Every finding on record at Carnegie Park Post Acute

Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization (Resident R1). Findings include:Review of facility Bed Hold and Returns, dated 3/10/26, revealed the facility has a requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payor source. Residents that seek to return to the facility within the bed hold time period are allowed to return to their previous room. Following hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.Review of Resident R1's clinical record revealed Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included schizoaffective (mental health condition that combines the symptoms of schizophrenia [serious mental disorder that affects how a person thinks, feels, and behaves] and mood disorder, depression and anxiety.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 3/2/26, indicated the diagnoses remain current.Review of a progress note dated 3/17/26, at 3:27 p.m. indicated Resident R1 told staff that they were depressed and stated I am better off dead. I was planning on slitting my wrists at dinner time.Further review of the progress notes indicated:-On 3/17/26, at 3:30 p.m. Resident R1 was sent to the local emergency room for thoughts of self-harm.-On 3/17/26, at 9:41 p.m. Update from the hospital indicated Resident R1 was staying overnight for a psychiatric evaluation (mental health assessment to understand your mental, emotional, and behavioral health) in the morning.-On 3/18/26, at 12:43 p.m. Resident R1 returned to the facility. The hospital reported to the facility that Resident R1 denied any thoughts of self-harm, and they were happy. When Resident R1 returned to the facility they stated they were very depressed, the hospital did nothing for them, and do not give them anything sharp or they would self-harm.-On 3/18/26, Resident R1 was transferred to the inpatient mental health hospital.Review of Resident R1's clinical record revealed no documented evidence that the facility was unable to meet Resident R1's care needs.During an interview on 4/16/26, at 10:00 a.m. the Director of Nursing stated the facility was unable to provide care needed for Resident R1 due to facility staffing concerns. They were unable to provide the date the resident was refused admission.During a telephone interview on 4/16/26, at 10:10 a.m. Physician Employee E2 stated the facility did not allow Resident R1 to return to the facility because the facility did not have the staff needed to provide one-on-one monitoring that they would require should Resident R1 return to the facility.During an interview on 4/16/26, at 2:00 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to permit Resident R1 to return to the facility after hospitalization without a documented reason in the clinical record. The NHA was unable to provide a date Resident R1 was denied re-admission to the facility.28 Pa. Code 201.29(f)(g)(h) Resident Rights

Based on clinical records, medication regimen reviews, and staff interviews, it was determined that the facility failed to respond in a timely manner to pharmacy recommendations for two of five residents (Resident R2 and R22).Findings include:Review of facility policy Medication Regimen Review reviewed 4/4/25 and 3/10/26, indicated the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist. The Medication Regimen Review (MRR) includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. It looks for irregularities like ensuring a written diagnosis, indication, or documented objective findings to support each medication. Recommendations are acted upon and documented by the staff and/or the prescriber. The Director of Nursing (DON) or designated licensed nurse address and document recommendations that do not require a physician intervention.Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease (gradual loss of memory and cognitive abilities, eventually leading to inability to perform simple tasks), dementia (group of symptoms affecting memory, thinking and social abilities), and anxiety.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 2/5/26, indicated the diagnoses remain current.Review of a physician's order dated 3/9/26, indicated to give Haloperidol (antipsychotic medication - used to treat nervous, emotional, and mental conditions) oral concentrate 2mg/ml (milligrams per milliliter) give 0.5 mg by mouth every six hours as needed for anxiousness for 14 days. (*Anxiousness is not an appropriate diagnosis for this medication.)Review of the Interim Medication Regimen Review dated 12/22/25, indicated the pharmacy recommendations for Resident R2 included: Per state and federal regulations, suggest that there is a diagnosis/indication listed on the POFs (Physician Order Forms)/MARs (Medication Administration Record) for each medication prescribed.This resident (Resident R2) is receiving the antipsychotic agent HALOPERIDOL but lacks an allowable diagnosis to support its use. The following are considered appropriate diagnoses/conditions:- Schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves)- Schizoaffective (mental health condition that combines the symptoms of schizophrenia and mood disorders)- Delusional disorder (one or more firmly held false beliefs that persist for at least one month without other symptoms of psychosis)- Mania (abnormally elevated mood, energy, and activity levels), bipolar type (fluctuations in mood, energy, and behavior), depression with psychotic features (symptoms of psychosis during an episode of depression), treatment- Refractory major depression (major depression that does not respond to conventional treatments)- Schizophreniform disorder (symptoms like schizophrenia, but lasting less than six months)- Psychosis NOS (not otherwise specified) (used when someone exhibits clear psychotic symptoms but does not fit in a specific disorder)- Atypical psychosis (category of psychotic symptoms that do not fit in a specific disorder)- Brief psychotic disorder (sudden and temporary psychiatric condition)- Dementing illnesses with associated behavioral symptoms (loss of thinking, remembering, and reasoning skills- Medical illnesses/delirium with manic/psychotic symptoms/treatment (confusion due to a medical condition/illness and is usually temporary)- Related psychosis/mania Further review of the Interim Medication Regimen Review revealed Certified Registered Nurse Practitioner (CRNP) Employee E4 marked the pharmacy recommendation as Disagree, signed the form but failed to date the form. Review of a mental health provider consult report dated 2/12/26, indicated haloperidol was prescribed for dementia with behavioral disturbances.Review of the clinical record indicated Resident R22 was admitted to the facility on [DATE], with diagnoses that included dementia, diabetes, and senile degeneration of the brain (progressive deterioration of brain tissue and function).Review of the MDS dated [DATE], revealed the diagnoses remain current.Review of a physician's order dated 12/29/25, indicated Risperidone (antipsychotic medication) 0.25 mg give two tablets one time a day for agitation/mood for a total of 0.5 mg. (*Agitation/mood is not an appropriate diagnosis for this medication.)Review of the Consultant Pharmacist Recommendation to Physical dated 12/23/25, indicated the pharmacy recommendations for Resident R22 included: This resident (Resident R22) is receiving the antipsychotic agent RISPERIDONE but lacks an allowable diagnosis to support its use.The following are considered appropriate diagnoses/conditions:- Schizophrenia - Schizoaffective- Delusional disorder - Mania, bipolar type, depression with psychotic features, treatment- Refractory major depression - Schizophreniform disorder - Psychosis NOS - Atypical psychosis - Brief psychotic disorder - Dementing illnesses with associated behavioral symptoms - Medical illnesses/delirium with manic/psychotic symptoms/treatment - Related psychosis/maniaFurther review of the Pharmacist Recommendations revealed CRNP Employee E4 marked the pharmacy recommendation as OTHER - Please see Doctor's Orders/Progress Notes, signed and dated the form on 1/5/26.Review of the physician orders and progress notes dated 12/23/25 through 1/5/26, failed to reveal an order or progress note regarding the pharmacy recommendation.Review of a mental health provider consult dated 1/12/26, indicated risperidone was prescribed for dementia with behaviors.During an interview on 3/13/26 at 12:15 p.m. the Director of Nursing confirmed the facility failed to follow up on pharmacy medication recommendations/reviews for Resident R2, and R22.28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa Code: 211.12(d)(1)(2) Nursing services.

