Every finding on record at Champion City Nursing and Rehabilitation Center

Based on review of facility policy, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for one out of three closed resident records (Closed Resident Record CR1).Findings include: Review of facility policy Conveyance of Resident Funds last reviewed 8/4/26, indicated the resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law), as applicable, within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death. Review of the clinical record revealed Closed Resident Record CR1 was admitted to the facility on [DATE], with diagnoses of anxiety, depression, and muscle weakness. Review of documentation indicated Closed Resident Record CR1 discharged to another nursing facility on 3/2/26. Review of facility provided Closed Resident Record CR1's Resident Fund Management Service (RFMS) document indicated the current balance was $0.00 and account was terminated on 3/11/26. Interview on 8/26/26, at 1:16 p.m. Business Office Manager (BOM) Employee E1 indicated in March 2026, Closed Resident Record CR1's entire check, minus $60.04, was crossed over to their account in accounts receivable. The resident should be refunded $973.05, and has not been as of this date. Interview on 8/26/26, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to convey resident funds and close resident accounts within 30 days upon discharge for one out of three closed resident records (Closed Residents CR1). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(b)(2)(e)(1) Management.

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two of five residents (Resident R1, and R2)Findings include: Review of the facility policy Homelike Environment last reviewed 8/4/26, indicated the residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Observation of Resident R1, on 8/26/26, at 11:34 a.m. indicated resident out of bed in his wheelchair. Registered Nurse (RN) Employee E2 and Nurse Aide (NA) Employee E3 assisted Resident R1 to a standing position. A pommel cushion (used to keep the knees apart, align the hips, and stop the person from sliding forward or slumping out of the chair) was noted to be on the seat of resident's wheelchair with three holes in it exposing the foam inside and the bedside table was uneven, peeling edges and particle board exposed. Interview on 8/26/26, at 11:35 a.m. RN Employee E2 confirmed the pommel cushion had three holes in it exposing the foam inside and the bedside table was uneven, peeling edges and particle board exposed. Review of the admission record indicated Resident R2 admitted to the facility on [DATE]. Interview on 8/26/26, at 12:00 p.m. Resident R2 indicated she is unable to get a shower in the morning because there is no hot water in the shower room. Observation and interview on 8/26/26, at 12:05 p.m. with NA Employee E4 of the 5 East shower room indicated cool water coming from the shower handle. NA indicated sometimes if it runs it'll heat up but did not during observation. Observation and interview on 8/26/26, at 12:15 p.m. Maintenance Technician Employee E5 conducted a temperature on the shower handle running water and achieved a temperature of 87 degrees. The ceiling of the shower stall had plaster/paint peeling and a large, darkened area in a circular shape. The base of the shower stall wall was missing a large portion of wall/plaster. Interview on 8/26/26, at 12:16 p.m. Maintenance Technician Employee E5 confirmed the shower's water was cold, the ceiling of the shower stall had plaster/paint peeling and a large, darkened area in a circular shape. The base of the shower stall wall was missing a large portion of wall/plaster. 28 Pa. Code 201.18(b)(3)(e)(2) Management.28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for three of three residents (Resident R1, R4, and R5). Findings include: Review of the facility policy Administering Medications through an Enteral Tube last reviewed 6/24/26, indicated to use a clean enteral syringe with administration through an enteral tube. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) a periodic assessment of care needs) dated 5/11/26, indicated the diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture caused by abnormal brain development), respiratory failure, and paraplegia (paralysis of legs and lower body). Section K indicated tube feeding seven days per week. Review of Resident R1's physician order dated 6/10/26, indicated enteral feed order every shift for tube feed. [NAME] Farms 1.5 peptide formula 60 milliliters/hour for twenty hours every day via g-tube. Review of Resident R1's current care plan indicated resident is at nutritional and/or dehydration risk related to NPO (nothing by mouth) with g-tube for all nutrition/hydration needs. Observation on 7/5/26, at 9:40 a.m. Resident R1's tube feeding pole had a bag of [NAME] Farms 1.5 peptide formula hanging. The formula failed to have the resident's name, date and time hung, and by whom. The windowsill had a piston syringe in a bottle of liquid. The bottle and syringe failed to be labeled with a date or what the solution was in the bottle. Observation and interview with the Director of Nursing on 7/5/26, at 9:50 a.m. confirmed the formula failed to have the resident's name, date and time hung, and by whom. The windowsill had a piston syringe in a bottle of liquid. The bottle and syringe failed to be labeled with a date or what the solution was in the bottle. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE] indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Section K indicated a feeding tube was present. Review of Resident R4's current physician orders indicated enteral feed order every shift - water flush for patency: 120 milliliters via g-tube. Review of Resident R1's current care plan indicated administer enteral nutrition per physician orders. Water flushes only, for patency. Observation on 7/15/26, at 10:00 a.m. Resident R4 was in bed. On the bedside stand was a piston syringe sitting in a bottle of liquid. The bottle and syringe failed to be labeled with a date or what the solution was in the bottle. Review of the admission record indicated Resident R5 admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE] indicated diagnoses of stroke, hemiplegia, and high blood pressure. Section K indicated a feeding tube seven days per week. Review of Resident R5's current physician orders indicated enteral feed order every shift - water flush for patency: 120 milliliters via g-tube. Review of Resident R5's current care plan indicated to flush tube feed per physician orders. Observation on 7/15/26, at 10:18 a.m. Resident R5 was in bed. On the bedside stand was a piston syringe sitting in a bottle of liquid. The bottle and syringe failed to be labeled with a date or what the solution was in the bottle. Interview on 7/15/26, at 3:05 p.m. the Nursing Home Administrator was informed that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications for three of three residents (Resident R1, R4, and R5). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for three of five residents observed (Resident R1, R2, and R3), and failed to provide a backup tracheostomy tube (a hollow, curved tube inserted directly into the windpipe through a surgical opening in the neck - stoma) for one of two residents with a tracheostomy tube (Resident R2).Findings include: Review of the facility policy Respiratory Therapy last reviewed on 6/24/26, indicated to obtain equipment (i.e., oxygen tubing, reservoir, and distilled water) change the oxygen cannula and tubing every seven days or as needed. Review of the facility policy Administering Medications through a Small Volume (handheld) Nebulizer last reviewed 6/24/26, indicated the purpose of this procedure is to safely and aseptically (acting in a sterile, sanitized manner to prevent contamination by harmful bacteria, viruses or other microorganisms) administer aerosolized particles of medication into the resident's airway. When equipment is completely dry, store in a plastic bag. Change equipment and tubing every seven days. Review of the facility policy Tracheostomy Care last reviewed 6/24/26, indicated tracheostomy care should be provided as often as needed. A replacement tracheostomy tube must be available at the bedside at all times. Review of the facility policy Suctioning the Tracheostomy Tube last reviewed 6/24/26, indicated determine the need for suctioning: visible secretions or respiratory sounds heard when listening. Empty and rinse collection container if necessary. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) a periodic assessment of care needs) dated 5/11/26, indicated the diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture caused by abnormal brain development), respiratory failure, and paraplegia (paralysis of legs and lower body). Section O, E1 indicated tracheostomy care being provided. Review of Resident R1's physician order dated 7/2/26, indicated tracheostomy - suction every shift and every two hours as needed. Review of Resident R1's current care plan indicated resident is at risk for respiratory distress,Decannulation (tracheostomy tube comes out) and infection related to having a tracheostomy tube and Chronic Respiratory Failure. Tracheostomy is intended to be long-term. Suction airway as needed. Observation on 7/5/26, at 9:40 a.m. Resident R1's suction cannister at the bedside was full of yellow/pale green liquid inside. An oxygen humidifier was detached from the concentrator and sitting on the floor. The humidifier bottle was not labeled with the date and time changed. Further observation on 7/5/26, at 9:41 a.m. Resident R1's bedside stand's top drawer was open. A nebulizer tube was noted in the drawer it was not labeled with the date and time changed or stored in a bag as required. Observation and interview with the Director of Nursing on 7/5/26, at 9:50 a.m. confirmed the suction cannister was full of yellow pale/green liquid, the oxygen humidifier was detached from the concentrator and sitting on the floor. The humidifier bottle was not labeled with the date and time changed and that R1's bedside stand's top drawer was open. A nebulizer tube was noted in the drawer it was not labeled with the date and time changed or stored in a bag as required. Review of the admission record indicated Resident R2 admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section O, E1 indicated tracheostomy care being provided. Review of Resident R2's physician order dated 7/2/26, indicated tracheostomy - suction every shift and every two hours as needed. Review of Resident R2's current care plan indicated resident is at risk for respiratory distress, decannulation and infection related to having a tracheostomy tube. Suction airway as needed. Observation on 7/5/26, at 9:45 a.m. Resident R2's suction cannister at the bedside was full of old secretions inside. Tracheostomy tube with visible mucous inside the cannula and around stoma. A replacement tracheostomy tube failed to be present at the bedside. Observation and interview on 7/5/26, at 9:45 a.m. Registered Nurse (RN) Employee E1 confirmed Resident R2's suction cannister at the bedside was full of old secretions inside. Tracheostomy tube with visible mucous inside the cannula and around stoma, and a replacement tracheostomy tube failed to be present at the bedside. Review of the admission record indicated Resident R3 admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated the diagnoses of respiratory failure, oxygen dependent, and diabetes. Review of Resident R3's physician order dated 7/2/26, indicated oral (mouth) suction every shift and as needed for secretions. Review of Resident R3's current care plan indicated resident has a potential for difficulty breathing and risk for respiratory complications related to chronic respiratory failure. Observation on 7/5/26, at 10:00 a.m. Resident R3's nebulizer mask was at bedside and failed to be labeled with a date and time, had dried secretions on it, and was not stored in a bag. The suction cannister was full of yellow/white liquid. Resident had thick white drainage dripping from nostrils and sounded audibly congested. Observation and interview on 7/5/26, at 10:10 a.m. Licensed Practical Nurse (LPN) Employee E2 was at bedside, confirmed the nebulizer mask was at bedside and failed to be labeled with a date and time, had dried secretions on it, and was not stored in a bag. The suction cannister was full of yellow/white liquid. Resident had thick white drainage dripping from nostrils and sounded audibly congested. LPN Employee E2 indicated I'm going to suction the resident now. 28 Pa. Code: 201.14(a) Responsibility of licensee.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, resident council grievance documentation, observations, resident and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for two out of five floors (Third and Fourth floors).Findings include: The facility Homelike environment policy last reviewed on 6/26/26, indicated that residents are provided with a safe, clean, comfortable and homelike environment. The facility staff maximizes the characteristics of the facility that reflect a homelike setting, this includes clean, sanitary environment. Review of resident council grievances dated 4/29/26 and 6/24/26, indicated that the resident council brought forward concerns related to seeing mice in the facility. During a tour of the facility on 7/15/26, starting at 8:57 a.m. the following was observed: -at 9:06 a.m. observations of fourth floor pantry found black specks indicative of mice droppings. During an interview on 7/15/26, at 9:08 a.m. Resident R6 stated: I did see some mice. During a tour of the facility on 7/15/26 the following was observed on the fourth floor:-at 9:10 a.m. observations of Resident R6's room found her wardrobe/closet with black specks indicative of mice droppings in a gray wash basin. Additional mice droppings were observed inside a pair of light brown slippers. The bottom of shelve of the wardrobe was observed covered in black mice droppings. Besides Resident R6's wardrobe was numerous black specks indicative of mice droppings. During an interview on 7/15/26, at 9:13 a.m. Nurse aide Employee E4 was asked if she had seen any mice and stated: no. just mouse droppings. During an interview on 7/15/26, at 9:26 a.m. observations of Resident R6's room with Housekeeper Employee E3. Housekeeper Employee E3 was asked if the black specks were mouse droppings, she stated: yes, they are. During a tour of the facility on 7/15/26 the following was observed on the fourth floor:-9:28 a.m. observations of Resident R7's room found numerous clear small cups under her bed. During an interview on 7/15/26, at 9:52 a.m. Maintenance supervisor Employee E5 was asked about actions to eradicate mice and stated: We have a weekly service coming here. We are making big changes to try to remediate the place as soon as possible. I'm aware of the pest issues here. During a tour of the facility on 7/15/26, the following was observed on the Third floor:-at 10:29 a.m. observation of Third floor pantry found small black specks indicative to mice droppings observed on left side of resident refrigerator. During an interview on 7/15/26, at 2:51 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to provide a clean, safe, comfortable, and homelike environment for two out of five floors as required. 28 Pa. Code 201.18(b)(3)(e)(2) Management. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy, resident council grievance documentation, pest control documentation, observations, resident and staff interviews it was determined that the facility failed to maintain an effective pest control program for two out of five floors (Third and Fourth floors). Findings include: The facility Pest control policy last reviewed on 6/26/26, indicated that the facility will maintain an effective pest control program. Review of resident council grievances dated 4/29/26 and 6/24/26, indicated that the resident council brought forward concerns related to seeing mice in the facility. Review of pest control documentation dated 6/2/26, 6/16/26, 7/2/26, 7/7/26, and 7/14/26, indicated traps were put in place to catch mice. During a tour of the facility on 7/15/26, starting at 8:57 a.m. the following was observed: -at 9:06 a.m. observations of fourth floor pantry found black specks indicative of mice droppings. During an interview on 7/15/26, at 9:08 a.m. Resident R6 stated: I did see some mice. During a tour of the facility on 7/15/26 the following was observed on the fourth floor:-at 9:10 a.m. observations of Resident R6's room found her wardrobe/closet with black specks indicative of mice droppings in a gray wash basin. Additional mice droppings were observed inside a pair of light brown slippers. The bottom of shelve of the wardrobe was observed covered in black mice droppings. Besides Resident R6's wardrobe was numerous black specks indicative of mice droppings. During an interview on 7/15/26, at 9:13 a.m. Nurse aide Employee E4 was asked if she had seen any mice and stated: no. just mouse droppings. During an interview on 7/15/26, at 9:26 a.m. observations of Resident R6's room with Housekeeper Employee E3. Housekeeper Employee E3 was asked if the black specks were mouse droppings, she stated: yes, they are. During a tour of the facility on 7/15/26 the following was observed on the fourth floor:-9:28 a.m. observations of Resident R7's room found numerous clear small cups under her bed. During an interview on 7/15/26, at 9:52 a.m. Maintenance supervisor Employee E5 was asked about actions to eradicate mice and stated: We have a weekly service coming here. We are making big changes to try to remediate the place as soon as possible. I'm aware of the pest issues here. During a tour of the facility on 7/15/26, the following was observed on the Third floor:-at 10:29 a.m. observation of Third floor pantry found small black specks indicative to mice droppings observed on left side of resident refrigerator. During an interview on 7/15/26, at 2:51 p.m. information was disseminated to the Nursing Home Administrator (NHA) that the facility failed to maintain an effective pest control program for two of five floors as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 207.2(a) Administrator's responsibility

