Every finding on record at Cedarwood Rehabilitation & Healthcare Center

Based on review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation after a fall to rule out abuse or neglect for one of seven residents reviewed (Resident 4).Findings include: The facility's policy regarding accidents and incidents - investigating and reporting, dated January 27, 2026, revealed the nurse supervisor/charge nurse and the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Incident accident reports would be reviewed by the safety committee for tends related to accident or safety hazards in the facility and to analyze any individual vulnerabilities. The report should include the circumstances surrounding the accident or incident, the names or witnesses and their account of the incident, and other pertinent data as necessary. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 15, 2026, revealed that the resident had moderate cognitive impairment, used a wheelchair, was independent with the ability to wheel at least 50 feet, and had diagnoses that included difficulty walking and generalized muscle weakness. A nursing note, dated March 21, 2026, revealed that at 1:58 p.m. Resident 4 had fall in the hallway where he reports he hit his head. Post event he complained of severe left shoulder pain and had a hematoma to back of head. Resident 4's family was updated and requested he be sent to emergency department for evaluation. Interview with Nurse Aide 1 on March 31, 2026, at 11:03 p.m. confirmed that she was assisting another aide with another resident when Resident 4 fell. She heard kitchen staff picked Resident 4 up off the floor. Interview with Nurse Aide 2 on March 31, 2026, at 2:04 p.m. confirmed that Nurse Aide 3 (who was working on another floor) responded when she heard that Resident 4 fell and was told that dietary staff had picked him up off the floor. Nurse Aide 3 then assisted to transfer the resident from a wheeled desk chair to his wheelchair for safety. Interview with Nurse Aide 3 on March 31, 2026, at 2:10 p.m. confirmed that she was told by a kitchen staff member there was a resident on the floor. However, when she went upstairs Resident 4 was sitting in a desk chair. Nurse Aide 3 told both dietary workers that they should not have moved the resident and she submitted a witness statement. Interview with Registered Nurse 4 on March 31, 2026, at 2:45 p.m. confirmed she was on another floor when staff reported that a resident fell. She assessed him sitting in his wheelchair. Resident 4 was holding his arm, guarded, and would cry out in pain. He also hit his head, and she sent him to the emergency room for evaluation. Registered Nurse 4 said she heard that dietary staff assisted the resident but since she did not witness them she did not include the information in her incident report. Usually when a resident sustained a fall staff would notify her and she would assess them before being moved. Interview with Dietary Aide 5 on March 31, 2026, at 3:07 p.m. confirmed that her and Dietary Aide 6 were on the unit and Resident 4 was on the floor. She tried to find a nurse but could not find anyone. Dietary Aide 6 was pulling him up off the floor and I had to help her. We put him on a desk chair, and then I went downstairs to tell someone. Interview with Dietary Aide 6 on March 31, 2026, at 3:17 p.m. confirmed that Resident 4 was on the floor, and she did not want to leave him there, so she assisted him off the floor. She indicated that she had completed a witness statement. A facility investigation, dated January 22, 2026, revealed that Resident 4 had an unwitnessed fall and included only the witness statements from Nurse Aide 2 and Licensed Practical Nurse 7. A witness statement from Nurse Aide 2 dated March 21, 2026, revealed that she was notified by another aide that Resident 4 fell. He was in a wheeled desk chair by the housekeeping closet. We transferred him to his wheelchair for safety. He said his head and shoulder hurt. A witness statement from Licensed Practical Nurse 7 dated March 21, 2026, revealed that after lunch the unit was flooded with visitors, children, and lots of people going back and forth. It seemed to make all the residents more anxious than usual. The unit also has an increase in humidity and stuffiness with temperatures increasing and the heat being on. All the residents have an increase in confusion, irritability, agitation, and wandering when it feels hot and stuffy. Resident 4 did not want to go to bed after lunch as he seemed mesmerized with watching all the children and visitors coming and going. However, Licensed Practical Nurse 7 also recalled that she was not on the floor at the time of the incident because she was on break. When she returned to the floor Registered Nurse 4 was assessing Resident 4. A witness statement from Nurse Aide 3 dated March 21, 2026, revealed that she was working on the third floor when a dietary worker told her that a resident was on the floor. Nurse Aide 3 went upstairs, and two dietary workers already had him up off the floor, and on a rolling computer chair in the hallway. Nurse Aide 3 called the Registered Nurse that was working and went to find the Nurse Aides who were on the fourth floor. An orthopedic consultation dated March 31, 2026, at 11:00 a.m. revealed that Resident 4 had a left proximal humerus fracture after a fall on cement. Resident 4 would need a computed tomography (ct scan- noninvasive imaging) for surgical planning and needed to have a family member attend the next appointment to have surgical discussions or conservative care. The facility's investigation revealed no documented evidence that a thorough investigation was conducted, as there was no documented evidence that the investigation included witness statements from the dietary aides that assisted the resident after the fall on March 21, 2026. Interview with Director of Nursing on March 31, 2026, at 3:43 p.m. confirmed that she did not obtain witness statements from dietary staff because she did not believe they would have done that. She also indicated that she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair. Interview with Nursing Home Administrator on March 31, 2026, at 3:53 p.m. confirmed that all facility staff were trained upon hire to report to a nurse if a resident had a change in condition. 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 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommendations from a wound consultant were reviewed with the attending physician for one of 5 residents reviewed (Resident 1).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.An annual Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 24, 2026, indicated that the resident w as cognitively intact, had a stage 4 pressure ulcer (a localized injury to the skin and underlying tissues, caused by prolonged pressure)Physician's orders for Resident 1 dated March 10, 2026 included an order for the right hip wound and surrounding tissue to be cleaned with soap and warm water, rinsed with saline, and a wound vac applied (a medical device that applies gentle continuous suction to a wound to accelerate healing using a special foam dressing, an airtight seal and a vacuum pump to remove fluids, reduce bacteria, increase blood flow, and draw wound edges together) making sure to place some of the black foam into the tunneling, change every Monday, Wednesday and Friday and continue suction at 120 mmHg.A wound consultant note for Resident 1, dated March 20, 2026, revealed that the resident had a stage 4 pressure ulcer to her right hip and required her wound vac suction to be changed from 120 mmHg to 150mmHg.A review of Resident 1's Treatment Administration Record (TAR), dated March 2026, revealed that as of March 31, 2026, the resident's recommended change in wound vac suction to her right hip had not been initiated. Interview with the Director of Nursing on March 31, 2026, at 12:25 p.m. confirmed that wound care recommendations made by the wound care clinic on March 20, 2026, were not updated in her clinical record as of March 31, 2026.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policy, clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 46 residents reviewed (Resident 92).Findings include: A facility policy for charting documentation dated January 27, 2026, revealed that a complete account of the resident's care, treatment, response to care, signs, symptoms, and the progress will be documented and will be concise, accurate, complete, and use objective terms.A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 92, dated January 13, 2026, revealed that the resident was cognitively intact and had a peg tube (a tube placed directly into the stomach to provide nutrition).Physician's orders for Resident 92 dated October 11, 2025, revealed 240 cubic centimeters of 1.5 Juven (a specialized nutrition power to support healing a build lean body mass) three times a day if the resident ate < 50% of the meal.Review of nurse aide task documents for Resident 92 for January 2026 revealed that the resident ate less than 50% of her meal on January 15, 2026, for breakfast, January 22, 2026, January 5, 2026 for lunch, January 6, 2026 for lunch, January 14, 2026 for lunch, January 19, 2026 for dinner, January 27, 2026 for dinner, and January 31, 2026 for dinner.Review of the Medication Administration Record (MAR) for Resident 92 for January 2026 revealed that on January 15, 2026, she ate 50% of breakfast and did not receive a tube feed. On January 22, 2026, she ate 100% of breakfast and did not receive a tube feed, January 30, 2026, January 5, 2026, she ate 100% of lunch and did not receive a tube feed, Januaryy 6, 2026, she ate 100% of lunch and did not receive a tube feed, January 14, 2026 ate 60% of lunch and did not receive a tube feed, January 19, 2026, ate 50% of dinner and did not receive a tube feed, January 27 2026, ate 65% of dinner and did not receive a tube feed, and on January 31, 2026, ate 50% of dinner. Interview with Nurse Aide 5 on February 5, 2026, at 9:46 a.m., revealed that nurse aide documentation for percent eaten was documented on a sheet of paper on a clipboard in the nurses station for the Licensed Practical Nurse to see the amount eaten prior to the nurse aids documenting in the clinical record.Interview with the Licenses Practical Nurse 1 revealed that she uses the documentation per the sheet in the nurses station to determine the amount eaten, and at times she has collected the tray and documented the % eaten.Interview with the Director of Nursing on February 5, 2026, at 1:29 p.m. confirmed that nurse aide documentation of Resident 92s percent eaten did not match the documentation on her MAR on the above dates and times and should have. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of observations, and staff interviews, it was determined that the facility failed to prepare and store ice under sanitary conditions for one of four ice machines (third floor pantry). Findings include:Observations of the ice machine in the third floor pantry room on February 4, 2026 at 10:41 a.m. revealed that there was no air gap for the drain pipe. The drain pipe traveled down and directly into the drain hole with no air gap present.Interview with the Maintenance Director on February 4, 2026 at 11:05 a.m. confirmed that the drain pipe coming from the ice machine in the third floor pantry was in direct contact with the floor drain, that there was no air gap, and that there should have been an air gap between the end of the pipe and the floor drain.28 Pa. Code 207.4 Ice Containers and Storage. 28 Pa. Code 211.6(f) Dietary Services.

