Every finding on record at Chapel Manor

Based on observations, facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one of one meal tray tested on the first floor nursing unit. Findings include: Review of facility policy Food: Preparation, revised 2026, revealed all foods will be held at appropriate temperatures, greater than 135 Fahrenheit (F) (or as state regulation requires) for hot holding, and less than 41 F for cold food holding. Interview with Resident R154 on June 23, 2026, at 11:00 a.m. revealed food always served cold. Interview with Resident R113 on June 23, 2026 at 11:05 a.m. revealed food is cold, they took away the microwave so we have no choice but to eat it cold now. Interview with Resident R83 on June 23, 2025 at 11:10 a.m. revealed food is terrible, it is always cold. Interview with Resident R14 on June 23, 2025 at 11:15 a.m. revealed food could be better, sometimes it is cold. Interview with Resident R137 on June 24, 2026 at 12:05 p.m. revealed food tends to be served on the colder side a lot. Observation of test tray on June 24, 2026, at 12:10 p.m. with Food Service Director, Employee E11, revealed the following food temperatures: Tomato Stew- 122 F Ham- 105 F Macaroni and Cheese- 100 F Apple Juice- 48 F Follow-up interview with Food Service Director, Employee E11, at 12:12 p.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on observations, and interviews with residents, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for the main lobby and two out of four nursing units (B and D wing).Findings Include: Observations on June 23, 2026, during a tour on the first-floor nursing unit (B-Wing) revealed the following: -room [ROOM NUMBER]B: Over-bed light inoperable for approximately two months, per an interview with Resident R1. -room [ROOM NUMBER]A: Wallpaper peeling behind the head of the bed; bathroom toilet soiled with feces; ceiling tile displaced exposing pipes; ceiling vent heavily soiled with crusted debris; stained ceiling tiles; night light missing protective cover exposing the light bulb. -room [ROOM NUMBER]: Bathroom ceiling tiles stained. -room [ROOM NUMBER]: Floor mat visibly dirty with a large slit in the center. -Wing B Hallway Bathroom: Brown-stained ceiling tiles observed. Continued observations on June 24, 2026, on B-Wing nursing unit revealed: -room [ROOM NUMBER]: Bathroom ceiling tiles stained with an approximately silver-dollar-sized blackened area. Missing floor tile to the left of sink, and area behind faucets the rear apron of the sink was buckled, and faucets corroded. -room [ROOM NUMBER]: Curtain rod and curtains falling off window. Observation of 1st floor main lobby on June 23, 2026, at 9:00 a.m. revealed strong odor of urine throughout. Observation of Unit D on June 23, 2026, at 10:34 a.m. revealed strong odor of urine throughout hallway. Observation of 1st floor main lobby on June 24, 2026, at 9:00 a.m. revealed strong odor of urine throughout. Observation of Unit D on June 24, 2026, at 10:15 a.m. revealed strong odor of urine throughout hallway. Observation of 1st floor main lobby on June 25, 2026, at 9:00 a.m. revealed strong odor of urine throughout. Observation of Unit D on June 25, 2026, at 12:25 a.m. revealed strong odor of urine throughout hallway. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical record, and staff interviews it was determined that the facility failed to develop a comprehensive care plan for one of 34 residents reviewed (Residents R17).Findings include:Review of the facility policy, Person-Centered Care Plan, last revised in September 15, 2025, revealed: The Center must develop and implement a person-centered care plan for each patient/resident (hereinafter patient) consistent with patient rights measurable objectives and timeframes to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality.Review of the facility policy, Restorative Nursing revised August 7, 2023, revealed practice standards include Develop restorative nursing programs appropriate to the patient's identified needs. Develop specific measurable goals and document goals and interventions on the patient's restorative care plan. Implement the restorative nursing program according to the specifics on the care plan.Review of Resident R17's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of left hip pain, muscle wasting.Review of Resident R17's Physical Therapy Discharge summary, dated [DATE], indicated discharge recommendations and status includes Restorative nursing program including LE/UE (Lower extremity and Upper Extremity) exercise and bed mobility with extensive assistance.Review of Resident R17's comprehensive care plan, no documented evidence of implementation of care plan for restorative nursing program.Interview on June 25, 2026, at 12:00 p.m. with Director of Nursing, Employee E2, confirmed no care plan developed for Resident R17 restorative nursing program.28 Pa Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain an environment that was free of accidents and hazards for one of six residents and one of four nursing units reviewed (Resident R163, D Wing). Findings include:Clinical record review revealed Resident R163 was admitted to the facility March 23, 2021 with a diagnosis of hemiplegia and hemiparesis (paralysis/weakness of one side of the body), heart failure (heart muscle does not pump as well as it should), and protein calorie malnutrition (the state of inadequate intake of food). Review of Resident R163's care plan, revised August 05, 2025, revealed the resident is at risk for falls related to impaired mobility, impulsive behavior, and poor safety awareness. Interventions included bilateral floor mat to be implemented for safety. Observation on June 23, 2026, at 10:43 a.m., revealed Resident R163 was lying in bed and did not have left side floor mat next to the bed. Follow-up observation on June 24, 2026 at 9:25 a.m. revealed Resident R163 was lying in bed and did not have left side floor mat next to the bed. Interview on June 24, 2026 at 9:27 a.m. with Nurse Aide, Employee E12, confirmed Resident R163 did not have a left side floor mat next to the resident's bed. Review of facility's emergency management plan revealed This center monitors potential fire risk. Any unsafe condition is reported to a supervisor immediately so corrective measures can be taken promptly. Upon discovering fire or smoke, center staff: i. Remove residents from immediate danger according to evacuation guidelines; ii. make announcement; iii. implement R.A.C.E (rescue, alarm, confine, extinguish/evacuate). Observation of resident room, D216, on June 23, 2026, at 11:15 a.m. revealed room cluttered with resident belongings, piles of clothing stacked in front of PTAC unit (heating and air conditioning unit designed for installation through an exterior wall), and a trash can in close proximity. Continued observation of resident room D216 on June 23, 2026, at 11:20 a.m. revealed odor of burning rubber. Upon further investigation, it was observed that the PTAC unit was smoking. Review of facility investigation revealed At approximately 11:15 AM on 6/23/2026 a burning odor was detected coming from resident room D216A. Staff responded immediately, the fire alarm was activated, and code red was initiated per facility protocol. The odor was identified coming from the air conditioning unit. The unit was immediately unplugged, and residents were promptly and safely removed from the room by staff. No flames were noted and no resident was injured. Following emergency protocols, all residents in the surrounding area were evacuated from their rooms and sheltered in a designated safe area. A head count was conducted, and all residents were accounted for. Interview on June 24, 2026, at 11:45 a.m. with Maintenance Director, Employee E13, revealed the smoke was being produced by a piece of trash bag that had been sucked up into the intake. This was discovered upon removal of the encasement and inspection of the air conditioning unit. Out of abundance of caution, the entire unit was changed out. Employee E13 demonstrated that the bag from the trash can likely was sucked up through the intake because it was left too close to the PTAC unit. Follow up observations during a tour of the facility on June 25, 2026, at 11:30 a.m. revealed the following rooms with trash can left next to the PTAC unit; Room D212, D209, D205, D204 and D215. Findings confirmed on June 25, 2026, at 11:30a.m. with Employee E14, Unit Manager. Interview with Employee E1, Nursing Home Administrator on June 25, 2026, at 2:00 p.m. confirmed plastic was found in the PTAC unit which caused incident on June 23, 2026, in room D216A. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records and staff interview it was determined that the facility failed to timely assess nutrition status to maintain acceptable parameters of nutritional status for one of eight residents reviewed (R94). Findings Include:Review of Resident R94's Minimum Data Set (MDS -federally mandated resident assessment and care screening) dated May 11, 2026, revealed the resident was admitted to the facility in July 2025 and has diagnoses of hypernatremia (elevated sodium level in the blood), hyperlipidemia (elevated levels of cholesterol and or triglycerides in the blood), dementia (a progressive disorder affecting memory, thinking and the ability to perform daily activities), and malnutrition (inadequate nutritional status resulting from insufficient intake or utilization of nutrients).Further review of Resident R94's MDS dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment, and is dependent on staff for all activities of daily living (ADLs). The MDS documented that the resident weighed 90 pounds and measured 61 inches in height.Review of resident R94's comprehensive care plan dated July 10, 2025, revealed the resident is at nutritional risk related to the need for a mechanically altered diet, the need for significant assistance with most meals, and a diagnosis of dementia.Review of Resident R94's clinical record revealed the following documented weight history:March 3, 2026 - 104.0 pounds (lbs.)April 2, 2026 - 90.2 lbs.May 2,2026 - 88.4 lbs.May 4,2026 - 91.6 lbs.June 1, 2026 - 88.2 lbs.Review of Resident R94's weight history revealed the resident sustained a significant 13.8-pound weight loss over one month (March 3rd to April 2, 2026).Continued review of Resident R94's clinical record revealed the weight loss was not addressed until April 30, 2026.Review of Resident R94's nutrition assessment dated [DATE], revealed the resident triggered for significant weight loss over one, three, and six months. Per the nutrition assessment, recommendations in response to the weight loss included a re-weigh to confirm accuracy of weight loss and weekly weights for monitoring.Review of Resident R94's clinical record revealed no documented evidence a reweigh was obtained or weekly weights were completed per recommendations.Interview on June 25, 2026, at 9:16 AM with Registered Dietitian, Employee E15, confirmed Resident R94's weights were not obtained per nutrition recommendations and subsequently was unable to accurately assess weight changes.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records and interview with staff, it was determined the facility failed to ensure pain assessment was completed prior to administration of PRN (as needed) pain medication for one of two residents reviewed for pain management (Resident 134).Findings include:Review of Resident R134's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of benign neoplasm of pituitary gland (noncancerous tumors on pituitary gland that may cause hormonal/vision problems), hypertension (high blood pressure), and chronic pain syndrome. Review of Resident R134's physician order, dated May 12, 2026, revealed an order for Hydromorphone (opioid medication) 2 milligram tablet- give 3 tablets by mouth every 12 hours as needed for pain for 30 days. Review of Resident R134's Medication Administration Record (MAR) for the month of June revealed the resident received PRN Hydromorphone on the following dates:-June 1, 2026-June 3, 2026-June 4, 2026-June 6, 2026-June 7, 2026-June 8, 2026 -June 9, 2026Review of Resident R134's pain assessments, nursing notes, and MAR documentation revealed there was no documented pain level assessment prior to administration of the PRN Hydromorphone. Interview on June 26, 2026, at 9:38 a.m. with Employee E2, Director of Nursing, confirmed no pain level was documented prior to the pain medication administration in Resident R134's clinical record. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges.Findings Include:Review of facility documentation Medication Room Temperature Log states, temperatures are to remain between 36-46 degrees.Observations on June 23, 2026, at 10:30 am, with Nurse Manager, Employee E10, of Wing B Medication Room Refrigerator (located behind the Nurses Station) revealed ten out of thirty-one days in the month of May 2026, May 3, May 4, May 5, May 10, May 11, May 16, May 17, May 29, May 30, and May 31, the refrigerator temperatures were not documented. Observations on June 24, 2026, at 10:30 am, with Nurse Manager, Employee E11, of Wing C Medication Room Refrigerator revealed three out of twenty-four days in June 2026, June 10, June 12, and June 23, the refrigerator temperature was documented below the acceptable range of 36-46 degrees.Interview on June 24, 2026, at 1:47 p.m., Nursing Home Administrator, Employee E1, confirmed that the facility failed to notify maintenance of the temperature variance and failed to remove or quarantine medications exposed to out of range temperatures.28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on a review of clinical records, facility policies and facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that two of five residents reviewed were free from abuse.(Resident R1 and Resident R2). Findings include: Review of a facility policy titled, Abuse Prohibition revised November 14, 2025, revealed that the policy is that Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. And the purpose is, to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. Review of the clinical record for Resident R3 revealed that the resident had been admitted to the facility on [DATE], with diagnoses including bipolar disorder (also known as manic depressive illness or manic depression, is a mental health condition characterized by significant mood swings, including manic (or hypomanic) episodes and depressive episodes). Further review revealed a care plan for resident being resistive to care such as medications, tube feed infusion, pulls at PEG tube and foley catheter related to intellectual disability, anxiety, schizophrenia (mental disease characterized by loss of reality contact), depression (major loss of interest in pleasurable activities), bipolar and difficulty adjusting to recent changes in condition.Continued review of Resident R3's clinical record indicate that Resident R3 was discharged back to her group home on May 20, 2026. Review of documentation submitted to the State Survey Agency revealed that Resident R3 reported on April 21, 2026, that the night before the nurse aide (Employee E19) slapped her on the face while providing her care. The report also states that Employee E19, the nurse aide giving care to Resident R3 the night of April 20, 2026, was suspended pending the outcome of the investigation. The facility investigation determined that the allegation of abuse was substantiated based on interviews with Resident R3 and her roommate (Resident R11) who witnessed and confirmed the allegations. Interview with Resident R11 at 1:15 p.m. on June 2, 2026, confirmed that she witnessed the altercation between her roommate (Resident R3) and the nurse aide who gave them care (Employee E19) on the evening of April 20, 2026. She said she remembered it and that she felt the facility had handled the situation appropriately. Review of the witness statement of Employee E20, the nurse aide that was passing breakfast trays on A Wing on April 21, 2026, when Resident R3 told her that the nurse aide giving her care the night before had hit her. She further stated that when she went to give care to her roommate, Resident R11, she also said that the nurse aide, Employee E19, had hit Resident R3. She further stated that she reported this to the night supervisor, Employee E21. Review of the telephone interview statement from on Employee E19, the nurse aide who allegedly struck Resident R3, revealed that while attempting to provide care to Resident R3, she kicked her in the chest and struck her in the face knocking her glasses off. She states she immediately stopped care and reported it to the charge nurse, Employee E22. She said she waited a little while and returned to finish Resident R2's care. Review of telephone interview of nurse aide Employee E19 on April 24, 2026, in the presence of nurse aide and union representative, Employee E23, revealed the following. While giving care to Resident R3 on the evening of April 20. 