Based on facility policy, menu, observations, and staff interviews, it was determined that the facility failed to follow the menu for five of five residents (Resident R6, R7, R8, R9, and R10).Findings include: Review of facility policy entitled Food and Nutrition Services dated 10/29/25, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets hir or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct menu is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Review of the admission record indicated Resident R7 was admitted to the facility 1/27/23. Review of Resident R7's physician orders indicated:Magic cup (oral nutritional supplement) with meals TID (three times per day) for weight support.Mighty shakes (oral nutritional supplement) with meals for weight support TID with meals. During an observation of Resident R7's lunch meal tray on 5/19/26 failed to include a magic cup or a mighty shake as ordered. During an interview on 5/19/26, at 11:50 a.m., Nurse Aide (NA) Employee E7 confirmed that neither oral nutritional supplement, magic cup or mighty shake, were present on Resident R7's lunch tray. A review of the provided menu indicated that the lunch meal on 5/19/26, was as follows:Cube steak, mushroom gravy, buttered noodles, seasoned zucchini, dinner roll, and peach crisp. During an observation of lunch trays on the sixth and fourth floor on 5/19/26, revealed the following:Resident R6 - was served diced peaches, not peach crisp as menu indicated.Resident R7 - was served diced peaches, not peach crisp as menu indicated.Resident R8 - was served diced peaches, not peach crisp as menu indicated. Resident R9 - was served diced peaches, not peach crisp as menu indicated. Resident R10 - was served diced peaches, not peach crisp as menu indicated. During an interview on 5/19/26, at 12:20 p.m., Executive Chef (EC) Employee E8 confirmed that the facility failed to serve peach crisp for lunch meal as menu indicated. During an interview on 5/19/26, at 1:01 p.m., Dietary Supervisor (DS) Employee E9 stated that Diet Aide (DA) Employee E10 failed to make peach crisp as part of her cold production responsibilities for lunch meal service. During an interview on 5/19/26, at 3:20 p.m., Regional Nursing Home Administrator Employee E6 confirmed that the facility failed to follow the menu for five of five residents (Resident R6, R7, R8, R9, and R10). 28 Pa. Code: 211.6(a) Dietary services

Based on review of clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition for one of three residents (Resident R4). Findings include:Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE].Review of Resident R4s MDS dated [DATE], indicated diagnoses of end stage renal disease, diabetes mellites and congestive heart failure (long-term condition in which your heart can't pump blood well enough to meet the body's needs). Review of Resident R4's progress note dated 5/12/26 indicated resident was in the ED (emergency department) on 5/11/26 for abdominal pain. There was no indication it was reported to the physician or an order to send to the hospital. During an interview on 5/19/26, at 2:00 p.m. Regional Nursing Home Administrator Employee E6 confirmed that the facility failed to notify the physician for change of condition as required. 28 Pa. Code: 211.12(d)(1) Nursing services.

Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1).Findings include: Review of facility policy Identifying Types of Abuse dated 10/29/25, indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them, and this has resulted in (or may result in) physical harm, pain, mental anguish or emotional distress. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/18/26, indicated diagnoses of olecranon fracture (a break in the bony tip of the elbow), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and falls. Section C0500 indicated a Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) score of 00, severe impairment. Review of facility provided documents indicated on 5/8/2026, at 6:30 a.m., the 11:00 p.m. - 7:00 p.m. Registered Nurse (RN) Supervisor, Employee E1 reported to the Director of Nursing, that Nurse Aide (NA) Employee E2 placed a sheet around Resident R1's hips during the 11:00 p.m.- 7:00 p.m. shift. Resident R1 was seated in a chair in front of the television, and the sheet prevented resident from transitioning from sitting to standing. Upon investigation the sheet was found to only be in place less than 15 minutes. Resident R1 resides on the locked dementia unit. Review of RN Supervisor Employee E1's signed witness statement dated 5/7/26, indicated RN was making rounds at 5:15 a.m. on the Third Floor. Resident R1 was sitting quietly in the common area. RN went over to resident and saw that resident was tied to the chair with two sheets. One sheet was tied over the arms; the other sheet was tied across the waist. RN tried to untie resident, but the sheets were so tightly knotted to the chair arms that the RN couldn't. RN untied resident from the back. Skin exam found no injuries or any bruising. Resident R1's NA Employee E2 was on a break at the time. RN called NA Employee E2 from the supervisor phone and asked if they were the one who tied resident to the chair and NA Employee E2 replied Yeah, I did it.' Review of NA Employee E2's signed witness statement dated 5/7/26, at 11:00 a.m. that was conducted during a telephonic interview by Infection Preventionist (IP) Employee E3, and Regional Nurse Employee E4, indicated Resident R1 was peeing everywhere. NA Employee E2 indicated, I know it was wrong and not right. I put a sheet around resident's waist to make a seatbelt for resident in the wheelchair with a slipknot in the back. Resident was not there for hours, and I only had one sheet around resident. I think the RN supervisor was having a bad day and called me out. It's not like I tied resident up and put resident in a room and left resident for hours. I put resident in front of the television. I did the sheet at 5:00 a.m. and went on a break at 5:06 a.m. and I forgot I had put the sheet around resident. RN Supervisor Employee E1 called me at 5:11 a.m. and asked me why I left the resident like I did. I was trying to take my scheduled break, and I was by myself because the other NA was sent home. I was tired of chasing resident around. I was just trying to keep resident safe, and from going into the other residents' rooms and waking them up. Review of Licensed Practical Nurse (LPN) Employee E5's signed witness statement dated 5/7/26, indicated I was called into the common area television room by the night shift supervisor. Resident R1 was found restrained around the waist area while sitting in the chair. NA Employee E2 stated she applied the restraint for his safety while NA was making their last rounds. I saw the restraint only when I was called over for a closer look by the RN Supervisor at around five thirty or five forty-five in the morning. Interview on 5/19/26, at 2:00 p.m. the Regional Nurse Employee E4 confirmed the facility failed to protect residents from neglect for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from physical restraints for one of five residents (Resident R1). Findings include: Review of facility policy Use of Restraints dated 10/29/25, indicated:-Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls.-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.-Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including placing a resident in a chair that prevents the resident from rising. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/18/26, indicated diagnoses of olecranon fracture (a break in the bony tip of the elbow), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and falls. Section C0500 indicated a Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) score of 00, severe impairment. Review of Resident R1's physician orders failed to include orders of restraint use of any type. Review of Resident R1's care plan failed to include documentation of restraint use of any type. Review of facility provided documents indicated on 5/8/2026, at 6:30 a.m., the 11:00 p.m. - 7:00 p.m. Registered Nurse (RN) Supervisor, Employee E1 reported to the Director of Nursing, that Nurse Aide (NA) Employee E2 placed a sheet around Resident R1's hips during the 11:00 p.m.- 7:00 p.m. shift. Resident R1 was seated in a chair in front of the television, and the sheet prevented resident from transitioning from sitting to standing. Upon investigation the sheet was found to only be in place less than 15 minutes. Resident R1 resides on the locked dementia unit. Review of RN Supervisor Employee E1's signed witness statement dated 5/7/26, indicated RN was making rounds at 5:15 a.m. on the Third Floor. Resident R1 was sitting quietly in the common area. RN went over to resident and saw that resident was tied to the chair with two sheets. One sheet was tied over the arms; the other sheet was tied across the waist. RN tried to untie resident, but the sheets were so tightly knotted to the chair arms that the RN couldn't. RN untied resident from the back. Skin exam found no injuries or any bruising. Resident R1's NA Employee E2 was on a break at the time. RN called NA Employee E2 from the supervisor phone and asked if they were the one who tied resident to the chair and NA Employee E2 replied Yeah, I did it.' Review of NA Employee E2's signed witness statement dated 5/7/26, at 11:00 a.m. that was conducted during a telephonic interview by Infection Preventionist (IP) Employee E3, and Regional Nurse Employee E4, indicated Resident R1 was peeing everywhere. NA Employee E2 indicated, I know it was wrong and not right. I put a sheet around resident's waist to make a seatbelt for resident in the wheelchair with a slipknot in the back. Resident was not there for hours, and I only had one sheet around resident. I think the RN supervisor was having a bad day and called me out. It's not like I tied resident up and put resident in a room and left resident for hours. I put resident in front of the television. I did the sheet at 5:00 a.m. and went on a break at 5:06 a.m. and I forgot I had put the sheet around resident. RN Supervisor Employee E1 called me at 5:11 a.m. and asked me why I left the resident like I did. I was trying to take my scheduled break, and I was by myself because the other NA was sent home. I was tired of chasing resident around. I was just trying to keep resident safe, and from going into the other residents' rooms and waking them up. Interview on 5/19/26, at 2:00 p.m. the Regional Nurse Employee E4 confirmed the facility failed to ensure that residents were free from physical restraints for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of resident-to-resident abuse to the local State field office for one of five sampled residents (Resident R2).Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 10/329/25, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations), and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/9/26, indicated diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and depression. Section C0500 indicated a Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) score of 10, moderate cognitive impairment. Review of Resident R2's progress notes dated 5/10/26, at 9:00 p.m. indicated Resident R2 was pushed to the floor by another resident causing Resident R1 to injure the back of the head, and that sent Resident R2 out to the hospital. Review of Resident R2's progress notes dated 5/10/26, at 10:57 p.m. further indicated an altercation between two residents occurred at approximately 9:00 p.m. Resident R2 charged at another resident in lounge area, who was sitting, watching television; this resident shoved Resident R2 away causing her to fall back and hit her head on floor. Moderate blood flow on the floor, one-inch open area; pressure held. Resident to chair once blood stopped. Dressing to head. Supervisor aware and on unit. Dr. Golani notified, patient being sent to outlying hospital. Review of facility provided report to the local State field office dated 5/10/26, at 9:00 p.m. indicated Event Type: Transfer/admission to Hospital Because of Injury/Accident. Resident R2 experienced a witnessed fall while ambulating on the unit, hitting head on the floor. Resident has a BIMS of 12 and is capable of taking off and putting on resident clothing and shoes. Resident had removed their shoes and was wearing socks. Sustained small laceration three centimeters (cm) to back of scalp. Resident sent to the Emergency Department for evaluation and treatment. Submitted by the Director of Nursing. Interview on 5/19/26, at 2:30 p.m. Regional Nurse Employee E4 indicated the Director of Nursing was on vacation. Further interview on 5/19/26, at 2:31 p.m. Regional Nurse Employee E4 indicated the facility provided report to the local State field office dated 5/10/26, at 9:00 p.m. was not reflective of the resident to resident abuse documented in the progress notes and that the facility failed to submit a report of an allegation of resident to resident abuse to the local State field office for one of five sampled residents (Resident R2). 28 Pa. Code: 201.14(a)(c) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code: 201.20(b) Staff development.28 Pa. Code: 211.10(c)(d) Resident care policies.