Based on observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items that were palatable. Findings include:Interview with a group of residents on February 2, 2026 at 1:30 p.m. revealed that the food delivered to the resident rooms and the dining rooms on their floors was served cold. Interview with Resident 48 on February 2, 2026 at 1:57 p.m. revealed that the food is cold.Interview with Resident 103 on February 2, 2026 at 11:42 a.m. revealed that the food is often cold and tastes bland.Observations in the kitchen for the lunch meal service on February 3, 2026 and 11:56 a.m. revealed that a test tray left the kitchen and arrived on the third floor at 12:14 p.m. The lunch meal on February 2, 2026, consisted of spaghetti and meatballs, vegetable blend, strawberry cake, milk, and juice. Trays were passed to the residents in their rooms and the last resident was served and eating at 12:28 p.m. The test tray on February 2, 2026 at 12:28 p.m. revealed that the temperature of the spaghetti and meatballs was 127.0 degrees Fahrenheit (F), the vegetable blend was 124.0 F, the milk was 44.8 degrees F, and the juice was 45.8 degrees F. The spaghetti, meatballs, and vegetable blend were cool to taste and not palatable.Interview with the Corporate Dietary Manager on February 3, 2026 at 12:30 p.m. confirmed that foods should be served to residents at proper and palatable temperatures. 28 Pa. Code 211.6(b) Dietary Services.

Based on review of facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management for two of 46 residents reviewed (Resident 7 & 48).Findings include:The facility's policy regarding pain management, dated January 27, 2026, indicated that the physician would order appropriate medication interventions to address the resident's pain. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 26, 2025, revealed that the resident was cognitively intact, was usually understood, and could usually understand, required assistance from staff for daily care needs, and received scheduled pain medication. The current care plan for pain indicated that Resident 7 had chronic back pain and medications were to be administered as ordered.Physician orders for Resident 7 dated December 24, 2025, included an order for her to receive one Lidocaine 4% patch (an over-the-counter medication patch used for the temporary relief of minor aches and pains) topically once a day in the morning for back and neck pain.Nursing administration notes for Resident 7, dated January 5, 2026, at 8:32 a.m.; January 6, 2026, at 8:02 a.m.; January 7, 2026, at 7:07 a.m.; and January 8, 2026, at 7:04 a.m indicated that the Lidocaine 4% External Patch was unavailable.An admission MDS assessment for Resident 48, dated November 1, 2025, revealed that the resident was cognitively intact, was understood, and could understand, required assistance from staff for daily care needs, and received scheduled pain medication. A care plan dated November 1, 2025, indicated that Resident 48 had pain to both knees and her right shoulder and medications were to be administered as ordered.Interview and observations of Resident 48 on February 2, 2026, at 1:57 p.m. revealed that the facility ran out of Lidocaine patches multiple times, and she has chronic pain. Physician orders for Resident 48 dated November 1, 2025, included an order for her to receive one Lidocaine 4% patch topically once a day in the morning to be applied to bilateral knees and the right shoulder. Nursing staff were to cut a patch into three strips.A nursing administration notes for Resident 48, dated December 29, 2025, at 7:18 a.m.; January 6, 2026, at 7:11 a.m.; and January 7, 2026, at 6:59 a.m. indicated that the Lidocaine 4% External Patch was unavailable.Interview with the Director of Nursing on February 4, 2026, at 3:32 p.m. confirmed that Lidocaine 4% patches were not administered as ordered to relieve pain for Residents 7 and 48, because the facility ran out, and the staff did not notify her, or the medical director. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of the residents. Findings include:Review of the activity calendar for the month of February 2026 revealed that there is one activity scheduled for a Sunday evening and it is for the super bowl. There were no other organized weekend activities. There were also no organized activities on the calendar after 2:00 p.m. for any unit other than the dementia unit. At 4:00 p.m. there is an activity on the dementia unit called tray pass. There were no other organized activities for the other units on the calendar after 2:00 p.m.Interview with a group of residents on February 2, 2026 at 1:30 p.m. revealed that they would like to have organized activities on the weekends and in the evenings. They stated that the organized activities end at 2:00 p.m. everyday and that there are no organized activities on the weekends. They stated that they have asked for weekend activities, but have been told that there is not enough interest to do them. Interview with the Activity Director on February 3, 2026 at 2:38 p.m. revealed that there are activity staff present on Saturday and Sunday for four hours, however, they do not hold organized activities. She stated that there had been no interest in the past and she didn't believe very many residents would participate. She stated she was aware that the residents would like organized activities on the weekends. She stated that there is an activity aide present in the facility until around 8:00 p.m. most nights, however, he focuses his time on the dementia unit from 4:00 p.m. on because they identified there were increased falls and he was to provide distraction activities. She stated that since he is on the dementia unit there would be no one else to hold evening activities for the other residents.28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for one of 46 residents reviewed (Resident 43). Findings include: The facility's policy regarding homelike environment, dated January 27, 2026, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated December 26, 2025, indicated that the resident was cognitively intact, required minimal assistance for care needs, and had diagnoses that included Alzheimer's and colon cancer. Observations of Resident 43's room on February 2, 2026, at 11:10 a.m., revealed that there were multiple quarter-sized to half-dollar-sized areas of chipped and peeling paint on the two walls around the resident's bed. Interview with the Maintenance Director on February 4, 2026, at 10:55 a.m., confirmed that the walls in room [ROOM NUMBER] were in need of repair to ensure a homelike environment for Resident 43. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident representative regarding a fall (change in condition) for one of 46 residents reviewed (Resident 29). Findings include: The facility's policy regarding notification, dated January 27, 2026, indicated that facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical/mental condition and/or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated October 23, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A nursing note for Resident 29 dated January 31, 2026, revealed that the resident slid out of her electric wheelchair and onto the floor. There was no documented evidence that daughter was notified after fall. A special notification banner in Resident 29's electronic health record indicated that her daughter was to be contacted at all times for any change related to the resident. Interview with Resident 29 on February 3, 2026, at 11:30 a.m., revealed that the resident was upset that her daughter was not notified of her fall. Interview with the Director of Nursing on February 3, 2026, at 1:18 p.m. confirmed that Resident 29's daughter was not notified after the resident's fall on January 31, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for three of 46 residents reviewed (Residents 4, 9, 11, ). Findings Include:The facility's policy regarding the use of psychotropic medications, dated January 27, 2026, indicated that the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 12, 2025, revealed that the resident was cognitively intact, received antipsychotic medications (a psychotropic medication), and had diagnoses that included depression and bipolar disorder (a chronic mental health disorder characterized by extreme shifts in mood, energy and activity levels).Physicians' orders for Resident 4, dated May 24, 2025, included an order for the resident to receive 25 milligrams (mg) of Seroquel (an antipsychotic medication used to treat bipolar disorder) at bedtime. Physician's orders for Resident 4, dated June 20, 2025, included an order for the resident to receive 50 mg of Seroquel at bedtime. Physician's orders for Resident 4, dated August 31, 2025, included an order for the resident to receive 100mg of Seroquel at bedtime.There was no documented evidence in Resident 4's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Seroquel.Interview with the Director of Nursing on February 4, 2026, at 3:36 p.m. confirmed that there was no documented evidence in Resident 4s clinical record that the resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Seroquel.