2026, she kicked me and my glasses fell off my face. I stepped back and asked her why she did that, and then I finished her care and left the room. I went and told the nurse, Employee E22 that Resident R3 was acting out and I did not return to the room after that. Review of an interview with Employee E22, the charge nurse, confirmed that Employee E22 was assigned to Resident R3 on the evening shift on April 20, 2026. Employee E22 also confirmed that she administered medications to the resident and was not told about any incident between Resident R3 and a staff member, Employee E19? Review of telephone interviews with three nurse aides and one licensed nurse also working on A Wing on April 20, 2026, all answers no have been aware of an incident between Resident R3 and Employee E19. Interview with Employee E1, Assistant Nursing Home Administrator (ANHA), and the Administrator on June 2, 2026, at 2:05 p.m. confirmed that the investigation was into abuse by Employee E19 on April 20, 2026, toward Resident R3 was substantiated based on the statements of Resident R3, and her roommate Resident R11. They indicated that Employee E19 was terminated after the investigation was substantiated. Review of the clinical record for Resident R2 revealed that the resident had been admitted to the facility on [DATE], with diagnoses including end stage renal disease (the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without dialysis or a kidney transplant). Review of documentation reported to the State Survey Agency on May 20, 2026, by nursing staff that a transportation driver entered Resident R2's room for a scheduled dialysis transport then exited the room alleging that Resident R2 struck him. The nurse, Employee E11, immediately went to assess the situation at which time the driver reentered the room and became verbally aggressive with Resident R2 and started throwing food items from the meal tray onto the floor. Staff reported that the driver pointed the tray toward the resident and allegedly struck Resident R2's left arm twice. Staff immediately intervened and escorted the driver out of the building. Review of the Employee E11's May 20, 2026, nurse note in the medical record revealed the same narrative as above, and that the resident was assessed for injuries and that the facility arranged alternate transportation with another company and the resident was taken to dialysis. A review of the social service note by Employee E28 dated May 20, 2026, revealed that Resident R2 was interviewed and was okay but was confused and could not give any details about the incident or if anyone hit him, and said he just was waiting for his brother to pick him up. Review of statement by Resident R2 given on May 20, 2026, in the presence of a police officer stated that his son came and hit him on his arm. Review of a May 20, 2026, statement by Resident R2's roommate, Resident R12 revealed he could not see anything during the incident as he was laying down. However he reported hearing yelling and cursing by the transport driver, and the food tray hit the floor. A review of the May 22, 2026, email from the transportation company revealed the name of the EMT (Emergency Medical Technician) driver, who was involved in the incident, confirmed receiving elder abuse training and that in the past 30 days he had only been scheduled to transport Resident R2 on May 13, 2026, and May 20, 2026. Interview with Employee E1, Assistant Nursing Home Administrator (ANHA), and the Administrator on June 2, 2026, at 2:05 p.m. confirmed that the investigation into alleged abuse by the transportation driver was substantiated. The administrator confirmed that the transportation driver had been terminated by the transport company. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services

Based on the review of clinical records and interview with staff it was determined that the facility failed to accurately document medical diagnosis for one of three residents reviewed (Resident R2).Findings Include:Review of facility policy, Medication Monitoring dated January 2024, stated Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities, their family, and /or resident representative.Review of Resident R2's clinical record revealed Resident R2 was admitted to the facility on [DATE], with diagnosis of Essential tremor, Major depressive disorder.Review of clinical records revealed Resident R2's physician order, dated January 2, 2024, Depakote Oral Tablet Delayed Release 250 MG, Give 1 tablet by mouth one time a day for Seizures. Review of Resident R2's clinical record revealed physician order, dated January 3, 2024, Primidone Oral Tablet 50 MG, give 0.5 tablet by mouth at bedtime for Seizures Take 25mg by mouth nightly. Review of Resident R2's clinical record revealed no diagnosis of seizures. Interview with Employee E1, Nursing Home Administrator on February 4, 2026, at 2:15 p.m. confirmed the above mentioned findings. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and interviews with facility staff, the facility failed to ensure that a safety device was properly function and monitor for one of one resident (Resident R2).Findings include:Review of Resident R2's clinical records dated August 3, 2025, revealed that the resident was admitted to the facility on [DATE], with a BIMS (Brief Interview of Mental Status) score of 12, indicating the resident had moderate cognitive impairment. Review of Resident R2's care plan, date-initiated January 27, 2025, revealed that the resident was at risk for elopement related to impaired cognition. Continued review of the resident's care plan revealed interventions including resident to wear a wander guard (devise placed on resident's wrist or ankle which activates a door locking mechanism), date-initiated May 27, 2025. Review of Resident R2's elopement evaluation dated July 25, 2025, revealed a score of three, indicating that the resident was at risk for elopement. Further review of Residents R2's elopement evaluation dated October 21, 2025, revealed a score of zero, indicating that the resident was not at elopement risk and currently not making any attempts to leave the unit. Review of nursing Notes for Resident R2, dated October 21, 2025, revealed that the resident no longer required staff to perform safety checks every 15 minutes as resident was no longer at risk for elopement. Continued review of nursing notes, dated October 22, 2025, at 3:58 p.m. revealed that code silver announced. Resident was found sitting on the benches near the parking lot . and that the resident stated, he was leaving. Review of facility investigation dated October 23, 2025, revealed that at approximately 2:15 p.m. Resident R2 left the building unattended and was found sitting on the bench outside the facility by staff, stating he wanted to go to the police department to tell them He didn 't want to be here and planned on coming back. Resident R2 was redirected and brought back into the facility at 2:20 p.m. by staff. Continued review revealed that Resident R2 ' s wander guard was not functioning properly. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on observation and staff interviews, it was determined that the facility failed to ensure that a resident was treated with respected during a group meeting for one of four residents reviewed (Resident 35). Findings include:On September 16, 2025, at 1:30 p.m., a resident council meeting was held with seven alert and oriented residents (R93, R78, R129, R35, R149, R52, and R13). At 1:57 p.m., during the meeting, Licensed Nurse Employee E8 entered and stated, Excuse me, I need to give Resident R35 medication. Employee E8 then proceeded to administer three pills in a medication cup along with a cup of water. The nurse left the room immediately after. Resident R35, appeared uncomfortable and unprepared to take his medication in front of peers.At 2:06 p.m., following the meeting, Resident R35 was interviewed privately regarding the incident. Resident R35 reported: It made me feel uncomfortable. I was surprised when the nurse came in to give me meds-it caught me off guard.At 2:30 p.m., a meeting was conducted with the Administrator, Employee E1 and Director of Nursing, Employee E2. Both confirmed that it was not appropriate for the nurse to administer medication during the resident council meeting. 28 Pa Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a resident fall for one of four residents reviewed (Resident R174). Findings Include: Review of facility policy Abuse Prohibition revised October 24, 2022, revealed the facility will implement an abuse prohibition program which would include investigation of incidents and accidents. Review of Resident R174's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS -a structured interview to assess cognitive function and orientation) score of 14 (intact cognitive response). Further review of Resident R174's the MDS revealed the resident had diagnoses of muscle weakness, osteoarthritis (joint pain and stiffness), mild cognitive impairment, and polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms such as pain, weakness, and sensory loss). Review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident was at risk for falls related to impaired mobility. Further review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident required assistance for transferring from one position to another related to difficulty ambulating and unsteady gait. Review of facility documentation submitted to the State Survey Agency on May 29, 2025, revealed on May 28, 205, Resident R174 had a fall on the facility van while out on an appointment escorted by facility van driver, Employee E6. Review of facility documentation revealed a statement was obtained by van driver, Employee E6. Review of the statement by van driver, Employee E6, dated May 2025, revealed Resident R174 was lifted onto the ramp [in his wheelchair] to the bus and as van driver, Employee E6, walked around to the passenger door Resident R174 pulled the wheelchair breaks and he/she fell backward, hitting his/her head on the side of the bus. Continued review of facility documentation/investigation revealed no documented evidence that a statement was obtained by Resident R174 regarding details of the incident and subsequent fall. 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understand for two residents reviewed for hospitalizations (Resident R171 and R3). Findings include:Review of Resident R171's medical records revealed that on July 21, 2025, the resident was admitted to the hospital for tachycardia (irregular heartbeat). Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator on September 18, 2025, at 12:35 p.m. confirmed this finding. Review of Resident R3's clinical record revealed that Resident R3 was transferred to the hospital on February 17, 2025, for influenza. Continued review revealed that the resident was transferred to the hospital on April 18, 2025, for lower extremity weakness. Further review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Follow-up interview with the facility administrator on September 18, 2025, at 10:29 a.m. confirmed the above-mentioned findings and stated that it is not facility practice providing the residents and/or their representative with a written notice for transfers. Further interview confirmed that the ombudsman was not notified regarding Resident R3's transfers on February 17, 2025, and April 18, 2025. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to develop comprehensive care plan for three of 33 residents reviewed (Resident R26, R102, and R61).Findings Include:Review of facility policy Person-Centered Care Plan revised September 15, 2025, revealed the facility will develop and implement person-centered care plan for each resident with measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The care plan must be customized to each individual patient's preferences and needs.Review of Resident R26's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 2, 2025, revealed a Brief Interview for Mental Status (BIMS - a structured interview to assess cognitive function and orientation) was not assessed because the resident is rarely/never understood. A staff assessment of mental status was conducted which revealed Resident R26 had short and long-term memory problems.Continued Review of Resident R26's MDS dated [DATE], revealed the resident had diagnoses of hemiplegia (paralysis) or hemiparesis (weakness), aphasia (loss of ability to understand or express speech, caused by brain damage), and anxiety (characterized by feelings of tension, worried thoughts, and physical changes). Per a review of the MDS Resident R26 was dependent on staff for all activities of daily living (eating, transferring, hygiene, grooming, dressing). Review of Resident R26's comprehensive care plan revised February 8, 2022, revealed the resident had impaired communication as evidenced by difficulty making self-understood.Further review of Resident R26's comprehensive care plan revised March 5, 2024, revealed the Resident R26 had impaired cognitive function or impaired thought processes.Review of Resident R102's quarterly MDS dated [DATE], revealed the resident had a BIMS score of 15 (intact cognitive response) and diagnoses of depression (persistent feeling of sadness and loss of interest) and bipolar disorder (extreme mood swings).Review of Resident R102's comprehensive care plan revised February 27, 2025, revealed the resident was able to safely transfer in and out of bed without assistance. Continued review of Resident R102's comprehensive care plan revised November 1, 2021, revealed the resident had the tendency to exhibit sexually inappropriate behavior with other residents.Observations on September 15, 2025, at 1:25 p.m. revealed Resident R26 and R102 were sitting close together in front of the nurses' station holding hands. Interview with Resident R26 revealed the two have been in a relationship for three years. Interview on September 15, 2025, at 1:40 p.m. with Registered Nurse, Employee E7, confirmed Resident R26 and R102 enjoy sitting together and holding hands. Registered Nurse, Employee E7, indicated that Resident R26 and R102 do not spend unsupervised time alone in either room. Resident R26 and R102 reportedly sit where staff can see them and the two only just hold hands. Review of Resident R26's clinical record revealed a care plan meeting note dated August 14, 2024, that indicated a discussion was had with Resident R26's guardian regarding friendship with Resident R102 and that the guardian was informed of the resident's holding hands. The guardian agreed with the friendship and appreciated education. Review of Resident R26 and R102's comprehensive care plans revealed no documented evidence that a person-centered care plan was developed for either resident regarding the consent/boundaries of the friendship. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders to place hearing aids in the residents ears each morning and remove them at bedtime for one of one resident reviewed for vision and hearing (Resident R7). Findings include:Review of physician orders dated September 7, 2025, revealed staff must place hearing aids in bilateral ears in the morning and remove at bedtime. Observations conducted on September 15, 2025, at 12:30 p.m., during screening, Resident R7 could not hear the surveyor and was observed without hearing aids. Observations on September 16, 2025, at 9:44 a.m. and 1:00 p.m., revealed resident R7 did not have the hearing aids in place. Observations on September 17, 2025, at 9:30 a.m. revealed the resident hearing aids on. Follow-up observations on September 17, 2025, at 2:20 p.m. again revealed the resident without hearing aids. Interview and observations conducted on September 17, 2025, at 2:30 p.m. with Nurse Manager, Employee E10, confirmed that Resident R7 did not have hearing aids in place. Review of medication cart did not reveal the hearing aids. Continued interview revealed that the hearing aids had been misplaced and not offered to Resident R7. The hearing aids were later located in the narcotic box. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of facility documentation, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide appropriate assistance/supervision for one of four residents reviewed for falls (Resident R174).Findings Include:Review of van driver, Employee E6, personnel file revealed the employee was hired as the facility van driver effective November 4, 2024. Review of van driver, Employee E6, job description for Positions that Involve Transporting Customers/Clients revealed the employee is responsible for assisting residents when boarding and disembarking the vehicle. The employee will operate the vehicle in a safe manner when transporting residents.Review of van driver, Employee E6, personnel file revealed a Vehicle Safety Competency dated November 15, 2024.Review of facility documentation Vehicle Safety Competency revised November 2018 revealed a competency checklist/instruction for operation of wheelchair van lift. Per the Vehicle Safety Competency the van should be placed in park with emergency brake on and wheelchair secured properly on lift platform. When loading/unloading patient on lift for a side-loading van, the patient must face away from van while on lift.Review of Resident R174's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS -a structured interview to assess cognitive function and orientation) score of 14 (intact cognitive response).Further review of Resident R174's the MDS revealed the resident had diagnoses of muscle weakness, osteoarthritis (joint pain and stiffness), mild cognitive impairment, and polyneuropathy (condition characterized by damage to multiple peripheral nerves, leading to symptoms such as pain, weakness, and sensory loss).Review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident was at risk for falls related to impaired mobility.Further review of Resident R174's comprehensive care plan revised December 30, 2024, revealed the resident required assistance for transferring from one position to another related to difficulty ambulating and unsteady gait.Review of facility documentation submitted to the State Survey Agency on May 29, 2025, revealed on May 28, 205, Resident R174 had a fall on the facility van while out on an appointment escorted by facility van driver, Employee E6.Review of facility incident report revealed on May 28, 2025, it was reported to nursing that Resident R174 fell while in his/her wheelchair on facility transport van. Resident R174 was being picked up from his/her appointment by the driver [Employee E6]. Van driver, Employee E6, was entering the van through the passenger double doors to get [Resident R174] into the van from the lift. Van driver, Employee E6, did not reach Resident R174 when he/she released bilateral brakes from his/her wheelchair. The van was reportedly parked on tilted/uneven ground at the time. When Resident R174 released the brakes, the wheelchair rolled backward due to the tilt of the ground and the wheelchair fell backward. Resident R174 subsequently landed on his/her back (inside the van) with the front wheels of the wheelchair in the air.Review of the statement by van driver, Employee E6, dated May 28, 2025, revealed Resident R174 was in his/her wheelchair and lifted onto the ramp to the bus and as van driver, Employee E6, walked around to the passenger door Resident R174 pulled the wheelchair brakes and he/she fell backward, hitting his/her head on the side of the bus. Continued review of statement by van driver, Employee E6, dated May 28, 2025, revealed Resident R174 often felt the need to help so when getting him/her on or off the bus he/she would push the brake. Van driver, Employee E6, reported to always redirect the resident to allow the driver to release the brakes. A tour of the facility van was conducted on September 18, 2025, at 12:25 p.m. with van driver, Employee E6. Observations revealed the van had a side-loading wheelchair ramp. The van was equipped with a ramp on the back, right side of the van that lowers to the ground to allow residents with wheelchairs to be rolled onto the ramp and lifted into the van. Interview on September 18, 2025, at 12:25 p.m. with van driver, Employee E6, revealed when picking up Resident R174 from his/her appointment on May 28, 2025, the van was parked on a slight slant due to the curve of the road. Van driver, Employee E6, loaded Resident R174 onto the wheelchair ramp with his/her wheelchair facing away from the van. Van driver, Employee E6, then lifted the ramp off the ground to be parallel with the van. Van driver, Employee E6, left Resident R174 unattended on the raised lift to enter the van from the front so he/she could continue backing the resident into the van. As van driver, Employee E6, walked away, Resident R174 released his/her wheelchair brakes and fell backwards into the van. Continued interview on September 18, 2025, at 12:25 p.m. with van driver, Employee E6, revealed Resident R174 did not appear to have any injuries so the resident was assisted back into the wheelchair and brought back to the facility for further assessment by nursing staff. Further interview on September 18, 2025, at 12:25 p.m. with van driver, Employee E6, revealed he/she would typically stay on the lift with the resident when being assisted into the van but due to the slant of the van the employee was nervous to stay on the ramp. The van driver, Employee E6, explained that Resident R174 often needed reminders not to release his wheelchair brakes as this is the responsibility of the van driver to ensure safety. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of five residents reviewed (Resident R142).Findings Include: Review of facility policy Weights and Heights dated July 15, 2025, revealed the facility will ensure all patients maintain acceptable parameters of nutrition status. Review of Resident R142's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 21, 2025, revealed the resident was admitted to the facility on [DATE], had diagnoses of diabetes mellitus (metabolic disorder that results in elevated blood sugar levels), hypokalemia (low potassium blood levels) gastroesophageal reflux disease (GERD - when stomach acid flows back into the esophagus) and dysphagia (difficulty swallowing).Continued review of Resident R142's MDS revealed his/her weight was coded as 199 pounds, was noted to have a weight loss of 5% or more in the last month of weight loss of 10% or more in the last month and was not a physician prescribed weight loss regimen.Review of Resident R142's comprehensive care plan revised August 8, 2025, revealed the resident was at nutritional risk related to diagnoses and abnormal weight loss.Review of Resident R142's clinical record revealed a comprehensive nutrition assessment dated [DATE], that assessed the resident's needs based on a recorded weight of 198.6 pounds. Continued review of Resident R142's nutrition assessment revealed the resident had a significant weight loss over six months (10.2% weight loss since January 8, 2025).Further review of Resident R142's nutrition assessment dated [DATE], revealed the resident had no noted edema at the time of assessment. Goals through the next review included weight to remain within usual body weight range without significant weight changes. Per the assessment, monitoring of the resident included monitoring of weights and PO (by mouth) intakes.Review of Resident R142's weight history revealed a documented weight on July 21, 2025, of 198.6 pounds and a documented weight on July 23, 2025, of 188.8 pounds which reflected a 9.8 pound / 4.9% significant weight loss in two days. The weight loss was confirmed/sustained with a documented weight of 189 pounds on August 13, 2025.Continued review of Resident R142's weight history revealed the weight loss was sustained and continued to trend down to 179.6 pounds on September 17, 2025, which reflected another significant weight loss of 9.4 pounds / 5% in one month.Review of Resident R142's entire clinical record revealed no documented evidence that Resident R142's weight loss from July 23, 2025, and onward was identified and assessed. Interview on September 18, 2025, at 10:26 a.m. with Registered Dietitian, Employee E9, confirmed there was no follow-up to address Resident R142's significant weight loss.28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observation, staff interviews, clinical record review, and review of facility policy, it was determined that the facility failed to ensure that a resident was provided with dialysis clamps for one of one resident reviewed receiving hemodialysis. (Residents 15).Findings include:Facility policy titled Dialysis: Hemodialysis (HD) - external catheter valuation and maintenance, last date revised December 16, 2024, stated under 2. Maintain two smooth edged clamps with the patient at all times. 2.1 Smooth edged clamps must be placed at the bedside at time of admission. 2.2 Smooth edged clamps are to be attend to the patient's clothing during transport to and from dialysis facility or for any appointment(s) outside the nursing center. 2.3 If patient is mobile throughout the Center, smooth edged clamps must be attached to the patient's clothing at all times.Review of Resident R15's clinical record indicated an admission date of June 15, 2025, with diagnosis of end stage renal disease, and anima in chronic kidney disease. Review of July 2025 physician orders revealed an order dated, July 25, 2025 monitor hemodialysis site on dialysis days, pre and post during dialysis days, Monday, Wednesday, and Friday and document. Pre and Post dialysis assessment documented. On dialysis days. Monitor hemodialysis LFA site for signs/symptoms of complications (e.g, bleeding, swelling, pain drainage, odor, hardness or redness at site), Notify the physician and dialysis center immediately with any urgent problems.On September 18, 2025, at 10:32 a.m., an interview was conducted with Licensed Nurse, Employee E4, who confirmed that Resident R15, a dialysis patient, should have clamps either at his bedside or in his wheelchair. Observations were made in Resident R15's room, and no clamps were found at the bedside. Employee E4 then stated that the clamps were located in Resident R15's wheelchair.Observations conducted at the above time with Licensed nurse, Employee E4 of Resident R15 revealed that Resident R15 was in the dining room seated in (his/her) wheelchair at an activity. Resident R15 reported that (his/her) clamps were in the wheelchair; however, upon being asked by Employee E4 to locate them, none were found. After Resident R15 stood up, Employee E4 confirmed that no dialysis clamps were present.Interview conducted on September 18, 2205 at 12:23 p.m., with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2. confirmed that dialysis clamps are required to remain with the resident at all times.28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on observation, clinical record review, and staff interview, the facility failed to ensure Resident R1 who required 1:1 supervision received adequate supervision to prevent accidents, which resulted in actual harm to Resident R1 who sustained an unwitnessed fall from bed and sustained a traumatic brain injury for one of five residents reviewed (Resident R1).This deficiency was cited identified as past non-compliance.Findings Include:Review of the facility policy titled Enhanced Patient Supervision: Continuous 1:1, revised September 15, 2025, revealed, When using Continuous 1:1 Supervision, designated staff will be assigned to manage the 1:1 supervision of the patient. The designated staff will only be involved with the delivery of care to this patient and no other patient (where possible, a staff member already known to the patient is recommended to ensure consistency of care). The designated staff must be with the patient at all times, must obtain coverage for breaks, and will provide positive interaction in conjunction with therapeutic interventions. Continuous 1:1 Supervision will be provided per nursing judgment or when recommended by a physician/advanced practice provider (APP). Allocation of staff:The nurse in charge of each shift has the responsibility to allocate staff(s) to carry out Continuous 1:1 Supervision.The staff allocated to supervise the patient will not discontinue the supervision until the next staff confirms they have taken responsibility for supervising the patient. Additional staff may be required when supervising very high-risk patients. Review of the clinical record for Resident R1 revealed the resident was readmitted to the facility on [DATE], with diagnoses including restlessness and agitation, lack of coordination, and difficulty in walking. Review of the entry/discharge MDS (Minimum Data Set - assessment of resident care needs) for Resident R1 dated October 2, 2025, revealed the resident's cognitive skills for daily decision making were severely impaired. The MDS indicated the resident was dependent on staff for transfers and toileting. There was no assessment of resident ambulation documented in the MDS assessment. Review of physician note for Resident R1 dated October 11, 2025, revealed the resident, a long-term care resident, was hospitalized from [DATE], through October 10, 2025, after sustaining a fall on September 29, 2025, at the facility. Additional review revealed, an initial evaluation at another hospital included imaging confirming a displaced left femoral neck fracture. The resident sustained a closed displaced fracture of the left femoral neck and underwent left hip replacement. Recommendations included full supervision and assistance with mobility. Review of physician progress note for Resident R1 dated October 13, 2025, at 9:56 a.m., revealed the resident was on 1:1 supervision