Based on review of facility document, personnel in-service training records, and staff interviews it was determined that the facility failed to provide training on the Quality Assurance and Performance Improvement (QAPI) program for three of ten staff members (Employee E1, E2, E3).Findings include:Review of the Facility Assessment dated 3/10/26 and 4/4/25, indicated All staff will receive the training, licensure, education, skill level, and measure of competency via facility training program for all new and existing staff including managers, nursing, and other direct care staff, contractors, and volunteers. Review of facility provided documents and training records revealed the following staff members did not have documented training on QAPI.Occupational Therapist (OT) Employee E1 had a hire date of 12/12/14, failed to have QAPI in-service education between 12/12/24, and 12/12/25.Dietary Aide Employee E2 had a hire date of 12/9/23, failed to have QAPI in-service education between 12/9/24, and 12/9/25.Activities Assistant Employee E3 had a hire date of 9/19/88, failed to have QAPI in-service education between 9/19/24, and 9/19/25.During an interview with the Nursing Home Administrator on 3/10/26, at 9:44 a.m. confirmed that the facility failed to provide training on QAPI for three of ten staff members. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa Code: 201.18(b)(1) Management.28 Pa Code: 201.20(a)(c) Staff Development.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents (Resident R1). Review of facility policy Medication Monitoring dated 3/14/25, indicated staff monitor and document events including medication error. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/12/25, included diagnoses of peritoneal abscess (abscess near the large bowel), colitis (inflammation in the colon), and high blood pressure. Review of the provider orders reveal the residents Total Parenteral Nutrition (TPN) is to run a cycle for twelve hours from 9 p.m. to 9 a.m. daily. Review of the clinical record on 5/9/25 revealed Resident R1 received the incorrect TPN. This was reportedly discovered and hour later when Resident R4 was to have TPN prepared and administered. The infusion was stopped, the provider was notified. During an interview with the Resident R1 on 5/29/25 at 11:30 a.m., she reported no ill effects or concerns with her daily TPN infusions. During an interview on 5/29/21 at 2:20 p.m., Licensed Practical Nurse (LPN) Employee E1 confirmed the wrong TPN was administered to the resident. During an interview with LPN Employee E1 on 5/29/25 at approximately 2:20 p.m., stated the TPN was administered by the shift supervisor, Registered Nurse (RN) Employee E2 on 5/10/25. The TPN is to run a cycle for twelve hours from 9 p.m. to 9 a.m. At approximately 5:00 a.m. the infusion pump read complete, and the pump stopped the infusion with medication remaining. The pump was reported to be set at the incorrect rate. Review of employee statement 5/29/25 at 2:46 p.m. RN Employee E 3 confirmed she mixed the incorrect TPN. Review of the TPN storage on 5/29/25 at 3:30 p.m. revealed the TPN products are packaged, labeled, sealed, and in a dedicated bin for the individual residents on TPN. Review of the facility record on date 5/11/25 revealed Resident R1 did not receive the complete dose of TPN. During an interview on 5/29/25 at approximately 2:50 p.m., with the Assistant Director of Nursing the investigation concluded that the pump was set at the incorrect rate. During an interview on 5/29/25, at approximately 4:30 p.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed the facility failed to make certain that residents are free of significant medication errors for two of three residents.

Based on review of personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (Employees E11, E12, E13, E14, and E15). Findings include: Review of employee personnel files indicated no nursing staff annual performance evaluations. During an interview on 4/16/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Infection Control for seven of ten staff members (Employee E11, E13, E14, E15, E16, E17, and E18). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) Review of facility provided documents and training records revealed the following staff members did not have documented training on Infection Control: Nurse Aide Employee E11 had a hire date of 3/26/23, failed to have Infection Control in-service education between 3/26/24, and 3/26/25. Nurse Aide Employee E13 had a hire date of 3/14/05, failed to have Infection Control in-service education between 3/14/24, and 3/14/25. Nurse Aide Employee E14 had a hire date of 1/12/95, failed to have Infection Control in-service education between 1/12/24, and 1/12/25. Nurse Aide Employee E15 had a hire date of 4/14/14, failed to have Infection Control in-service education between 4/14/24, and 4/14/25. Registered Nurse Employee E16 had a hire date of 4/15/22, failed to have Infection Control in-service education between 4/15/24, and 4/15/25. Medical Records Employee E17 had a hire date of 4/6/10, failed to have Infection Control in-service education between 4/6/24, and 4/6/25. Therapy Employee E18 had a hire date of 2/9/09, failed to have Infection Control in-service education between 2/9/24, and 2/9/25. During an interview on 4/18/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Infection Control for seven of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on facility policy, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for three of fourteen residents who require care (Residents R63, R67, and R8). Findings included: Review of facility policy Resident Rights last reviewed 3/14/25, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record revealed Resident R67 was originally admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (reduced blood flow to the heart muscle) and heart failure (heart cannot keep up with its workload). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R67 required partial/moderate assistance with toileting hygiene. During an interview with Resident R67 on 4/16/25, at 1:34 p.m., the following was stated: I have sat in a dirty brief for more than an hour. Last week was the most recent time it happened to me. It regularly takes them an hour to answer the call lights no matter what you need. Review of the clinical record revealed Resident R63 was originally admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of seizure disorder (abnormal electrical activity in the brain) and bipolar disorder (extreme mood swings). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R63 was independent for toileting hygiene. Review of Section GG: 0170 Mobility toilet transfer, indicated Resident R63 requires supervision or touch assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently). During an interview with Resident R63 on 4/16/25, at 1:45 p.m., the following was stated: I can change my brief myself, I need some help in the bathroom. I have had accidents in bed and need help getting things cleaned up. I can only do so much of it and the bed needs changed. Sometimes the staff come in and wake me up at 2:00 a.m. for me to change my brief so I don't have an accident, and I don't like them waking me at 2:00 a.m . Monday night (4/14/25) it happened to me again. I had an accident and had to wait for more than an hour for help to get things cleaned up. Waiting an hour or longer when you call for help is normal here. Review of the clinical record revealed Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of heart failure and sepsis (infection in the bloodstream). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R8 required partial/moderate assistance for lower body dressing. During an interview and observation on 4/15/25, at 2:20 p.m., Resident R8 was observed dressed in a shirt and a brief. Resident R8 stated that he did not like not having any pants on. During an interview on 4/17/25, at approximately 9:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for three of fourteen residents. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services 28 Pa. Code 201.29 (j) Resident Rights

