resident was admitted into the hospital's Neuro ICU (Neurological Intensive Care Unit) with unresponsiveness and concern for [DIAGNOSES REDACTED]. (A [MEDICAL CONDITION] that lasts longer than 5 minutes or having more than 1 [MEDICAL CONDITION] within a 5 minutes period, without returning to a normal level of consciousness between episodes. This is a medical emergency that may lead to permanent brain damage or death). An Immediate Jeopardy situation was identified to the Nursing Home Administrator on February 10, 2021, at 7:21 p.m. for the facility's failure to notify the physician in a timely manner of a resident's change in medical condition, failure to conduct ongoing assessments, including neurological checks, according to the plan of care and failure to secure appropriate emergency transportation to transfer an unresponsive resident to the hospital. The Immediate Jeopardy template was provided. The facility submitted a written plan of action on February 10, 2020, at approximately 10:15 p.m. and implemented the plan of action which included: 1. An audit was completed for all residents with known [DIAGNOSES REDACTED]. Licensed staff in facility were provided education on the monitoring and assessment of residents during an active [MEDICAL CONDITION]. Licensed staff will notify the nursing supervisor of the resident's [MEDICAL CONDITION] activity and the physician will be notified related to the changes in condition for residents with [MEDICAL CONDITION] activity. Licensed staff will be provided education on the process for timely notification of the physician and follow up if physician does not return call. As of 10:00 p.m., 22% of licensed staff have been trained. By 10:00 p.m. on 2/11/21, 80% of licensed staff will be educated. And by 10:00 p.m. on 2/12/21, 100% of staff will have been educated. Licensed staff prior to the start of their next shift and upon hire will have the education on monitoring and assessing residents during and post [MEDICAL CONDITION] and the timely notification of the physician related to significant change. During clinical morning meeting and change of shift residents will be reviewed for residents with significant change or recent [MEDICAL CONDITION] activity and will be assessed including vital signs. 2. A random audit of documentation will be completed by the Director of Nursing daily x 7 days then weekly x3 to monitor for assessment and evaluation of those with [MEDICAL CONDITION] and timely notification of the physician. These audits will be reviewed for compliance and quality improvement and changes made to the plan of action if indicated monthly x3 month. On February 11, 2020, at 2:00 p.m. the action plan was reviewed, and interviews were conducted with nursing staff to confirm the in-service education was completed. A review of facility audit of all resident's with [DIAGNOSES REDACTED]. The Director of Nursing was notified that the I.J. was lifted on February 11, 2021, at 4:52 p.m. The facility failed to notify the physician in a timely manner of a resident's serious change in medical condition, failed to conduct ongoing neurological assessments according to the plan of care and failed to secure appropriate emergency transportation to transfer an unresponsive resident to hospital for further evaluation and treatment. 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.12(d)(3) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services 28 Pa. Code: 211.2(a) Physician services

Based on observation, review of clinical records, review of facility policies and facility documentation and interviews with staff, it was determined that the facility failed to implement adequate safeguards to protect residents from sexual abuse. This failure allowed one resident, with a history of non-consensual sexual intercourse, to sexually assault another resident (Resident R3) resulting in actual harm to that resident and resulting in an Immediate Jeopardy situation. Findings include: Review of facility policy, Freedom from Abuse, Neglect and Exploitation, dated June 12, 2020, revealed that the facility will provide a safe resident environment and protect residents from abuse. This includes freedom from verbal, mental, sexual, or physical abuse. The guidelines included: that for allegations of abuse the facility will immediately implement safeguards to prevent further potential abuse; resident to resident abuse - the facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g physical, sexual or verbal aggression). The policy further stipulated that the types of abuse included sexual abuse. Additionally, the policy indicated that non-consensual contact of any type with a resident who appears to want the contact to occur, but lacks the cognitive ability to consent or a resident who does not want the contact to occur. Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent. Residents without the ability to consent will not engage in sexual activity. A review of documentation submitted by the facility revealed that on September 28, 2020, at 12:40 p.m., Resident R1, who has severe cognitive impairments was observed in his room at around 12:40 p.m., this afternoon engaged in sexual intercourse with his roommate, Resident R2, a long term resident who also has severe cognitive impairments. The documentation further indicated that the incident had occurred on the 4 West Nursing Unit, a dedicated memory care unit. A review of documentation submitted by the facility on September 29, 2020, one day following the incident noted above, revealed that Resident R3, a female long-term resident, with a severe cognitive impairment was observed in the bed of Resident R1, in room [ROOM NUMBER] B. She was found with her underwear down and the male resident with his clothes completely on and in place but he was touching her vaginal area. Review of Resident R3's clinical record revealed a nursing progress note dated September 29, 2020, which revealed: While I was coming from the bathroom on 4 West I heard commotion in the low side hallway. When going to see what the commotion was I observed staff escorting Resident R3 out to the nurses desk. Per staff, Resident R3 was found in room [ROOM NUMBER] B, Resident R1's room, with her pants pulled down. Staff stated Resident R1 was over top of Resident R3 in 409 A bed and was pinning her down with his left arm and trying to pull her pants and brief (disposable underwear) down with his right hand. NP [Nurse Practitioner] in the building notified . and ordered to send out to ER for evaluation. Review of Employee E7's, unit clerk, witness statement dated September 30, 2020, revealed that the employee had seen Resident R3 on September 29, 2020, at approximately 12:10 - 12:15 pm. The employee indicated that Resident R3 was in room [ROOM NUMBER], laying in the A bed, trying to push/fight Resident R1 off her. Resident R1 was noted as pushing her down with his left forearm and with his right hand he was pushing it in her vagina area. Resident R3 was noted with her pants and pull up (disposable brief) pulled down exposing her vaginal area. Interview with Employee E7, unit clerk, on October 5, 2020, at 10:15 a.m, confirmed that on September 29, 2020, the employee along with Employee E10, housekeeping, had responded to a noise went to room [ROOM NUMBER] where she observe Resident R3 on the bed and Resident R1, who had his left forearm on her forehead and his right hand was forcefully trying to go into her vagina. Resident R3 was trying to push him away and Resident R1 was trying to push her back down. The employee further indicated that Resident R3 was trying to push Resident R1 off to get off the bed. and . There was another incident the day before. Continued interview with Employee E7 on October 5, 2020, at 10:15 a.m., revealed that there were no staff observing Resident R1 when we went into the room on September 29, 2020. Interview with Employee E4, Nurse Aide, on October 5, 2020, at 11:05 a.m., indicated that Resident R3 walks around, very sweet lady, some memory issues we have to redirect her, she goes in and out of people's rooms. Interview with Employee E8, Nurse Aide, on October 5, 2020, at 10:25 a.m. revealed that Resident R3 walks around, walks without assistance and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee E8 further indicated that Resident R1's fully ambulatory and walks without assistance. Interview with Employee E9, Licensed Nurse, on October 5, 2020, at 11:15 a.m. revealed that the employee was assigned to Resident R1 on September 29, 2020. The employee further indicated that Resident R1 was not on a 1:1 supervision on September 29, 2020, he was just in a room by himself. and . Resident R1 was on no type of increased observation. Interview with Employee E10, housekeeping, on October 5, 2020, at 11:40 a.m. revealed that the residents have dementia they don't know what they're doing. There always wandering around in each other's rooms. None of this what of happened if rounds were being done. Everyone is all over the place up here. Interview with Employee E14, LPN, on October 6, 2020, at 1:00 p.m. revealed that 40 residents reside on the fourth floor west memory care unit. Employee E14 further indicated that 16 of the 40 residents have been identifed with wandering behaviors, where they wander (roam) the hallways or go into other residents rooms. Additionally, the interview confirmed that Resident R1, R2, and R3, resided on the fourth floor west memory care unit on September 28, and September 29, 2020. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on October 6, 2020, at 2:45 p.m. related to the facility's failure to ensure that adequate safeguards were implemented to protect the residents on the Four West Memory Care Unit from sexual abuse. The facility's failure resulted in Resident R1 sexually assaulting Resident R3 on September 29, 2020, and resulted in actual harm to two of three residents reviewed (Resident R2 and R3) The corrective action plan included the following interventions: 1. Facility IDT and Administration initiated 1:1 supervision for Resident# 1, 2 and 3. Observation audit initiated for monitoring of compliance with 1:1 for Resident to be completed 2 x per shift. All care employees assigned to Resident# 1, 2, and 3 will be provided 1:1 monitoring education, a copy of Resident's Behavior and Activity Care Plans. The three identified residents were evaluated for Psychosocial by SW/Psych NP with no adverse effects noted as they were all unable to recall incidents. They will be continued to be monitored by staff for any change in condition or increase in behaviors noted. They will have SW review weekly x 4 or until additional intervention is needed. 2. Changes to Resident# l, #2 and #3's care plans are reflected by the following; 1:1 at all times may be eliminated post Nursing, IDT and Psychosocial review, assigned staff to identify and intervene when/if any of them exhibits the following behaviors; (making sexual comments, commenting on a resident's appearance, or pulling on residents that may enter their room) or for Res #2 and #3 nursing will intervene when they are observed wandering into others rooms as appropriate. Resident #1 based on his usual and customary status and routine does not leave his room (resident #1 moved into private room). Therefore, he was moved to another unit where the residents do not wander. Assigned staff will provide monitoring and supervision of Resident #2, and #3's location during 1:1. Staff will notify Supervisor of any indication of change in behavior or resident to resident interactions. Education to assigned Staff on behaviors, Offer Psych Services weekly x 4 weeks and PRN post resident to resident altercation; assess for ongoing need for services and frequency. 