and to continue 1:1 supervision. Review of nursing note for Resident R1 dated October 13, 2025, revealed the resident was noted with safety concerns and provided 1:1 supervision. Review of physician note for Resident R1 dated October 14, 2025, at 8:08 a.m., revealed during the weekend, staff reported continuous agitation and restlessness, with repeated attempts to get out of bed, requiring 1:1 supervision. Review of physician note for Resident R1 dated October 16, 2025, at 10:30 a.m., revealed a recommendation for fall precautions and 1:1 supervision. Review of the facility incident investigation dated October 17, 2025, revealed Resident R1 who was dependent for transfers and all Activities of Daily Living, at approximately 4:35 a.m., while Nurse aide, Employee E3 was performing care to another resident, she heard a noise and immediately went to Resident R1's room where resident was observed on the floor. The resident was last seen by Nurse aide, Employee E3 at 4:25 a.m., in bed, in a low position, with the call light within reach. Nurse aide, Employee E3 immediately called for the nurse, and upon assessment, Resident R1 was found with lacerations to the left eyebrow, forehead, and an abrasion on the left lower arm. Resident R1 was unable to recall the incident or report any pain. Further review of the facility's incident report revealed that the Nursing Supervisor and physician were notified and determined that the resident should be sent to the hospital for evaluation due to the head injury. The resident was transferred to the hospital for further evaluation via ambulance. Upon investigation, it was noted that the resident was placed on 1:1 increased behaviors on October 16, 2025. Follow-up call made to the hospital notified that results of CT (computed tomography scan- medical image that uses a combination of x-ray and computer image to create crossed sectional images of the inside of the body) were positive for subdural hematomas. Investigation was immediately initiated. Nurse aide, Employee E3 was suspended pending investigation. Investigation concluded and found that Nurse aide, Employee E3 did leave Resident R1 unattended while providing care for another resident when the fall occurred. Review of a written statement from Nurse aide, Employee E3 dated October 17, 2025, at 4:35 a.m., revealed that she was assigned to do 1:1 supervision with Resident R1 and left the room without notifying anyone to clean other residents because it was almost the time she normally began morning care. Nurse aide, Employee E3 stated the resident was restless throughout the night. Nurse aide, Employee E3 also stated that the resident did not have non-skid footwear on because the resident removed them. Employee E3 stated that she was not able to see Resident R1 from the room where she was providing care. Review of the hospital records dated October 17, 2025, revealed that the resident was admitted with diagnoses of Traumatic Brain Injury, subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) and cerebral contusion from the fall. Review of CT (Computed Tomography) of the Head for Resident R1 dated October 17, 2025, revealed that the result showed trace acute subarachnoid hemorrhage. Review of nursing note for Resident R1 dated October 17, 2025, revealed that at 4:35 a.m., the nurse was notified that Resident R1 was on the floor. Upon arrival to the resident's room, the resident was observed at the bottom of the bed in a sitting position with a laceration to the left eyebrow area and the left side of the forehead. A skin abrasion on the left elbow was also seen. A neurological assessment was done and was normal within the resident's baseline. The physician was notified and ordered for the resident to be transfer to the hospital. Further review of nursing note revealed the resident was admitted with a traumatic brain injury. Observation of Resident R1 on November 3, 2025, at 11:00 a.m., revealed that the resident was sitting in a recliner chair. The resident was constantly trying to get out of the chair unassisted, and the staff who was on 1:1 redirected the resident back to the chair. Interview with the Nursing Home Administrator, Employee E1 on November 3, 2025, at 11:30 a.m., revealed there were staffing issues during the night shift of October 16 from 11:00 p.m. to 7:00 a.m. shift. Nurse aides were rotated to provide 1:1 supervision to Resident R1 throughout the shift while they were dividing time providing care to other assigned residents. However, nurse aide, Employee E3, who was assigned to 1:1 approximately 4:30 a.m., left the 1:1 assignment to provide morning care for another resident. Resident R1 fell shortly after the nurse aide left the room. The Nursing Home Administrator, Employee E1 confirmed Resident R1, who was identified as needing 1:1 observation, should have been provided close staff supervision all the time. This deficiency was identified as actual harm past non-compliance for failure to provide 1:1 supervision to Resident R1 resulting in the resident falling from off bed and sustaining serious head injuries. On November 3, 2025, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on October 17, 2025, to address the failure to provide appropriate supervision to Resident R1 which resulted in Resident R1 falling off the bed and sustaining serious head injuries requiring hospitalization. Facility plan of correction included the following information:Physician and resident representative notification of the fall of Resident R1 completed October 17, 2025.Resident was sent to the hospital for evaluation and admitted completed October 17, 2025.Fall investigation initiated completed October 17, 2025.Nurse Aide placed on administrative leave during investigation completed October 17, 2025.Nursing staff re-educated on 1:1 Supervision, Abuse completed October 17, 2025.An initial audit of current residents with orders/care planned for increased supervision completed to identify if increased supervision is still required and is being provided as per care plan. An IDT (interdisciplinary team) note will be documented for residents no longer requiring increased supervision completed October 17, 2025.ADHOC QAPI (Quality Assurance Improvement Plan)- DON (Directo of Nursing)/designee to conduct random audits 3x per week x 2 weeks, then weekly x 2 weeks, then monthly x 2 of residents with orders/care planned for increased supervision to verify supervision is being provided as per plan of care and documented. The facility alleged compliance with their plan of correction as October 17, 2025. A review was conducted of clinical records, facility documentation, staff education, and documentation of audits conducted by the facility. Interview with staff revealed that the staff was knowledgeable about facility 1:1 policy. Resident R1 was observed with continuous 1:1, and the 1:1 documentation was completed by the assigned staff. It was determined that the plan of correction was implemented and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(b)(2) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(5) Nursing services28 Pa. Code 211.12(d)(1) Nursing service

Based on observation, record review, and staff interview, the facility failed to provide adequate staffing to ensure continuous supervision for Resident R1, who required 1:1 observation as ordered by the physician. This failure resulted in actual harm to Resident R1 who was left unsupervised, sustained a fall from the bed, requiring transfer to the hospital and diagnosis of traumatic head injury for one of five residents reviewed. (Resident R1) Findings Include: Review of facility assessment revealed under section titled, Function - Care Requirements 3. Staff/Personnel required: Consider the specific needs of each resident unit in the facility to adjust as necessary (i.e. number of staff, skill sets). This includes the staffing needs for each shift, such as day, evening, night, weekends, and adjust as necessary based on any significant changes to the resident population for person centered care planning. Cognitive care Requirements 3. Staff/Personnel required: Consider the specific needs of each resident unit in the facility to adjust as necessary (i.e. number of staff, skill sets). This includes the staffing needs for each shift, such as day, evening, night, weekends, and adjust as necessary based on any significant changes to the resident population for person centered care planning.Review of the clinical record for Resident R1 revealed the resident was readmitted to the facility on [DATE], with diagnoses including restlessness and agitation, lack of coordination, and difficulty in walking.Review of the Entry/Discharge MDS (Minimum Data Set - assessment of resident care needs) for Resident R1 dated October 2, 2025, revealed the resident's cognitive skills for daily decision making were severely impaired. The MDS assessment indicated the resident was dependent on staff for transfers and toileting. There was no assessment of resident ambulation documented in the MDS.Review of the facility's incident investigation, dated October 17, 2025, revealed Resident R1, dependent on transfers and all ADLs, at approximately 4:35 a.m., while Nurse Aide, Employee E3 was performing care to another resident, she heard a noise and immediately went to Resident R1's room where the resident was observed on the floor. The resident was last seen by Nurse aide, Employee E3 at 4:25 a.m., in bed, in a low position, with the call light within reach. Nurse aide, Employee E3 immediately called for the nurse, and upon assessment, Resident R1 was found with lacerations to the left eyebrow, forehead, and an abrasion on the left lower arm. Resident R1 was unable to recall the incident or report any pain. Further review of the facility's investigation revealed that the Nursing Supervisor and physician were notified and determined the resident should be sent to the hospital for evaluation due to head injury. The resident was transferred to the hospital for further evaluation via ambulance. Upon investigation, it was noted the resident was placed on 1:1 supervision due to increased behaviors on October 16, 2025. Follow-up call made to the hospital revealed the results of CT scan were positive for subdural hematomas. Investigation was immediately initiated. Employee E3 was suspended pending investigation. Investigation concluded and found that Employee E3 left Resident R1 unattended (without supervision) while providing care for another resident when the fall occurred.Review of a written statement from Nurse aide, Employee E3 dated October 17, 2025, at 4:35 a.m., revealed she was assigned to do 1:1 supervision with Resident R1 and left the room without notifying anyone to attend to other resident's personal hygiene needs. Nurse aide, Employee E3 indicated the resident was restless throughout the night. Employee further indicated the resident did not have non-skid footwear on because the resident removed them. Employee E3 stated she was not able to see Resident R1 from the room where she was providing care.Review of the hospital records dated October 17, 2025, confirmed the resident was admitted with diagnoses of Traumatic Brain Injury, Subarachnoid Hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) and cerebral contusion from the fall.Review of CT (Computed Tomography scan) of the head for Resident R1 dated October 17, 2025, revealed the scan results showed trace acute subarachnoid hemorrhage.Review of nursing note for Resident R1 dated October 17, 2025, revealed that at 4:35 a.m., the nurse was notified Resident R1 was on the floor. Upon arrival to resident's room, Resident R1 was observed at the bottom of the bed in a sitting position with a laceration to the left eyebrow area and the left side of the forehead. A skin abrasion on the left elbow was also seen. A neurological assessment was performed and noted to be normal within the resident's baseline. The physician was notified and ordered for the resident to be transfer to the hospital.Further review of the progress note revealed the resident was admitted with Traumatic Brain Injury.Review of nursing note for Resident R1 dated October 13, 2025, revealed that the resident was noted with safety concerns and provided 1:1 supervision.Review of physician progress note for Resident R1 dated October 13, 2025, at 9:56 a.m., revealed the resident was on 1:1 supervision and to continue 1:1 supervision.Review of physician progress note for Resident R1 dated October 14, 2025, at 8:08 a.m., revealed during the weekend, staff reported continuous agitation and restlessness, with repeated attempts to get out of bed, requiring one-to-one supervision.Review of physician note for Resident R1 dated October 16, 2025, at 10:30 a.m., revealed a recommendation for fall precautions and 1:1 supervision.Observation of Resident R1 on November 3, 2025, at 11:00 a.m., revealed the resident was sitting in a recliner chair. The resident was constantly trying to get out of the chair unassisted, and the staff who was on 1:1 redirected the resident back to the chair.Review of staffing data submitted by the facility revealed the following:-On October 16, 2025, for night shift (October 16, 2025, 11:00 p.m. to October 17,2025,5 at 7 a.m. facility required 84 nurse aide hours (11.2 FTE-Full Time Equivalent) for a resident census of 168. Facility provided 60 hours of nurse aide hours, short of 24 hours. -Continued review of the staffing data revealed that On October 16, 2025, for night shift (October 16, 2025, 11:00 p.m. to October 17,2025,5 at 7 a.m. facility required 33.6 hours (4.20 FTE) of LPN (Licenses Practical Nurse) hours. Facility provided 32 hours (4.0 FTE) of LPN hours, short of 2 hours. Interview with the administrator on November 3, 2025, at 11:30 a.m., revealed on the night shift of October 16-17, 2025, from 11:00 p.m. to 7 a.m., the facility had staffing issues. Nurse aides were rotated to provide 1:1 supervision to Resident R1 throughout the shift while they were dividing time providing care to assigned residents. However, the nurse aide, Employee E3, who was assigned to be Resident R1's 1:1 supervision at approximately 4:30 a.m. left the 1:1 supervision assignment to provide personal care in a different room. Resident R1 fell shortly after the nurse aide exited the room. The administrator confirmed Resident R1, who was identified as needing on 1:1 supervision, should have been provided continuous close staff supervision. The administrator confirmed the facility was short-staffed for the night of October 16-17, 2025. The facility failed to provide adequate staffing to ensure continuous supervision for Resident R1, who required 1:1 observation as ordered by the physician. This failure resulted in actual harm to Resident R1 who was left unsupervised, sustained a fall from the bed, requiring transfer to the hospital and diagnosis of traumatic head injury. Refer to F68928 Pa Code: 211.12 (d)(4) Nursing services 28 Pa Code: 211.12 (f)(3) Nursing services28 Pa Code: 201.14(a) Responsibility of licensee28 Pa Code:201.18(a)(3) Management