Based on review of facility policy, facility records, and resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for 15 of 22 residents as required (Resident R500, R501, R502, R503, R504, R505, R506, R507, R508, R509, R8, R68, R69, R125, and R243). Findings include: The facility policy Call System, Residents dated 3/14/25, indicated calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment During a resident group interview on 4/14/25, at 1:30 p.m., ten of fourteen residents in attendance stated that they consistently wait one hour or longer for their call light to be responded to. (Residents R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). The residents in attendance expressed frustration regarding the wait time. The residents stated they have reported this at their resident council meeting. Review of the 2/26/25, resident council meeting minutes, under the nursing section, reveals complaints regarding the agency staff they don't care. If you need help no one answers, they are always on their phones. During an interview on 4/18/25, at 8:00 a.m. Director of Nursing (DON) confirmed the facility failed to make certain call bells were answered timely for ten of fourteen residents as required (Resident R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). During an interview on 4/14/25, at 12:59 p.m. Resident R243 stated that the call light response time is long. During an interview on 4/14/25, at 1:16 p.m. Resident R68 stated that he waits a long time for his clothes to be returned from being laundered. Stated staff keeps saying they will look, but he doesn't have his clothes back. Stated he is wearing facility clothing, and the pants are too tight. Observation at this time revealed long, unkempt fingernails and that Resident R68 was malodorous. During an observation on 4/14/25, at 1:20 p.m. Resident R125 was observed to have long, unkempt fingernails. During an interview and observation on 4/15/25, at 2:20 p.m. Resident R8 was observed dressed in a shirt and a brief. Resident R8 stated that he did not like not having any pants on. During an interview on 4/15/25, at 2:36 p.m. Resident R69 stated that sometimes call lights can be long. Resident R69 stated that she has only had two showers since admission. Resident R69 stated she was given a bed bath, but that she prefers showers. Review of Resident R69's nurse aide task list indicated Resident R69 is scheduled to receive showers on Mondays and Thursdays, during evening shift. Review of Resident R69's bathing record (from 4/2/25, through 4/18/25) Resident R69 did not include a shower for the scheduled shower date of 4/7/25. During an interview on 4/18/25, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance for 15 of 22 residents. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in the unused dining room on the first floor. Findings include: Review of facility policy Storage of Medications dated 3/14/25, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, should be returned to the dispensing pharmacy or destroyed. During an observation of the first-floor dining room(unused) on 4/14/24, at 9:35 a.m. the following was observed: -(1) box of Midline blood glucose test strips expiring 7/8/23. -(1) adult manual resuscitator expiring 7/8/23 During an interview on 4/14/25, at 10:32 a.m. Unit Manager Employee E1 confirmed the above observations. During in observation of the ground floor clean utility room on 4/14/25, at 1:14 p.m. the door was noted to have a keypad lock, but the door was not closed. Within that room, an unlocked treatment cart was observed with the following items inside: -(3) open, partially used tubes of medical honey ointment, without names, date of opening, and allowed to commingle without being individually bagged. -(5) wound dressing packages, with an expiration date of 07/2022. During an interview on 4/14/25, at 1:20 p.m. Licensed Practical Nurse Employee E5 confirmed the above observations. During an interview on 4/15/25, at approximately 10:30 a.m. the Director of Nursing confirmed that the facility failed to make certain that medications were properly stored and/or disposed of in the unused dining room on the first floor. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of facility policies, the Four-week Spring Summer (SS) cycle menu diet extension sheets, and staff interviews it was determined that the facility failed to follow a preplanned cycle menu (lunch meal on 4/14/25), as required and failed to provide resident's their preferences and standing order food choices (Residents R47 and R90). Findings include: Review of the facility policy Menus, last reviewed on 3/14/25, with a previous review date of 8/13/24, indicated that menus are developed and prepared to meet resident choices while following established national guidelines for nutritional adequacy. Review of the facility policy Resident Food Preferences, last reviewed on 3/14/25, with a previous review date of 8/13/24, indicated individual food preferences are assessed upon admission, and communicated to the interdisciplinary team. The facility has documented food preferences and dislikes on each resident food ticket. During a resident group interview on 4/14/25, at 1:30 p.m., the resident consensus identified that the facility had provided pot pie for lunch on 4/14/25, however, they were expecting chicken tenders which had been on the menu. During an observation of the posted menu for 4/14/25, indicated chicken tenders while the posting on the wall indicated that the pot pie had been substituted however, the residents were not made aware of the change. During an interview on 4/15/25, at 12:35 p.m., the Nursing Home Administrator confirmed that the facility failed to notify the residents of the menu change prior to the date, as required. During an observation on 4/15/25, at 8:20 a.m., Resident R 47 stated that she was provided toast and a bagel and one cup of coffee. Resident R47 stated that she has a preference indicated on her ticket. The ticket shows standing orders of two cups of coffee, orange juice and a boiled egg. Resident R47 had no protein on her breakfast tray. During an observation on 4/15/25, at 8:30 a.m., Resident R90 was provided a scrambled egg. Observation of her standing orders indicated a boiled egg and her dislike is identified as a scrambled egg. The resident stated that they never give her a boiled egg and you never know what you're gonna get. During an interview on 4/15/25, at 1:20 p.m., the Dietary Services Director Employee E6 confirmed that he has made menu changes to see what the residents like. The residents have dislikes and preferences and I could track them easier in a different computer system so if they don't get what they want, I cannot track there preferences. He was shown the incorrect tickets which indicated standing orders and preferences. No comment was made. During an interview on 4/18/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to follow a preplanned cycle menu and failed to provide resident's their preferences and standing order food choices. Pa Code: 211.6(a) Dietary services. Pa Code: 201.14(a) Responsibility of licensee

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for eight of ten staff members (Employee E11, E12, E13, E15, E16, E17, E18, and E19). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) Review of facility provided documents and training records revealed the following staff members did not have documented training on behavioral health: Nurse Aide Employee E11 had a hire date of 3/26/23, failed to have behavioral health in-service education between 3/26/24, and 3/26/25. Nurse Aide Employee E12 had a hire date of 3/8/22, failed to have behavioral health in-service education between 3/8/24, and 3/8/25. Nurse Aide Employee E13 had a hire date of 3/14/05, failed to have behavioral health in-service education between 3/14/24, and 3/14/25. Nurse Aide Employee E15 had a hire date of 4/14/14, failed to have behavioral health in-service education between 4/14/24, and 4/14/25. Registered Nurse Employee E16 had a hire date of 4/15/22, failed to have behavioral health in-service education between 4/15/24, and 4/15/25. Medical Records Employee E17 had a hire date of 4/6/10, failed to have behavioral health in-service education between 4/6/24, and 4/6/25. Therapy Employee E18 had a hire date of 2/9/09, failed to have behavioral health in-service education between 2/9/24, and 2/9/25. Registered Nurse Employee E19 had a hire date of 3/12/07, failed to have behavioral health in-service education between 3/12/24, and 3/12/25. During an interview on 4/18/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on behavioral health for eight of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that the call bell system was in full working order for one of four nursing units (Second Floor Nursing unit). Findings include: Review of the facility policy Call System, Residents 3/14/25, indicated that the call system communication will be audible and visual and the resident call system will be functional at all times. During an observation of the Second Floor Nursing Unit, central call bells identified in the A, B, and C halls did not illuminate when resident call bells in their rooms of each hall had been activated. During an interview on 4/15/25, at 9:10 a.m., the Director of Nursing confirmed that the central call bells were not functioning to provide unobstructed visual communication of which hall the call bell was coming from due to the ceiling bulkhead. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b) (1) Management.

