Every finding on record at Claremont Nursing & Rehabilitation Center

Findings include: Review of Resident 1's clinical record revealed diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident 1's current physician orders revealed the following orders dated April 3, 2026:Insulin Aspart Subcutaneous Solution Pen-injector 100 UNIT/ML (medication to treat diabetes) inject 28 units subcutaneously two times a day.If blood sugar is less than 150 or NPO/not eating hold and notify provider. If blood sugar is greater than 400 notify provider; check blood sugar for signs and symptoms of high/low blood sugars and notify physician if the blood sugar is less than 60 or greater than 400.Give appropriate snack or administer as needed glucagon per physician orders; and glucagon solution prefilled syringe inject one syringe subcutaneously every 15 minutes as needed for blood sugar less than 50 for unresponsive (stuporous, unable to take oral intake) resident; inject one syringe and repeat blood sugar in 15 minutes, may repeat injection twice if resident remains unresponsive. Notify physician. If resident is able to after first injection, give a snack/drink Review of Resident 1's emergency medical service (EMS) report dated April 10, 2026, revealed that they arrived at the facility at 6:40 PM, and found Resident 1 laying in bed, conscious, breathing without difficulty, not alert and not responding normally. Nursing home staff reported they had the pt in a wheelchair and he all of a sudden slumped over. Pt is normally A[lert] & O[riented] x 4 (person, place, time, and event), is not a diabetic, does not have a seizure history and he just has an extensive cardiac history. The report further indicated that at 6:45 PM the EMS crew took Resident 1's blood sugar and that it was 34 and that Resident 1 was given a dextrose intravenous infusion, and by 6:50 PM Resident 1's blood sugar was up to 177. The report further indicated that after treatment was provided to Resident 1, he was able to answer EMS questions and that he stated he was a really bad diabetic and was able to state his name and age, which did not match the paperwork provided by the facility. Resident 1 refused to go the emergency room for further evaluation and was taken back into the facility at 7:00 PM. Review of Resident 1's clinical record failed to reveal any nurses' notes on April 10, 2026, about Resident 1's change in condition, actions taken to include calling EMS or that Resident 1's physician was made aware. Review of Resident 1's clinical record vital signs section failed to reveal that any blood sugars were taken on April 10, 2026, after 12:00 PM. Review of Resident 1's April 2026 Medication Administration Record (MAR) revealed that his blood sugar on April 10, 2026, at 12:00 PM, was 117 and insulin was documented as being administered. Further review of Resident 1's MAR revealed that on April 9th at 12:00 PM his blood sugar was 119; on April 11th at 8:00 AM his blood sugar was 145; and on April 12th at 12:00 PM his blood sugar was 147. Insulin was signed as being administered outside of physician ordered parameters. Further review of Resident 1's clinical record failed to reveal any documentation that his physician was made aware of his blood sugars being below 150. During a staff interview with the Nursing Home Administrator (NHA) and DON on April 15, 2026, at 1:45 PM, the DON indicated that she was notified via email by EMS representative on April 14, 2026, of the situation with Resident 1 that occurred on April 10, 2026. She said that she then began looking into the situation. She indicated that Employee 1 was out of the country on a family emergency, but that she was able to speak to him by phone and she wrote the note based on what he told her during their discussion. She said that Employee 1 also indicated he had Employee 2 print paperwork for transfer while he remained with Resident 1 and that he had called 911 from Resident 1's room. She indicated that Employee 1 said he was the nurse who gave report to the EMS crew and that Employee 2 handed the crew the paperwork. She said that Employee 2 usually works on the other hall of the unit and was not familiar with the residents on the hall where Resident 1 resided. The DON confirmed that the paperwork given to EMS was for Resident 3 who has the same first name as Resident 1. The DON also indicated that Employee shared that he did not understand the discrepancies in Resident 1's blood sugars at the time the event occurred. The NHA indicated that they are looking at measures to ensure accurate information is provided to care providers, as well as entering name alerts in their electronic health records to prevent reoccurrence. During a final staff interview with the NHA and DON on April 15, 2026, at 2:38 PM, both confirmed that they would expect nurses to complete all necessary documentation at time of occurrence. In addition, the DON confirmed that she would expect nurses to provide EMS with accurate records and to follow a physician's orders. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility contract, clinical record review, and resident family and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for one of three residents reviewed (Resident 1).Findings include:Review of facility contract with outside agency, titled Care Agreement with an effective date of August 5, 2025, read, in part, Providers shall furnish medically necessary hospital care, medical services, and/or extended care services that are authorized by [outside agency] in accordance with the terms of this agreement (covered services).Review of Resident 1's clinical record revealed diagnoses that included dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), emphysema (a long-term lung condition that causes shortness of breath), and post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress).Review of Resident 1's clinical record revealed he had a BIMS (Brief Interview of Mental Status- a quick test used in long-term care settings to check cognitive function) score of 0.0, indicating severe impairment with thinking or memory. Review of Resident 1's nursing progress notes revealed a note on January 29, 2026, at 4:34 PM, that stated, Resident is back from appointment with no new orders. There was no note on January 29, 2026, indicating when he left the unit for his appointment.Further review of Resident 1's nursing progress notes revealed a note on January 30, 2026, at 11:10 AM, that stated, [Resident 1's wife] called in to ask why no escort was sent with resident yesterday at his appointment. This writer advised that facility was told she would be attending appointment, so facility did not send escort. Wife was advised that an escort would be present for all appointments whether family comes or not. Wife thanked writer for call.Interview with Resident 1's wife on February 11, 2026, at 11:47 AM, revealed the outpatient appointment center called her in the afternoon on January 29, 2026, stating her husband was not at his appointment and asking if she was there. She revealed she never discussed attending his appointment with anyone at the nursing facility or the outpatient center, as she would not have had the transportation to attend. During an interview with Employee 1 (Unit Secretary) on February 11, 2026, at 12:16 PM, she revealed she remembered hearing that Resident 1's wife was attending the appointment prior to the appointment, but she does not remember who she heard it from. She stated that on the day of Resident 1's appointment, the outside transport employee came into the facility to get Resident 1 for his appointment and took him to the transport vehicle. She confirmed that Resident 1 did not have an escort from the facility. Interview with Employee 2 (Nurse Unit Manager) on February 11, 2026, at 12:36 PM, revealed he spoke with Resident 1's wife on the day of the appointment and she was upset that he did not have an escort from the nursing facility. He further revealed they don't always put a note in the medical record as to what time residents leave the unit for their appointments. Interview with Employee 3 (Assistant Director of Nursing) on February 11, 2026, at 1:05 PM, revealed Resident 1 left the unit around 11:30 AM or noon on January 29, 2026, but the exact time is unknown. She revealed his appointment was at 1:00 PM, and he returned to the facility at 4:34 PM, according to the note. She further revealed his appointment was not on his calendar in the health record as it should have been, and there should have been a note detailing what time he left the facility, written by the unit manager or designee. Interview with the Nursing Home Administrator (NHA) on February 11, 2026, at 1:43 PM, confirmed that Resident 1 did not have an escort the day of his appointment, but it was the facility's understanding that his wife was going to meet him there. He revealed he received an email from an employee for the outside agency surrounding the incident and reiterating the contract between the two entities, stating the facility is to send an escort unless a family member is meeting them at their appointment. He confirmed his appointment should have been on his calendar, and facility staff should have documented when he left for his appointment. Email correspondence between the NHA and Employee 4 (Outpatient Center Case Manager) on January 30, 2026, at 2:21 PM, read, in part, We received a call from [Resident 1's] spouse, who was very upset about an incident that occurred yesterday regarding transport to [the outpatient center]. Both the spouse and [our] staff reported that [he] was sent for an appointment without staff accompanying him from Claremont. The [resident] was located and safely transported to the correct area; however, the CT scan could not be completed per the case manager. If you have time, I would appreciate a quick call on Monday to ensure Claremont is aware of the policy: [Residents] being transported by [our] transportation must have someone accompany them from the [nursing home] facility unless it has otherwise been arranged that a family member will accompany the [patient] upon arrival at the [outpatient center]. Additionally, the spouse expressed concern that the [patient] was sent via transport wearing only a thin jacket when the temperature was 10 degrees outside. I would like an opportunity to discuss this incident and make sure we are all on the same page moving forward.During a phone interview with Employee 5 (Outpatient Center Employee) on February 11, 2026, at 3:05 PM, she revealed the outpatient center's transportation driver picked Resident 1 up from the nursing facility and dropped him off at the entrance to the outpatient center. She stated there are volunteers or employees of the center right inside the entrance that greet the patients as they walk in. She stated Resident 1 approached them and told them his name and they brought him to his appointment. Once there, he was registered for his scan. As he walked back with an employee for his scan, he started to become agitated and asked where his wife was. The outpatient center staff then called his wife who told them she was not at the appointment and that someone from the facility should have joined him. The Resident displayed confusion and started to become belligerent and refused the scan, and the outpatient center staff called their transportation to pick him up and return him to the center.Review of Resident1's clinical record revealed he frequently refuses care, tests, laboratory work, and medications due to agitation. Further into the phone interview with Employee 5 on February 11, 2026, at 3:12 PM, she stated she got a call shortly after the incident from Employee 2 stating Resident 1's wife called and said he was unattended at his appointment and he thought the outpatient agency was responsible to arrange an escort for transport. She explained that per the agreement, it is the responsibility of the nursing center to arrange an escort or a family member to meet a patient for their appointment. Employee 4 later called back to the facility to speak to Employee 3 about the event and make her aware of the concern that he was not dressed properly. Interview with the NHA on February 11, 2026, at 3:39 PM, revealed he would expect residents with cognitive impairment to be accompanied by a staff escort or a family member for outside appointments. He further revealed his expectation that staff document when residents leave and return from their appointments, the appointments to be noted on their calendars in their health records, and for residents to be dressed appropriately for outside appointments. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to label medications properly in three of six medication carts observed (Third Floor [NAME] Hall, C-Wing C Hall, and Transitions East Hall) and two of four medication rooms observed (First Floor and Heritage Harbor); and the facility failed to discard expired medications in three of six medication carts observed (First Floor West, C-Wing C Hall, and Transitions East Hall) and in one of four medication rooms observed (Third Floor).Findings include: Review of facility policy, titled Medication Storage, with a last review date of March 17, 2025, revealed, in part, 8. Unused Medications: All medication rooms are routinely inspected by the IDT members for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy or returned to the pharmacy. Review of policy, titled Insulin Pen, with a last review date of March 17, 2025, revealed, in part, 2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used; a new pen must be ordered from the pharmacy. 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. Review of policy, titled Medication Administration, with a last review date of March 17, 2025, revealed, in part, 10. Identify expiration date. If expired, notify nurse manager. Review of policy titled Multi-Dose Vials, with a last review date of March 17, 2025, revealed, in part, 2. Multi-dose vials will be re-labeled with a beyond use date, 28 days after the vial is opened or punctured (unless otherwise specified by the manufacturer). 3. The medication label will also include the initials of the nurse who opened the vial. 5. Visually inspect the vial before each use to double check the expiration date, beyond use date if previously opened, and ensure there is no visible contamination. 6. Discard the vial accordingly if the vial is out of date (past the beyond use date/manufacturer's expiration date) or is visibly contaminated. 