Based on review of clinical record, facility policy, facility documentation, and staff interviews, it was determined the facility failed to ensure Resident R1 was free from neglect by failing to place Resident R1's bed in a safe position after the completion of care. This failure resulted in actual harm to Resident R1 who fell out of bed, sustained a subdural hematoma and an intertrochanteric fracture of left femur (thigh) for one of four residents reviewed for falls (Resident R1). Findings include: Review of facility policy titled Falls Management, revised 2024, revealed patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Also, practice standards include implementing and documenting patient-centered interventions according to individual risk factors in the patient's care plan. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- prevents airflow to the lungs, causing breathing problems), Osteoporosis (condition that weakens bones and increases the risk of fractures), and Dementia (decline in cognitive function that interferes with daily life). Review of Resident R1's quarterly Minimum Data Set (MDS- mandated assessment of a resident's abilities and care needs), dated February 4, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident was assessed with lower extremities impairment, dependent of staff for rolling from left to right, for moving from lying position to a sitting position and from bed to chair transfer. Review of Resident R1's care plan, dated April 16, 2021, revealed Resident R1 was at risk for falls related to cognitive loss, lack of safety awareness, side effects of medications, vertigo (sensation of spinning or dizziness), COPD, pain in feet, and impaired balance. One of the interventions to limit falls included Resident R1's bed to be in lowest position. Review of documentation submitted to the State Survey Agency on March 18, 2025, revealed on March 17, 2025, after Resident R1 received morning care, the resident was left lying on his/her right side in bed. The nurse aide turned to get the resident's wheelchair and the resident rolled out of bed and landed on the left side, hitting the left side of the head on the floor. The nurse aide was not able to stop the fall. The resident was assessed for any injuries and was noted with a hematoma on the left side of head. Review of facility investigation, dated March 17, 2025, revealed Resident R1 received morning care on March 17, 2025, at approximately 11:20 a.m. Resident R1 was then lying flat in the middle of the bed after care was performed. Nurse Aide, Employee E1, then walked away from the bed to retrieve Resident R1's wheelchair near the door. Resident R1 then turned to his/her side, rolled out of bed, and landed on his/her left side. Resident R1 hit the left side of the head and was noted with a hematoma on the left side of resident's head. Resident R1 complained of left foot pain. X-ray was ordered and results confirmed positive fracture of acute left trochanteric (thigh) area. Resident R1 was transferred to the emergency department for further evaluation and treatment. Review of Resident R1's physician notes dated March 17, 2025, (12:16 p.m.) revealed Resident R1 experienced a fall, resulting in a hematoma on the resident's left forehead and left sided pain, particularly in the lower extremity. There is a high concern for a femur fracture given the immediate pain in [his/her] left lower extremity. The potential for neurological complications subdural hematoma exits . Immediate transfer to the emergency department is requited if any changes are observed, due to risk of . subdural hematoma. Review of Resident R1's nursing notes dated March 18, 2025, at 8:24 a.m. indicated resident left face had bruised, ice was apply for comfort. Review of nursing notes dated March 18, 2025, at 8:26 a.m. revealed the physician called and ordered for the resident to be transferred to the hospital for hematoma. Continued review of Resident R1's nursing note dated March 19, 2025, at 1:40 a.m. revealed that a call was made to the hospital nurse reported resident admitted with subdural hematoma and fracture of left femur. Review of Resident R1's hospital discharge summary document, dated March 24, 2025, confirmed Resident R1 was diagnosed with a subdural hematoma and intertrochanteric fracture of left femur. Interview conducted on April 01, 2025, at 10:39 a.m. with Nurse Aide, Employee E1, revealed Employee E1 raised Resident R1's bed while providing care and the bed was at the height of Employee E1's waist. After care was performed, Employee E1 then walked away from Resident R1's bed to retrieve resident's wheelchair. Employee E1 confirmed Resident R1's bed was left in the high position when she walked away. Interview on April 01, 2025, at 11:53 a.m. with Director of Nursing, Employee E2, confirmed Resident R1's bed should be in the low position when away from the bed. The facility failed to ensure that Resident R1 was free from neglect by failing to place Resident R1's bed in a safe position after the completion of care. This failure resulted in actual harm to Resident R1 who fell out of bed and sustained a subdural hematoma and a intertrochanteric fracture of left femur. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on the review of facility policies and procedures, clinical records, facility documentation, hospital records, review of surveillance camera, observations, interviews with residents and staff, it was determined that the facility failed to provide appropriate staff supervision during resident smoking times and non-smoking times for residents who smoke in the facility and residents with the history of drug abuse. This failure resulted in two residents (Resident R2 and R3) obtaining and abusing illicit drugs and placed residents who smoke in the facility at risk for serious harm, resulting in an Immediate Jeopardy situation for seven of nine residents reviewed. (Resident R2, R3, R4, R5, R6, R7, R8) Findings Include: Review of facility policy of Smoking dated March 1, 2022, revealed that Supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact and able to respond to emergency situation. The patient will be allowed to smoke only with direct supervision until the interdisciplinary team has evaluated him/her. Review of facility smoking contract revised on May 2023, revealed that The resident MUST only smoke during assigned smoking times and under the direct supervision of a staff member. Smoking is only allowed in designated smoking area. Resident cannot use illicit drugs. Review of facility smoking time sheet revealed that facility smoking times were 9 a.m. to 10 a.m., 1 p.m.to 2 pm, 6 p.m. to 7 p.m. Non-smoking patio times were 10 a.m. to 11 a.m., 2 p.m. to 3 p.m. and 7 p.m. to 7:30 p.m. Review of facility reported incident for Resident R2 dated July 5, 2023, at 3:00 p.m. revealed that resident observed inappropriately touching staff and belligerent. Resident stated that he was having fun and partying in the courtyard and denied substance abuse. He stood up from unlocked wheelchair and fell on left knee, causing abrasion to knee. Nurse practitioner assessed patient. 911 (Emergency Medical Services) called and transferred patient to ER (emergency room ) to rule out substance abuse and for further evaluation. Further review of the report included a follow up action which revealed that resident had a history of opioid use disorder and ETOH (alcohol) dependence. Room searched with patient's permission and no illegal substances found. Resident will be supervised by staff while outside in the courtyard. Review of progress note for Resident R2 dated July 5, 2023, revealed that resident was out in the courtyard with other residents and returned to unit via wheelchair. Resident was loud and calling out saying we were partying in the courtyard. Resident then attempted to stand from wheelchair with wheels unlocked and fell on his left knee causing an open area. Nurse Practitioner made aware and evaluated the resident. Resident was ordered to be sent to the emergency room for eval and treat. Resident left via fire rescue stretcher. Review of the nurse practicioner note for Resident R2 dated July 5, 2023, revealed that the resident appears intoxicated. He was swinging his arm making random noises. Per nursing, he just returned from outside smoking. The patient stated he was partying out in the courtyard, and he is having fun. He was asked if he was taking anything while outside, he put his index finger on his mouth making a hush sign. Complete review of system is unable to obtain as the patient appears intoxicated. Review of Urine Drug Screen (UDS) for Resident R2 dated July 5, 2023 obtained at the hospital, revealed that resident was tested positive for THC (a crystalline compound that is the main active ingredient of cannabis) and PCP (a mind-altering drug that may lead to hallucinations (a profound distortion in a person's perception of reality. It is considered a dissociative drug, leading to a distortion of sights, colors, sounds, self, and one's environment). Review of clinical record revealed that Resident R2 was admitted to the facility on [DATE], with diagnosis including osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward) and opioid (a class of narcotic substance used to relive pain) abuse. Review of a quarterly MDS (Minimum Data Set- Assessment of resident care needs) for Resident R2 dated May 25, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that the resident's cognitive status was intact. MDS also revealed that the resident needed limited staff assistance for transfer and ambulation. Review of care plan for Resident R2 dated March 28, 2021, revealed that the resident was at risk for substance use (alcohol/drugs) related to a history of addiction to alcohol. Resident was observed with possession of small quantity of marijuana. Interventions included monitor conditions that may contribute to substance use and monitor the nature and circumstances (e.g., history and triggers) of the substance use behavior: past experiences, stimulation, involvement with others, patterned, etc. and adjust approaches appropriately. Review of physician progress note for Resident R2 dated July 6, 2023, revealed that the resident was recently issued a 30-day notice as he violates the facility policy and consumed illegal substances. He reports feeling sad about the event. He states that he has a history of alcohol abuse but has since quit. He states that the last incident with the PCP was a one-time event and expresses his wish to completely avoid any substance due to prior addiction history. He reports that he got the joint last week because the resident who left last Friday offered it to him asking if he would like to get high and the patient said yes. He wants to be monitor periodically to prove that he has since stopped taking any illegal substance. Review of clinical record revealed that the Resident R3 was admitted to the facility on [DATE], with diagnoses including myocardial infraction (Also known as heart attack, occurs when the flow of blood to the heart is severely reduced or blocked.) and diabetes mellitus (Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose)), Review of a quarterly MDS for Resident R3 dated May 24, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 13 which indicated that the resident's cognitive status was intact. MDS also revealed that the resident needed supervision for transfer and ambulation. Review of facility investigation for Resident R3 dated July 5, 2023, at 3:00 p.m. revealed that resident observed with unsteady gait with swaying, slurred speech, pinpoint pupils, and unable to follow conversation. NP (Nurse Practicioner) assessed patient. 911 called and transferred patient to ER to rule out substance abuse and for further evaluation. Further review of the report included a follow up action which revealed that resident had a history of opioid use disorder and ETOH dependence. Room searched with patient's permission and no illegal substances found. Resident will be supervised by staff while outside in the courtyard. Review of progress note for Resident R3 dated July 5, 2023, revealed that resident came in from the courtyard after smoking cigarettes and was noted to have an unsteady gait, slurred speech, pin point pupils that were reactive, unable to follow conversation, and when sitting on the side of the bed, he was swaying. Resident was assessed by Nurse Practitioner and ordered to be sent to the emergency room . Fire rescue was called, resident left facility via stretcher with fire rescue. Review of physician progress note for Resident R3 dated July 5, 2023, revealed that nursing noted that the resident had a sudden change in gait and has slurred speech. The patient returned from smoking. Resident denied taking anything different and reports only smoking several cigarettes. However, he was slow to respond and was unable to sit straight on the side of the bed which was a change from his baseline. He denied any changes. Review of Urine Drug Screen obtained at the hospital for Resident R3 dated July 5, 2023, revealed that resident was tested positive for THC and PCP. Review of care plan for Resident R3 dated December 21, 2022, revealed that the resident was at risk for substance use (alcohol/drugs) related to a history of addiction. Interventions included monitor conditions that may contribute to substance use. Review of physician progress note for Resident R3 dated July 6, 2023, revealed that resident was sent to the ER for possible intoxication. UDS was positive for marijuana and PCP. The patient states that he just happened to pick up a joint on the ground yesterday and smoked it. Education given about the harm of drug use. Continue to monitor. Interview with Nursing Home Administrator, Employee E1, on July 20, 2023, at 1:30 p.m. stated, Resident R2 and Resident R3 were interviewed by the facility after the resident came back from the hospital. Resident R2 and R3 stated they called a number to obtain illicit drug, the person threw the drug over the fence while they were outside smoking. Employee E1 stated the incident was after the smoking time and the facility intervention was to supervise all residents when they were outside including smoking and non-smoking times. Continued interview with Nursing Home Administrator, Employee E1 confirmed staff provided supervision to all residents who smoked at the facility, and they were required to be present at the location of smoking in their direct view to intervene in case of emergency. Review of facility smoking list revealed that Residents R4, R5, R6, R7, R8 required smoking aprons during smoking and there were 46 residents on the list who were actively smoking. A review of facility security camera facing the courtyard (Designated supervised smoking area for Residents) for July 5, 2023, at 1:00 p.m. to 3: 00 p.m. completed with Maintenance Director, Employee E3, revealed that at 12:43 p.m. (time on the surveillance camera) residents started going out to the courtyard for smoking. No staff was seen on the camera. Residents were lighting cigarettes without any staff supervision or support. Continued observation revealed that at 12:49 p.m. one activity staff came out to the courtyard with a resident to smoke. At 1:13 the activity staff went inside. No staff were present in the Courtyard. Further observation revealed that, Resident R3 was sitting at a table with Resident R1. After activity staff went inside at around 1:30 p.m., Resident R2 was smoking at a different table but stopped smoking and went to Resident R1's table. Resident R1 handed something to Resident R2, and he started smoking or ingesting the substance. No staff was seen at the courtyard from 1:13 p.m. to 2:20 p.m. when all residents went inside. All the observations were confirmed by Maintenance Director, Employee E3. Continued review of facility security camera facing the courtyard for July 5, 2023, at 6:00 p.m. to 7: 30 p.m. completed with Maintenance Director, Employee E3 revealed that at 5:49 p.m. residents started going out to the courtyard for smoking. No staff was seen on the camera. Residents were lighting