Based on review of facility policy, clinical records, and resident and staff interviews, it was determined that the facility failed to notify the resident representative of changes in appointment and transportation times for one of four residents (Resident R69). Findings include: Review of the facility policy, Notification for Medical Appointments dated 3/14/25, previously dated 8/13/24, indicated when a medical appointment is scheduled: - Document the appointment details in the resident's medical record. - Notify the responsible party at least 48 hours in advance, unless the appointment is emergent. - Use the resident's preferred communication method (e.g., phone, email, written notice). The notification to the responsible party should include: - Date and time of the appointment. - Name and specialty of the healthcare provider. - Purpose of the appointment. - Any special instructions or preparations required. Review of the clinical record indicated Resident R69 was admitted to the facility on [DATE]. Review of Resident R69's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/6/25, included diagnoses diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and multiple fractures. Review of Resident R69's demographic profile indicated her son as her emergency contact and medical power-of-attorney. Review of a physician's progress note dated 4/8/25, at 6:54 p.m. indicated, Spoke with patient's son regarding her appointment with plastics and the outcome of that appointment which was a referral to an orthopedic surgeon for her shoulder and otherwise no new orders. Patient's son voiced frustration over not being made aware of the appointment ahead of time which I passed along to administrative staff. During an interview on 4/16/25, at 2:15 p.m. Resident R69's son stated he was upset that his mother had gone to her appointment by herself soon after she was admitted . The son stated that it should be in the record that he is notified of all appointments and any time that Resident R69 was to be taken out of the facility, to which Resident R69 agreed. Resident R69's son stated that he had previously voiced concern to with facility administration, and was assured it would never happen again, but that it had just happened again. Resident R69's son stated that he was going to accompany his mother to her appointment (4/15/25), with her traveling in wheelchair transportation. Resident R69's son said when he arrived at the facility, his mother had already departed, as there had been a change in the transportation time that he had not been informed of. Resident R69's son stated, I don't want my [resident's age, greater than [AGE] years] old mother having to go anywhere by herself. During an interview on 4/18/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that this concern had been previously brought to facility administration and further confirmed that the facility failed to notify resident representative of changes in appointment and transportation times for one of four residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy , observations, and staff interviews it was determined that the facility failed to maintain a homelike environment in the facility (resident dining rooms) for one of four resident dining locations (first floor nursing unit). Findings include: A review of the facility Homelike Environment Policy dated 3/14/25, indicated residents are provided with a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. During an observation of the facility on 4/14/25, at 10:00 a.m., the following was revealed: First floor resident dining room had a bed, mattress, and two treatment carts stored in this location. During an interview on 4/14/25 at 10:32 a.m. Employee E1 unit manager confirmed the bed, mattress, and two treatment carts were stored in this location. During an interview on 4/15/25, at 10:30 a.m., the Nursing home Administrator and Director of Nursing confirmed that the facility failed to maintain the facility in a homelike environment for one of four resident dining locations (first floor nursing unit). Pa Code: 207.2 (a) Administrator's responsibility

Based on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required for one of 12 months (3/3/25 through 4/14/25). Findings include: Review of the Activities Director job description required Qualifications Certificates, Licenses, Registrations - Activity Director certificate. During an interview on 4/16/25, at 1:30 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to provide a qualified professional to direct the activities program for one of 12 months (3/3/25 through 4/14/25). 28 Pa Code 201.18(b)(3) Management. 28 Pa Code 201.18(e)(6) Management

Based on review of facility policies and documents, clinical records, and staff interviews, it was determined that the facility failed to provide care and services after hospitalization for one of three residents (Resident R68). Review of the clinical record indicated that Resident R68 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/24/25, included diagnoses of anemia (too little iron in the body causing fatigue), chronic kidney disease (gradual loss of kidney function), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Review of hospital discharge instructions dated 3/19/25, indicated for the facility to reinforce the dressing. No direction for changing the dressing was documented. Review of a progress note dated 3/20/25, at 9:07 a.m. indicated, Pt (patient) has dressing intact to RLE (right lower extremity). Orders state to reinforce only, DO not change until F/U (follow-up) appointment in 2 weeks. Review of a progress note dated 3/21/25, at 2:44 p.m. indicated, this nurse spoke with dr. office regarding right foot wound care. per md office do not remove dressing only reinforce until f/u pt in 1 1/2 weeks. Review of a physician's order dated 3/21/25, indicated, DO NOT REMOVE RIGHT LEG DRESSING PER SURGEON. ONLY REINFORCE CALL OFFICE IF EXCESSIVE DRAINAGE. Review of a progress note dated 3/22/25 at 6:29 p.m. indicated, The resident has an excessive amount of drainage to the right leg. He has orders in the system not to remove surgical dressing to reinforce and notify Dr of excessive drainage to site. Current CNA (nurse aide) stated she told [Unit Manager Employee E1 and Registered Nurse (RN) Employee E3] the Nurse cut off the white cast and wrapped the wound with the dirty ace wrap. And nothing was done. The dirty ace wrap has been on since Wednesday. Today on my shift 3-11 the wound has excessive drainage when checking the system the order states do not remove call reinforce dressing call the doctor for excessive drainage when reading off the order my hall partner called [Unit Manager Employee E1] if he was aware the cast had been removed since Wednesday he stated no, told her to tell [LPN Employee E4]. [RN Employee E3] told us that she had told both [Unit Manager Employee E1 and [RN Employee E3] the cast was cut off and that she wrapped the fresh dressing with a soiled bandage. He said [LPN Employee E5] to take pictures with her phone send it to him he was going to call, the Dr. As I was writing the note in the system. And calling the Dr. I have been asked to leave. During an interview on 4/18/24, at 10:40 a.m. Unit Manager Employee E1 confirmed that Resident R68's dressing was changed without an order. During an interview on 4/18/24, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care and services after hospitalization for one of three residents. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c)(d) Resident rights. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of five residents (Residents R244). Findings include: Review of the facility policy, Pharmacy Services Overview dated 3/14/25, the facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Review of the clinical record indicated Resident R244 was admitted to the facility on [DATE]. Review of the facility diagnosis list included chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness), spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), and chronic pain syndrome. Review of a physician's orders dated 4/11/25, indicated Resident R244 was to receive oxycodone (a narcotic pain medication to treat moderate to severe pain) 10 mg (milligrams), 1.5 tablet (15 mg) by mouth every four hours as needed for severe pain. Review of a physician's orders dated 4/11/25, indicated Resident R244 was to receive Methocarbamol (muscle relaxant that works by calming overactive nerves in the body) 1000 mg four times a day for muscle spasms for ten days. Review of a physician's orders dated 4/11/25, indicated Resident R244 was to receive Ketorolac Tromethamine (nonsteroidal anti-inflammatory drug (NSAID) specifically recommended for moderate to severe pain) 10 mg, one tablet by mouth four times a day. Review of Resident R244 ' s documented pain levels indicated the following levels based on a zero to ten scale with zero being no pain and ten being the worst: 4/12/25, at 9:10 a.m. - 8 4/12/25, at 5:09 p.m. - 7 4/12/25, at 9:38 p.m. - 8 4/13/25, at 5:59 a.m. - 7 4/13/25, at 12:22 p.m. - 9 4/14/25, at 9:10 a.m. - 8 4/14/25, at 8:38 a.m. - 10 Review of Resident R1's Medication Administration Record (MAR) for April 2025, indicated: 4/11/25: No documentation of oxycodone provided. 4/11/25: Ketorolac, documented as 9 (9 is code for order Other/See Nurse Notes). The pain level noted with this scheduled administration was 10. Review of the associated progress note dated 4/11/25, at 11:07 p.m. indicated, per [physician] ok to give when arrives from pharmacy. 4/12/25: Methocarbamol, documented as 9. Review of the associated progress note dated 4/12/25, at 11:55 a.m. indicated, indicated that the medication was on order from the pharmacy. Review of an admission progress note dated 4/11/2025, at 10:13 p.m. indicated, explained to us she has several bone fractures on the right side of her lumbar spine and 8 pins and 8 rods on left side of spine. c/o pain of 10. Review of the facility provided inventory for the automated medication dispensing machine included oxycodone 5 and 10 mg tablets and Methocarbamol 500 mg tablets. During a follow-up communication on 4/18/25, at 1:30 p.m. the Director of Nursing was made aware that the facility failed to implement procedures to ensure availability of prescribed medications for one of five residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to ensure a safe, functional and clean environment for two of 33 residents of the Third floor B wing nursing unit (Resident R99 and R112). Findings include: During an observation on 4/16/25, at 8:50 a.m., of the Third Floor Nursing Unit, two maintenance workers were observed exiting Resident R99 and R112's resident room. Upon entering the resident room, a four foot by four foot area (approximately) wall behind Resident R99's bed had been removed exposing wires and insulation. When asked, Maintenance Director Employee E7 stated that the wall had pulled away, from the television being too heavy and it needed repaired. Resident R99 and R112's belongings were scattered all over the room allowing debris to fall onto them and into their personal items. During an interview on 4/16/25, at 9:25 a.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, functional resident room for Residents R99 and R112. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Prevention of Abuse and Neglect for one of ten staff members (Employee E18). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Required training topics include the following: a. Effective communication with residents and family (direct care staff); b. Resident rights and responsibilities; c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: d. Elements and goals of the facility QAPI program; e. The infection prevention and control program standards, policies and procedures; f. Behavioral health; and g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) Review of facility provided documents and training records revealed the following staff members did not have documented training on Prevention of Abuse and Neglect: Therapy Employee E18 had a hire date of 2/9/09, failed to have Prevention of Abuse and Neglect in-service education between 2/9/24, and 2/9/25. During an interview on 4/18/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Prevention of Abuse and Neglect for one of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees Employee E11 and E15). Findings include: Review of the facility policy, In-Service Training, All Staff most recently reviewed 3/14/25, indicated all personnel will receive education and training related to resident care. Review of Nurse Aide (NA) Employees Employee E11 and E15 ' s education records, with hire date greater than 12 months, revealed the following: NA Employee E11 had a hire date of 3/26/23, with approximately four of in-service education between 3/26/24, and 3/26/25. NA Employee E15 had a hire date of 4/14/14, with approximately four hours of in-service education between 4/14/24, and 4/14/25. During an interview on 4/18/25, at approximately 1:00 p.m. confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for two of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.20(c) Staff Development.

Based on review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident for one of eighty-seven residents (Resident R1), resulting in immediate jeopardy. Findings include: The Pennsylvania Code Title 49, Professional and Vocational Standards through the Department of State indicates under Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals. Review of AHA Guidelines dated 2024, indicated if a person is unresponsive with no breathing and has no pulse for more than 10 seconds, start CPR. The facility's CPR policy titled. Cardiac and/or Respiratory Arrest reviewed [DATE], indicated the following guidelines are available and are to be utilized in the event of a resident emergency. If a witnessed or unwitnessed arrest for patients without a Do Not Resuscitate (DNR) First, the licensed nurse will evaluate the patient for obvious clinical signs of irreversible death unless not permitted by state regulation. If at least ONE obvious clinical sign of irreversible death is present, do not initiate CPR (Obvious clinical signs of irreversible death include: lividity or pooling of blood in dependent body parts, hardening of muscles or rigidity (rigor mortis) or injuries incompatible with life). If there are no obvious clinical signs of irreversible death, initiate CPR/AED, call 911 and notify primary physician, designate an individual to record events, continue CPR until EMS arrives, notify family health care decision maker of patient's status. Review of Resident R1's clinical record indicated an admitted [DATE], with diagnoses that included high blood pressure, muscle weakness, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of diseases that block airflow and make it difficult to breathe, emphysema and chronic bronchitis are most common conditions). Review of Resident R1's Minimum Data Set (MDS-a periodic assessment of care needs) dated [DATE], indicated the diagnoses were current. Review of Resident R1's physician order dated [DATE], current through [DATE], indicated Resident R1 was a full code (allows for all interventions needed to restore breathing or heart functioning). Resident R1 ceased to breathe on [DATE] at 12:22 p.m. Review of Resident R1's closed record revealed a Physician Order for Life Sustaining Treatment (POLST) form dated [DATE], indicated if the resident has no pulse and is not breathing, attempt resuscitation. The form was signed by Nurse Practitioner E5 and it was indicated a verbal consent was provided from Resident R1's daughter who was listed as emergency contact. Review of Resident R1's care plan dated [DATE], indicated the resident was a full code. Interventions indicated CPR will be performed as ordered. Review of Resident R1's Task list dated [DATE], indicated the resident was a full code. Review of Resident R1's progress note dated [DATE], at 12:37 p.m. entered by Licensed Practical Nurse (LPN) Employee E3, indicated resident ceased to breathe (CTB) at 12:22 p.m. There was no documentation that CPR was administered as ordered. During an interview on [DATE] at approximately 9:00 a.m. the Nursing Home