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated November 12, 2025, indicated that the resident was always understood, could always understand others, and was cognitively intact. A nursing note for Resident 9, dated August 5, 2025, revealed that the resident's antidepressant medication Cymbalta was to be increased from 30 milligrams to 60 milligrams daily and that the resident's representative was aware. There was no documented evidence that a written informed consent was given to representative regarding increase in psychotropic medication. Interview with Director of Nursing on February 4, 2026 at 03:34 p.m. stated that she could not find informed consent signed by resident representative for increase in Cymbalta dose from 30 milligrams to 60 milligrams on August 2, 2025, and confirmed that a signed informed consent should have been obtained. A quarterly MDS assessment for Resident 11 dated December 3, 2025, revealed that the resident was cognitively impaired, received antipsychotic medications and had diagnoses that included non-Alzheimer's Dementia.Physician's orders for Resident 11, dated August 26, 2025, included an order for the resident to receive 2.5mg Zyprexa (an antipsychotic medication) at bedtime. Physician's order for Resident 11, dated August 26, 2025, included an order for the resident to receive 25mg Seroquel twice a day.There was no documented evidence in Resident 11's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting the medications.Interview with the Director of Nursing on February 3, 2026, at 2:25 p.m. confirmed that there was no documented evidence in Resident 11's clinical record that that resident or resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to starting Zyprexa or Seroquel. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights. 28 Pa. Code 201.29(a)(j) Resident Right

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for two of 46 residents reviewed (Residents 88, 114). Findings include:The facility's policy regarding falls, dated January 27, 2026, revealed that resident's identified as fall risks will have interventions in place to prevent further falls.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated January 21, 2026, indicated that the resident was cognitively intact and required assistance for daily care. Resident 88's care plan, dated December 14, 2025 indicated that the resident was at risk for falls. Fall interventions included keeping her personal belongings within reach, and that she would have a reacher tool (used to grab objects that are beyond your reach).Observations of Resident 88 on February 5, 2026 at 10:30 a.m. revealed that she was sitting in her wheelchair beside her bed coloring on her over bed table. Her crayons were on her bed within reach, however, her other coloring books and colored pencils were further down her bed and not within her reach. Her reacher tool was on the other side of the bed on her nightstand. Interview with Resident 88 on February 5, 2026 at 10:30 a.m. revealed that she would use her reacher tool if she could reach it. Interview with Licensed Practical Nurse 1 on February 5, 2026 at 10:35 a.m. confirmed that Resident 88's reacher tool was out of her reach and that it should have been closer to her. Interview with the Director of Nursing on February 5, 2026 at 11:52 a.m. confirmed that Resident 88's reacher tool should have been in her reach.admission diagnosis for Resident 114 revealed that she has a fracture of the femur, difficulty in walking, and generalized muscle weakness.Observations of Resident 114 on February 3, 2026, 12:04 p.m. revealed that the resident was transported in his chair by Nurse Aide 2 from her bedroom towards the dining room for lunch with no leg rests on her chair. An interview with Nurse Aide 2 at that time confirmed that she did not apply leg rests to Resident 114's chair prior to transporting the resident because they were in the therapy department and she should have. An interview with the Director of Nursing on February 4 at 12:21 p.m. confirmed that leg rests should have been used as ordered when transporting Resident 114.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to properly date medications after they were opened in one of three medication carts reviewed (second floor cart), failed to discard expired medical supplies, and failed to permanently affix a narcotic storage box to the refrigerator.Findings include: The facility's policy regarding medication storage and labeling, dated [DATE], revealed that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Observations in the second floor medication cart on February 4, 2026 at 10:32 a.m. revealed that there was one Insulin Lispro Subcutaneous Solution pen (medication used for diabetes) that had expired on [DATE], and there was one Novolog injection Solution pen (medication used for diabetes) that was open and undated. Interview with Licensed Practical Nurse 3 on February 4, 2026 at 10:35 a.m. confirmed that the Insulin Lispro pen was expired and should have been discarded and that the Novolog pen was open and should have been labeled with the date it was opened.Observations in the third floor medication room on February 4, 2026 at 10:48 a.m. revealed that there was a box of Lorazepam syringes (controlled medication used to treat anxiety) in the refrigerator. The refrigerator was not locked and the box containing the Lorazepam was not permanently affixed to the refrigerator.Interview with Licensed Practical Nurse 4 on February 4, 2026 at 10:48 a.m. confirmed that the medication refrigerator was not locked and that the narcotic box was not permanently affixed to the refrigerator.Interview with the Director of Nursing on [DATE] at 3:21 p.m. revealed that the expired insulin pen should have been discarded, the open insulin pen should have been dated, the narcotic refrigerator should have been locked, and the narcotic box should have been permanently affixed to the refrigerator. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the annual survey ending January 10, 2025 and a complaint survey ending March 5, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 5, 2026, identified repeated deficiencies related to safety/accidents, labeling and storage of medications, palatable food, and sanitary food practices. The facility's plans of correction for deficiencies regarding safety/accidents, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding safety/accidents.The facility's plans of correction for deficiencies regarding labeling and storage of medications, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding the labeling and storage of medications.The facility's plans of correction for deficiencies regarding palatable food, cited during the survey ending January 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding palatable food.The facility's plans of correction for deficiencies regarding sanitary food practices, cited during the surveys ending January 10, 2025 and March 5, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to maintain ongoing compliance regarding sanitary food practices.Refer to F689, F761, F804, F812.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management

Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 46 residents reviewed (Resident 103).Findings include:CDC guidance on suspected or confirmed Clostridioides (C. diff, a germ that causes infectious diarrhea and colitis). Facilities were to isolate and initiate contact precautions (infection control measures designed to prevent the spread of germs transmitted through direct or indirect contact with a patient or their environment).The facility's policy regarding isolation and initiating transmission based precautions, dated January 27, 2026, indicated that the transmission based precautions would be utilized when a resident meets the criteria for transmissible infection and the resident has the risk factors that increase the likelihood of transmission. A review of Resident 103's clinical record revealed that she was admitted to the facility on [DATE].Interview and observations with Resident 103 on February 2, 2026, at 11:42 a.m., revealed that she was alert and oriented, able to make her needs known, and understood her medical needs. She stated that she does not attend in person activities because she has C diff. Outside of her room was a sign that said contact precautions that requires facility staff to wear gloves and a gown for care needs.Physician's orders for Resident 103, dated January 28, 2026, included an order for the resident to be administered 125 milligrams of Vancomycin HCL (antibiotic medication) every six hour for 14 days for C. diff. Physician's orders for Resident 103, dated January 28, 2026, included an order for the resident to be provided contact precautions for C. diff.A nursing noted for Resident 103 dated February 2, 2026, indicated that her chemotherapy treatment was changed from February 4, 2026 to February 18, 2026 due to active C. diff infection. Observations of Resident 103's on February 4, 2026, at 1031 a.m. revealed that Nurse Aide 5 entered the room without putting on a gown and gloves. Upon entering the Room Nurse Aide 5 was performing perineal care (cleaning of the genital, groin, and rectal areas to maintain hygiene) and changing Resident 103's adult brief wearing only gloves. Interview with Nurse Aide 5 at the time of the observation confirmed that she did not know that the resident was on contact precautions and she should have asked another staff.Interview with the Director of Nursing on February 5, 2026 at 1:14 p.m. confirmed that Nurse Aide 5 should have donned a gown prior to performing Resident 103's care.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of personnel files as well as interviews with staff, it was determined that the facility failed to ensure that the required In-Service Training was completed for one of four nurse aides reviewed (Nurse Aide 6).Findings include:Review of Nurse Aide 6's personnel file revealed that she was hired on March 28, 2017. Review of her continuing education transcript revealed that she did not have the required 12 hours of Nurse Aide training per year.Interview with the Director of Nursing on February 4, 2026 at 3:33 p.m. confirmed that Nurse Aide 6 failed to complete the necessary 12 hours of training. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for four of 32 residents reviewed (Residents 6, 39, 43, 97). Findings include: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 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 6 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on December 27, 2025, which was 2 days after admission.An annual MDS assessment for Resident 39 revealed that the resident's annual MDS assessment was due to be completed by December 11, 2025, however, it was dated as completed on December 27, 2025, which was 16 days late.An admission MDS assessment for Resident 43 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on January 2, 2026, which was 15 days after admission.An annual MDS assessment for Resident 97 revealed that the resident's annual MDS assessment was due to be completed by November 22, 2025, however, it was dated as completed on December 7, 2025, which was 16 days late.Interview with the Director of Nursing on February 5, 2026 at 2:35 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on a review of facility policy and observations, as well as staff interviews, it was determined that the facility failed to ensure that a safe and comfortable environment was maintained for three of nine residents reviewed (Residents 7, 8, 9) who were in the day room with temperatures above 81 degrees Fahrenheit (F). Findings include: Review of the facility policy Homelike Environment, last reviewed January 30, 2024, indicated that the facility reflected a homelike setting to provide comfortable and safe temperatures between 71 degrees F and 81 degrees F. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated June 9, 2025, indicated that the resident was severely cognitively impaired, was sometimes understood and was sometimes able to understand others, was dependent of staff for care needs, and had diagnoses that included dementia. A quarterly MDS assessment for Resident 8, dated March 24, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and was rarely able to understand others, was dependent of staff for care needs and had diagnoses that included dementia. A quarterly MDS assessment for Resident 9, dated June 9, 2025, indicated that the resident was severely cognitively impaired, was rarely understood and was rarely able to understand others, was dependent of staff for care needs and had diagnoses that included dementia. Observations of Residents 7, 8, and 9, who were in the fourth floor day room on June 26, 2025, at 1:43 p.m. revealed a room temperature of 83.9 degrees F. All three residents were sitting in wheelchairs with their eyes closed. At 2:09 p.m., Residents 8 and 9 were removed from the room at 2:09 p.m. and Resident 8's face appeared clammy. Resident 7 was removed from the room at 2:15 p.m. and her face was flushed and pink. Interview with the Maintenance Director on June 26, 2025, at 11:30 a.m. revealed that an audit of all PTAC units (packaged terminal air conditioner - units used to heat or cool a room.) was conducted on June 24, 2025. and determined that there were multiple PTAC units in the building that were not functioning, including the fourth floor day room. Interview with the Nursing Home Administrator on June 26, 2025, at 3:20 p.m. indicated that the resident common areas should be within safe temperatures, and he was currently looking into purchasing new units to replace the ones that were not functioning. 28 Pa. Code 201.14(a)(c)(e) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies.

Based on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the residents' rooms. Findings include: Manufacturer's instructions for the Packaged Terminal Air Conditioner (PTAC - a heating and cooling system designed to be mounted through a wall to control room temperature) indicated that the air filters are to be cleaned every two weeks, or more often if necessary. Observations in resident room [ROOM NUMBER], on May 15, 2025, at 10:22 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a gray-brown layer of removable debris. Observations in resident room [ROOM NUMBER] on May 15, 2025, at 11:51 a.m. revealed that the room had a PTAC unit. The Maintenance Director was able to remove the filter from the unit and it was covered with a thick, gray-brown layer of removable debris. Interview with the Maintenance Director at May 15, 2025, at 10:22 a.m confirmed that the PTAC filters needed cleaned. Each resident room has it own PTAC unit and he believed their filters should be cleaned twice a year, approximately every six months. He started employment with the facility in January 2025 and has not cleaned any filters as part of routine maintenance. He thought they were cleaned in October or November of 2024. 28 Pa. Code 201.18(b)(3) Administrator's Responsibility.