3. Changes to Resident#1, 2, and 3's Activity Care Plans are reflected by the following; Resident will be offered preferred activities as able while adhering to 1:1 status. 4. The facility IDT will continue ongoing monitoring of Resident #1 and Resident# 2 and #3 to identify any change of condition or behaviors that would dictate care plan revisions. 5. All alert and oriented residents will be interviewed to identify if there are any additional concerns regarding potential abuse by 10/7/2020. Resident interviews on the identified unit (4 West) completed on 9/30/2020 with any identified concerns reviewed and taken through Grievance Process. 6. All staff will be educated, by the Unit manager or supervisor starting 9/29 and will be completed by end of day 10/7 on the facility abuse policy specific to reporting, types of abuse and protection of the resident. Staff will also be educated on the identification of signs of behaviors of someone who may be sexually abusive. Understanding for current staff will be validated. Ongoing the education will be added to the current Agency Orientation Packet. Education will be completed with 100% of active current facility staff (prior to the start of shift). 7. Abuse pathway questionnaires will be completed by Unit Managers/designee on 20 residents per week x 4 weeks then monthly x 3 months to identify any instances of abuse. The Unit Manager/designee will monitor for residents requiring 1:1 for safety and will complete 5 resident reviews weekly x 4 weeks then monthly x 3 months to identify any safety measures needing to be implemented. 8. The facility held a QAPI meeting on 9/29/20, to review the immediate plan. The facility will review the Abuse Policy and 1:1 supervision policy as it relates to abuse investigations and safety evaluations and specific event outcome. 9. Weekly counseling will be provided to all identified residents #1, #2 and #3 via psych services/SW x 1 month. Psychologist scheduled for weekly counseling with x 1 month with an assessment at that time to determine frequency of ongoing consults. This is based on their cognitive impairment as may not be able to actively participate. Care plan to be updated with identified interventions based on consults. A Monitoring visit was conducted on October 7, 2020, to verify the implementation of the immediate action plan and to review staff re-education documentation. All staff in the building at the time of the visit on October 7, 2020, had been in-serviced on recognizing the signs of sexual abuse and on safety surveillance. Interviews with the staff working on the floor, including RN'S, LPN'S, NA's, Unit Clerk's, and Dietary staff, reported they had all been in-serviced on recognizing signs of sexual abuse and on safety surveillance. The education included the seven types of abuse, physical signs of sexual abuse, mental signs of abuse, resident behaviors who had been abused, characteristics or staging of a perpetrator that could be targeting a possible victim for sexual abuse, to whom to immediately report an allegation of abuse, and one to one monitoring. Observations and interviews with Resident R1, R2, and R3, revealed all three residents remained on a 1:1 staff observation. Abuse pathway resident questionnaires for the identified alert and oriented residents had been completed by facility staff. The Immediate Jeopardy was lifted on October 7, 2020, at 3:40 p.m. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.12(a)(c) Nursing services

Based on observation, review of clinical records, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that one resident (Resident R1) who had a history of non-consensual sexual intercourse with another resident (Resident R2) was adequately supervised and monitored following the incident. This lack of supervision allowed the resident to sexually assault an additional resident (Resident R3) resulting in actual harm to the resident and constituted an Immediate Jeopardy situation. Findings include: Review of facility policy, Freedom from Abuse, Neglect and Exploitation, dated June 12, 2020, revealed that the facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse. The policy futher indicated that for allegations of abuse the facility will immediately implement safeguards to prevent further potential abuse. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included [CONDITION(S)] (serious liver infection caused by the [CONDITION(S)] virus (HBV)), [CONDITION(S)] C (liver infection caused by the [CONDITION(S)] C virus (HCV)), Dementia (group of thinking and social symptoms that interferes with daily functioning), [CONDITION(S)] (mental disorder characterized by a disconnection from reality), and Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). A review of the Quarterly Minimum Data Set (MDS-a periodic assessment of needs) dated August 1, 2020, for Resident R1 revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screen that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 3 indicating that the resident had a severe cognitive impairment. Review of Resident R1's care plan initiated on April 19, 2020, and revised on October 5, 2020, included that Resident R1 had a history of making sexually inappropriate comments toward