Based on review of facility documents, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation for an allegation of resident-to-resident abuse for one of five residents (Resident R2) Findings include: Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 10/329/25, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations), and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/9/26, indicated diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and depression. Section C0500 indicated a Brief Interview for Mental Status (BIMS is a screening test that aids in detecting cognitive impairment) score of 10, moderate cognitive impairment. Review of Resident R2's progress notes dated 5/10/26, at 9:00 p.m. indicated Resident R2 was pushed to the floor by another resident causing Resident R1 to injure the back of the head, and that sent Resident R2 out to the hospital. Review of Resident R2's progress notes dated 5/10/26, at 10:57 p.m. further indicated an altercation between two residents occurred at approximately 9:00 p.m. Resident R2 charged at another resident in lounge area, who was sitting, watching television; this resident shoved Resident R2 away causing her to fall back and hit her head on floor. Moderate blood flow on the floor, one-inch open area; pressure held. Resident to chair once blood stopped. Dressing to head. Supervisor aware and on unit. Dr. Golani notified, patient being sent to outlying hospital. Review of Resident R2's form #1812 Physical Aggression initiated, dated 5/10/26, at 9:00 p.m. indicated after the altercation between two residents, Resident R2 was pushed to the floor by other resident and hit the back of the head to cause it to open and start bleeding. Staff nurse stopped the bleeding after several attempts and wrapped the head in bandages. Physician, Director of Nursing, and family were notified as well as the police. Review of facility provided report to the local State field office dated 5/10/26, at 9:00 p.m. indicated Event Type: Transfer/admission to Hospital Because of Injury/Accident. Resident R2 experienced a witnessed fall while ambulating on the unit, hitting head on the floor. Resident has a BIMS of 12 and is capable of taking off and putting on resident clothing and shoes. Resident had removed their shoes and was wearing socks. Sustained small laceration three centimeters (cm) to back of scalp. Resident sent to the Emergency Department for evaluation and treatment. Submitted by the Director of Nursing. 28 Pa. Code: 201.14(a)(c) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code: 201.20(b) Staff development.28 Pa. Code: 211.10(c)(d) Resident care policies.

Based on review of facility policy, clinical record review, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold for an agreed upon rate during a hospitalization) for one of three residents (Resident R4).Findings include: Review of facility policy Transfer or Discharge Documentation dated 10/29/25, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility of provider. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of Resident R4s MDS dated [DATE], indicated diagnoses of end stage renal disease, diabetes mellites and congestive heart failure (long-term condition in which your heart can't pump blood well enough to meet the body's needs). Review of the clinical record indicated Resident R4's was transferred to the hospital on 5/11/26. Review of Resident R4's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 5/19/26, at 2:00 p.m. Regional Nursing Home Administrator Employee E6 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider, failed to notify the resident's representative of the facility bed-hold policy for Residents R4 as required. 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to perform post-fall documentation of assessment and failed to make certain that residents were provided appropriate treatment and care in accordance with professional standards of practice for one of five residents (Residents R3). Findings include: Review of facility policy Assessing Falls and Their Causes dated 10/29/25, indicated if an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/6/26, indicated diagnoses of high blood pressure, renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Section GG indicated supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance as for Section K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. Review of Resident R3's current care plan indicated at risk for falls due to history of falls, impaired mobility, and muscle weakness. Review of Resident R3's progress note dated 5/18/26, at 7:52 a.m. indicated writer was called by the receptionist on the first floor, which stated that Resident R3 was sitting on the floor in the lobby. Writer went to the first floor and resident was sitting on floor on buttocks. Resident stated that they were trying to pick something up off of the floor and put their right knee on the floor and could not get up so they sat on their buttocks on the floor. Resident fell at 7:40 p.m. on the right side of the receptionist desk. Resident was lifted up by Security and the Receptionist. Resident stated that they were not hurt. Resident refused vital signs. Interview on 5/19/26, at 2:26 p.m. Regional Nurse Employee E4 confirmed that a documented assessment is required prior to moving a resident who has fallen and that the facility could not produce a documented assessment prior to assisting Resident R3 from the floor. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluation for one of three records (Nurse aide (NA) Employee E2).Findings include: Review of employee personnel files on 5/20/26, at 2:30 p.m. indicated the following: Review of NA Employee E2's personnel record indicated a date of hire as 3/6/25. Further review of NA Employee E2's personnel record indicated a Job Description/Competency/Evaluation (Annual and Probationary) document dated 3/6/25. The form was entirely blank except NA Employee E2's signature on the last page dated 3/6/25. No documentation for the year 2026 was presented. Interview on 5/19/26, at 2:30 p.m. Regional Nursing Home Administrator Employee E6 confirmed the facility failed to complete annual nurse aid employee evaluation as required for NA Employee E6. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of clinical records and staff interview, it was determined that the facility failed to appropriately document progress notes in the clinical record for one of three residents (Resident R5). Findings include:Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE].Review of Resident R5's MDS dated [DATE], indicated diagnoses of Bipolar (mental health condition characterized by alternating episodes of mania and depression, affecting mood, energy and thought), depression and neurologic neglect syndrome (cognitive disorder). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Resident R5's MDS assessment section C0200 BIMS score was a 11, indicating moderately impaired Review of Resident R5's medical record revealed two letters' regarding her Medicaid Long-Term Care Application. One dated 4/14/26 and 5/7/26, both were signed by Resident R5. During an interview on 5/19/26, at 1:00 p.m. Regional Nurse Employee E4 confirmed that the facility shouldn't have had Resident R5 sign the letters because of being cognitively impaired. 28 Pa. Code: 211.5(f)(g)(h) Clinical Records.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store food products and maintain proper infection control practices in the main kitchen and dish room which created the potential for cross contamination in the designated main kitchen, dish room. The facility policy entitled Food Preparation and Service dated 10/29/25, indicated Food and nutrition employees prepare, distribute, and serve food in a manner, that complies with safe food handling practices. During an observation of the main designated kitchen on 3/23/26, at 9:45 a.m. the following was observed: -(2) cups were stored in the flour bin -(2) packages uncooked ground pork stored improperly -(1 )open bag of hashbrowns in the freezer, open, not dated -(2) cases ice cream stored on walk in freezer floor -(5) individual ice cream, open, walk in freezer During tray line observation of the main designated kitchen on 3/24/2026 at 11:42 a.m. -11:49 a.m. server observed picking up Salisbury steaks with gloved hands, opened warming cart door, did not change gloves -lid covers for plates were still wet from being washed from breakfast During dish room observation 3/26/26 at 9:37 a.m. the following was observed: -dietary staff loading dirty dishes, when wash cycle was complete, he proceeded to clean side and unloaded without washing hands. This was observed x 5. During an interview on 3/26/26 at 10:00 a.m., Dietary Manager Employee E21 confirmed that the facility failed to properly label and date food products and maintain sanitary conditions which created the potential for cross contamination.28 Pa. Code: 201.18(b)(1) Management28 Pa. Code: 211.6(c) Dietary services28 Pa. Code: 201.14(a) Responsibility of licensee

Based on review of the facility policy and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (March 2025, through February 2026) Findings include: Review of facility Antibiotic Stewardship policy dated 10/29/25, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's Infection Control Program from March 2025, through February 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring and ensuring appropriate usage was completed. During an interview on 3/25/26, at 10:51 a.m. Director of Nursing reviewed the facilities infection control documents with State Agency (SA) and was unable to provide the facilities antibiotic stewardship program and stated, I haven't been here that long. We just hired a new infection preventionist, and we will be working to get all the infection control in order. During an interview on 3/26/26, at 9:00 a.m. Director of Nursing stated, I did find an antibiotic stewardship binder in one of the offices and confirmed that it just had reports from the lab in it and failed to include any facility tracking of antibiotics. During an interview on 3/26/26, at 9:09 a.m. the Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (March 2025, through February 2026). 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, closed clinical records, resident fund account statements and staff interview it was determined that the facility failed to convey resident funds and close accounts upon discharge within 30 days for three out of three closed resident records (Closed Resident Records CR186, CR187, and CR188).Findings include:Review of facility policy Conveyance of Resident Funds dated 10/29/25, indicated the resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate (individual or probate jurisdiction per state law), as applicable, within thirty (30) days from the date of the resident's discharge or eviction from the facility, or death. Review of the clinical record revealed Closed Resident Record CR186 was admitted to the facility on [DATE], with diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and unsteadiness on feet. Review of documentation indicated Closed Resident Record CR186 ceased to breath (CTB) at the facility on 2/5/26. Review of the clinical record revealed Closed Resident Record CR187 was admitted to the facility on [DATE], with diagnoses of high blood pressure, muscle weakness, and dysphagia (difficulty swallowing). Review of documentation indicated Closed Resident Record CR187 was transferred to the hospital on 9/24/25, and ceased to breathe at the hospital on 9/25/25. Review of the clinical record revealed Closed Resident Record CR188 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, anxiety, and high blood pressure. Review of documentation indicated Closed Resident Record CR188 ceased to breathe at the facility on 8/19/25. Review of the facility trust fund account (resident funds account with current accounts open and holding resident monies) dated 3/23/26, indicated the following:Closed Resident Record CR186 had a balance of $3778.30Closed Resident Record CR187 had a balance of $240.54Closed Resident Record CR188 had a balance of $517.07 During an interview on 3/26/26, at 1:14 p.m. Regional Business Office Manager Employee E14 confirmed that the facility failed to convey resident funds and close resident accounts within 30 days upon discharge for three out of three closed resident records (Closed Residents CR186, CR187, and CR188). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.18(b)(2)(e)(1) Management.