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of eight residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 1, dated April 18, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included diabetes. A dental summary note, dated August 2, 2024, revealed that Resident 1 was present for the insertion of lower complete denture. Denture care and wearing instructions were given to the resident. Observations and interview with Resident 1 on May 15, 2025, revealed that he had no natural teeth and was not wearing any dentures. He said he did not have any dentures right now, because they broke. He said he wanted dentures because some of the foods are difficult to chew. Review of nurse aide task documents for February, March, April and May 2025 revealed that the resident was to have denture care during the day shift and the evening shift. Not applicable/refused was documented on the day shift on April 1 and on the evening shift on February 2, 25, 26; March 6, 11, 12, 13, 19, 27; April 2, 9, 10, 13, 15, 17, 22, 30; and May 1, 8, and 14, 2025. All other entries were documented as Y (yes). Interview with Nurse Aide 1 on May 15, 2025, at 3:08 p.m. indicated that Resident 1 did not have the dentures in his mouth or did not have them to provide denture care. She explained that she was documenting refused, but she changed to not applicable because he did not refuse, there were no dentures. Interview with the Director of Nursing on May 15, 2025, at 3:29 p.m. confirmed that nurse aide documentation of Resident 1's denture care was not accurately documented because the resident's dentures were lost. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that a dental appointment was scheduled for one of eight residents reviewed (Resident 6). Findings include: A facility policy for dental care, dated January 30, 2025, revealed that the facility is to provide routine and emergency dental care for residents including follow-up dental appointments. A quarterly MDS assessment for Resident 6, dated May 5, 2025, revealed that the resident was cognitively intact, required staff supervision with care, and had her own natural teeth. A physician's order for Resident 6, dated October 10, 2024, revealed that the resident was to see the oral surgeon for tooth extraction. An interview with Resident 6 on May 15, 2025, at 11:44 a.m. revealed that she has an extremely sensitive tooth on her right side, and she believed that she was to have a tooth pulled and has not had it pulled. As of May 15, 2025, there was no documented evidence that Resident 6 saw the oral surgeon to have her tooth pulled. An interview with the Director of Nursing on May 15, 2025, at 11:52 a.m. confirmed that the appointment to have her tooth pulled with the oral surgeon was never made and should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 28 Pa. Code 211.15(a) Dental Services.

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident 2), resulting in harm due to a fall with fractures. This deficiency is being cited as past non-compliance. Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation dated January 30, 2025, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The nursing facility will implement measures to address factors that may lead to abusive situations by adequately preparing staff for caregiving responsibilities. Admission paperwork for Resident 2, dated April 4, 2025, revealed that the resident was admitted to the facility on [DATE], after having fallen at home and suffering a hip fracture, which required surgery on March 30, 2025. The resident was alert with slight confusion and required extensive assistance from two staff members for care, including bed mobility. The resident's care plan, initiated April 4, 2025, revealed that the resident required two staff members for bed mobility. An incident note for Resident 2, dated April 7, 2025 revealed that the resident was receiving care from Nurse Aide 1 while in bed. Nurse Aide 1 rolled the resident to do a complete bed change when the resident rolled out of bed and landed face down on the floor. Nurse Aide 1 was the only nurse aide providing care for the resident at the time of her fall out of bed. X-ray reports, dated April 7, 2025, confirmed that Resident 2 had a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process (also known as the dens, a bony projection of the second cervical vertebra), and a left frontal scalp laceration requiring sutures. Education records for Nurse Aide 1 revealed that he signed that he received education regarding the facility's abuse policy on August 12, 2024, and again on February 5, 2025, and education regarding the facility's policy for reviewing the resident's Kardex (a documentation system that helps nursing staff access key patient information from their care plan) on February 14, 2025. A written statement by Nurse Aide 1, dated April 7, 2025, revealed that he did not review the resident's Kardex prior to providing care for her and therefore, he did not know that she required two staff for care. He stated that while she was on her side she was holding onto the nightstand; however, she fell to the floor. An interview with the Director of Nursing on April 17, 2025, at 10:21 a.m. confirmed that Nurse Aide 1 failed to follow Resident 2's care plan for bed mobility resulting in her falling out of bed and sustaining facial and neck fractures. Following the incident on April 7, 2025, the facility's corrective actions included: On April 7, 2025, the resident was immediately assessed and transferred to the hospital for further assessment. Nurse Aide 1 was immediately removed from care, interviewed, and suspended. He was then terminated for admitted ly not following the resident's care plan regarding the need for two persons to assist with bed mobility. The alert and oriented residents of the facility were interviewed to determine if they were transferred and received care according to their care plan. Non-interviewable residents were observed and assessed to determine if they had any injuries as a result of improper assistance with bed mobility. Education records, dated April 8 and 9, 2025, revealed that all of the facility's nursing staff received education regarding the facility's abuse/neglect policy, as well as reviewing the resident's Kardex/care plan prior to providing resident's with care. The Director of Nursing or designee will audit five random resident's care to ensure that their plan of care was followed five days a week for one week, and then three days a week for one week, and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on April 9, 2025. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of four residents reviewed (Resident 2) who required two staff for bed mobility, resulting in a fall with fractures. This deficiency is being cited as past non-compliance. Findings include: Admission paperwork for Resident 2, dated April 4, 2025, revealed that the resident was admitted to the facility on [DATE], after having fallen at home and suffering a hip fracture, which required surgery on March 30, 2025. The resident was alert with slight confusion and required extensive assistance from two staff members for care, including bed mobility. The resident's care plan, initiated April 4, 2025, revealed that the resident required two staff members for bed mobility. An incident note for Resident 2, dated April 7, 2025, revealed that the resident was receiving care from Nurse Aide 1 while in bed. Nurse Aide 1 rolled the resident to do a complete bed change when the resident rolled out of bed and landed face down on the floor. Nurse Aide 1 was the only nurse aide providing care for the resident at the time of her fall out of bed. X-ray reports, dated April 7, 2025, confirmed that Resident 2 had a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process (also known as the dens, a bony projection of the second cervical vertebra), and a left frontal scalp laceration requiring sutures. Education records for Nurse Aide 1 revealed that he signed that he received education regarding the facility's policy for reviewing the residents' Kardex (a documentation system that helps nursing staff access key patient information from their care plan) on February 14, 2025. A written statement by Nurse Aide 1, dated April 7, 2025, revealed that he did not review the resident's Kardex prior to providing care for her and therefore, he did not know that she required two staff for care. He stated that while she was on her side she was holding onto the nightstand; however, she fell to the floor. An interview with the Director of Nursing on April 17, 2025, at 10:21 a.m. confirmed that Nurse Aide 1 failed to follow Resident 2's care plan for bed mobility resulting in her falling out of bed and sustaining facial and neck fractures. Following the incident on April 7, 2025, the facility's corrective actions included: On April 7, 2025, the resident was immediately assessed and transferred to the hospital for further assessment. Nurse Aide 1 was immediately removed from care, interviewed, and suspended. He was then terminated for admitted ly not following the resident's care plan regarding bed mobility. The alert and oriented residents of the facility were interviewed to determine if they were transferred and received care according to their care plan. Non-interviewable residents were observed and assessed to determine if they had any injuries as a result of improper care with bed mobility. Education records dated April 8 and 9, 2025, revealed that all of the facility's nursing staff received education regarding reviewing the resident's Kardex/care plan prior to providing resident's with care. The Director of Nursing or designee will audit five random resident's care to ensure that their plan of care was followed five days a week for one week, and then three days a week for one week, and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on April 9, 2025. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the physician was notified timely of a change in condition, resulting in hospitalization and death for one of 11 residents reviewed (Resident 1). Findings include: The facility's policy regarding physician notification, dated February 23, 2023, indicated that the physician would be notified in a timely manner when a change in condition involving the resident occurred. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 29, 2023, revealed that the resident was cognitively intact, required only supervision for daily care tasks, and was continent of bowel and bladder. A nursing note for Resident 1, dated November 1, 2023, at 2:00 a.m., revealed that the resident had an unwitnessed fall and was found getting herself off the floor. She refused to be assessed at that time. A nursing note, dated November 2, 2023, at 2:36 p.m., revealed that the resident was noted to have an unsteady gait and was shuffling her feet. A nursing note, dated November 4, 2023, at 1:36 p.m., revealed that the resident had an unsteady gait and was weaker than normal, had difficulty holding a glass of juice and was shaking and spilling it, and had slurred speech and difficulty finding words or making sense. The staff had to help the resident multiple times with transfers and ambulation and the resident required a wheelchair. A nursing note for Resident 1, dated November 4, 2023, at 9:55 p.m., indicated that the resident was lethargic (sluggish) and difficult to arouse. A nursing noted for Resident 1, dated November 5, 2023, at 5:45 a.m., revealed that the resident's gait was unsteady, she required the use of a wheelchair, was tearful, and had difficulty finding her words. A nursing note for Resident 1, dated November 5, 2023, at 8:42 a.m., revealed that the resident complained of pain in her face and nose and that she was to get an x-ray of the facial bones. A nursing note for Resident 1, dated November 5, 2023, at 11:25 a.m., revealed that the resident's gait was unsteady and she required staff assistance for transferring and ambulation, had slurred speech with trouble finding words, was tearful and yelling per favor (please in Spanish), and when staff spoke to her she stared and did not respond. A nursing note for Resident 1, dated November 5, 2023, at 11:39 a.m., revealed that the resident was repetitively yelling and screaming and was inconsolable. A nursing note for Resident 1, dated November 6, 2023, at 5:15 a.m., revealed that the resident had an unwitnessed fall, was yelling in her room, and was found sitting on the edge of her bed. When staff attempted to assist her, she fell and landed on the floor. A nursing note for Resident 1, dated November 6, 2023, at 5:12 p.m., revealed that the resident fell , was yelling out, and that she was exhibiting an unusual level of orientation. A nursing note for Resident 1, dated November 6, 2023, at 9:54 p.m., revealed that the resident was yelling and crying, talking in Spanish and would not speak English, had a blank stare at staff, and her gait remained unsteady. A nursing note for Resident 1, dated November 7, 2023, at 12:54 p.m., revealed that the resident's unsteady gait continued, she stares at staff when they speak to her, she was not speaking English, and she required a wheelchair for mobility. A nursing note for Resident 1, dated November 8, 2023, at 5:13 a.m., revealed that the resident had an unsteady gait and that her speech was garbled. A nursing note for Resident 1, dated November 8, 2023, at 10:33 a.m., revealed that the resident had an unsteady gait, had unclear and slurred speech, and had saliva running out the right side of her mouth. A nursing note for Resident 1, dated November 9, 2023, at 6:13 a.m., revealed that the resident's speech was slurred and she was difficult to understand, her gait was unsteady, and she was now requiring two staff for toileting and transferring. A note for Resident 1, dated November 9, 2023, at 3:44 p.m., revealed that she was assessed by the Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse) and was referred due to her altered mental status and weakness. The note revealed that the resident had a ground-level fall where she struck her head and she had psychiatric medication adjustments. She was noted to have swelling and ecchymosis (bruising) to her nose and eyes. Since her fall she has had increased weakness and overall decline in mentation. She was previously independent with transfers and was now requiring maximum staff assistance. She was drooling and could not follow simple commands. Upon assessment at that time, she was not responding to verbal stimulation, she was drooling, and had focal weakness on her right side. Her pupils were slow to react to light. The CRNP ordered that the resident be sent to the hospital for evaluation of a brain injury related to her falls. A nursing note for Resident 1, dated November 9, 2023, at 6:50 p.m., revealed that the resident was admitted to the hospital and she had a brain bleed. Hospital documentation revealed that the resident passed away as a result of the brain bleed. There was no documented evidence in Resident 1's clinical record to indicate that the physician was notified timely regarding the change in the resident's condition when she first started having noted changes in her mentation and physical abilities. The resident did not receive care for the change in condition for at least eight days after her first unwitnessed fall, which she hit her head. Interview with the Director of Nursing on December 1, 2023, at 3:15 p.m. confirmed that the physician was not notified timely about Resident 1's changes in condition, which led to her hospitalization and death from a subdural hematoma (brain bleed). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the Pennsylvania Nurse Practice Act, facility policies, residents' clinical records, and a resident's hospital records, as well as staff interviews, it was determined that the facility failed to ensure that a resident was assessed after a change in condition for one of 11 residents reviewed (Resident 1), resulting in a delay in sending the resident to the hospital for a serious medical condition. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's policy regarding changes in a resident's condition, dated February 23, 2023, indicated that the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident and the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated [DATE], revealed that the resident was cognitively intact, required only supervision for daily care tasks, and was continent of bowel and bladder. The resident's care plan, dated [DATE], indicated that the resident was at risk of falls related to ambulating and transferring independently. A nursing note for Resident 1, dated [DATE], at 2:00 a.m., revealed that the resident had an unwitnessed fall and was found getting herself off the floor. She refused to be assessed at that time. A nursing note, dated [DATE], at 2:36 p.m., revealed that the resident was noted to have an unsteady gait and was shuffling her feet. A nursing note, dated [DATE], at 1:36 p.m., revealed that the resident had an unsteady gait, was weaker than normal, had difficulty holding a glass of juice and was shaking and spilling it, and had slurred speech and difficulty finding words or making sense. The staff had to help the resident multiple times with transfers and ambulation and the resident required a wheelchair. A nursing note for Resident 1, dated [DATE], at 9:55 p.m., indicated that the resident was lethargic (sluggish) and difficult to arouse and that the registered nurse was made aware of this change. A nursing noted for Resident 1, dated [DATE], at 5:45 a.m., revealed that the resident's gait was unsteady and she required the use of a wheelchair, was tearful, and had difficulty finding her words. A nursing note for Resident 1, dated [DATE], 8:42 a.m., revealed that the resident complained of pain in her face and nose and that she was to get an x-ray of the facial bones. A nursing note for Resident 1, dated [DATE], at 11:25 a.m., revealed that the resident's gait was unsteady and she required staff assistance for transferring and ambulation, had slurred speech with trouble finding words, was tearful and yelling per favor (please in Spanish), and when staff spoke to her she stared and did not respond. A nursing note for Resident 1, dated [DATE], at 11:39 a.m., revealed that the resident was repetitively yelling and screaming and was inconsolable. A nursing note for Resident 1, dated [DATE], at 5:15 a.m., revealed that the resident had an unwitnessed fall, was yelling in her room, and was found sitting on the edge of her bed. When staff attempted to assist her, she fell and landed on the floor. A nursing note for Resident 1, dated [DATE], at 5:12 p.m., revealed that the resident fell , was yelling out, and that she was exhibiting an unusual level of orientation. A nursing note for Resident 1, dated [DATE], at 9:54 p.m., revealed that the resident was yelling and crying, talking in Spanish and would not speak English, had a blank stare at staff, and her gait remained unsteady. A nursing note for Resident 1, dated [DATE], at 12:54 p.m., revealed that the resident's unsteady gait continued, she stares at staff when they speak to her, she was not speaking English, and she required a wheelchair for mobility. A nursing note for Resident 1, dated [DATE], at 5:13 a.m., revealed that the resident had an unsteady gait and that her speech was garbled. A nursing note for Resident 1, dated [DATE], at 10:33 a.m., revealed that the resident had an unsteady gait, had unclear and slurred speech, and that she had saliva running out the right side of her mouth. A nursing