staff, and had been reported stable and under control per the Nurse Practitioner's (NP) findings on 6/15/2020. The goals of the care plan included that Resident R1 would exhibit less impulsive behavior and would respond to nursing staff redirection. The interventions listed for the resident in the care plan included to intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. A review of documentation submitted by the facility revealed that on September 28, 2020, at 12:40 p.m. Resident R1, who has severe cognitive impairments was observed in his room at around 12:40 p.m. this afternoon engaged in sexual intercourse with his roommate, Resident R2, a long term resident who also has severe cognitive impairments. The documentation further indicated that the incident had occurred on 4 West Nursing Unit, a dedicated memory care unit. Review of Employee E13, LPN, witness statement dated September 28, 2020, revealed: Around 12:40 p.m. I took Resident R2's lunch tray to him in his room, 409. Upon entering the room, I placed it on his bedside table. He was not sitting in his chair or bed at the time, so I looked across the room to the other side, Resident R1's side. I saw both of them on that side -Resident R2 was in bed B, bent over and with his pants and brief down. Resident R1 was standing over him with his pants/brief down and Resident R1's penis was penetrating Resident R2's anus from behind clearly, the two men were having anal sex. Both of them froze (stood still) when they realized I was in the [sic] but they did not rush to get dressed. Interview with Employee E13, LPN, on October 6, 2020, at 9:30 a.m. revealed that on September 28, 2020, the employee had knocked on door of Resident R1's and R2's room, introduced myself and put the lunch tray down. I noticed Resident R2 wasn't in his bed so I turned to the B bed and Resident R2 had both of his palms on the bed with his back to Resident R1 and his back arched over and he was receiving intercourse from his roommate, Resident R1. Resident R2 was completely naked and Resident R1 had a shirt on with pants down to his ankles. Resident R1 had an erection and was penetrating Resident R2. Resident R1 was already inside of Resident R2. They both froze when I came in. and Employee E13 further indicated that she had immediately separated the two of them then left the room to report it to the unit manager and then she took it from there. Further interview with Employee E13 revealed that when I returned with the unit manager Resident R1 stated that they were taking care of business and this is what we were supposed to be doing. and . we went to DON 's office and sat down for an hour and we contacted everyone we needed. Social services were notified. Resident R2 was moved to a different room. We discussed moving Resident R1 to a different unit. Further review of Resident R1's clinical record revealed a Social Service (SS) progress note dated September 29, 2020, which indicated that social services was notified by nursing about the incident in Resident R1's room involving he and his roommate engaging in sexual practices on September 28, 2020. Nursing found the two in a very compromised positions and immediately separated them . and . Interventions have been placed including moving his roommate out of the room, lab work to be drawn- nursing to make Dr. aware, psych consult, and continuing to monitor resident. and . No other concerns at this time. SS will continue to f/u prn. A review of documentation submitted by the facility on September 29, 2020, one day following the incident noted above, revealed that Resident R3, a female long-term resident, with a severe cognitive impairment was observed in the bed of Resident R1, in room 409 B. She was found with her underwear down and the male resident with his clothes completely on and in place but he was touching her vaginal area. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (A group of thinking and social symptoms that interferes with daily functioning) and psychotic disorder with hallucinations (A perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). Review of the Quarterly Minimum Data Set (MDS-a periodic assessment of needs) dated September 10, 2020, revealed that Resident R3 had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 3 indicating that she had a severe cognitive impairment. Further review of Resident R3's clinical record revealed a nursing progress note dated September 29, 2020, which revealed: While I was coming from the bathroom on 4 West I heard commotion in the low side hallway. When going to see what the commotion was I observed staff escorting Resident R3 out to the nurses desk. Per staff, Resident R3 was found in room 409 B, Resident R1's room with her pants pulled down. Staff stated Resident R1 was over top of Resident R3 in 409 A bed and was pinning her down with his left arm and trying to pull her pants and brief (disposable underwear) down with his right hand. Resident R3 was immediately taken to her bedroom for safety and a full body assessment was completed by this nurse. Resident asked what happened but could not verbalize what happened due to her state of dementia. NP [Nurse Practitioner] in the building notified and came and assessed the resident and ordered to send out to ER for evaluation. Review of Employee E7's, unit clerk, witness statement dated September 30, 2020, revealed that the employee had seen Resident R3 on September 29, 2020, at approximately 12:10 - 12:15 pm. The employee indicated that Resident R3 was in room 409, laying in the A bed, trying to push/fight Resident R1 off her. Resident R1 was noted as pushing her down with his left forearm