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications for four of five residents (Residents R13, R16, R37, and R139).Findings include: Review of facility policy Psychotropic Medication Use dated 10/29/25, indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics/sedatives. Review of facility policy Medication Regimen Reviews dated 10/29/25, indicated a licensed pharmacist reviews the medication regimen of each resident at least monthly. The consultant pharmacist provides the director of nursing services and medical director with copy of all medication regimen reports. Upon receiving the MRR report from the pharmacist, the director of nursing reviews the recommendations with the attending physician, responds to the report, and documents what (if any) actions were taken to address them. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/26, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) , cerebral infarction (necrotic tissue in the brain resulting in loss of blood and oxygen to the brain), and high blood pressure. Review of Resident R13's MRR dated 3/31/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: The resident is receiving the antipsychotic agent Quetiapine (a mind-altering medication) but lacks an allowable diagnosis to support its use. Please consider an appropriate diagnosis. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/31/25. Review of Resident R13's MRR dated 8/30/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Escitalopram Oxalate (a medication used to treat depression) 15 milligrams (mg) by mouth once a day. If an antidepressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible gradual dose reduction (GDR) in an effort to find the lowest effective dose. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 8/30/25. On 9/4/25, a CRNP addressed the MRR, stating, Depression ongoing-any further GDR would likely exacerbate underlying symptoms. Review of Resident R13's MRR dated 9/29/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Quetiapine 100 milligrams by mouth two times a day. The resident is receiving the antipsychotic agent Quetiapine but lacks an allowable diagnosis to support its use. Please consider an appropriate diagnosis. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 9/29/25. On 10/9/25, a CRNP addressed the MRR, stating, Please add schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms); refer to psych notes. Review of Resident R13's MRR dated 1/31/26, indicated the following recommendation from the pharmacist to the physician: Recommendation: Quetiapine 100 milligrams by mouth two times a day. Resident is due for a GDR in an attempt to find the lowest effective dose. Please consider a trail dose reduction. Review of Resident R13's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/31/26. Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated diagnoses of depression, dementia, and insomnia (difficult sleeping). Review of Resident R16's MRR dated 3/31/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Zyprexa (a mind-altering medication) 2.5 milligrams by mouth two times a day. The resident is receiving the antipsychotic agent, but lacks an allowable diagnosis to support its use. Please consider an appropriate diagnosis. Review of Resident R16's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 3/31/25. Review of Resident R16's MRR dated 7/31/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Zyprexa 2.5 milligrams by mouth two times a day. The resident is receiving the antipsychotic agent, but lacks an allowable diagnosis to support its use. Please consider an appropriate diagnosis. Review of Resident R16's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 7/31/25. Review of Resident R16's MRR dated 9/29/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Zyprexa 2.5 milligrams by mouth two times a day. The resident is due for a GDR in an attempt to find the lowest effective dose. Please consider a trial dose reduction. Review of Resident R16's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 9/29/25. Review of Resident R16's MRR dated 11/26/25, indicated the following recommendation from the pharmacist to the physician: Recommendation: Remeron (a medication used to treat depression) 15 milligrams by mouth once a day. If an antidepressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible GDR in an effort to find the lowest effective dose. Review of Resident R16's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 11/26/25. Review of Resident R16's MRR dated 2/28/26, indicated the following recommendation from the pharmacist to the physician: Recommendation: Zyprexa 2.5 milligrams by mouth two times a day. The resident is due for a GDR in an attempt to find the lowest effective dose. Please consider a trial dose reduction. Review of Resident R16's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 2/28/26. Review of the clinical record revealed Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Review of a physician order dated 8/29/24, through 5/26/25, indicated to administer Xanax (an anti-anxiety medication) 0.5 mg give one tablet by mouth two times a day for anxiety. Review of a physician order dated 5/26/25, indicated to administer Xanax 0.5 mg give one tablet by mouth three times a day for anxiety. Review of Resident R37's clinical record failed to reveal documentation that a MRR had been completed by the consultant pharmacist for March 2025, April 2025, May 2025, June 2025, and July 2025. Review of the clinical record revealed Resident R139 was admitted to the facility on [DATE]. Review of Resident R139's MDS dated [DATE], indicated diagnoses of depression, schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms), and muscle weakness. Review of a physician order dated 3/27/24, through 5/5/25, indicated to administer Remeron (an anti-depressant medication) 15 mg by mouth at bedtime for depression. Review of a physician order dated 2/14/25, through 6/30/25, indicated to administer Abilify (an antipsychotic) 10 mg by mouth twice a day for mood. Review of a physician order dated 6/6/25, through 8/10/25, indicated to administer Ativan (an anti-anxiety medication) 0.5 mg by mouth twice a day for anxiety. Review of Resident R139's clinical record failed to reveal documentation that a MRR had been completed by the consultant pharmacist for March 2025, April 2025, May 2025, June 2025, and July 2025. During an interview on 3/25/26, at 3:05 p.m. the Director of Nursing (DON) stated, I don't have any [MRRs] from before August 2025. The completed MRRs I gave you is all I have. During this interview, the DON confirmed that the facility failed to provide documentation that medication regimens were free from potentially unnecessary medications for four of five residents (Residents R13, R16, R37, and R139). 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined that the facility failed to protect Resident R3 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R1 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident R2 on February 18, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R1 was found naked on top of Resident R3. (Resident R1, R2 and R3) Findings Include: Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2/3/25, 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. Review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2/3/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. b. when the desired outcome is not met. c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly assessment. Review of Resident R1's clinical record indicated that he was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of dementia (a decline in cognitive function that interferes with daily life), mood disorder (mental health condition that primarily affect emotional states), and paranoid schizophrenia (subtype of schizophrenia characterized by persistent paranoid delusions). Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicate Resident R1 scored an 11, moderately impaired. Review of Resident R1's clinical progress note dated 2/18/25, at 10:46 a.m., stated a Nurse Aide (NA) reported that Resident R1 was in his room with female Resident R2. Evaluated situation, Resident R1 naked, with female Resident R2 naked from waist down, call placed to Supervisor and Administration. Review of facility documentation submitted 2/18/25, indicated that Resident R1 was seen sitting at bedside naked with Resident R2 in his bed naked. Staff told Resident R2 its time to get up, and Resident R1 became upset and told staff she is a grown women and can do what she wants. Resident R2 taken back to room, skin assessment completed with no injury notes, patient unable to recall or report pain. Resident R1 was placed on one to one. Review of facility documentation submitted witness statement by Nurse Aide (NA) Employee E2 dated 2/18/25, NA Employee E2 was looking for Resident R2 and when Employee E2 found her, she was in a males (R1) room, laying on his bed with her vagina visible and the gentleman (R1) attempting to cover her up with his blanket as to why he was naked on the side of the bed. Employee E2 got her (R2) up from his bed and reported incident to the nurse on the floor and she contacted the Director of Nursing (DON) and the Administrator (NHA). Review of Resident R1's clinical physician progress note dated 2/19/25, at 2:41 p.m., stated an immediate request to see patient because of an unwanted sexual encounter with another resident who is older and much more cognitively impaired. Patient has now become very agitated and aggressive when confronted; that he has been very mad all day and has been refusing his medications and meals. Patient is alert and oriented times two, and was in denial that any of this had happened; that all of the things staff were saying he did were not true; agreed that their allegations were bad things, but was adamant that he didn't do it and wouldn't ever do it again even if he did. Review of Resident R1's care plan on 4/2/25, indicated that on 2/18/25, his care plan was updated to include a problem focused on behavior due to sexual, combative and aggression towards staff and other residents; Care plan goal that Resident R1 will have fewer episodes of sexual, combative, aggression weekly. Further review of the care plan indicated that 15-minute checks for related sexual behavior was initiated on 2/18/25, and resolved 3/20/25. Further review of care plan failed to indicate that the facility developed appropriate care plan interventions to prevent further sexually inappropriate behaviors, specifically addressing supervision of Resident R1 and the safety of other residents from an alleged perpetrator of sexual abuse. Review of facility provided documentation revealed Resident Observation q 15 Minute Checks Documentation was initiated 10:00 a.m., on 2/18/25, and was stopped at 10:45 a.m., on 2/19/25. Interview conducted on 4/1/25, at 3:30 p.m., with [NAME] President of Clinical Operations (VP of Ops) Employee E1 revealed that every (q) 15 minute checks were stopped once Resident R1 was seen and evaluated by Psychiatric physician for follow-up which occurred 2/19/25, at 10:15 a.m. VP of Ops Employee E1 confirmed that facility failed to develop interventions after 2/18/25, event, that continually monitored and supervised Resident R1 behavior and actions towards others, to include cognitively impaired residents residing on unit. Review of Resident R2's clinical record indicated that she was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set, dated dated dated [DATE], indicated diagnoses of Alzheimer's disease (chronic neurodegenerative condition that primarily affects memory, thinking, and behavior), dementia, and major depressive disorder (mental disorder characterized by persistent low mood, loss of interest or pleasure in activities, and a range of emotional and physical problems). Further review of MDS Section B- Hearing, Speech, and Vision, B0700 Makes Self Understood is coded 3, rarely/never understood; B0800 Ability to Understand Others is coded 3, rarely/never understands; Section C - Cognitive Patterns, C1000 Cognitive Skills for Daily Decision-Making is coded 3, severely impaired - never/rarely makes decisions. Section E - Behavior, E0900 Wandering - Presence and Frequency was coded 1, indicating behavior of this type occurred 1 to 3 days. Review of Resident R2's clinical progress note dated 2/18/25, at 10:54 a.m., stated Resident R2 was found in a male resident's room in bed, naked from the waist down. Evaluation done, no apparent injures, old scratches noted, Supervisor and ADON made aware. Review of Resident R2's clinical physician progress note dated 2/19/25, at 2:42 p.m., stated that today staff request for me to see patient; reported that she had a suspected sexual encounter with another resident who is much younger and much more cognitively intact. Review of facility submitted documentation on 2/18/25, indicated that female Resident R2 was evaluated at the hospital and placed on another unit. Family refused rape kit at hospital. Review of Resident R2's care plan dated 6/21/21, revised on 3/26/23, indicated that resident has impaired cognitive function/dementia or impaired thought processes regards to Alzheimer's, dementia. Intervention dated 6/21/21, included to cue, reorient, and supervise as needed. Further review of care plan dated 1/7/21, revised on 9/13/23, indicated that Resident R2 is an elopement risk/wanderer. Intervention dated 1/7/21, included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Review of Resident R2's current care plan failed to indicate that her care and services was reviewed, updated, or revised to address alleged sexual abuse by another resident which occurred 2/18/25. Further review of Resident R1's clinical progress note dated 3/20/25, at 7:32 a.m., stated Resident R1 was found in his room on top of another female Resident R3. Orders received to send Resident R1 out to the hospital for further treatment and evaluation. Further review of Resident R1's clinical progress note dated 3/20/25, at 7:56 a.m., stated Resident R1 was found to have female Resident R3 in his room. She (R3) was caught in a sexual position under resident (R1). Review of Resident R3's clinical record indicated that she was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set, dated dated dated [DATE], indicated diagnoses of dementia, major depressive disorder, and adult failure to thrive. Further review of MDS Section C - Cognitive Patterns, C0100 Should Brief Interview for Mental Status be conducted was coded 1, indicating that yes interview should be conducted. Section C0500 was coded 99, indicating Resident R3 was unable to complete interview. Section C1000, Cognitive Skills for Daily Decision Making was coded 3, indicating that Resident R3's cognition is Severely impaired - never/rarely made decisions. Review of Resident R3's clinical progress note dated 3/20/25, at 6:04 a.m., stated resident (R3) was found across the hall in another resident's (R1) room. Resident (R3) was found by a Nurse Aide (NA) in a sexual position in resident's (R1) bed. She (R3) was encouraged to leave the room. Further review of Resident R3's clinical progress note dated 3/20/25, at 7:04 a.m., stated NA on duty immediately informed me Resident R3 was found in a room lying on B bed, the resident (R1) from B bed lying on top of her (R3). Resident R3 to be sent out to the hospital for further treatment and evaluation. Review of facility documentation submitted witness statement from NA Employee E3 dated 3/20/25, stated that Resident R3 was no longer in her bed when doing rounds, having just checked on her (R3) 15 minutes prior. Went to check in the male room (Resident R1's room) across the hall due to the fact that he had a situation in the past. Knocked on the door and witnessed the male resident (R1) on top of the female resident (R3). Resident R1 was told to get off of her (R3) and called for help. Resident R3 was taken to her room. Review of facility documentation initially submitted on 3/20/25, indicated that hospital records from Resident R3's encounter on 3/20/25, that patient was unable to tolerate any swab or internal exam of orifices, and this was subsequently deferred. Patient was seen by our discharge planning team to help with possible change in residency or going home, but for now family is comfortable the patient going back to the nursing care facility. The reported assailant is no longer at facility. Patient was overall at her usual state of health and was discharged from our facility. Review of Resident R3's care plan dated 3/1/25, revised 3/20/25, indicated that resident has a behavior problem attention seeks, flirtatious behavior, wanders in and out of other resident rooms regards to dementia, with goals for fewer episodes daily, and interventions to administer medications as ordered and monitor for side effects; anticipate and meet resident's needs; and caregivers to provide opportunity for positive interaction, attention: stop and talk with her as passing by. The Director of Nursing (DON), the Nursing Home Administrator (NHA), and the VP of Ops Employee E1 were made aware that an Immediate Jeopardy situation existed for residents on 4/2/25, at 10:03 a.m. and an immediate action plan was requested. On 4/2/25, at 10:03 a.m. the Immediate Jeopardy template was provided to the facility administration. On 4/2/25, at 6:08 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Resident R1: was discharged to the hospital and will not return to the center. Resident R2: was assessed by nursing for any adverse effects of the alleged event and found no harm. Resident R2's responsible party and physician were contacted. Resident sent to acute care hospital for in depth evaluation. Resident returned to facility with medication and found to be at baseline. Psych consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe. Resident R3: was assessed for any adverse effects of the alleged event and found no harm. Resident R3's responsible party and physician were contacted Resident sent to acute care hospital for in depth evaluation. Resident returned to facility with medication and found to be at baseline. Psychosocial assessments performed with negative findings. Psychological services were consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe. Root cause analysis identified that facility failed to provided adequate supervision to the alleged perpetrator. Actions taken to identify any residents with sexual behaviors: House education done by 4/3/25, by DON/Designee provided to all staff reviewing identifying type of abuse, anonymous reporting and reporting abuse. [NAME] law list check ran on all residents on 3/20/25, by DON/Designee. DON/Designee will audit all new admissions since 3/20/25, to ensure [NAME] law list checks were performed prior to admission. This will be completed by 4/3/2025. The DON/Designee was educated by the VP of Clinical Services on 4/2/25, on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk. The DON/Designee will perform sexual activity scale on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors by 4/3/25. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed. DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly times three months and as needed. Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated on 4/2/25. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting. Immediate Jeopardy was lifted on 4/3/25, at 3:04 p.m., and the abatement plan was verified as follows: Immediate actions verified. Resident interviews were reviewed, and it was verified that 159 of 159 residents were interviewed to determine whether they had knowledge of sexually inappropriate behaviors amongst residents, if they feel safe, and if they know how to report concerns. Root cause analysis identified that facility failed to provide adequate supervision to the alleged perpetrator. Facility identified 185 staff members from all departments. Staff interviews completed. 22 of 22 clinical staff members and 43 of 43 non-clinical staff interviewed in person and training was verified as completed and content understood. A total of 65 of 65 in-house staff present in facility were verified as trained. 100% of staff on-site have been verified as receiving abuse training. 129 staff members were verified as having received abuse training via in-person signatures. Two of five staff members answered telephonic communication and verified that training was received and understood via phone; three of five were left voicemails to return call. All staff unaccounted for at this time will receive and sign abuse education training prior to next scheduled shift. Review of [NAME]'s Law check completed on 3/20/25, was verified for 163 of 163 residents. Review of new admissions from 3/20/25, verified that ten of ten residents [NAME]'s Law checks were completed. Review of Clinical Education Services form verified that VP of Clinical Services completed education to the DON on the Sexual Activity Scale (SAS) tool and interventions for residents who are identified to be high risk on 4/2/25. Sexual Activity Scale tool was completed as of 4/3/25, for 152 of 152 residents. There were no new residents identified as high risk. Review of audit tool for future monitoring of Sexual Activity Scale tool completion confirmed. Revised Abuse policy was verified as updated of 4/3/25. The change made to the policy Residents have the right to engage in sexual activity. However, anytime there is a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse, including evaluating whether the resident has the capacity to consent to sexual activity. Next facility QAPI meeting scheduled on April 16, 2025. During an interview on 4/3/25, at 3:10 p.m., information was disseminated to the Nursing Home Administrator (NHA) and VP of Ops Employee E1 that the facility failed to protect Resident R3 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R1 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident R2 on February 18, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R1 was found naked on top of Resident R3, and because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in these residents' position would have experienced severe psychosocial harm- dehumanization, and humiliation- as a result of the sexual abuse. (Resident R2 and R3) 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies

Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 53 residents who were identified as high risk for elopement (Resident R1). Findings include: Review of facility policy Wandering and Elopements reviewed 1/15/23, indicated that if an employee observes a resident leaving the premises, he/she should: A) Attempt to prevent the resident from leaving in a courteous manner. B) Get help from other staff members in the immediate vicinity, if necessary; and C) Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. Review of the clinical face sheet indicated that Resident R1 was admitted on [DATE]. A review of the Minimum Data Set Assessment (MDS-periodic assessment of care needs) dated 10/27/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech, and behavior), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one ' s daily activities), and depression (a constant feeling of sadness and loss of interest, which stops one from doing normal activities). Review of Resident R1's medical record revealed a Nursing Admission Assessment completed on 6/19/23, which contained a section entitled Elopement Risk, which consisted of the following information: 1) Is the patient cognitively impaired with poor decision-making skills and or does the patient have a diagnosis of dementia, OBS (organic brain syndrome- disturbances in cognitive function), Alzheimer ' s, delusions, hallucinations, anxiety disorder, depression, manic depression, or schizophrenia? Yes 2) Does the patient ambulate independently, with or without the use of an assistive device? Yes 3) Does the patient have a history of elopement while at home or in another setting? Yes 4) If yes, include the number of episodes: 1. 5) Does the patient have a history of leaving facility without needed supervision? Yes 6) If yes, include number of episodes: 1. 7) Does the patient have a history of leaving facility without notifying staff? Yes 8) If yes, include number of episodes: 1. 9) Has the patient verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door? Yes 10) Does the patient exhibit any wandering behavior? Yes 11) If yes, is there a pattern to the wandering or a routine tied to the residents past? Yes 12) Has the family/responsible party voiced concerns that would indicate the patient may try to leave? Yes 13) Recommendations: Based on the above evaluation, determination is as follows: At risk for elopement (implement plan of care for unsafe wandering/exit seeking behavior) 14) If at risk for elopement, was a Wanderguard/alarming security bracelet placed on resident? No Review of medical records revealed that Resident R1 was placed on the secured unit (a locked unit that prevents at risk residents from leaving without staff 's presence) at admission on 6/19/23. Review of medical records further revealed that Resident R1 was moved off the secured unit on 7/12/23. Review of Resident R1's medical records revealed documentation from psychiatry on 9/15/23, that Resident R1 reiterated that he came here because he was homeless and was outside until he got hypothermia; that police then picked him up and sent him to a Personal Care Home (PCH), but then later was discharged here for further evaluations, and that Resident R1 showed some signs of delusional thinking (believes things that couldn't possibly be true). Review of Resident R1's medical record revealed an additional Elopement Assessment completed on 9/20/23. Instructions on Elopement Assessment state that resident at risk or high risk to update quarterly. The Elopement Assessment contained the following information: A) The resident is comatose, dependent on ADL (activities of daily living- activities related to personal care), and cannot move without assistance? No B) The resident: Can follow instructions. C) The resident: is ambulatory (able to walk around). D) The resident: can communicate. E) The resident: has history of wandering (past hospitalization or history from resident/family). F) The resident has: medical diagnosis of dementia/cognitive impairment. G) The resident: has wandered in the past month. Category: High Risk to Wander Review of Resident R1's Plan of Care, revised on 10/05/23, indicated that Resident R1 is an elopement risk related to history of elopement, and has a goal of not leaving the facility unattended. The plan of care contains an intervention that states when Resident R1 is exhibiting exit seeking behavior, redirect to an appropriate area and provide supervision. Review of facility documents revealed that on 11/18/23 at approximately 2:30 p.m., Nurse Aide (NA Employee E1) reported that Resident R1 was not in his room and did not eat his lunch. Resident R1 was last seen prior to lunch when NA Employee E1 told him that lunch was coming. The building was searched and 911 was called. Pittsburgh City Police were dispatched with a canine unit. Resident R1 was returned to the facility on [DATE], 10:50 p.m. Resident R1 stated that he was going to get his driver's license. During an interview on 11/20/23, at 1:30 p.m., the Director of Nursing (DON), confirmed that Resident R1 had been gone from the building for more than 32 hours without supervision. DON informed that resident had left the building, exact time unknown, and boarded a bus which took him to [NAME] County, and that bus fare was funded by six months of Resident R1's bingo winnings. DON confirmed that Resident R1 was found by the police who called the facility to request that someone arrive at the police station to retrieve Resident R1. DON retrieved Resident R1 from [NAME] City Police Station and returned him safely to the facility at which time he was evaluated and found not to be in any physical distress. DON also confirmed that resident was removed from the secured unit earlier this year as he had not displayed any wandering behaviors. During an interview on 11/20/23, at 2:05 p.m. Resident R1 confirmed that he boarded a bus with his bingo winnings and arrived in [NAME] County. He stated that he was trying to get [NAME], PA as he built a house two years ago there and that he also had family in that area. Resident R1 stated that he did not account for any changes in the bus schedule during the weekend, therefore his trip was cut short. When Resident R1 was asked if he had eaten during the time he was gone, he replied yeah, I ate at a chicken place, but not KFC. Maybe Chicken [NAME]. When Resident was asked if he had money for food and indicated that he did have a small amount. He stated he was trying to get to a bank for more money, but that it was closed. When Resident R1 was asked where he slept, he stated I didn't, I just walked around all night. When Resident R1 was asked if he was cold he stated, No. It was 32 degrees and I had on two shirts, a sweatshirt and boots and gloves. Resident R1 was able to verify that he was found by the police and taken to the police station where he was retrieved by facility staff. Resident R1 added, I didn't know it would be that big of a deal, regarding his elopement. During an interview on 11/20/23, at 2:50 p.m., Receptionist Employee E2 stated that there were books for each floor that were to contain photographs of residents that were a high elopement risk. These books are for Reception Desk Staff to utilize in identifying high elopement risk residents who may attempt to leave the facility unsupervised. When State Agency looked through all the books, no photograph of Resident R1 was located. Receptionist Employee E2 stated I can save you time with that. Those books haven't been updated since I've worked here. When asked how long Receptionist Employee E2 was employed at the facility she replied, about a year. Receptionist Employee E2 further explained that it was not her job to update these books and that she was told that it was the responsibility of the Activities Department. During an interview on 11/21/23, at 9:44 a.m., Resident R1's Power of Attorney (Resident R1 POA), stated that he had been assigned to Resident R1 as POA prior to his admission to the facility, as Resident R1 had a history of elopement from a Personal Care Home. Resident R1 POA stated that Resident R1 was homeless prior to his stay in the Personal Care Home. Resident R1 POA stated that he believed that Resident R1 would have gone to [NAME] County since he has a sister that lives in Houston, PA, and that he shared this information with law enforcement, who were able to locate him at approximately 8:30 p.m., the following day. During an interview on 11/21/23, at 10:11 a.m., Activities Director (AD) Employee E3 stated that she was familiar with Resident R1 as he would often attend activities including bingo and church, and that he would also attend outdoor supervised activities and never gave any indication that he would try to elope. AD Employee E3 stated that Resident R1 never needed redirected when he was outside. When AD Employee E3 was asked if her department was responsible for updating the book used at the front desk to identify resident who were at high risk for elopement, she replied that she was just made aware of it after he got out and had never updated the books. AD Employee E3 clarified that she has been in her current position for approximately one and a half years. On 11/21/23, at 12:05 p.m., the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for one of 53 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During an interview on 11/21/23, at 12:46 p.m. Licensed Practical Nurse (LPN) Employee E4 explained that if a resident has met the criteria to be at risk for wandering, that nursing must document how times the resident exhibited any wandering behaviors during the shift into the medical record. LPN Employee E4 also stated that although the facility used to have Wanderguards (an electronic device that notifies staff when a resident leaves a safe area), they no longer utilize these monitors. Review of Resident R1's medical record did not reveal any documentation of attempts to wander during October and November. During an interview on 11/21/23, at 1:32 p.m. Receptionist Employee E5, confirmed that he was on duty at the Front Desk at the time of Resident R1's elopement; however he stated, I didn't see him. Receptionist Employee E5 stated that he was unaware of who Resident R1 was and had never seen him before. He confirmed that there were no pictures posted of Resident R1 and was never made aware of high elopement risk residents. Receptionist Employee E5 clarified that There is a lot going on there, you don't just sit. There are fire drills sometimes and lots of people go out at once. If they knew he (Resident R1) was like that he should have a monitor. During an interview on 11/21/23, at 4:46 p.m., Missing Persons Detective (MPD) stated that she was assigned to the case involving Resident R1 and that she had spoken with Resident R1 POA, who had informed her that Resident R1 had eloped before to [NAME] County. MPD stated that she has worked on many cases where a patient elopes from a healthcare facility and that Once someone does it once, they do it again. MPD stated that the police contacted local news stations who ran the story on the local news for the public to help locate Resident R1. This method was successful as someone reported that Resident R1 had been at the Department of Motor Vehicles (DMV) in [NAME], PA, to renew his driver's license but did not have any money. [NAME] City police were dispatched and were able to locate Resident R1 at a grocery store on 11/19/23, which is less than two miles from the DMV, and approximately 35 miles from the facility from which he eloped. Resident R1 was transported to [NAME] City Police Department where he stayed until facility staff could retrieve him and return him safely to the facility at approximately 10:30 p.m. on 11/19/23. MPD also verified that Resident R1 has a sister that lives in Houston, PA, which is approximately eight miles from where Resident R1 was found, however that sister informed law enforcement that she has not seen Resident R1 in five years. On 11/21/23, at 6:35 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Possible elopement was identified on 11/18/23, at approximately 2:30 p.m., when Resident R1 was not located in his room and that did not eat his lunch. Code Green was called, and property was searched. 911 was called, as well as doctor and Resident R1 s responsible party. Staff conducted search of local streets. [NAME] City Police Department notified facility on 11/19/23, at approximately 8:50 p.m., that Resident R1 was in police custody and that facility staff should come to pick him up. Resident R1 returned to the facility on [DATE], at approximately 10:30 p. m. and was assessed for injuries and found to be in stable condition. New Elopement Assessment was conducted for Resident R1, who was then placed on secured unit. Residents: All other residents had new Elopement Assessment completed on 11/19/23. All Residents care plans and orders were reviewed and updated as needed. System Correction: Review of Elopement policy was done by DON and NHA on 11/18/23. In person staff education started 11/18/23, which included what to do in the event of an elopement and how to identify wondering behaviors, such as packing belongings, or expressing desire to go home. A mass recorded call went out to 100% of the staff for education, Remaining staff were called prior to start of their next shift and education reviewed by 11/22/23 at 1:00 p.m. Front entrance door was locked at 2:00 p.m. on 11/20/23, requiring all residents and visitors to be buzzed into and out of the facility. A binder was assembled with residents' photograph and consists of residents who are at risk for elopement, high risk for elopement, and residents who live on the secured unit. At risk residents are printed on yellow paper, high risk residents are printed on red paper and secure unit residents are printed on regular paper. Binder will be updated upon admission, quarterly, annually, and significant change. A policy update will be completed by 11/22/23. Monitoring: Audits of nurses' notes and behavior sheets will be performed by the DON or designee five days a week for four weeks to identify wondering behaviors and elopements. Audits will then be conducted three times per weeks for four weeks. Results will be reported to Quality Assurance and Process Improvement Team During a review of facility documents it was verified that the policy Wandering and Elopement was updated on 11/22/23. Review of facility documents on 11/22/23, revealed that the facility has 164 employees. 153 of these employees received formal education on the policy Wandering and Elopement, which included identification of exit-seeking behaviors, and interventions to reduce risks, and 11 employees received this education via telephone as they had not been working in the building. During employee interviews on 11/22/23, from 9:35 a.m. through 2:15 p.m. 24 employees confirmed they had received education on the new facility elopement policy and procedures, as stated above. 19 of these employees had received education in person and five employees had received education over the telephone and will be signing the training sheet once they are in the building. During a medical record review on 11/22/23, it was verified that all residents had received updated wandering assessments. During an interview on 11/22/23, at 12:49 p.m., NA Employee E1 confirmed that she was the nurse aide assigned to take care of Resident R1 on the day of his elopement. NA Employee E1 stated that the last time she recalls seeing Resident R1 was about noon on 11/18/23, as the lunch meals had just arrived on the floor, and she told Resident R1 that they would be eating soon. NA Employee E1 stated that she went past his room around 2:30 p.m. and realized that Resident R1 had not eaten his lunch and was not in his room, and this is what alerted her to Residents R1's absence. When NA Employee E1 was asked how she normally goes about monitoring location of her residents, she stated that normally she would be checking people more often if they rang their call bells to use the restroom, however Resident R1 is able to toilet himself and shower himself, and able to walk around the facility, so the main way she checks on residents who are more independent is to check in on them during mealtimes. The Immediate Jeopardy was lifted on 11/22/23, at 3:32 p.m. when the action plan implementation was verified. During an interview on 11/22/23, at 3:36 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for Resident R1 which resulted in an elopement from the facility. This failure created an immediate jeopardy situation for one of 53 residents who were identified as high risk for elopement. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility staff education documents, clinical records and facility specific documents, and staff interviews, it was determined that the facility failed to provide the needed level of care and failed to make certain that residents were free from harm for one of four residents (Resident R101) when the resident fell from the bed during care and sustained a fractured clavicle (collarbone). The facility provided education document American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated (MONTH) (YEAR), indicated that Section G: Functional Status, Question G0110 A indicates Bed Mobility is how the resident moves to and from lying position, turns side to side, and positions body while in bed. The RAI User ' s Manual further defines bathing as solely how the resident takes a full body bath, shower or sponge bath, including transfers in and out of the tub or shower. The facility's current Nursing Assistant Job Description indicated that the Nurse Aide (NA) must provide nursing care and services in accordance with the resident's assessment and care plan. The Admission Record indicated that Resident 101 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 8/9/19, Section G: Functional Status G0110 A indicated that Resident R101 requires two plus physical assist for bed mobility. The care plan dated 8/5/19, indicated that Resident R101 is totally dependent on two staff for repositioning and turning in bed related to limited mobility associated with left-sided [MEDICAL CONDITION] as a result of a previous [MEDICAL CONDITION] (stroke), and for contractures of bilateral hands and left wrist. A nurse's note dated 9/4/19, at 10:53 p.m. indicated that Resident R101 was lying face down on the floor on the right side of the bed. Nurse aide reports resident rolled out of bed during incontinence care. There was an area of blood under resident's head. The resident was immediately turned onto her back and a laceration over the right eye was revealed. Hospital paperwork dated 9/4/19, at 7:26 p.m. indicated a displaced impacted right medial clavicular fracture (a broken collarbone, where the bones are no longer in alignment, and where the one part of the bone is driven into the other). Hospital paperwork dated 9/4/19, at 7:26 p.m. indicated that Resident R101 has no purposeful movement of her extremities, and that she is complaining of head and neck pain. Hospital discharge paperwork dated 9/5/19, at 11:53 a.m. indicated that Resident R101 had discharge [DIAGNOSES REDACTED]. A review of the facility investigation or Resident R101's 9/4/19, fall from bed, indicated that while Resident R101's bed was in a high position, NA Employee E1 rolled the resident away from her. The nurse aide's investigation statement confirms that she was aware the resident required two people to roll and reposition the resident in bed but did not request assistance. During an interview on 10/8/19, at 1:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain that residents were free from neglect that resulted in actual harm for one resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/1/18, 9/18/18, 5/18/18, 5/16/18, 3/30/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/26/19, 11/1/18, 9/18/18, 5/16/18, 3/30/18, 9/19/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/1/18, 9/18/18, 5/18/18, 5/16/18, 3/30/18, 9/19/17. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 9/18/18, 3/30/18, 2/12/18, 9/19/17, 6/16/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 11/1/8, 9/18/18, 5/18/18, 3/30/18, 2/12/18, 9/19/17, 6/16/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 3/30/18, 1/22/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/1/18, 9/18/18, 3/30/18, 1/22/18, 6/16/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/1/18, 9/18/18, 5/16/18, 3/30/18, 3/12/18, 2/12/18, 1/22/18.