Administrator (NHA) and Registered Nurse (RN) Employee E2 confirmed CPR was not initiated for Resident R1 on [DATE]. RN Employee E2 indicated that the family had arrived at 12:20 p.m. on [DATE], asked for her to evaluate the resident since they found him with his head bent, [employee] ran out of the room to grab her stethoscope to obtain vital signs (apical pulse-pulse point on your chest at the bottom of the heart) and grabbed RN Supervisor Employee E4. LPN Employee E3 also in the room acknowledged that Resident R1 was a full code. RN Employee E2 revealed she did not start CPR because the daughter was too upset and they did not want to start in front of her. RN Employee E2 pronounced Resident R1 CTB at 12:22 p.m. The resident's POLST form was for a Full Code as found in the resident's chart and on the electronic record, placing all residents at risk if they become unresponsive and pulseless, which resulted in an Immediate Jeopardy situation. On [DATE], at 3:32 p.m. the Nursing Home Administrator and the Director of Nursing was notified that an immediate jeopardy was identified and was provided a copy of the completed IJ template. On [DATE], at 6:26 p.m. and Immediate Action Plan was accepted with the following actions: Immediate Action: -Whole house audit was conducted and completed on [DATE], on all code status of all residents' to ensure all orders are out in medical record, care planned and POLST forms are to be uploaded into the medical record and the original form placed in the physical chart. -Any POLST forms not uploaded into the chart will be uploaded to the electronic record on [DATE]. -All primary staff will be educated by end of day [DATE], on code status and recognition of signs of death and proper procedure of notification to nursing staff if there is an occurrence. All agency and PRN staff will be instructed to complete education prior to the start of their next shift. -All primary Nurses prior to the start of their next shift, or by [DATE], will be educated on signs of irreversible death, proper documentation in medical records of the occurrence and Policy NSG208 Cardiopulmonary Resuscitation (CPR) and Procedure: Cardiac and/or Respiratory Arrest. All agency and PRN staff will be instructed to complete education prior to starting next shift. -Primary Licensed staff will be educated to facilitate CPR on residents who have elected such services until EMS arrives and assumes responsibility for the residents by [DATE]. All agency and PRN staff will be instructed to complete education prior to their next scheduled shift. -All new admissions will be audited to ensure code status orders are entered into the medical record accurately, care planned, and uploaded into the medical chart. They will also ensure the physical copy of the advance directive is placed in the physical chart weekly x 4. -Mock codes will be conducted every shift x2 days then randomly daily x1 week, then weekly x 4. -QAPI completed on [DATE]. -Audit completed for nurses CPR cards on [DATE]. -AED/Crash carts verified with stocked and expiration dates of PADS on [DATE]. -Education related to change in condition and notifications NSG122 will be completed by end of day [DATE]. Entering Advance Directives orders are put in the medical record, care planned and Advance Directives are to be uploaded in the medical record and he original form placed in the physical chart by end of day [DATE]. The facility's CPR policy titled Cardiac and/or Respiratory Arrest was revised on [DATE] and reviewed on [DATE], and indicated the center will support the right of every patient to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The center will perform CPR on all patients, except in certain limited circumstances, unless there is a written physician's order agreed to by the patient or health care team representative, in accordance with state regulation/law. The facility's Procedure: Cardiac and/or Respiratory Arrest was revised on [DATE], and reviewed on [DATE], and indicated upon discovery of a patient in cardiopulmonary arrest to first call for assistance, alert licensed nurse and CPR/automated external defibrillator (AED) certified staff, prepare patient for CPR/AED while determining the code status, call 911 and notify primary physician, designate an individual to record events on the CPR/AED flow sheet. Continue CPR until EMS arrives, restoration is effective, rescuer is unable to continue because of exhaustion, and state regulation allows licensed nurse to pronounce/certify death, reliable and valid criteria indicating irreversible death are met or criteria for termination of resuscitation are met. 114 of 139 residents code status, including orders, POLST and care plan were reviewed and accurate as of [DATE]. On [DATE], at 10:07 a.m. 90 of 92 nursing staff (1-Maternity Leave of Absence, 1-Vacation out of country) verified they were educated prior to start of their shift via signature sheet. All nursing staff in facility on [DATE], were interviewed and confirmed training and understanding. All nursing staff were educated on what to do in an event of an emergency. Staff must determine unresponsiveness, notify a licensed nurse immediately, verify resident's code status. If an emergency response is required to activate in-house emergency communication system, and call 911. If necessary, initiate cardiopulmonary resuscitation (CPR) and chart completely all events up to the situation, what transpired during situation, and the events that followed. The physician and healthcare decision maker must be notified. The facility will continue to educate nursing staff prior to the start of the shift. The Director of Nursing (DON) or designee will conduct audits to ensure policy is being followed and findings will be reported in upcoming QAPI meetings. On [DATE], the Immediate Jeopardy was lifted at 2:05 p.m. after ensuring the Immediate Plan of Correction had been implemented. During an interview on [DATE], at 3:47 p.m. RN Unit Manager, Employee E6 stated that they conduct training on CPR, they also stated if a resident is not breathing, she would check the POLST located in the front of the resident's hard chart or in the electronic record and if a full code would begin CPR as per the resident's wishes. During an interview on [DATE], at 3:49 p.m. LPN, Employee E7 stated if a resident ceases to breathe, the resident's code status is checked in the resident's paper chart. During an interview of [DATE], at 3:53 p.m. RN Employee E8 stated she would check the paper chart for the most up to date POLST. During an interview on [DATE], at 4:08 p.m. LPN Employee E9 stated if no respirations or pulse she would check in either the paper chart or electronic record for a code status and if a full code would start CPR. During an interview on [DATE], at 4:11 p.m. Transitional Nurse-RN Employee E10 stated that they would check in the front of the paper chart for the pink paper for the code status. During an interview on [DATE], at 4:13 p.m. Certified Nursing Assistant (CNA) Employee E11 stated that if they walked into a room and the resident was unresponsive they would grab a nurse or the nurse supervisor and then go to the paper chart to obtain the POLST for the nurse for code status. During an interview on [DATE], at 4:15 p.m. CNA Employee E12 stated that if they walked into a room and a resident was unresponsive they would yell for help, get a nurse, call a code, get crash cart if needed and can assist with writing things down. During an interview on [DATE], at 4:17 p.m. RN Unit Manager Employee E13 stated that they educate CNA's on where to find the POLST and about bringing it to the nurse in emergency situations. During an interview on [DATE], at 10:07 a.m. LPN Employee E14 stated that they received education before the start of their shift and know that the POLST is located on the paper chart and in the electronic record. During an interview on [DATE], at 10:09 a.m. LPN Employee E15 stated that they received education before the start of their shift and know that the POLST is located on the paper chart or in the electronic record. Stated she would call for help and if not a DNR would