and with his right hand he was pushing it in her vagina area. Resident R3 was noted with her pants and pull up (disposable brief) pulled down exposing her vaginal area. Employee E7 indicated that she had yelled at Resident R1 to stop and get off of her. Employee E7 further indicated that Resident R1 stopped after the second time I yelled at him to stop. Interview with Employee E7, unit clerk, on October 5, 2020, at 10:15 a.m, revealed that on September 29, 2020, while sitting at the nurses station and talking to coworkers, I heard a faint noise so the housekeeper, Employee E10, started walking and I followed and we ended up in room 409, Resident R1's room. The door was open. Resident R3 was on the bed, Resident R1, had his left forearm on her forehead and his right hand was forcefully trying to go into her vagina. Resident R3 was trying to push him away and Resident R1 was trying to push her back down. The employee further indicated that she was trying to push him off to get off the bed. Then I started to yell for him to stop and for him to get off of her. and . There was another incident the day before. There were no staff observing Resident R1 when we went into the room on September 29, 2020. Review of Resident R3's clinical record revealed a Nurse Practitioner note dated September 29, 2020, which revealed . Follow up for an incident reported by nursing September 29, 2020 . and .: Resident seen for follow up per nursing request, according to nurses, resident was found in a male residents' room, Resident R1, in his bed, screaming, with pants half down and that male resident had her pindown with one hand and was trying to take her diaper off , staff immediately removed the resident from that room and examined . and . Will send the resident out to ER for further evaluation. Interview with Employee E10, housekeeping, on October 5, 2020, at 11:40 a.m. revealed that on September 29, 2020, the employee was standing at the desk and heard a faint yell. The employee went to see where the noise was coming from and arrived at room 409, Resident R1's room. The employee indicated that she stood at doorway and observed Resident R3's pants and pullup (disposable brief) were halfway down to her knees. Resident R1 had his left arm forearm holding Resident R3 down and the other hand was messing with her private area. Employee E7, unit clerk, was two seconds behind me and she yelled get off of her. They said that Resident R1 did it on Monday September 28, 2020, then why did they keep Resident R1 around why didn't they keep him on a 48 watch. 48 watch means that the Resident needs watching they put them on a 1:1 (direct supervision by staff). They should have done it on Monday (September 28, 2020). Continued interview with Employee E10 on October 5, 2020, at 11:40 a.m. revealed that when Employee E7, Unit Clerk, yelled get off of her then Resident R1 did get up. Resident R3 was down on the bed and Resident R1 was on top of her. He was holding her down on the bed while he was on top of her. Resident R3 was yelling and hollering. Resident R3 couldn't do anything because Resident R1 is a big guy. Resident R3 was trying to fight Resident R1 and get him off of her. The only thing that Resident R3 could do was holler. Additionally, Employee E10 indicated they have dementia they don't know what they're doing. There always wandering around in each other's rooms. None of this what of happened if rounds were being done. Everyone is all over the place up here. Interview with Employee E9, Licensed Nurse, on October 5, 2020, at 11:15 a.m. revealed that the employee was assigned to Resident R1 on September 29, 2020. The employee further indicated that Resident R1 was not on a 1:1 supervision on September 29, 2020, he was just in a room by himself. The incident with Resident R2 happened on Monday, September 28, 2020. Resident R2 was moved out of his room on Monday the day of the incident and Resident R1 stayed in the room by himself. and . Resident R1 was on no type of increased observation. Everyone is just monitored with your eyes. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and the Director of Nursing on October 6, 2020, at 2:45 p.m. related to the facility's failure to ensure that one resident who had a history of perpetrating nonconsensual sexual intercourse on his roommate on September 28, 2020, was properly monitored and supervised, following the incident. The facility's failure resulted in Resident R1 sexually assaulting Resident R3 on September 29, 2020, and resulted in actual harm to two of three residents reviewed (Resident R2 and R3) The corrective action plan included the following interventions: 1. Facility IDT and Administration initiated 1:1 supervision for Resident# 1, 2 and 3. Observation audit initiated for monitoring of compliance with 1:1 for Resident to be completed 2 x per shift. All care employees assigned to Resident# 1, 2, and 3 will be provided 1:1 monitoring education, a copy of Resident's Behavior and Activity Care Plans. The three identified residents were evaluated for Psychosocial by SW/Psych NP with no adverse effects noted as they were all unable to recall incidents. They will be continued to be monitored by staff for any change in condition or increase in behaviors noted. They will have SW review weekly x 4 or until additional intervention is needed. 