cigarettes without any staff supervision or support. It was observed that one resident was lighting cigarette for some other residents. Through out the observation no staff came out to the courtyard except, a nursing assistant opened the courtyard door and stood at the door for approximately 30 seconds and went back inside. It was also observed that Residents who required smoking aprons and smoking supervision were smoking without aprons or supervision. Resident R4, R5, R6, R7 and R8 were smoking without a smoking apron or smoking supervision. Review of the smoking assessment for Resident R4 dated May 22, 2022, revealed that resident was not allowed to smoke due to poor smoking safety awareness. Review of smoking assessment for Resident R5 dated April 26, 2023, revealed that resident required supervision during smoking. Review of care plan for Resident R5 dated November 1, 2022, revealed a smoking care plan with interventions to provide smoking supervision and to provide smoking apron if indicated. Review of smoking assessment for Resident R6 dated October 1, 2022, revealed that resident required supervision during smoking and required smoking apron. Review of care plan for Resident R6 dated June 19, 2023, revealed a smoking care plan with interventions to provide supervision during smoking. Review of smoking assessment for Resident R7 dated June 9, 2023, revealed that resident required supervision during smoking and required smoking apron. Review of care plan for Resident R7 dated January 4, 2023, revealed a smoking care plan with interventions to provide supervision during smoking. Review of care plan for Resident R8 dated revealed a smoking care plan with interventions to provide supervision during smoking. Interview with Activity staff, Employee E4, on July 21, 2023, at 10:37 p.m. stated Activities Department oversaw smoking supplies and smoking supervision. Employee E4 stated staff sit inside and watch through the glass door to the courtyard. Employee E4 stated staff did not always provide direct supervision at the location of smoking. Employee E4 stated activity staff was not informed to supervise during non-smoking times. Interview with Activity Director, Employee E5, on July 21, 2023, at 1:00 p.m., stated activity staff provided smoking supervision and kept all smoking supplies. Activity staff has other activities scheduled after smoking times as a result they were not able to provide direct supervision after smoking break. Observation of facility courtyard on July 21, 2023, at 10:15 p.m. revealed that there was no staff at the courtyard to provide supervision. There were approximately five residents in the courtyard. Nursing Home Administrator was notified of the observation and confirmed the observation. Nursing Home Administrator stated this was a non-smoking time and staff should provide supervision when residents were out in the courtyard to prevent use of illicit drug use. Resident R2 and R3 were in the courtyard without staff supervision. Observation of the courtyard from inside the facility revealed that only half of the courtyard was visible from inside. It was not possible to get a full view of the courtyard where Activity staff, Employee E4 stated staff sit to observe during smoking times. Interview with the Nursing Home Administrator, Employee E1, on July 21, 2023, confirmed that the staff did not provide supervision for residents who smoke. Employee E1 also stated facility did not provide supervision for residents who had history of drug abuse while at facility courtyard during non-smoking times. Review of facility records revealed that the facility had 26 residents with alcohol abuse history, 1 resident with cannabis abuse history, 10 residents with cocaine abuse history, 2 residents with inhalant abuse history, 6 residents with opioid abuse history, 5 residents with psychoactive substance abuse history. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on July 21, 2023, at 3:22 p.m., for the facility's failure to provide appropriate staff supervision during smoking and non-smoking times for residents who smoke in the facility and residents with the history of for drug abuse. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 21, 2023, at 3:22 p.m. The facility submitted a written plan of action on July 21, 2023, at 6:40 p.m. and implemented the plan of action which included: 1. Residents who smoke will be assessed using the smoking evaluation. Smoking times will be at 9:00 am to 10:00 a.m., 1:00 p.m. to 2:00 p.m. & 6:00 p.m. to 7:00 p.m. daily. Scheduled times may be subject to change depending on inclement weather. Supervision will be provided during resident smoking times by a staff member. The staff member providing supervision will distribute and collect smoking materials. Residents will be notified of the smoking times and the policy requiring the smoking materials to be held by the facility. Smoking policy will be updated to reflect the changes. Residents care plans will be revised. Non-Smoking residents may go out to the courtyard with supervision at their discretion. Will be completed on 7/21/2023. 2. Residents who have a history or diagnosis of substance use disorder wil have a psych eval and the IDT team will meet to review the need for supervision upon admission and readmission. If a resident is determined as needing supervision a staff member will accompany them to the courtyard. The courtyard door has a keypad alarm. The keypad alarm code will be changed weekly this will ensure staff are alerted when resident wish to access the courtyard. Substance Abuse policy will be updated to reflect the changes. Residents care plans will be revised. Will be completed on 7/21/2023. 3. Facility staff will be educated on the smoking policy and supervision requirements. Facility staff will be educated on the policy of supervising residents with a history of substance abuse if they have been identified by the Interdisciplinary team as needing supervision. Both educations will be 90 percent completed on 7/22/2023 with 100 percent completion on 7/25/2023. 4. Adherence to the smoking supervision and courtyard supervision will be audited to ensure compliance. Audits will be conducted 7 days a week x 2 weeks then 3x a week x 2 weeks, then 2x a month x 2 months. Results will be reviewed at the QAPI (Quality Assurance Improvement Program) meeting. 5. Adherence to the substance use supervision and courtyard supervision will be audited to ensure compliance. Audits will be conducted 7 days a week x 2 weeks then 3x a week x 2 weeks, then 2x a month x 2 months. Results will be reviewed at the QAPI meeting. On July 22, 2023, the action plan was reviewed, and interviews were conducted with nursing staff to confirm the in-service education was completed. Observations of facility courtyard was completed during smoking and non -smoking times. The Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on July 22, 2023, at 5:09 p.m. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services

Based on the review of facility documentations, policies and procedures, clinical records, hospital records, EMS records, observations, and interviews with staff, it was determined that the facility failed to provide appropriate staff supervision and failed to complete a thorough assessment of the resident environment for drug paraphernalia for Resident R355, who was readmitted from the hospital with diagnosis of drug abuse, and tested positive for cocaine in her urine. This failure of the facility to provide appropriate staff supervision and failure to conduct a thorough assessment of resident's room and personal property resulted in the resident able to access drug paraphernalia, possible abuse of controlled substance, leading to a cardiac arrest and subsequent death in the facility. In addition, this failure placed the residents who had a diagnosis of substance abuse at the facility at risk for harm and resulted in Immediate Jeopardy situation for one of 44 resident clinical records reviewed. (Resident R355) Findings include: Review of facility policy Enhanced Patient Supervision: Continuous 1:1 dated [DATE], revealed, The whereabouts and wellbeing of patients is part of routine nursing supervision; however, a patient may require a temporary period of enhanced supervision in order to maintain his/her safety and safety of others. Patients requiring enhanced supervision may include, but are not limited to Head Injury/neurological problems Violent behaviors pending transfer, Substance abuse/withdrawal Mental distress such as acute delirium Sexually aggressive behaviors. Continuous 1:1 Supervision provided for nursing judgment or when recommended by a physician/advance practice provider (APP). Review of facility policy Personal Property: Patients dated [DATE], revealed, All items brought into the center will be listed on the Inventory of Personal Effects form and kept in the patients clinical chart. Any additional items brought into the center after admission must be added to this list. Review of facility policy Visitation dated [DATE], revealed, Visitation and illegal substance use: The center staff are expected to note the presence of signs, symptoms, and triggers of possible illegal substance use such as changes in patient behavior, particularly after interaction with visitors or leave of absence, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes and or loss of consciousness, etc. Staff may at times have to ask patients who appear to have used an illegal substance (e.g. cocaine hallucinogens. heroin.) whether or not they possess or have used an illegal substance. To protect the health and Safety of patients, the Center may increase monitoring or supervision of the visitor and patient. Center staff may conduct a search of patient or their personal belonging only if patient or patient legal representative agrees to a voluntary search and understand the reason for the search. Review of clinical record for Resident R355 revealed that the resident was admitted to the facility with diagnoses including chronic osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and cocaine abuse. Review of hospital record dated [DATE], revealed that Polysubstance Use Disorder: History of Opioid Use Disorder: Cocaine. Prior IVDU (Intravenous Drug Use), none for 10 months. Not interested in suboxone (medication to treat narcotic dependence). Social History: Drugs used Heroin, Crack' cocaine, IV and methamphetamines. Further review of hospital record revealed an infectious disease consult note which showed resident had a UTOX (Urine Drug Screen) positive for cocaine. Review of physician's note dated [DATE], revealed that Patient with polysubstance use disorder. She denies any drug use in last 10 months however her UDS (Urine Drug Screening) in the hospital was positive for cocaine. Review of the resident's clinical record revealed no documented evidence that the facility conducted an assessment of the resident's environment including the resident's room and personal belongings after Resident R355's initial admission on [DATE]. Review of Resident R355's care plan initiated on [DATE], did not reveal interventions developed to monitor and assess resident's environment for possible drug paraphernalia and supervision of the resident after resident's admission with positive cocaine drug screen. Review of progress note for Resident R355 dated [DATE], revealed that the resident was sent to the hospital and admitted with bacteremia (presence of bacteria in the bloodstream). Review of progress note for Resident R355 dated [DATE], revealed that the resident was returned to the facility with left upper extremity PICC (Peripherally inserted Center catheter) line access for IV antibiotic administration. Review of progress note for Resident R355 on [DATE], at 12.00 a.m. revealed that the resident stated to the nurse, I don't feel good, I am sweating, I am weak, I can't even get up to go to the bathroom, and I am dizzy. Further review of progress note at 12:19 a.m. resident became unresponsive to verbal stimuli, 911 called. Review of emergency room (ER) record for Resident R355 dated [DATE], revealed that Patient has bizarre behavior and her acidosis and tachycardia all due to cocaine abuse her elevated troponin was false elevation she was not having an MI (Myocardial Infraction-heart attack). Will discharge back to nursing home she is received 2 liters of saline already and looks much better after receiving Haldol and Ativan which reverses the effect of cocaine. Further review of ER record revealed that the resident's Urine Drug Screening was positive for cocaine. Review of hospital Toxicology Drug screens dated [DATE], revealed that urine cocaine was unconfirmed positive. Resident was also discharged with diagnosis of cocaine use disorder. Review of physician's note dated [DATE], revealed that the resident was sent to the hospital with change in mental status with increased confusion, tachycardia and hypotension. The resident denied use of cocaine. The resident had a change in mental status due to cocaine use. Encourage cessation, although patient denying any recent use after testing positive for Cocaine during ED (emergency department) visit today. Previous history of heroine abuse. The medical director was consulted and it was discussed with nursing to monitor. Review of nursing note dated [DATE], at 9:49 a.m. revealed checked room for any drug paraphernalia, no items found. Resident denied use of cocaine while in the facility in spite of hospital positive result. Review of the residen'ts clinical record revealed no documented evidence that facility implemented interventions to monitor or supervise Resident R355 as recommended by the physician. Review of nursing note dated [DATE], revealed that at 4:45 a.m. resident. Could be heard yelling help from her room. C.N.A (nursing assistant) Went to investigate and found resident sliding from bed onto floor. Where she landed on her stomach. Aide called for nurse, who went into assess. At that time, Resident was noted to be making grunting/growling noises. Supervisor came into room around 4:50 AM. and resident appeared to stop breathing at that time. CPR (cardiopulmonary resuscitation) was initiated. AED (automatic external defibrillator- medical devise use to help those experiencing sudden cardiac arrest) applied and 911 called. When staff went to roll resident over to her back, resident was noted to have a saline flush syringe, no needle, against her arm where her PICC site was located but not connected to her PICC. Narcan was prepared and administered via PICC x 2 doses. 4:55 a.m. and 5:00 a.m. CPR continued by staff until EMS (emergency medical system) arrived at 5:07 a.m. EMS pronounced (death) resident at 6:05 a.m. Review of facility investigation dated [DATE], revealed that a syringe was found near the resident with suspicious pink liquid inside. Review of CPR/AED flow sheet dated [DATE], revealed that at 4:50 a.m. arrest recognized, 4:51 a.m.