start CPR. During an interview on [DATE], at 10:10 a.m. RN Employee E16 stated if they walked into a resident's room and resident appeared unresponsive would do a sternal rub, check extremities, start CPR and have someone call 911. Employee E16 stated education was reviewed before the start of her shift regarding POLST. During an interview on [DATE], at 10:13 a.m. CNA Employee E17 stated they received training before the start of their shift and if they walked into a room with an unresponsive resident would seek help immediately and obtain the POLST from the paper chart for the nurse. During an interview on [DATE], at 10:16 a.m. LPN Employee E18 stated they received training before the start of their shift and would locate code status by either checking the chart, report sheet, or electronic record. During an interview on [DATE], at 10:19 a.m. LPN stated they received training before the start of their shift and would locate code status in the paper chart. During an interview on [DATE], at 10:22 a.m. CNA Employee E20 stated they received training before the start of their shift and would follow the steps if they are a full code or a DNR. During an interview on [DATE], at 10:26 a.m. CNA Employee E21 stated they received training before the start of their shift and would obtain the POLST from the paper chart for the nurse. During an interview on [DATE], at 10:28 a.m. RN Employee E22 stated they received training before the start of their shift and would obtain the POLST from the paper chart or the electronic record and would start CPR. During an interview on [DATE], at 10:30 a.m. RN Employee E23 stated they received training before the start of their shift. They stated that the POLST is located on the paper chart and the electronic record, If the resident is unresponsive and known Full Code would start CPR and yell for help. During an interview on [DATE], at 10:46 a.m. RN Employee E24 stated they received training before the start of their shift and would obtain the POLST from the paper chart, would also write it on their resident report sheets for quick reference and to know if they needed to start CPR immediately. During an interview on [DATE], at 10:48 LPN Employee E25 stated that they received training before the start of their shift and know that the POLST is located in the paper chart and the electronic record. During an interview on [DATE], at 12:15 p.m. the NHA and DON confirmed that staff failed to follow policy and procedure and failed to administer CPR to Resident R1 as per the POLST and physician order. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 12 residents (Resident R340). Findings include: A review of the facility policy Elopement of Resident reviewed 2/7/23, stated that the facility will identify patient's elopement risk upon admission, re-admission, quarterly, or with a significant change in condition. It is indicated for patients identified as a risk; an interdisciplinary elopement prevention patient-centered care plan will be developed. An Elopement Risk Identification form for all patients at risk of elopement is to be completed. It is also indicated if staff witness a confused patient or an identified elopement risk patient attempting to leave the unit, staff will intervene as appropriate to redirect the patient to a safe area and prevent elopement. A review of the facility policy Dementia reviewed 2/7/23, stated if the assessment shows cognitive loss or dementia then the resident will be monitored for elopement risk. A review of the facility policy Accidents/Incidents reviewed 2/7/23, stated if an employee witnesses a patient accident or incident, the employee will provide immediate assistance and remove the individual from immediate harm, if needed. It is also indicated the Administrator, Director of Nursing (DON), or designee will review all accidents and incidents to determine if the accidents or incidents have been appropriately and timely reported, required documentation has been completed, and the accident or incident has been investigated, and interventions to eliminate if possible, and if not, reduce the risk of the accident or incident form reoccurring have been identified and implemented. A review of the Admission Record indicated Resident R340 was admitted to the facility on [DATE], with diagnoses that included nicotine dependence, depression, and high blood pressure. A review of Resident R340's clinical record failed to include an elopement risk assessment that was completed upon admission. A review of the Speech Therapy SLP Evaluation form dated 4/20/23, indicated that Resident R340 had a mild cognitive impairment (MCI) and required minimum to close supervision. A Brief Cognitive Assessment Tool (BCAT-provides objective measures to determine cognitive abilities and the impact on function) was completed and Resident R340 scored a 35/50, consistent with mild cognitive impairment (44-50 normal cognitive functioning: independent living, 34-43 MCI: functional decline in instrumental activities of daily living (IADL), 25-33 mild dementia: IADL deficits, memory and cognitive decline, 0-24 moderate to severe dementia: functional deficits, marked decline in memory and executive functions, behavioral and psychological symptoms common; requires complex care). It is indicated MCI is a serious health condition that can have far reaching implications for independence and everyday functioning. Patients with MCI are at risk for developing dementia, especially Alzheimer's disease. A progress note dated 4/18/23, entered by Registered Nurse (RN) Employee E11 indicated that Resident R340 states he has some short-term memory loss and has fallen at home a few times. A progress note dated 4/18/23, entered by RN Employee E12 indicated Resident R340 is awake, alert, forgetful. A progress note dated 4/19/23, entered by Nurse Practitioner, Employee E13, indicated Resident R340 was being seen for alcohol withdrawal and Resident R340 stated he normally drinks approximately six large glasses of wine every day, seven days a week. A progress note dated 4/19/23, entered by Licensed Practical Nurse (LPN) Employee E14, stated wife informed facility that resident drinks 20 out of 24 hours in a day. A progress note dated 4/20/23, entered by Physician Employee E15 indicated Resident R340 was alert and oriented x2 and confused. A progress note dated 4/22/23, entered by Physician Assistant Employee E10 indicated Resident R340 admits to short term memory loss. A review of Resident R340's care plan dated 4/20/23, indicated Resident R340 has cognitive and communitive deficits, interventions included speech therapy and speech therapy group treatment. The baseline care plan failed to show documented risks, goals or interventions related to the risk of elopement or wandering. A review of Resident R340's physician order dated 4/18/23 through the elopement date of 4/23/23, failed to show any documented orders or protocols to follow for Resident R340 in case of elopement or wandering behaviors. A progress note dated 4/23/23, entered by RN Supervisor Employee E18, stated she was called to first floor for resident outside the building. It was indicated Resident R340 stated he was going to the road for his wife to pick him up. A review of the Elopement incident report completed by RN Supervisor Employee E18 entered on 4/23/23 indicated the patient stated he was going to meet his wife up by the road, he just got off phone with her. A progress note dated 4/23/23, entered by LPN Employee E19, stated Resident left the unit and went outside, he stated he was going to see his wife. A review of facility provided documents, dated 4/25/23, indicated that on 4/23/23, at 4:16 a.m. Resident R340 eloped from the facility. During an interview on 4/25/23, at 12:02 p.m., the Director of Nursing stated the facility did not consider Resident R340 an elopement risk because he was alert and oriented x3 and an investigation was not completed. During an interview on 4/25/23, at 1:51 p.m., Speech Therapist, Employee E21 stated I evaluated him on 4/20/23, I have not seen him since the evaluation. When I evaluated him, he scored 35 out 50, which means he