note for Resident 1, dated [DATE], at 6:13 a.m., revealed that the resident's speech was slurred and she was difficult to understand, her gait was unsteady, and she was now requiring two staff for toileting and transferring. A note for Resident 1, dated [DATE], at 3:44 p.m., revealed that she was assessed by the Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse) and was referred due to her altered mental status and weakness. The note revealed that the resident had a ground-level fall where she struck her head and she had psychiatric medication adjustments. She was noted to have swelling and ecchymosis (bruising) to her nose and eyes. Since her fall she has had increased weakness and overall decline in mentation. She was previously independent with transfers and was requiring maximum staff assistance. She was drooling and could not follow simple commands. Upon assessment at that time, she was not responding to verbal stimulation, she was drooling, and had focal weakness on her right side. Her pupils were slow to react to light. The CRNP ordered that the resident be sent to the hospital for evaluation of a brain injury related to her falls. A nursing note for Resident 1, dated [DATE], at 6:50 p.m., revealed that the resident was admitted to the hospital and she had a brain bleed. Hospital documentation for Resident 1, dated [DATE]-18, 2023, revealed that she was admitted to the hospital on [DATE], with a subdural hematoma (brain bleed) as a result of a fall at the nursing facility. Further documentation, dated [DATE], revealed that the resident suffered major neurologic changes, required emergent evacuation of a brain bleed, and did not recover. The resident died as a result of the brain bleed. There was no documented evidence in Resident 1's clinical record that a registered nurse assessed the resident at any time that she was noted to have a change in condition after she fell and hit her head, until she was seen by the CRNP on [DATE], at which time she was sent to the emergency room and admitted to the hospital. Interview with the Director of Nursing on [DATE], at 1:15 p.m. confirmed that there was no documented evidence that a registered nurse assessed Resident 1 when she had changes in her mentation as noted by the licensed practical nurse. She further stated that the resident had a very long psychiatric history and she believed that the changes were possibly from psychiatric medication changes made prior to the fall. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of policies, clinical records, and facility reports, as well as staff interviews, it was determined that the facility failed to ensure that supervision and adequate interventions were in place to prevent elopement while out of the facility for an appointment, which threatened the resident's safety for one of 56 residents reviewed (Resident 47) who was identified as at risk for elopement. The facility's failure created a situation in which the resident obtained and used illegal drugs, which placed the resident in immediate jeopardy of the likelihood of serious bodily injury, harm or death. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding transportation, diagnostic services, revised December 2008, revealed that a member of the nursing staff, or Social Services, will accompany the resident to the diagnostic center when the resident's family is not available. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated January 7, 2021, revealed that the resident was understood, could understand others, and was independent for his daily care tasks. A care plan for the resident, dated September 30, 2020, revealed that the resident had a self care deficit related to impaired decision making and impaired safety awareness. The resident was independent with his transfers and ambulation (walking). A progress note for Resident 47, dated November 10, 2020, at 10:06 a.m. revealed that the resident gathered his belongings and planned on leaving the facility. The resident was redirected and was currently in his room watching television. The registered nurse was made aware. A care plan for Resident 47, dated November 11, 2020, revealed that the resident was an elopement risk related to cognitive impairment. Staff were to allow the resident to vent his feelings and/or frustration as needed. An additional intervention added to the care plan on October 1, 2021, revealed that staff were to encourage socialization with others and provide recreational programming. A progress note for Resident 47, dated January 13, 2021, revealed that the resident was seen today due to a lesion (an abnormal change to an area of skin compared to surrounding tissue) to left mid back. A new order was received to refer the resident to a dermatologist (a physician who specializes in diseases with the skin). Dermatology was contacted and an appointment was scheduled for February 10, 2021, at 11:00 a.m. The resident was made aware. A progress note for Resident 47, dated February 10, 2021, at 2:07 p.m. revealed that the resident had not returned from his dermatology appointment. The registered nurse called the facility's contracted transport service to determine when the resident was expected to return. The facility's contracted transport service stated they had made multiple trips to dermatology to retrieve resident, but they were unable to locate him. The facility's contracted transport service did not call the facility to inform them. A call was placed to the hospital's security, who was aware that the resident was missing. The Nursing Home Administrator immediately left the facility to search for the resident at the hospital. The resident's first contact was informed and provided suggestions as to where resident may have gone to. Local police departments were informed, and calls were placed to local hospitals, bus companies, and a bank that the resident used in the past. A missing person report was completed with 9-1-1 dispatcher. A progress note at 7:09 p.m. revealed that a call was received from the police to confirm that the resident was located at a hotel. The Nursing Home Administrator and the Assistant Director of Nursing were also on site. The resident was transported back to facility by the Nursing Home Administrator. During the ride back to the facility, the resident mentioned he obtained weed and cocaine from a guy on the bus. The physician was updated. New orders were received to obtain a urine drug screen on February 11, 2021. The resident's responsible party was updated. A drug screen laboratory report for Resident 47, dated February 11, 2021, revealed that the resident was presumptive positive for Benzodiazepine (a class of drugs primarily used for treating anxiety), cocaine (a powerfully addictive stimulant drug), marijuana (can also be called cannabis, weed, pot, or dope), and [MEDICATION(S)] (a powerful drug used for pain relief and treatment of drug addiction). The facility's investigation report, dated February 10, 2021, revealed that Resident 47 left the faciity on [DATE], at 10:15 a.m. for an appointment at the hospital's dermatology clinic. He was transported by the facility's contracted transport service. The resident had not returned to the facility at 2:00 p.m. A call was placed to the facility's contracted transport service to determine when the resident's expected return was. The facility's contracted transport service informed the facility that they were unable to locate the resident. The Nursing Home Administrator and Director of Nursing were informed. A call was placed to the hospital's security, who stated that they were aware that the resident did not return with the facility's contracted transport service. The Nursing Home Administrator left the facility to go to the hospital to look for the resident. The facility's contracted transport service supervisor confirmed that they did not inform the facility that the resident was unable to be located. 9-1-1 was called and given a description of the resident. The resident's responsible party was contacted and she indicated that he may be trying to get to his bank. A call was received from 9-1-1 that the resident was located at the bank in Duncansville and was in the custody of police. The facility's contracted transport service was on their way to pick the resident up. A follow-up call to the facility's contracted transport service revealed that they were not informed or on their way to the bank. The facility's contracted transport service did send a unit to the bank's location. However, the resident and/or the police were not there. After speaking with the resident's responsible party she suggested we look at the Econolodge or Rodeway Inn. Econolodge could not run the resident's credit card, so the resident was denied and then he went to the Rodeway Inn. This is where the facility staff found Resident 47. The resident stated that he walked to Super Shoes, Reliance Bank, and two motels, and used public transportation. Police were then made aware. Staff was attempting to get the resident out of the motel when the police arrived and was able to assist in getting the resident out of the motel room. When the door was opened to motel room there was a smell of THC (is the substance that's primarily responsible for the effects of marijuana). Police let staff take the Resident 47 back to the facility and a drug test was done. Interview with the Director of Clinical Nursing on April 26, 2022, at 3:55 p.m. confirmed that at the time the incident occurred with Resident 47, it was the facility's policy that a member of the nursing staff or Social Services would accompany the resident to the diagnostic center when the resident's family is not available. She indicated that after the incident they developed a four-step plan to correct the problem that had been identified with the resident not