Based on a review of facility policies, manufacturer guidelines, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation practices while sanitizing equipment, tableware, and utensils, label and date food products, properly rotate food stock, properly wash equipment, and properly perform hand washing, in the Main Kitchen, which created the potential for cross-contamination and food borne illness and placed 84 of 94 residents in Immediate Jeopardy. Finding include: A review of the facility's policy Sanitary Conditions dated 1/30/19, indicated that the Dietary Department practice sanitary techniques to prevent food borne illness. The Manual and Machine(NAME)Washing Section: indicated that during manual ware washing procedures, equipment and utensils are immersed in a solution containing a quaternary compound with a concentration of 150-200 parts per million (ppm) and tableware and utensils are sanitized utilizing a dish machine. Sanitizing is done with a chlorine chemical solution with a concentration of at least 50 ppm. A review of the facility's document American Dish Service Conveyor Dishwashers Service Manual dated 10/02 indicated for chemical sanitizing: sanitizer required is 50 ppm available chlorine. A review of the facility's policy Sanitary Conditions dated 1/30/19, revealed the facility's Dietary Department practices sanitary techniques in storing, preparing, serving, and distributing food to prevent food borne illness. Sanitation is maintained through cleaning of all equipment and safe handling techniques. The policy indicates that the definition of sanitizing is the reduction of the number of micro-organisms such as bacteria to safe levels. The facility utilizes a First In First Out (FIFO) method for stock rotation. All food is labeled and dated with a use by date. Foods and beverages are checked daily for expiration dates. The facility does not permit hand sanitizer to be used as a substitute for proper handwashing. Gloves are changed, and hands washed for each new work assignment and whenever the gloves become contaminated. Employees may not contact ready to eat food products with their hands and will utilize suitable serving equipment. During an observation of the dish washing procedures in the Main Kitchen on 2/13/19, at 9:50 a.m. Food Service Aide Employee E3, tested the dish machine sanitizing chemical solution concentration level, which revealed a level of zero ppm. Food Service Aide Employee E3, continued completing dish washing procedures. During an observation of the sanitizing chemical solution concentration level for the dish machine on 2/13/19, at 9:54 a.m. Food Service Director Employee E2, obtained a chemical concentration level test indicating a concentration level of 10 ppm. During an observation of the three-compartment manual ware washing sink procedures in the Main Kitchen on 2/13/19, at 9:58 a.m. it was revealed that the drain pipes, from the rinse and sanitizing sinks, were joined together and were disconnected with the pipe draining into a bucket that contained pooling water and failing to provide an air gap between the drain pipe and the pooling water in the bucket. The disconnected elbow drain pipe from the rinse and sanitizing sinks was stored on the faucet handles of the rinse sink. The wash sink contained soapy water and the sanitizing sink contained water indicating that the facility was utilizing the three-compartment manual ware washing sink. A test of the sanitizing chemical solution concentration for the sanitizing sink conducted by Food Service Director Employee E2, revealed a concentration level of 100 ppm. During an interview on 2/13/19, at 10:10 a.m. the Food Service Director Employee E2, confirmed that the facility failed to maintain acceptable concentration levels for the sanitizing solutions used for the dish machine and sanitizing sink of the three compartment manual ware washing sink and that an air gap was not provided for the drain pipe for the drains for the rinse and sanitizing sinks, failing to prevent the potential back flow of pooling water contained in the bucket. He further confirmed the disconnected drain pipe stored on the faucet of the rinse sink failed to provide sanitary conditions in the rinse sink. He confirmed that the facility had no other means to sanitize equipment, tableware, and utensils. During an interview on 2/13/19, at 9:58 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to follow proper sanitation practices while sanitizing equipment, tableware, and utensils in the Main Kitchen, which created the potential for cross-contamination and food borne illness, and that the facility had no other means to properly sanitize equipment, tableware, and utensils, which placed the residents in immediate jeopardy. Immediate Jeopardy was called on 2/13/19, at 10:56 a.m. due to the facility's failure to follow proper sanitation practices while sanitizing equipment, tableware, and utensils resulting in improper sanitizing of equipment, tableware, and utensils utilized in the preparation and service of food products to the residents. The facility was notified of the Immediate Jeopardy on 2/13/19, at 10:56 a.m. and an immediate corrective action plan was received on 2/13/19. The plan included, after the issue was identified, water supply to the three compartment sink and dish machine was turned off, the power to the dish machine was turned off, an outside contract vendor was called to service the dish machine, resident meals were served utilizing disposable products, the drain pipes for the three compartment sink were repaired, upon repair of the dish machine and three compartment sink sanitizing solution chemical concentration levels were checked for compliance. Once in compliance all equipment, tableware, and utensils were re-washed by the dietary department. Dietary staff were re-trained in proper chemical concentration levels and proper dish washing and manual pot washing procedures, dietary staff not present at the time of the re-training were to be trained prior to the start of their shifts, testing of chemical concentration was to be conducted prior to the start of dish washing procedures (three times a day) and each time the sanitizing solution was changed, test results are recorded on sanitizing solution monitoring logs and monitored by the administrator to ensure compliance with regulatory guidelines. Continued monitoring of the facility conducted by the state agency revealed the following: On 2/14/19, at 6:56 a.m. observation of manual ware washing revealed the facility had the three-compartment manual ware washing sink set up and was using the sink to manually wash pots. In the sanitizing sink there were 3 pots. An observation of a test of the sanitizing chemical solution concentration for the pot sink conducted by Cook Employee E5, revealed a concentration level of zero ppm. During an interview Cook Employee E5, confirmed that the test he had conducted at the start of utilizing the pot sink indicated a chemical concentration of zero ppm. He further confirmed that he had not been re-trained at the beginning of his shift, as he was not on duty the previous day. During an interview on 2/14/19, at 6:58 a.m. Food Service Aide Employee E6, confirmed that he had not been retrained on the procedures to test and record sanitizing chemical solution concentration. On 2/15/19, at 9:14 a.m. during an observation of the dish room procedures it was revealed that Food Service Aide Employee E7, failed to test the sanitizing chemical solution concentration prior to the beginning of dish washing procedures. A review of the facility sanitizer log confirmed that Food Service Aide Employee E7, failed to record that a test was completed. During an interview Food Service Aide Employee E7, confirmed that she had not been trained on the procedures due to her being off duty the previous day and had not been trained prior to the start of her shift. On 2/15/19, at 1:00 p.m. the Registered Dietitian (RD) Employee E1, confirmed that the facility was not operating the dish machine due to the sanitizing solution failing to be at the required concentration level. On 2/16/19, at 8:27 a.m. during an observation of the test of the sanitizing chemical concentration for the pot sink conducted by Cook Employee E5, it was revealed that the concentration level was not able to be determined. On 2/17/19, at 12:22 p.m. during an observation of the test of the sanitizing solution concentration for the dish machine conducted by RD Employee E1, revealed that the concentration was at zero ppm. The facility failed to prepare and distribute food using proper sanitation and food handling practices when they failed to maintain the three-compartment manual ware washing sink and the dish machine in proper working condition in the Main Kitchen, which created the potential for cross-contamination and food borne illness and placed 84 of 94 residents in Immediate Jeopardy. During an observation of the Main Kitchen on 2/11/2019, at 9:02 a.m. stored in the walk-in refrigerator on the bread rack were the following items: -one package of hot dog buns dated 12/29/18, -two packages of hot dog buns dated 1/2/19, -two packages of hot dog buns dated 2/8/19, -one package of hot dog buns dated 2/9/19, -one loaf of raisin bread dated 2/8/19, -one loaf of cinnamon bread that was not dated. In the salad walk in refrigerator there were 3 metal pans that were not labeled with the contents of the pan. Stored on the clean pan rack was a metal pan that contained a buildup of grease and a pan that contained food residue. During an interview on 2/11/19, at 9:25 a.m. Registered Dietitian Employee E1, confirmed that the facility failed date food products honor expiration dates and properly clean equipment, which created the potential for cross contamination. During an observation of the tray line operations on 2/12/19, at 11:57 a.m. it was revealed that Food Service Aide/Relief Cook Employee E7, with gloved hands, retrieved china plates from a heated cabinet, touching the outside door, the plates, and then closing the door. Employee E7 then proceeded to touch the outside of a package of hot dog buns, retrieve a hot dog bun from the package, open the hot dog bun, place the bun on a plate, place ground sausage into the opened bun, and then place the plate on the thermal base, without performing hand washing and changing her gloves. It was also revealed that Food Service Director Employee E2, Cook Employee E5, and Food Service Aide Employee E6, failed to wear beard guards to properly restrain facial hair. During an interview on 2/12/19, at 12:13 p.m. Food Service Director Employee E2, confirmed that Food Service Aide/Relief Cook Employee E7, failed to perform handwashing and change her gloves when they became contaminated and Food Service Director Employee E2, Cook Employee E5 and Food Service Aide Employee E6, failed to properly restrain facial hair, which created the potential for cross contamination. During an observation of the dish room operations on 2/13/19, at 9:30 a.m. Food Service Aide Employee E3, was observed with gloved hands racking soiled dishes and equipment on the soiled side of the dish machine. She then removed the gloves and used hand sanitizer to sanitize her hands and proceeded to re-glove and unrack clean dishes and equipment on the clean side of the dish machine. At 9:43 a.m. she was observed with gloved hands racking soiled dishes and equipment on the dirty side of the dish machine, where she then, without changing her gloves or performing hand washing, proceeded to unrack clean dishes and equipment on the clean side of the dish machine. During an interview on 2/13/19, at 9:54 a.m. the Food Service Director Employee E2, confirmed that dietary staff are not permitted to use hand sanitizer to clean their hands and that Food Service Aide Employee E3, failed to perform proper handwashing and change her gloves which created the potential for cross contamination. 42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary. Previously cited 5/16/18, 3/30/18. 28 Pa. Code 211.6(c)(d) Dietary services. Previously cited 5/16/18, 3/30/18, 6/16/17. 28 Pa. Code 211.6(f) Dietary services. Previously cited 5/16/18, 3/30/18.