2. Changes to Resident# l, #2 and #3's care plans are reflected by the following; 1:1 at all times may be eliminated post Nursing, IDT and Psychosocial review, assigned staff to identify and intervene when/if any of them exhibits the following behaviors; (making sexual comments, commenting on a resident's appearance, or pulling on residents that may enter their room) or for Res #2 and #3 nursing will intervene when they are observed wandering into others rooms as appropriate. Resident #1 based on his usual and customary status and routine does not leave his room (resident #1 moved into private room). Therefore, he was moved to another unit where the residents do not wander. Assigned staff will provide monitoring and supervision of Resident #2, and #3's location during 1:1. Staff will notify Supervisor of any indication of change in behavior or resident to resident interactions. Education to assigned Staff on behaviors, Offer Psych Services weekly x 4 weeks and PRN post resident to resident altercation; assess for ongoing need for services and frequency. 3. Changes to Resident#1, 2, and 3's Activity Care Plans are reflected by the following; Resident will be offered preferred activities as able while adhering to 1:1 status. 4. The facility IDT will continue ongoing monitoring of Resident #1 and Resident# 2 and #3 to identify any change of condition or behaviors that would dictate care plan revisions. 5. All alert and oriented residents will be interviewed to identify if there are any additional concerns regarding potential abuse by 10/7/2020. Resident interviews on the identified unit (4 West) completed on 9/30/2020 with any identified concerns reviewed and taken through Grievance Process. 6. All staff will be educated, by the Unit manager or supervisor starting 9/29 and will be completed by end of day 10/7 on the facility abuse policy specific to reporting, types of abuse and protection of the resident. Staff will also be educated on the identification of signs of behaviors of someone who may be sexually abusive. Understanding for current staff will be validated. Ongoing the education will be added to the current Agency Orientation Packet. Education will be completed with 100% of active current facility staff (prior to the start of shift). 7. Abuse pathway questionnaires will be completed by Unit Managers/designee on 20 residents per week x 4 weeks then monthly x 3 months to identify any instances of abuse. The Unit Manager/designee will monitor for residents requiring 1:1 for safety and will complete 5 resident reviews weekly x 4 weeks then monthly x 3 months to identify any safety measures needing to be implemented. 8. The facility held a QAPI meeting on 9/29/20, to review the immediate plan. The facility will review the Abuse Policy and 1:1 supervision policy as it relates to abuse investigations and safety evaluations and specific event outcome. 9. Weekly counseling will be provided to all identified residents #1, #2 and #3 via psych services/SW x 1 month. Psychologist scheduled for weekly counseling with x 1 month with an assessment at that time to determine frequency of ongoing consults. This is based on their cognitive impairment as may not be able to actively participate. Care plan to be updated with identified interventions based on consults. A Monitoring visit was conducted on October 7, 2020, to verify the implementation of the immediate action plan and to review staff re-education documentation. All staff in the building at the time of the visit on October 7, 2020, had been in-serviced on recognizing the signs of sexual abuse and on safety surveillance. Interviews with the staff working on the floor, including RN'S, LPN'S, NA's, Unit Clerk's, and Dietary staff, reported they had all been in-serviced on recognizing signs of sexual abuse and on safety surveillance. The education included the seven types of abuse, physical signs of sexual abuse, mental signs of abuse, resident behaviors who had been abused, characteristics or staging of a perpetrator that could be targeting a possible victim for sexual abuse, to whom to immediately report an allegation of abuse, and one to one monitoring. Observations and interviews with Resident R1, R2, and R3, revealed all three residents remained on a 1:1 staff observation. Abuse pathway resident questionnaires for the identified alert and oriented residents had been completed by facility staff. The Immediate Jeopardy was lifted on October 7, 2020, at 3:40 p.m. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.12(a)(c) Nursing services

Based on observation, review of facility documentation, policy review and staff interview, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards related to an appropriate hot water temperature range, which resulted in an Immediate Jeopardy situation, placing residents in three of seven nursing units at risk for burn from hot water temperatures above 121.3 degrees Fahrenheit. (One East, Two East and Three East). Findings include: Review of a facility policy titled Water Temperature dated as effective 12/11/18 revealed the facility ensures that plumbing fixtures that supply hot water and are accessible to the residents are thermostatically controlled so the water temperature at the fixture does not exceed one hundred and ten degrees Fahrenheit (F) (110 F). The water should be at a temperature range of 105-110 F. The policy states the following in the event of hot water system failure: If the hot water system should fail and temperatures reach above 110 F you should immediately shut the hot water system down and notify your administrator. Observations conducted of hot water temperatures taken by the Director of Maintenance (DOM), using a facility electronic thermometer, on (MONTH) 4, 2019, starting at 3:25 p.m. revealed the following: - Two East, resident room [ROOM NUMBER] sink hot water faucet was 126.6 degrees F; - Two East, resident room [ROOM NUMBER] sink hot water faucet was 125.4 degrees F; - Three