is mildly cognitively impaired. The test completed was the B-CAT. It's a group task to determine the level of supervision for the resident. As the Nursing Home Administrator (NHA) said, none of the residents should be outside the front door. He would need minimum to close supervision. During a phone interview on 4/25/23, at 2:09 p.m., Nurse Aide (NA) Employee E16 indicated she observed Resident R340 on 4/23/23, walking down the hall and observed him turning the corner towards the exit. NA, Employee E16, stated she answered a resident's call light and when she went to see where Resident R340 went, he was nowhere to be found. NA Employee E16 stated she looked outside and saw that Resident R340 was outside. NA Employee E16 stated before going outside to retrieve the resident, she went back to get her jacket because it was really cold. NA Employee E16 indicated by the time she returned to retrieve Resident R340 from outside another aide, NA Employee E17 seen Resident R340 was outside and both aides went outside to assist the resident. NA Employee E16 stated Resident R340 was not wearing shoes or a jacket, he had on jeans and a t-shirt. NA Employee E16 stated that Resident R340 stated he wanted to go home. NA Employee E16, confirmed Resident R340 had intermittent periods of confusion. NA Employee E16 confirmed the facility failed to provide adequate supervision for Resident R340 resulting in elopement. A review of the weather forecast on 4/23/23 around 4:00 a.m., indicated it was 42 degrees Fahrenheit. No written statements from NA Employee E16, NA Employee E17, RN Employee E18, or LPN Employee E19 were available. The DON did not complete an investigation and did not consider Resident R340 being found outside on 4/23/23 at 4:16 a.m. as an elopement. The facility provided a Witness Interview Record dated 4/25/23 for NA Employee E16 and NA Employee E17 that was not signed. It was indicated the statement was obtained from over the phone and was signed by the DON. A late entry progress note for 4/24/23, dated 4/25/23, entered by the DON, stated During review of incident, interdisciplinary team did not determine it was an elopement. It also indicated after further review of records, interviews, and incident facility concludes it was not an elopement. During an interview on 4/25/23, at 3:32 p.m. the NHA and the DON were made aware that Immediate Jeopardy (IJ) existed due to Resident R340's elopement on 4/23/23. The IJ template was provided to facility administration at that time and a corrective action plan was requested. Notification on 4/25/23 at 9:22 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R340 was assessed after the elopement to determine any injury, none at that time. An alert bracelet was applied to Resident R340, a behavior assessment was completed and care plan for elopement risk was implemented to include redirection of resident, the alert bracelet, and educating family and visitors to notify staff when leaving. Residents: A review of residents currently living in the center using the new Elopement Evaluation was completed by the Director of Nursing/Designee to identify other residents who are at risk for wandering and or exit seeking. The review started on 4/25/23 at 6:00 p.m., and it was indicated it would be completed by 4/26/23 at 8:00 a.m. If a resident is identified as exit seeking, an alert bracelet is to be applied and the resident's care plan is updated at the time of identification to address the risk of elopement to include redirection of resident and education of family and visitors. Whole house audit was conducted by the NHA, DON, and Clinical Leader Employee E1 on elopement risks with updated assessments done on every resident. Residents who were identified to be at risk, care plans were updated to include interventions to address elopement risk. System correction: Education with center staff by the director of Nursing/designee on elopements, exit seeking risks, and possible interventions for risk including redirection, verbal reassurance, reminiscing, offering snack and activities was initiated 4/25/23 at 4:40 p.m. Any staff who are not scheduled will be contacted for education. Education will be completed on or before 4/26/23 at 8:00 a.m. Any staff who has not received education at this time will not be permitted to work until the education has been received. New admissions to the center will be evaluated for exit seeking/wandering risk on admission using the elopement evaluation. The admitting nurse is responsible for completing Elopement Risk Assessments upon admission. This will be implemented with new admissions on 4/25/23. Residents who currently reside in the center were reevaluated for exit seeking risks using the elopement evaluation. The review began on 4/25/23 at 6:00 p.m. and the facility indicated it was to be completed on or before 4/26/23 at 8:00 a.m. Current residents were reevaluated for exit seeking rest using the elopement evaluation with change of behavior where resident displays wandering/exit seeking behavior. This review was initiated on 4/25/23 at 6:00 p.m. and completed by 4/26/23 at 8:00 a.m. Current residents and new admissions will be provided supervision. This was initiated 4/25/23 at 4:40 p.m. Current residents and new admissions who identified as an elopement risk had their care plan updated at the time as identification to address risk of elopement to include redirection of resident, any activities as appropriate, and education of family and visitors. Their picture in Elopement Risk Identification form was placed in the center exit seeking binder located at the front desk. The exit seeking information is available to center staff on duty in this location. Monitoring: New admissions will be reviewed daily for one week, then three times a week for two weeks, then weekly for two weeks to ensure they were evaluated for exit seeking risks by the DON/Designee. The monitoring began on 4/26/23 and is to continue daily through 5/2/23. Monitoring is to be conducted three times a week for the weeks of 5/2/23 and 5/9/23, and then weekly for the weeks of 5/16/23 and 5/23/23. Results of the reviews are to be submitted to the center QAPI Committee for review and development of an action plan as needed. A review of Resident R340's care plan on 4/26/23, indicated the plan of care was updated on 4/25/23, after the incident. Continued review of 12 sampled charts verified the part of the plan that residents were re-evaluated for identifying elopement behaviors. During an interview with RN Employee E20 on 4/28/23 at 10:55 a.m., it was confirmed that she had received the education for elopement policy, potential risk factors, interventions for resident care plans, and education on identifying signs and symptoms of resident potential for elopement. During an interview on 4/28/23 at 12:30 p.m., RN Employee E12 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview on 4/28/23 at 12:45 p.m., RN Employee E7 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview on 4/28/23 at 1:15 p.m., RN Employee E22 confirmed she received education on elopement, potential risk factors, intervention for the resident's care plans, and education on identifying signs and symptoms of a resident's potential for elopement. During an interview with Registered Nurse Assessment Coordinator (RNAC) Employees E3 and E4, it was confirmed both employees were educated on elopement assessment and determination of risk factors and identification of elopement risks. It was indicated that they were educated and were able to identify how to use the new elopement tool and values associated with risk levels. During interviews on 4/28/23, from 10:55 a.m. through 1:15 p.m. six total staff employees confirmed they had received education on elopement policy, identifying signs and symptoms of residents potential for elopement, and potential risk factors and interventions for residents care plan. Facility provided documentation and sign in sheets verifying 171 out of 172 staff members had received the education via in-person or telephone. The IJ was lifted on 4/28/23, at 1:22 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.