Based on review of job descriptions, facility policies, manufacturer guidelines, observations, and staff interviews it was determined that the Nursing Home Administrator (NHA) failed to effectively manage the facility to make certain that the residents were protected from improperly sanitized equipment, tableware, and utensils, which placed 84 of 94 residents in an Immediate Jeopardy situation. Findings include: The job description for the NHA specified the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state, and local standards, guidelines and regulations that govern long term care facilities. During observations in the Main Kitchen it was determined that the facility failed to properly maintain essential equipment and sanitize equipment, tableware, and utensils, which resulted in the potential for cross-contamination. On 2/13/19, at 9:50 a.m. the concentration level for the sanitizing chemical solution for the dish machine tested at zero parts per million (ppm) which was below the required level, On 2/13/19, at 9:58 a.m. the drain pipes for the three-compartment manual ware washing sink were disconnected and flowing into a bucket of pooling water, and the concentration level for the sanitizing chemical tested at 100 ppm which was below the required level, On 2/13/19, at 9:58 a.m. the NHA confirmed that the facility had no other means to sanitize equipment, tableware, and utensils, which placed the residents in an Immediate Jeopardy situation. On 2/14/19, at 6:56 a.m. the concentration level for the sanitizing chemical for the three-compartment manual ware washing sink tested at zero ppm which was below the required level, On 2/15/19, at 9:14 a.m. Food Service Aide Employee E7 failed to test the chemical concentration for the sanitizing chemical for the dish machine as required. On 2/16/19, at 8:27 a.m. the test of the chemical concentration level for the sanitizing chemical for the three-compartment manual ware washing sink was undeterminable. On 2/17/19, at 12:22 p.m. the test of the chemical concentration level of the sanitizing chemical for the dish machine was at zero ppm which was below the required level. The facility failed to maintain the three-compartment manual ware washing sink and the dish machine sanitizing chemical at required concentration levels and failed to re-train staff as outline the the immediate corrective action plan for the Immediate Jeopardy situation Based on the findings in this report that identified that the facility failed to properly maintain essential equipment and sanitize equipment, tableware, and utensils, which resulted in the potential for cross-contamination and the NHA failed to fulfill his essential job duties to ensure that the federal and state guidelines and regulations were followed, thereby, placing 84 of 94 residents in an Immediate Jeopardy situation. Refer to F802, F812, F865, F867 and F908. 42 CFR 483.70 Administration. Previously cited 9/18/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 11/1/18, 9/18/18, 5/18/18, 5/16/18, 3/30/18, 6/16/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/26/19, 11/1/18, 9/18/18, 5/16/18, 3/30/18, 9/19/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/18/18, 5/16/18, 3/30/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/1/18, 9/18/18, 5/18/18, 5/16/18, 3/30/18, 9/19/17.

Based on review of facility policy, facility documents and staff interview, it was determined that the facility failed to make certain that residents were protected from unsafe water temperatures that resulted in actual harm [MEDICAL CONDITION] the skin that required hospitalization and skin grafting for one of 83 residents (Resident R1) and placed all facility residents in an immediate jeopardy situation. Findings include: Review of the facility disaster manual and nursing policy and procedure manuals, last reviewed 7/19/17, did not include a Legionella prevention and control program policy for monitoring water temperatures. During an interview on 9/6/18, at 10:40 a.m. the Nursing Home Administrator (NHA) and Maintenance Director Employee E1 confirmed that there was no Legionella policy in any of the facility manuals and that the facility failed to establish a written Legionella prevention and control program as required. Review of facilty documentation indicated that on 8/26/18, at 9:00 p.m. the facility Maintenance Director Employee E1, Maintenance Assistants Employees E2, E3 and E4, and a representative of a contracted plumbing service increased the temperature of the boiler, which provides hot water to the facility's resident care areas, in order to flush the water lines of Legionella Bacteria that had been detected during an earlier test on (MONTH) 31, (YEAR). Documentation from the plumbing service invoice indicated that the water temperature was 148 degrees Farenheit. Maintenance Director Employee E1 indicated that this task was completed on 8/27/18, at approximately 1:00 a.m. During interviews on 9/6/18, from 10:40 a.m. until 12:15 p.m. with Maintenance Director Employee E1 and Maintenance Assistant Employees, E2, E3 and E4, indicated that no periodic water temperatures were obtained after the water lines were flushed on 8/27/18, at 1:00 a.m. until the morning of 8/29/18, at 6:00 a.m. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 7/24/18, indicated that Resident R1 was in a persistent vegetative state with no discernible consciousness and the admission [DIAGNOSES REDACTED]. Review of an incident report, submitted by the facility, indicated that on 8/28/18, (no time was specified) Resident R1, who is a ventilator dependent resident and is not alert and oriented, presented with skin irritation, blistering and the skin was peeling from both lower extremities, ranging from the upper inner thigh continuing down both legs to the mid/lower calf area. Review of witness statements completed by Nurse Aide (NA) Employee E7, indicated that on 8/28/18, at approximately 9:00 a.m. while showering Resident R1, blisters were noted between her legs which started to peel. The statement indicated that, The water went from warm to real hot with steam so I stopped, got the nurse . During a telephone interview on 9/6/18, at 1:00 p.m. NA Employee E7 indicated that she had laid the hand held shower head on Resident R1's legs and turned to obtain soap. NA Employee E7 indicated that the shower head suddenly changed position and sprayed her in the arm with extremely hot water and that the water was steaming. NA Employee E7 indicated that she shut the water off and called for a nurse. Review of the clinical record indicated that Resident R1 was seen by the wound care Certified Registered Nurse Practitioner (CRNP) Employee E8 on 8/28/18, at 9:55 a.m. The documentation indicated that Resident R1 had large open extensive blistering to bilateral post (posterior) calf and inner/post thighs. red moist draining serous (bloody) drainage. left hip with few serous filled blisters. An antibiotic ointment and dressings were initiated and an indwelling urinary catheter was inserted to divert urine from the area. Review of the clinical record indicated that Resident R1 was transferred to the hospital Emergency Department on 8/28/18, at 11:34 p.m. per the mother's request. Review of the hospital Emergency Department documentation dated 8/29/18, at 1:11 a.m. indicated that Resident R1 had [MEDICAL CONDITION] blistering, sloughing (peeling) of skin over both posterior (back) thighs, medial (inner) thighs extending to the lower leg, perineum and lower buttocks. The resident was admitted to the trauma burn Intensive Care Unit. Review of the hospital documentation indicated that on 8/31/18, Resident R1 underwent excision and cadaveric grafting (removal of dead tissue and covered with tissue of a dead individual to repair a defect in a living person) to the 14% total body surface [MEDICAL CONDITION] the lower extremities. During an interview on 9/5/18, at 4:40 p.m. the NHA indicated that the results of the facility investigation concluded that Resident R1 was burned from the hot water in the shower. During an interview on 9/6/18, at 4:00 p.m. the NHA indicated that on 8/28/18, she was not notified of the elevated hot water temperatures until approximately 12:00 p.m. and indicated that the temperature at that time was 147 degrees Farenheit. The NHA confirmed that the facility Maintenance Director Employee E1, failed to lower the temperature of the hot water boiler to a safe level and failed to monitor water temperatures from 8/27/18 until 8/29/18, which resulted [MEDICAL CONDITION] Resident R1 and placed all facility residents in an immediate jeopardy situation. Immediate Jeopardy was called on 9/10/18, due to the facility failure to check hot water temperatures after raising the boiler temperature resulting in a resident being burned, requiring hospitalization and skin grafting. The facilty was notified of the Immediate Jeopardy on 9/10/18, at 10:30 a.m. and an immediate corrective action plan was received on 9/12/18. The plan included: after the issue was identified, the boiler was immediately turned down and the system was drained of hot water by running all sinks; shower rooms were placed out of service during this process; water temperature policy was updated to include maintenance checking water temperatures at least three times a day at random times, at least three rooms per floor and shower rooms; staff were educated on the water temperature policy; shower temperature logs were placed in shower rooms with a thermometer for the staff to temp the water prior to showering residents; a safety shut of valve was placed on the boiler to prevent the temperature from rising above regulatory guidelines; water temperature logs are monitored by the administrator to ensure compliance with regulatory guidelines. The Immediate Jeopardy was lifted on 9/12/18, when the action plan implementation was verified. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 5/18/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/18/18, 5/16/18, 3/30/18, 9/19/17, 6/16/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/16/18, 3/30/18, 9/19/17, 6/16/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/16/18, 3/30/18. 28 Pa. Code 201.18(e)(1)Management. Previously cited 5/18/18, 5/16/18, 3/30/18, 9/19/17, 6/16/17. 28 Pa. Code 205.37(e) Equipment for bathrooms. 28 Pa.Code 205.63(c) Plumbing and piping systems required for existing and new construction. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 5/16/18, 3/30/18, 2/12/18, 1/16/18, 6/16/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 5/18/18, 3/30/18, 2/12/18, 9/19/17, 6/16/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/16/18, 3/30/18, 3/12/18, 2/12/18, 9/19/17, 6/16/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/30/18, 1/22/18, 6/16/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/16/18, 3/30/18, 3/12/18, 2/12/18, 1/22/18, 9/19/17, 6/16/17.