East, resident room [ROOM NUMBER] sink hot water faucet was 123.1 degrees F, and - One East, resident room [ROOM NUMBER] sink hot water faucet was 122.2 degrees F. Interview with the Director of Maintenance (DOM) on (MONTH) 4, 2019, at 3:35 p.m. revealed confirmation of the above stated hot water temperatures. The DOM confirmed that the water serving the resident sink faucets and showers in the East building came from the same boiler, water mixer and water tank. The DOM confirmed all hot water outlets in the East building were delivering water over 110 degrees Fahrenheit. Further interview with the Director of Maintenance (DOM) on (MONTH) 4, 2019, at 3:35 p.m. revealed that prior to (MONTH) 2019, the facility did not monitor resident accessible hot water temperatures throughout the facility. Additionally, the DOM confirmed that the maintenance staff had not been trained, in-serviced in measuring hot water temperatures with a thermometer since they started measuring the temperatures in (MONTH) 2019. Review of facility documentation revealed no hot water temperature logs prior to (MONTH) 2019. Observation of Employee E12, Maintenance Supervisor, using a facility electronic thermometer to measure the temperature of water flowing out of a shower head on the Central Bathing Room in the Two East nursing unit on (MONTH) 4, 2019, at 4:20 p.m. revealed the employee intermittently placed the thermometer in and out of the water coming from the shower head to measure the temperature. Parts of the probe were touched by water and parts were in the air and this method yielded a wildly fluctuating reading of the temperature. Interview with Employee E12, Maintenance Supervisor, on (MONTH) 4, 2019, at 4:21 p.m. revealed confirmation that the method was not accurate but that he did not know of a better way to record the temperature of water flowing from a shower head. Observation on (MONTH) 4, 2019 of hot water temperatures obtained in the resident shower in the Central Bathing Room on the Two East nursing unit with Employee E12, Maintenance Supervisor, using a facility electronic thermometer submerged into a shallow cup of flowing water revealed: - 4:23 p.m. Two East 127.8 degrees Fahrenheit - 4:28 p.m. Three East 126.3 degrees Fahrenheit - 4:34 p.m. One East 121.3 degrees Fahrenheit Interview with Employee E12, Maintenance Supervisor, on (MONTH) 4, 2019, at the above listed shower temperature measuring times revealed confirmation that the temperatures were too hot for resident bathing and that when he had previously recorded resident faucet and shower temperatures, he had not utilized an immersion method but rather intermittently placed the thermometer into the flow of water from the faucet or the shower. Employee E12 stated he had not been trained on any method(s) for obtaining the temperature of hot water. Interview with Employee E6, Nursing Assistant, on (MONTH) 4, 2019, at 4:50 p.m. revealed the employee checked shower temperatures by holding the head of the shower in his right hand and feeling the water temperature on the back of his left hand. Then Employee E6 would ask the resident to check the water temperature with their hand to see if it's OK. Interview with Employee E7, Nursing Assistant, on (MONTH) 4, 2019, at 4:52 p.m. revealed, as stated, hot water should not be too hot, it should be like lukewarm. I feel it on my hand. Just a lukewarm water, just feel it with your hand and give it to the resident. Interview with Employee E9, Nursing Assistant (NA), on (MONTH) 4, 2019, at 4:59 p.m. revealed, as stated, you have to check with your elbow, and you have to have the temperature. You have to regulate it and then give to resident on a wash cloth and squeeze a little water on the resident to know; if they say, 'oh it's too cold' then increase the temperature. Based on the above findings Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator (NHA) on (MONTH) 4, 2019, at 6:10 p.m. for the facility's failure to monitor and ensure safe hot water temperatures in three of seven nursing units placing the residents on this unit at risk for burn as a result of hot water temperatures. An immediate action plan was requested at this time to immediately put systems in place to ensure a safe hot water range. The facility submitted an implemented an action plan which included the adjustment of the mixing valve to a target temperature setting of 110 degrees Fahrenheit. The boiler temperature was lowered from 175 degrees to 115 degrees. Once those temperatures stabilized, approximately 200 gallons of water were drained from the storage tank allowing cooler water to refill. Water temperatures were monitor every two hours beginning at 7:00 p.m. on 9/4/19. The maintenance staff on duty were educated on the proper procedure to check water temperatures and recording the temperatures. The maintenance staff continued to monitor the temperature of the hot water every 2 hours until 11 p.m. on 9/4/19, then passing it onto the overnight nursing staff who have been educated on the procedure and for water temperatures to be recorded daily water. CAUTION: HOT WATER signs were posted at all showers, bathrooms, including staff and visitor lavatories. In service education to all nursing staff (3-11 shift) on the appropriate temperature ranges (no greater than 110 degrees) for showers and faucets. All shower rooms were equipped with thermometers and the nursing staff educated on their proper use. A mandatory in-service for the remaining nursing staff until 100% of staff were educated. Further, the Maintenance Director in service the remaining maintenance staff on the proper procedure to check water temperatures and on following the facility water temperature policy. Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was removed on (MONTH) 6, 2019, at 10:38 a.m. The facility failed to ensure that the resident environment remained as free of accident hazards as possible related to hot water temperatures in resident sink faucets and showers located in the One East, Two East and Three East nursing units; which placed residents at risk [MEDICAL CONDITION] hot water temperatures ranging from 121.3 degrees Fahrenheit to 127.8 degrees Fahrenheit. This resulted in an an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/30/19, 03/08/19, 11/07/18, 11/05/18, 05/15/18, 12/07/17 28 Pa. Code 201.18(a) Management Previously cited 05/15/18 28 Pa. Code 201.18(b)(1) Management Previously cited 08/01/19, 04/30/19, 03/08/19, 11/07/18, 11/05/18, 12/07/17 28 Pa. Code 201.18(b)(3) Management Previously cited 08/01/19, 04/30/19, 03/08/19, 11/07/18, 05/15/18, 05/07/18, 12/07/17 28 Pa. Code 201.18(e)(1) Management Previously cited 08/01/19, 04/30/19, 03/08/19 28 Pa Code 201.20(a)(c) Staff development 28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 04/30/19, 05/07/18

Based on a clinical record review, interviews with facility staff, reviews of dietary menus and hospital documentation, it was determined that the facility did not provide adequate supervision to maintain a safe eating environment for one resident. The lack of supervision during food distribution, service and storage placed this resident in an environment that caused actual harm. (Resident Cl1) Findings include: The Minimum Data Set Assessment (MDS - a periodic assessment of resident needs) was completed for Resident Cl1 on [DATE]. This significant change assessment indicated that this resident's cognitive abilities were severely impaired. The resident required supervision (oversight, encouragement or cueing) and a one person physical assist with eating. The assessment also indicated that this resident was not walking with an assistive device and had no functional limitations in range of motion of the upper and lower extremities. A wheelchair was indicated as the mobility device used by Resident Cl1. The physician's current order sheet on the clinical record listed [DIAGNOSES REDACTED]. The physician ordered Resident Cl1 a mechanical soft diet consistency (this diet is used for residents who had difficulty chewing regular textured foods). Resident Cl1's care plan indicated that this resident required the following interventions to promote safe toleration of all meals: a scoop dish as adapted feeding equipment, staff monitoring/oversight/observation for signs and symptoms of aspiration during meals and verbal cues and directions from staff at meal times. The occupational therapy evaluation dated [DATE], indicated that this resident had extended episodes of uncontrolled drooling while trying to communicate with staff. Interview with the Registered Nurse Manager on the third floor nursing unit at 11:30 a.m., on [DATE], revealed that Resident Cl1 had some missing teeth and did not wear dentures. A review of the dietary menu for [DATE], revealed that a turkey, ham and cheese sandwich, packet of mayonnaise, pasta salad, pickled beets, milk and vanilla ice cream was planned for the dinner meal. A review of the Licensed Nurse's witness statement for the ,[DATE] tour of duty, indicated that Resident Cl1 sat in the dining room on the third floor nursing unit for the dinner meal on that day. Further review of the investigation report revealed that the facility staff was unable to verify that Resident Cl1 received the mechanical soft diet as ordered by the physician. Nursing progress notes for [DATE] and 12, 2013, indicated that Resident Cl1 was becoming increasingly agitated and at times aggressive toward staff. The licensed staff documented in the clinical record that at 9:30 p.m., on [DATE], Resident Cl1 refused to take the medications scheduled for 9:00 p.m. Additionally, the nurse also documented that Resident Cl1 attempted to stand, transfer and ambulate from the wheelchair. At 4:00 a.m., on [DATE], the nursing progress notes indicated that this resident was placed on one to one monitoring by the nursing staff due to increasing agitation. At 5:00 a.m., the nursing progress notes indicated that a Charge Nurse approached Resident Cl1 in his room with a cup of water and applesauce to administer medications. Resident Cl1 turned around in bed and attempted to hit the Charge Nurse. This nurse also gave a witness statement that indicated Resident Cl1, "went unconscious". The Charge Nurse documented in a statement that Resident Cl1 appeared in distress and CPR (cardiopulmonary resuscitation) was initiated. At the same time emergency services were contacted for Resident Cl1. According to the hospital emergency room records dated [DATE], Resident Cl1 was found with an obstructed airway from a large food bolus and a mustard packet in the posterior pharynx that was impacted into the resident's airway. The mechanical obstructions had to be removed prior to intubation. The radiology report at the hospital dated [DATE], indicated that this resident assessment was consistent with anoxic [DIAGNOSES REDACTED] (lack of oxygen to the brain). Resident Cl1 expired at the hospital, on [DATE]. Resident Cl1 who was diagnosed with [REDACTED]. This failure to adequately supervise Resident Cl1 resulted in the resident swallowing foods that were not indicated in his diet along with a condiment packet that resulted in blockage of the resident's airway, resulting in actual harm to Resident Cl1. 28 PA. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 PA. Code: 201.18(b)(1) Management