- ventilations and compressions initiated, 4:51a.m. -911 called, 5:07 a.m. rescue squad arrived. Resuscitation stopped at 6:05 a.m. Review of EMS record dated [DATE], revealed that EMS observed drug paraphernalia at the scene. Etiology was documented as drug overdose. Interview with Director of Nursing and Administrator on [DATE], at 11:43 a.m. revealed that the police took syringe and a medication cup found near the resident. Facility was informed by the police that the syringe and medication cup would be given to medical examiner's office for their investigation. Interview with the Nurse Practitioner, Employee E24, on [DATE], at 1:03 p.m. stated she was aware of Resident R355 positive drug screen at the hospital for cocaine. Employee E24 talked to medical director and he recommended to monitor the resident. Employee also informed this to Employee E22 and Assistant Director of Nursing, Employee E4 to monitor the resident. Employee E24 was not sure if any kind of supervision or monitoring was in place. Interview with Director of Nursing and Administrator (NHA) on [DATE], at 11.35 a.m. confirmed that the resident was not on close supervision at any time during her stay at the facility. DON and NHA stated facility was still conducting investigation into [DATE] incident where resident tested positive for cocaine. Interview with Registered Nurse, Employee E21, on [DATE], at 2.00 p.m. revealed that she did not have this resident on [DATE], to [DATE], 11p.m.- 7 a.m. shift. Nursing assistant asked for help and nurse assigned to the resident was on break. After calling code, she turned the resident then saw the syringe. Employee E21 also stated when she looked around, she saw few pills on the floor, she went to open the drawer and saw medication cup one with pink residue. Pills on the floor was picked up and placed on bedside table. She stated she picked up four (4) pills from the floor and placed on top of the bedside table. Also, another pill, looked like, Senna (laxative) on the other side of bed she stated she could not reach. Interview with Registered Nurse, Employee E7, on [DATE], at 9.47 a.m. revealed that she was a desk nurse, and she did the room search on [DATE]. Resident R355 did not refuse or decline the search. She stated she was looking for syringes, needles and medication. She looked in the drawers, a bag was found, she pulled the cloths and looked inside the bag. Employee E7 confirmed that she did not check inside pockets of the cloths found inside the bag. Employee E7 also confirmed she did not start an inventory of personal effect form. Employee E7 stated no close supervision was initiated for Resident R355. Employee E7 interviewed resident and she denied using cocaine. When asked about positive test, Resident R355 became quiet and looked down. Employee E7 stated resident was sluggish and slow to respond. Observation of Resident R355's room and personal belongings was conducted on [DATE], at 3:30 p.m. with Registered Nurse Employee E23 and Director of Nursing (DON), Employee E2. A bag was stored in nursing office on the first floor. Employee E23 stated she saw the pills sitting on the bedside table after fire rescue and police left the room. She discarded the pills. Surveyor asked Employee E23 and DON to open the bag and pull the cloths from the bag. Surveyor requested Employee E23 search the pockets of the cloths, when Employee E23 searched inside the pocket of a black pants, a syringe was found. The syringe contained pink colored liquid substance. When DON searched inside a purple sweater broken cigars were found with some cigar filters. Interview with Director of Nursing and Administrator on [DATE], at 9:35 a.m. did not give an explanation of how the resident accessed syringes or how medications were found inside resident's room. DON stated staff was supposed to dispose used syringes in biohazard containers located in each medication cart or in the biohazard room. Also, staff should ensure resident swallow medication after medication administration. A review of facility document dated [DATE], revealed that the facility had a total of 28 residents with history of substance abuse disorder including 10 residents with diagnosis of cocaine abuse, one resident with hallucinogen abuse, 1 resident with inhalant abuse, three residents with opioid abuse and three residents with other psychoactive substance abuse. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 1:19 p.m. for the facility's failure to provide appropriate staff supervision and failure to complete a thorough assessment of resident environment for drug paraphernalia for one resident who was readmitted from the hospital with diagnosis of drug abuse and tested positive for cocaine in her urine. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 1:19 p.m. The facility submitted a written plan of action on [DATE], at approximately 5:45 p.m. and implemented the plan of action which included: 1. All current residents' room checks were completed on [DATE] with permission of the residents to verify no drug paraphernalia or environmental hazards were present in the room. 2. Residents admitted or returning from a hospitalization with a positive drug test will have belongings/room checked to include, drawers, clothes, pockets, bags and floors upon return to the facility with resident or resident representative consent to a voluntary search. 3. All staff will be re-educated prior to the start of their next shift on Policies Enhanced patient supervision; continuous 1:1. 4. Staff will be re-educated prior to the start of their next shift on signs and symptoms of potential drug use. 59.4.% staff was completed as of [DATE]. 85% staff education will be completed by [DATE]. 100% compliance of active staff will be completed by [DATE] and any staff on LOA will be completed upon return. 5. All residents with a positive drug test upon admission or return from the hospital will have their care plan for supervision reviewed. In addition, all current residents with history drug abuse care plans will be reviewed for supervision and monitoring for signs and symptoms. 25% care plans have been reviewed as of [DATE]. 100% compliance will be achieved by tomorrow. 6. Weekly random audits will be completed for 90 days for residents admitted or returning from a hospitalization with a positive drug test will have belongings/room checked to include, drawers, clothes, pockets, bags and floors upon return to the facility with resident or resident representative consent to a voluntary search. 7. Weekly random audits will be completed for 90 days for all current residents with history drug abuse care plans will be reviewed for supervision and monitoring for signs and symptoms. 8. Audits results will be reviewed monthly by the QAPI committee for further review/ recommendations as indicated. On [DATE], the action plan was reviewed, and interviews were conducted with nursing staff to confirm the in-service education was completed. It was confirmed that all resident rooms were assessed to ensure a resident environment free of controlled substances, drug paraphernalia or environmental hazards Following the verification of the immediate action plan the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on [DATE], at 4:00 p.m. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services

Based on the review of facility documentation, review of policies and procedures, review of clinical records, review of hospital records, observations, and interviews with staff, it was determined that the facility failed to have enough supply of Narcan available during a potential emergency drug overdose. This failure of the facility to appropriately administer and have enough supply of Narcan available for a resident who was prescribed opiates and had a history of opiate abuse placed Resident R355 at risk for serious injury including death and 3 other residents at risk for serious injury for one of 4 residents reviewed with a history of opioid abuse. (Resident R355) Finding include: Review of facility policy Opioid overdose dated, [DATE], revealed that the Centers will have medications and procedures in place to treat suspected and/or actual opioid overdose. Naloxone (NARCAN(R)) may be used for the treatment of an opioid emergency such as an opioid overdose or a possible opioid overdose with observed signs and symptoms. Naloxone (NARCAN(R)) is to be given as soon as possible and does not take the place of emergency medical care. Get emergency medical help immediately after giving the first dose of naloxone (NARCAN(R)), even if the patient responds. Naloxone (NARCAN(R)) may be administered by a licensed nurse or other licensed professional to patients as indicated for the complete or partial reversal of opioid overdose. PURPOSE To provide for the timely and safe treatment of a suspected and/or opioid overdose. PROCESS 1. Evaluate for clinical signs and symptoms of opioid overdose including, but not limited to: 1.1 Loss of consciousness; 1.2 Unresponsive to sternal rubor applied external stimulus; 1.3 Slow, shallow, erratic, or absent breathing; 1.4 Irregular or absent pulse; 1.5 Pinpoint pupils; 1.6 Bluish purple skin tone (light skinned patient)/grayish ashen skin tone (dark skinned patient); 1.7 Choking sounds and/or snore-like gurgling noise; 1.8 Vomiting; 1.9 Body is limp; 1.10 Cyanosis. 2. If the patient exhibits signs and symptoms of opioid overdose: 2.1 Activate emergency medical system (EMS). 2.2 Initiate rescue breathing or cardiopulmonary resuscitation (CPR), if indicated. 2.3 Notify supervisor and attending physician/advanced practice provider (APP). 2.4 Check vital signs. 2.5 Obtain emergency medication: 2.5.1 Naloxone 0.4mg/mL injection, or 2.5.2 NARCAN (Naloxone) nasal spray 4mg/0.1mL. 2.6 Administer 0.4mg injection via intramuscular (IM) route or 4mg nasal spray via single nostril. 2.6.1 For IM route: 2.6.1.1 IM injection may be repeated every two (2) to three (3) minutes until a response is obtained, up to a maximum dose of 10mg. 2.6.1.2 If no response after IM administration of 10 milligrams (mg) total, the presumed diagnosis of opioid overdose should be questioned. 2.6.2 For nasal spray: 2.6.2.1 Additional doses can be administered every two (2) to three (3) minutes via alternating nostrils until EMS arrives. Review of drug information for Narcan available at https://www.drugs.com/dosage/naloxone.html revealed that Usual Adult Dose for Opioid Overdose Initial dose: 0.4 mg to 2 mg IV; alternatively, may give IM (intra muscular) or subcutaneously If desired response is not obtained, doses should be repeated at 2 to 3 minute intervals If no response is observed with a total dose of 10 mg, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned. The duration of action of some opioids exceeds that of this drug, therefore, repeat doses may be needed; the need for repeat doses will depend on the amount, type, and route of administration of the opioid being antagonized. Review of clinical record for Resident R355 revealed that the resident was admitted to the facility with diagnosis including chronic osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and IV (intravenous) opioid use, and cocaine abuse. Review of physician orders for Resident R355 dated [DATE], revealed an order to administer Oxycodone 10 mg, one tablet every 4 hours for severe pain. Review of Medication Administration Record for Resident R355 revealed that the resident received five doses of Oxycodone 10 mg. on [DATE]. Review of Medication Administration Record for Resident R355 revealed that the resident received five doses of Oxycodone 10 mg from [DATE], at 10:43 a.m. to [DATE], at 4:08 a.m. Review of nursing note for Resident R355 on [DATE], at 12.00 a.m. revealed that the resident stated to the nurse, I don't feel good, I am sweating, I am weak, I can't even get up to go to the bathroom, and I am dizzy. Further review of nursing notes at 12:19 a.m. revealed resident became unresponsive to verbal stimuli, and 911 was called. Review of emergency room (ER) record for Resident R355 dated [DATE], revealed that Patient has bizarre behavior and her acidosis and tachycardia all due to cocaine abuse her elevated troponin was false elevation she was not having an MI (Myocardial Infraction-heart attack). Will discharge back to nursing home she is received 2 liters of saline already and looks much better after receiving Haldol and Ativan which reverses the effect of cocaine. Further review of ER record revealed that the resident's Urine Drug Screening was positive for cocaine. Review of hospital Toxicology Drug screens dated [DATE], revealed that urine cocaine was unconfirmed positive and opioids. Resident was also discharged with diagnosis of cocaine use disorder. Review of nursing progress note dated [DATE], revealed that at 4.45 a.m. resident. Could be heard yelling help from her room. C.N.A (nurse aide) Went to investigate and found resident sliding from bed onto floor. Where she landed on her stomach. Aide called for nurse, who went into assess. At that time, Resident was noted to be making grunting/growling noises. Supervisor came into room around 4:50 AM. and resident appeared to stop breathing at that time. CPR (cardiopulmonary resuscitation) was initiated. AED (automatic external defibrillator) applied and 911 called. When staff went to roll resident over to her back, resident was noted to have a saline flush syringe, no needle, against her arm where her PICC site was located but not connected to her PICC. Narcan was prepared and administered via PICC x 2 doses. 4:55 a.m. and 5:00 a.m. CPR continued by staff until EMS (emergency medical system) arrived at 5:07 a.m. EMS pronounced (death) resident at 6:05 a.m. Interview with Registered Nurse, Employee E21, on [DATE], at 1:43 p.m. revealed that staff observed a syringe with pink colored substance inside the syringe before Resident R355 went unresponsive. Resident's Oxycodone was also pink in color. Employee E21 stated staff suspected overdose and gave Narcan from the emergency box at 4:55 a.m. Review of facility investigation revealed that staff administered first dose of Narcan at 4:55 a.m. and the second dose at 5:00 a.m. which was a 5-minute interval. Facility staff did not have available third dose in the emergency box and removed a dose from Omnicell (Automatic Medication dispensing cabinet/machine) at 5:03 a.m. Staff did not administer a third dose. It was documented that the EMS arrived at the scene at 5:07 a.m. Review of facility emergency box content dated [DATE], revealed that one E kit (emergency medication box) contained one vial of Narcan 0.4mg/ml. Facility had a total of 4 Ekits. Facility had one Omnicell which was located on second floor. Omnicell had a total of 2 Narcan 0.4mg/ml vials. Altogether facility had a total of 6 vials of Narcan 0.4mg/ml. Interview with Registered Nurse, Employee E21, on [DATE], at 2.00 p.m. revealed that she administered Narcan to Resident R355 on [DATE]. Interview with the Nurse Practitioner, Employee E24, on [DATE], at 11.03 a.m. stated, staff should give Narcan as recommended in the event of a suspected overdose and the benefit outweighs the risk during an emergency. Interview with Director of Nursing (DON) and Administrator (NHA) on [DATE], at 9.35 a.m. confirmed that facility only had a total of 6 vials Narcan 0.4mg/ml vials and only one in each Ekits. A review of facility document dated [DATE], revealed that the facility had a total of three residents with a history of opioid abuse. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 3:16 p.m., for the facility's failure to have enough supply of Narcan available during a potential emergency drug overdose. The facility submitted a written plan of action on [DATE], at approximately 5:45 p.m. and implemented the plan of action which included: 1. The facility will review/revise the emergency policy and procedure for the addition of IV administration of Narcan, if applicable. The facility policy will be updated/ revised by [DATE] 2. All licensed staff will be re-educated on Opioid Overdose policy (NSG264) and location of Narcan prior to the start of the next shift. 69.2.% staff was completed as of [DATE] for Opioid Overdose policy. 85% staff education on the Opioid overdose policy and Narcan location will be completed by [DATE]. 100% compliance of active staff will be completed by [DATE] and any staff on LOA will be completed upon return. 3. The facility contacted Pharmacy on [DATE] to increase the supply of Narcan to 25 vials, 5 Narcans will be added to each e-kit on all four units and 5 Narcans will be added to Omnicell. Additional Narcans will be available at the facility by [DATE]. 4. CNE/ Designee will conduct weekly random audits of Narcan availability for 90 days. 5. Audit results will be reviewed monthly by the QAPI committee for further review/ recommendations as indicated. On [DATE]. the action plan was reviewed, and interviews were conducted with nursing staff to confirm the in-service education was completed. Observation of facility Ekit revealed that each Ekit contained 6 Narcan 0.4mg/ml vials and Omnicell contained 6 Narcan 0.4mg/ml vials. Following the verification of the immediate action plan the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on [DATE], at 4:00 p.m. 28 Pa. Code: 201.14(a)Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(f)(2)(4)(g)(h)(k) Pharmacy services