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to complete physician ordered neurological assessments for changes in condition resulting in the death of Resident R1 due to subdural and subarachnoid hemmorhages and/or potential of physical harm for three of six residents (Resident R1, R6 and R8) resulting in Immediate Jeopardy of serious physical harm for other residents. Findings include: The facility policy dated 7/21/16, entitled Neurological Assessment indicated that the charge nurse and/or supervisor will perform a neurological assessment (a test for brain and nerve function) when a resident has an unwitnessed fall, a fall with a head injury, a [MEDICAL CONDITION] or a change in level of consciousness. The Neurological Assessment policy also indicated that the neurological assessment should be completed every shift for 72 hours and documented on a Neurological Assessment form. The facility policy entitled Abuse dated 7/21/16, indicated that neglect refers to failure through inattentiveness, carelessness or omission to provide timely, consistent, safe, adequate and appropriate service, treatments or care. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing progress note dated 10/10/16, at 5:00 p.m. indicated that Resident R1 had walked into the hall, lost his balance and fell to the floor. Nursing progress note dated 10/10/16, also indicated that Registered Nurse (RN), Employee E1, called Resident R1's family member (RF1) regarding the fall on 10/10/16, and Resident RF1 stated that he/she was concerned because Resident R1 would not talk on the phone, but just mumbled. Review of the Medication Administration Records for the month of October 2016, indicated that Resident R1 had not received medications on 10/11/16, at 9:00 a.m. because he/she was, unresponsive, unable to swallow. Review of RN, Employee E3's, nursing progress note dated 10/13/16, indicated as a, late entry from 10/11/16 stated that he/she was notified by Licensed Practical Nurse (LPN), Employee E2, to, check Resident R1 as there was a change in condition. The 10/13/16 nursing progress note did not include Resident R1's complete neurological assessment and/or vital signs. Review of the facility incident reports indicated that Resident R1 had fallen on 10/7/16 at 5:15 a.m., on 10/9/16 at 6:30 a.m., and on 10/9/16, at 7:45 p.m., however, no incident report was completed for the fall on 10/10/16, at 5:00 p.m. Review of a physician's orders [REDACTED]. Review of the, Vital Sign Flow Sheet, indicated that Resident R1's vital signs were taken on 10/6/16, but did not include any other vital signs after that date. During an interview on 11/21/16, at 2:00 p.m. the RN Staff Development Coordinator, Employee E4, confirmed that the clinical record did not include the vital signs taken after admission on 10/6/16, and did not include neurological assessments that were to have been done for 72 hours after the falls on 10/7/16 at 5:15 a.m., on 10/9/16 at 6:30 a.m., on 10/9/16 at 7:45 p.m., and on 10/10/16 at 5:00 p.m. During an interview on 11/22/16, at 9:50 a.m. the Director of Nursing (DON) confirmed that the staff failed to perform vital signs and neurological assessments after Resident R1's falls on 10/7/16, 10/09/16 and 10/10/16, and change of condition on 10/11/16. The DON also confirmed that the RN Supervisor failed to complete an incident report for Resident R1's fall on 10/10/16, at 5:00 p.m. Review of the hospital emergency room physician records dated 10/11/16, indicated that Resident R1 was sent to the emergency room from the hospital [MEDICAL TREATMENT] unit with an altered mental status, inability to speak and twitching movements. A Computerized Tomography scan (CT - an enhanced X-ray) of the head was done which showed a bilateral subdural hemorrhage and subarachnoid hemorrhage (bleeding into the spaces between the skull, the brain covering membranes and the brain which can be life threatening). Resident R1 was admitted on to Hospice care (end of life care) with a [DIAGNOSES REDACTED]. On 11/23/16, at 11:10 a.m. the state survey team notified the Nursing Home Administrator and the Director of Nursing of an identified Immediate Jeopardy for failing to complete physician ordered neurological assessments for changes in condition resulting in the death of Resident R1 due to subdural and subarachnoid hemmorhages An action plan was requested on 11/23/16, at 11:30 a.m. to immediately implement measures to ensure post-fall assessments were completed. The facility submitted a corrective action plan on 11/23/16, which included performance of fall assessments and updating the care plans for all of the residents in the facility. In addition, a procedure was implemented to have the Registered Nurse Supervisor notified of all falls and will complete assessment for injury and incident reports, notifications to physician and family, make certain ongoing assessment for a change in condition including neurological assessment and vital signs are completed and documented. Education on newly developed neurological assessment procedures as well as completing required documentation was initiated to include all licensed nursing staff. Audits of all falls will be ongoing by administration. The facility implemented an acceptable corrective action plan and the Immediate Jeopardy was removed on 11/28/16, at 4:00 p.m. Review of the clinical record indicated that Resident R6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing progress note dated 10/13/16, at 1:50 p.m. indicated that Resident R6 was found on the floor with a bump noted on their head and was subsequently transferred to the emergency room by order of the physician. Review of the nursing progress note dated 10/13/16, at 3:41 p.m. indicated that Resident R6 was returned from the hospital with one staple to close a laceration on the top right side of the head. Review of a physician's orders [REDACTED]. Review of the, Vital Sign Flow Sheet, indicated that Resident R6's vital signs were taken on 10/18/16, but did not include any other vital signs after that date. During an interview on 11/21/16, at 2:00 p.m. the RN Staff Development Coordinator, Employee E4, confirmed that the clinical record did not include any vital signs taken other than on 10/18/16, and did not include neurological assessments to be done for 72 hours after the falls on 10/13/16. During an interview on 11/22/16, at 9:50 a.m. the Director of Nursing confirmed that the staff failed to complete an incident report for Resident R6's fall on 10/13/16, and to document vital signs in the clinical record for 72 hours after the 10/13/16 fall. Review of the clinical record indicated that Resident R8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nursing progress note dated 11/9/16, at 11:50 a.m., indicated that Resident R8 had noted [MEDICAL CONDITION] activity while being transported back from therapy. Review of a physician's orders [REDACTED]. During an interview on 11/21/16, at 2:00 p.m., the RN Staff Development Coordinator, Employee E4, confirmed that the clinical record did not include the neurological assessments that should have been done for 72 hours after the [MEDICAL CONDITION] activity on 11/9/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/3/16, 7/30/16, 5/25/16, 2/29/16, 9/18/15. 28 Pa. Code 201.14(c) Responsibility of licensee. Previously cited 10/3/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/3/16, 7/30/16, 2/29/16, 9/18/15. 28 Pa. Code 201.29(a) Resident rights. Previously cited 7/30/16. 28 Pa. Code 201.29(c) Resident rights. Previously cited 10/3/16. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 7/30/16, 12/14/15, 9/18/15. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/30/16, 4/19/16, 12/14/15, 9/18/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/3/16, 7/30/16, 5/25/16, 4/19/16, 2/29/16, 12/14/15, 9/18/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/30/16, 2/29/16, 9/18/15.

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to notify the physician of a change in condition resulting in harm for one of 11 residents reviewed (Resident R1). Findings include: The facility policy entitled, Change of Condition, dated 7/21/16, indicated that staff must notify the physician of any change in condition including an accident or incident such as a fall, a significant change in the resident's physical, mental or emotional status, such as a decline in mental status. The policy dated 7/21/16, also indicated that the nursing supervisor or charge nurse assess the resident and that the supervisor was to notify the resident's attending physician. The facility policy entitled, Notification of a Resident's Change of Condition, dated 7/21/16, indicated that the charge nurse was responsible for notifying the resident's physician and responsible family members when there is any change in a resident's condition. The facility policy dated 7/21/16, entitled Neurological Assessment indicated that the charge nurse and/or supervisor will perform a neurological assessment (a test for brain and nerve function) when a resident has an unwitnessed fall, a fall with a head injury, a [MEDICAL CONDITION] or a change in level of consciousness. The Neurological Assessment policy also indicated that the neurological assessment should be completed every shift for 72 hours and documented on a Neurological Assessment form. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital emergency room physician's records dated 10/11/16, indicated that Resident R1 was sent to the emergency room from the hospital [MEDICAL TREATMENT] unit with an altered mental status, inability to speak and twitching movements. A Computerized Tomography scan (CT - an enhanced X-ray) of the head was performed, which showed a bilateral subdural hemorrhage and a subarachnoid hemorrhage (bleeding into the spaces between the skull, the brain covering membranes and the brain, which can be life threatening). Resident R1 was admitted to Hospice care (end of life care) on 10/12/16, with a [DIAGNOSES REDACTED]. Review of the nursing progress note dated 10/10/16, at 5:00 p.m. indicated that Resident R1 had walked into the hall, lost his balance and fell to the floor. The nursing progress note dated 10/10/16, at 5:00 p.m. indicated that Registered Nurse (RN), Employee E1, called Resident R1's family member (RF1) who stated that he/she was concerned because Resident R1 would not talk on the phone, but just mumbled. Review of the Medication Administration Records for the month of October 2016, indicated that Resident R1 had not received medications on 10/11/16, at 9:00 a.m. because he/she was unresponsive, unable to swallow. Review of RN, Employee E3's, nursing progress note dated 10/13/16, indicated, late entry from 10/11/16, and stated that he/she was notified by Licensed Practical Nurse (LPN), Employee E2, to check Resident R1 as there was a change in condition. The 10/13/16 nursing progress note did not include Resident R1's neurological assessment, vital signs or any indication of a notification to the physician of a change in condition. During an interview on 11/22/16, at 9:50 a.m. the Director of Nursing confirmed that the clinical record did not indicate that Employee E3 notified the physician of Resident R1's change of condition on 10/11/16. During an interview on 11/22/16, at 11:10 a.m. Resident R1's physician stated that he/she was not notified of the change in condition on 10/11/16, and would have ordered the resident to be seen in the emergency room because of the decrease in consciousness occurring after the history of recent falls and the increased risk of bleeding due to the anticoagulant therapy. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/3/16, 7/30/16, 5/25/16, 2/29/16, 9/18/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/3/16, 7/30/16, 2/29/16, 9/18/15. 28 Pa. Code 201.29(a) Resident rights. Previously cited 7/30/16. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 7/30/16, 4/19/16, 12/14/15, 9/18/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 10/3/16, 7/30/16, 5/25/16, 4/19/16, 2/29/16, 12/14/15, 9/18/15.

Based review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide medications to two of 22 residents reviewed resulting in actual harm to the residents (Resident R12 and R27.) Findings include: Review of the facility's policy, Medication Administration, updated 7/22/16, indicated that medication administration will always be accomplished by licensed nursing staff. Medications administered via patch ([MEDICATION NAME]) require rotation of the site, if a medication error occurs, the attending physician is notified, an incident report and medication error report is completed by the nurse who makes or discovers the error. A review of Resident R12's clinical record indicated that Resident R12 was admitted to the facility on [DATE], and the current [DIAGNOSES REDACTED].) A review of Resident R12's physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident R12's nurses' notes dated 7/14/16, at 8:00 p.m. indicated that the duotube was obstructed. A review of Resident R12's physician's orders [REDACTED]. An additional physician note also indicated the [MEDICATION NAME] is a sustained release tablet and is not be given via the tube. A review of Resident R12's nurses' notes dated 7/15/16, at 6:00 p.m. indicated that the resident's duotube was obstructed and had been replaced, and all medications ordered through the duotube remained on hold until placement of the duotube was verified by an X-ray. A review of Resident R12's nurses' notes dated 7/16/16, at 5:00 p.m. indicated that the resident returned from [MEDICAL TREATMENT] stating, I am in pain, please help. Further review indicated that at this time no pain medications were ordered. The Registered Nurse Supervisor was aware of this two day situation, and they had been in contact with the physician and that there was no word back or medications ordered. Resident R12 continues to yell out that the pain was, severe without relief noted. A review of Resident R12's nurses' notes dated 7/15/16, at 6:30 p.m. indicated that the duotube placement had been verified by X-ray and was ready to use. A review of Resident R12's nurses' notes dated 7/16/16, at 2:30 a.m. indicated that the resident was yelling outward and crying in pain. The note revealed that the previous narcotics were destroyed and that Resident R12 was anxious and screaming with 10 plus pain level (pain is evaulated on a scale of 1 to 10 with 10 being the highest level.) During interview on 7/28/16, at 11:45 a.m. the Director of Nursing confirmed that Resident R12's duotube had not been functioning for 22 hours, that the facility left Resident R12 in severe pain without relief, causing actual harm to the resident, as a result of the medication error of omision. A review of the [DIAGNOSES REDACTED]. The resident's current [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A Review of the Medication Administration Record [REDACTED] During an observation on 6/26/16, at 5:30 p.m. Resident R27 was observed standing in the hallway asking Licensed Practical Nurse, Employee E20, for her pain medication. During an interview on 6/26/16, at 5:45 p.m. Employee E20 confirmed that Resident R27 missed their last three ordered doses of [MEDICATION NAME]. An interview on 6/26/16, at 6:00 p.m. with the Nursing Home Administrator confirmed that the facility failed to administer Resident R27's last three doses of [MEDICATION NAME] as ordered, a significant medication error. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/25/16, 2/29/16, 9/18/15, 7/27/15, 3/18/15, 12/18/14. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/29/16, 9/18/15, 3/18/15, 12/18/14. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/25/16, 4/19/16, 2/29/16, 12/14/15, 9/18/15, 7/27/15, 12/18/14. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/29/16, 9/18/15, 7/27/15, 12/18/14.