being escorted to the appointment. Following the incident on February 10, 2021, the facility's corrective actions included: Upon return to the facility a full-body assessment was completed, an elopement risk completed, care plan, and task list were updated for Resident 47. An audit was completed on current residents to identify need for escort to go with to appointments. Reviewed the last 30 days of resident appointments and compared residents' cognitive scores to determine if any required escort. Residents' cognitive scores were completed and updated. Education was provided to staff regarding appointments and escort needs. Developed a process to review the resident's appointment needs. Audits would be completed daily at morning meeting. Audits would review upcoming resident appointments and individual needs based on process criteria to determine if escort is needed and planned. Audit information would be reviewed and discussed during QA meetings for recommendations or resolution to improve the process. On April 26, 2022, at 5:03 p.m. the Nursing Home Administrator was given the Immediate Jeopardy template and informed that the health and safety of Resident 47 was placed in Immediate Jeopardy as past non-compliance due to the failure to ensure that supervision and adequate interventions were in place to prevent elopements while out of the facility for an appointment. The Immediate Jeopardy was lifted on April 26, 2022, at 6:00 p.m. when it was confirmed that the corrective action plans developed on February 10, 2021, were completed by February 12, 2021, and that Resident 47 and any other resident who was out of the facility on an appointment had not eloped since February 12, 2021. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a personal safety alarm was in place for one of seven residents reviewed (Resident CR1), who experienced a fall that resulted in a fracture, and failed to ensure that the staff transported residents in a safe manner for one of seven residents reviewed (Resident R7). Findings include: A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR1, dated August 22, 2017, revealed that the resident was admitted to the facility on [DATE], after experiencing a fall with a fracture. The MDS assessment revealed that the resident required the extensive assistance of two staff for transfers and needed staff assistance to balance herself. The resident's care plan, dated August 24, 2017, revealed that the resident was at risk for falls and was to use pressure-sensing alarms (a device that alarms when pressure is released from a pad placed underneath the resident) on her bed and wheelchair. An incident report, dated September 2, 2017, revealed that Resident CR1 was found on the floor in her room, bleeding from her right nostril. The resident's bed alarm was not sounding. Prior to the incident, the resident was placed in bed by the therapy staff. The resident's nose appeared to be deviated to the left, and her right cheek and peri-orbital (around the eye) were reddened. The incident report indicated that the resident was put into bed by the therapist, and the alarm was not transferred from the wheelchair to the bed. A statement from Physical Therapy Assistant 5, dated September 5, 2017, revealed that he was not aware that Resident CR1's alarm needed to be transferred from her wheelchair to her bed. The facility's investigative documentation for Resident CR1's fall, undated, indicated that the cause of the resident's fall was a lack of communication between the nursing and therapy departments regarding residents' safety equipment. A CT scan (a computerized scan that creates detailed images) report for Resident CR1, dated September 2, 2017, revealed that the resident had fractures of the walls of the right maxillary sinus (an air-filled cavity behind the cheek bone). An interview with the Director of Nursing on November 2, 2017, at 4:30 p.m. confirmed that the facility's investigation concluded that Resident CR1's pressure alarm should have been applied to her bed and activated by Physical Therapy Assistant 5. She indicated that at the time of the resident's fall, the facility did not have a process in place for communicating personal alarm use to therapy department staff. A comprehensive admission MDS assessment for Resident R7, dated October 30, 2017, revealed that the resident was cognitively impaired, displayed physical behaviors at times, required extensive assistance for most care, including locomotion between locations, and used a wheelchair. A worksheet associated with the MDS assessment indicated that the resident was very confused and restless, and was constantly trying to get out of his wheelchair and ambulate (walk). There was no documented evidence in Resident R7's clinical record to indicate that he was assessed to determine if it was safe for the resident to be transported in a wheelchair without foot rests. Observations of Resident R7 on November 2, 2017, at 4:30 p.m. revealed that Nurse Aide 1 was pushing the resident down the hall in his wheelchair, without foot rests in place. Interview with Nurse Aide 1 at that time revealed that she had been employed by the facility for one month and did not know where foot rests were kept, as therapy dealt with all that. Interviews with Nurse Aides 2 and 3 on November 2, 2017, at 4:35 p.m. revealed that wheelchair foot rests were kept in the closet and were to be applied when pushing residents. Interview with Registered Nurse 4 on November 2, 2017, at 4:35 p.m. confirmed that foot rests should have been applied to Resident R7's wheelchair before Nurse Aide 1 transported the resident. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 8/17/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/7/17, 7/28/17, 8/17/16. 28 Pa. Code 201.18(e)(3) Management. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 9/7/17, 6/23/17, 11/16/16, 5/5/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/7/17, 7/28/17, 5/3/17, 2/28/17, 5/5/16. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 9/7/17, 7/28/17, 6/23/17, 5/3/17, 2/28/17, 8/17/16, 5/5/16.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to schedule a recommended consultation with a specialist, resulting in a delay in treatment for [REDACTED]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR3, dated May 3, 2017, indicated that the resident was cognitively impaired and had [DIAGNOSES REDACTED]. A dental report for Resident CR3, dated September 13, 2016, revealed that a recommendation was made for the resident to be evaluated by an oral surgeon for possible [MEDICAL CONDITION] issues under the right anterior (front) tongue and under the left base of the tongue. Following the dentist's recommendation, there was no documented evidence that Resident CR3 was evaluated by an oral surgeon or any other specialist related to possible [MEDICAL CONDITION]. A nursing note for Resident CR3, dated March 28, 2017, at 8:57 a.m. revealed that the resident was noted to have a, large growth underneath his tongue that continues to grow and is impeding his abilities to eat any food without pain and difficulties, resident stated he wanted something done by the physician because 'that thing' is pushing his tongue to the one side. A nursing note dated March 28, 2017, at 9:49 p.m. revealed that the resident was noted to have a large growth of pink to dark pink mucous tissue at the base of the right front gum line, small rice-size pockets covered the entire area, and the resident stated that he gets food stuck there. A nursing note for Resident CR3, dated March 30, 2017, at 8:26 p.m. revealed that there was a pink tissue-like growth noted underneath the resident's tongue that connected behind the resident's lower gum line. The area of growth was approximately the size of a quarter and had small white areas scattered on it. The resident verbalized discomfort with eating and was medicated for pain per the physician's orders [REDACTED]. An ENT consultation for Resident CR3, dated April 4, 2017, revealed that a biopsy (sample of tissue taken from the body in order to examine it more closely) was obtained from the growth in the resident's mouth. An ENT consult, dated April 12, 2017, revealed that the resident had a wart-like growth that measured 3.0 x 3.0 centimeters (cm) and a biopsy confirmed that the resident [MEDICAL CONDITION] of the anterior tongue and floor of the mouth. A CT/PET scan (computerized imaging test that allows the doctor to check for diseases in your body), dated May 8, 2017, revealed [MEDICAL CONDITION] had metastasized (spread) to the resident's lymph node (small bean-shaped organs that filters lymph - fluid that contains white blood cells), and a nursing note for Resident CR3, dated June 14, 2017, revealed that the resident was scheduled for surgery on June 28, 2017. Interview with the Nursing Home Administrator on July 27, 2017, at 4:38 p.m. confirmed that Resident CR3 did not see the oral surgeon as recommended by the dentist on September 13, 2016. Interview with Physician 1, the resident's ENT physician, on July 28, 2017, at 3:40 p.m. confirmed that the earlier a resident would be evaluated, the better the prognosis could be. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 2/28/17, 8/17/16, 5/5/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/23/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/23/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/17/16. 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/23/17, 2/28/17, 5/5/16. 28 Pa. Code 211.5(g) Clinical records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/17/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/23/17, 5/3/17, 8/17/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/3/17, 2/28/17, 5/5/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/23/17, 5/3/17, 2/28/17, 8/17/16, 5/5/16.