Based on review of medical records, facility documentation and interviews with staff, it was determined that the facility failed to provide a safe environment for one of six residents reviewed, who sustained actual harm (laceration) from a fall (Resident R1). Findings include: Review of Resident R1's medical record revealed physician's orders [REDACTED]. the joints), [MEDICAL CONDITIONS] (narrowing of the blood vessels which supply the heart with oxygen), and diabetes (the inability to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment). Continued review of Resident R1's medical record revealed a quarterly Minimum Data Set assessment (MDS-assessment of resident needs tool) dated (MONTH) 31, 2019, which indicated that the resident had limited range of motion bilaterally (both sides) in both her upper and lower extremities. Additionally, Resident R1's plan of care dated as revised (MONTH) 24, 2019 indicated that the resident was dependent on the physical assistance of staff for activities of daily living including bed mobility and transfers (moving from one area to another). The care plan, dated initiated (MONTH) 6, (YEAR), further indicated that a slide device would be used requiring two persons for repositioning in bed. Review of information submitted by the facility revealed that on (MONTH) 21, 2019, Resident R1 had fallen from her bed while receiving care from her aide at approximately 4:30 a.m Further review of the facility information revealed that the resident had sustained a laceration above her left eye as a result of the fall. The resident was sent to the emergency room for evaluation, the resident returned with a hematoma (a collection of blood) to the area above her left eye and steri strips (small bandaids to hold the skin together until healed). The statement submitted by the aide indicated that she entered the room alone, she raised the bed to approximately mid-thigh level to provide care, she was standing on the right side of the resident, she then removed the sheets from that side, and went to the left side of the bed. She then pulled the resident towards the center of the bed. The aide then rolled the resident towards the right side over the rolled up sheets and the resident slid off the bed onto the floor. According to the facility's reference tool dated (MONTH) 1, 2007, indicated that stickers placed on the residents door which are color coded and indicate the number of personnel needed to perform the transfer. TA2 indicates that two persons are required for transfers and bed mobility. Interview with the Director of Nursing on (MONTH) 15, 2019, at approximately 3:10 p.m. revealed that the TA2 signage, which indicated that resident R1 requires the assistance of two staff persons for bed mobility and transfers was posted on Resident R1's door at the time of the incident. The aide failed to follow the facility's protocol by not following the instructions on the signage posted outside the resident's door which indicated that two staff persons were required for care for Resident R1. An interview with the Director of Nursing on (MONTH) 15, 2019, at 3:10 p.m. revealed that the nurse's aide was provided a competency related to this assessment tool prior to the incident which included the meaning of the signage on the door, but failed to follow the determination of the assessment. The Nursing Home Administrator and the Director of Nursing confirmed during an interview on (MONTH) 15, 2019, at 3:10 p.m. that the facility failed to ensure the resident was provided care in a safe manner which resulted in an injury and actual harm to Resident R1. Pa. Code: 211.11(a) Resident Care Plan Pa. Code: 211.12(c)(d)(5) Nursing Services Previously cited 7/31/18

Based on clinical record review, staff interview, review of facility policy and procedure and facility documentation, it was determined that the facility failed to safely transfer, with a mechanical device, one of 29 residents reviewed that cause actual harm of a fractured hip. (Resident CL1). Findings include: Review of the facility policy and procedure titled, Safe Resident Handling/Transfer Equipment, revised May 15, 2017, revealed that residents will be assessed to determine the correct equipment to use and that the divided leg sling on the total lift is used for the majority of patients. Review of the facility policy and procedure titled, Safe Resident Handling Program, revised May 12, 2016, revealed, 1-Staff will follow the Centers' nursing policies and procedures related to the use of lifts and transfer positioning devices and 3-Transfer assistance, mobility and other resident handling tasks are to be carried out in accordance with the Lift/Transfer Assessment and care plan. Review of Resident CL1's Annual Minimum Data Set assessment (MDS- a periodic review of care needs) dated August 9, 2016, revealed [DIAGNOSES REDACTED]. Review of Resident CL1's plan of care dated May 2017 revealed that the resident was to be transferred using a two person assist and a medium (purple) sling. Review of the documentation related to the investigation of Resident CL1's fall out of the Hoyer lift (hydraulic/mechanical lift) on October 10, 2016, revealed that the resident was placed on the Hoyer sling by Employee E9, Nurse Aide, then Employee E10, Nurse Aide, came into the room to help Employee E9 transfer the resident from the bed to the chair. The resident fell out of the sling when the sling was elevated and the resident slid out of the sling to the floor. The physician was notified and an X-ray was ordered which revealed a fractured hip. There was no information in the investigation of what size sling was used. Review of the interview documentation with Employee E9 revealed that the divided leg straps on the sling were not applied on the resident and this same employee did not use the crisscross straps, as required for transfers, with the Hoyer lift, and used whatever sling was in the room to transfer the resident (the crisscross straps prevent the resident from sliding out of the sling.) Employee E9 was terminated from employment as the facility substantiated for neglect of the employee. Employees E9 and E10 had received training in the use of the Hoyer lift on May 13, 2015. The facility failed to ensure a safe transfer using a Hoyer lift and a Hoyer sling by not following the facility policy resulting in a fall with fracture for Resident CL1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 09/03/15, 07/12/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/03/15, 07/12/16 28 Pa. Code 201.18(b)(1) Management Previously cited 09/03/15, 07/12/16 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(c) Resident care policies Previously cited 7/12/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/03/15, 07/12/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 09/03/15, 07/12/16 28 Pa. Code 211.12(d)(2) Nursing services

Based on observation, review of a clinical record, facility documentation, interviews with facility staff, and a review of facility policies and procedures, it was determined that the facility failed to accurately replace a Percutaneous Endoscopic Gastrostomy (Peg Tube-a surgical opening in the abdomen used to provide nutrition) resulting in actual harm to a Resident (Resident R1). Findings include: A review of Resident R1's physician's orders [REDACTED]. A review of a Nursing Note for Resident R1, dated April 11, 2014, at 1:24 p.m. revealed that Resident R1 was transferred to the hospital-unplanned because of a dislodged (not in place) Peg Tube, that it was replaced in the facility, it was patent (unobstructed), flushed with water, pain was present when water was instilled, and the Resident vomited twice. A review of the facility's investigation into Resident R1's dislodged Peg Tube revealed that on April 11, 2014, at 9:20 a.m. the charge nurse was attempting to administer medications and experienced difficulty giving these medications, documented that the device (balloon) at the end of the Peg Tube which holds it in place was deflated . The Peg tube was replaced. A review of the portion of the facility's investigation, identified as "Follow-Up-Care", revealed that the Peg Tube was replaced, the resident was sent to the emergency room at 1:51 p.m. and was admitted at 2:15 p.m. with the [DIAGNOSES REDACTED]. A review of Employee E3's statement, dated April 11, 2014, related to Resident R1's dislodged Peg Tube revealed that she was the nurse administering medications and found the tube difficult to instill water into, another nurse realized the the balloon was deflated and a new Peg Tube was placed, it was patent and bowels sounds (used to identify proper digestive properties) were present. The facility's policy on Peg Tube Care, updated 1/2/14, identified that to verify placement of a Peg Tube, 10 cc's (cubic centimeters) of air should be injected into the Peg Tube while a stethoscope is placed over the epigastric (upper area of the stomach) region and a whooshing sound would be heard. Also to verify placement, using a syringe, attached it to the Peg Tube and pull back, stomach contents should be seen if Peg Tube is placed correctly. Checking bowel, sounds as described above does not confirm placement of Peg Tube. A review of Resident R1's History and Physical, completed in the emergency room (ER) by the ER Physician, dated April 11, 2014, revealed that the resident did have a Perforated [MEDICATION NAME] (an abnormal opening in the stomach) and required immediate exploratory surgery and was admitted to the Intensive Care Unit (ICU) following the surgery. Further review of Resident R1's Operative Report, dated April 11, 2014, revealed that the surgeon followed the track of the Peg Tube placed earlier in the Facility and it was misplaced. The tip of the Peg Tube and inflated balloon was located in the resident's intraperitoneal space (the area next to, but outside the stomach) rather than within the stomach. A review of the Hospital's Transfer Form back to the facility, dated April 16, 2014, identified the resident's readmission [DIAGNOSES REDACTED]. An observation of Resident R1 on April 25, 2014, at 11:45 a.m. with the Director of Nursing in his room revealed that the resident had 14 staples present in his abdominal area and a new Peg Tube was present at the top of this incision. The facility failed to accurately replace or confirm proper placement of a Peg Tube resulting in harm to Resident R1, who required immediate surgery and hospitalization after the attempt to replace a Peg Tube while in the facility on April 11, 2014. 483.25 Quality of Care. Previously cited 8/1/13 & 7/10/12. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/1/13, 2/25/13 & 7/10/12. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/1/13, 2/25/13 & 7/10/12.

Based on a review of clinical records, facility documentation, facility policies and procedures, and interviews with staff, it was determined that the facility staff did not provide appropriate safety precautions while providing incontinence care resulting in actual harm to one resident. (CL1). Findings include: Review of the clinical record for CL1 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS- an assessment tool) dated September 8, 2010, revealed that Resident CL1 had short and long term memory deficits and had sustained partial loss of voluntary movement on one side of her body. Further review of the MDS indicated that the resident required extensive assistance from two staff persons for bed mobility, transfers and toilet use. Additionally, the resident needed extensive assistance by one staff person for dressing, eating and personal hygiene. A reportable event dated March 26, 2011, received via the Pennsylvania Department of Health Event Reporting System revealed that at 4:30 a.m., the resident had fallen out of bed during incontinence care. The resident was noted to have a laceration on the back of her head immediately following the fall and was transferred to the hospital for further evaluation. Review of Resident CLI's emergency room record dated March 26, 2011, indicated that the resident had sustained a subarachnoid hemorrhage (bleeding within the skull) as a result of the fall. In addition, the hospital record indicated that the resident was transferred to a hospice center on March 28, 2011. Review of facility policy, "1.0-PA Abuse Prohibition" dated revised August 3, 2009, indicated that the facility defined neglect as the withholding of services and/or goods which are necessary to maintain the physical and/or mental health of the resident. Review of the Resident CL1's clinical record revealed a Resident Assessment Protocol Summary (RAPS-assessment of care areas) dated September 8, 2010, which indicated that the resident had care needs identified in the areas of ADL function (ADL-activities of daily living includes basic self care tasks such as personal hygiene) and falls. Review of Resident CL1's care plan dated last revised March 14, 2011, revealed that the resident was at risk for falls and denoted that staff use two half siderails for mobility and independence. Additional review of the clinical record revealed a physician's orders [REDACTED]. Review of facility documentation related to the fall revealed that on March 26, 2011, at 4:30 a.m., Resident CL1 had fallen out of bed while incontinence care was being provided by facility staff. Further review of the documentation indicated that staff had rolled the resident on to her side, had turned away from the resident to get supplies and the resident rolled off of the bed onto the floor. The bed was raised in an elevated position off of the floor and one of the half side rails was not raised at the time of the fall. An interview with the director of nursing on April 12, 2011, at 2:30 p.m., confirmed that during the administration of incontinence care, Resident CL1 had fallen off the bed from an elevated position and that both half side rails were not raised at the time of the fall. Further interview with the director of nursing confirmed that the resident was transported to the hospital for treatment of [REDACTED]. The facility failed to ensure that appropriate safety measures (raised half rails while bed is in an elevated position) were employed by staff during the delivery of incontinence care to one resident. Facility staff did not utilize adequate safety measures during the provision of care which resulted in actual harm to the resident. 28 Pa. Code: 211.12(d)(5) Nursing Services 28 Pa Code: 211.10(d) Resident care policies