7. Unit Manager will perform random checks of opened multi-dose vials for appropriate dating. Review of DermaRite Liquid Active Protein data sheet on DermaRite.com revealed that the supplement should be used or discarded within three to six months of opening. Review of tuberculin testing solution information at www.pa.gov revealed that tuberculin skin testing solution expires 30 days after the initial puncture into the vial. Observation of the Third Floor [NAME] Hall Medication Cart on November 19, 2025, at 10:20 AM, with Employee 1 (Licensed Practical Nurse), revealed an opened bottle of DermaRite Liquid Protein Supplement with no open date indicated, and a bottle of geritussin that had no legible manufacturer expiration date noted. Employee 1 confirmed the findings and indicated that she would discard the medications. Observation of the Third Floor Medication Room on November 19, 2025, at 10:25 AM, with Employee 1, revealed an unopened box of lorazepam (a controlled medication used to treat anxiety) liquid for Resident 189 that had a manufacturer expiration date of September 2025. Employee 1 confirmed the finding and indicated that she would discard the medication when she could find another nurse to witness the destruction. Observation of the First Floor [NAME] Hall Medication Cart on November 19, 2025, at 10:37 AM, with Employee 2 (Licensed Practical Nurse), revealed a bottle of Senna Plus (a stool softener) with an opened date of June 25, 2025, and a manufacturer expiration date of October 2025. Employee 2 confirmed the finding. Observation of the First Floor Medication Room on November 19, 2025, at 10:40 AM, with Employee 2, revealed an opened vial of tuberculin testing solution with no opened date indicated. Employee 2 confirmed the finding. Observation of the C-Wing C Hall Medication Cart on November 19, 2025, at 10:47 AM, with Employee 3 (Licensed Practical Nurse), revealed an opened bottle of Nephro Vitamins C and B Complex with an opened date of October 18, 2025, and a manufacturer expiration date of August 2025; and a bottle of iron liquid supplement with an opened date of June 30, 2025, that had no legible manufacturer expiration date noted. Employee 3 confirmed the findings. Observation of the Transitions Unit East Hall Medication Cart with Employee 4 (Licensed Practical Nurse) on November 19, 2025, at 10:59 AM, revealed an opened Lantus Insulin Pen with no resident name or open date; a Lispro Insulin Pen for Resident 187 with no open date indicated; a bottle of Nephro Vitamins with an open date of November 1, 2025, and a manufacturer expiration date of October 2025; and an opened bottle of DermaRite Liquid Protein Supplement with no open date indicated. Employee 4 confirmed the findings. Observation of Heritage Harbor Medication Room on November 19, 2025, at 11:12 AM, with Employee 5 (Licensed Practical Nurse), revealed an opened vial of tuberculin testing solution with no open date indicated. Employee 5 confirmed the finding. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on November 19, 2025, at 2:13 PM, the DON confirmed that she would expect medications to be labeled properly and to be discarded when expired. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3) Nursing services

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 8).Findings include: Review of facility policy, titled Wound Treatment Management, with a last review date of March 17, 2025, revealed, in part, 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. Review of Resident 8's clinical record revealed that he was originally admitted to the facility on [DATE], with diagnoses that included a stage 3 pressure injury to the right buttock, unspecified severe protein-calorie malnutrition (nutritional status in reduced availability of nutrients that leads to changes in body composition and function), and cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). Review of Resident 8's current physician orders revealed the following orders: Measure right buttock wound and complete Wound Evaluation every Friday on evening shift for stage 4 pressure injury, dated September 17, 2025. Further review of Resident 8's physician order history revealed that this order was originally initiated on August 20, 2025. Review of Resident 8's August Treatment Administration Record (TAR) revealed that his wound evaluation was coded as being completed on August 20 and 27, 2025, but a wound evaluation form was not completed. Review of Resident 8's September TAR revealed that his wound evaluation on September 3, 2025, was coded as 9 (other/see progress note), but review of progress notes failed to reveal a corresponding progress note. His wound evaluation for September 19, 2025, was signed as completed but no wound evaluation form was completed. His wound evaluation for September 26, 2025, was blank, and no wound evaluation form was completed. Review of Resident 8's October TAR revealed that his wound evaluation was coded as being completed on October 3, 10, 17, 24, and 31, 2025. A wound evaluation form was not completed on October 3, 17, or 24, 2025. A wound evaluation form was completed on October 10 and 30, 2025. Review of Resident 8's November TAR revealed that his wound evaluation was coded as being completed on November 7, 2025; and on November 14, 2025, the wound evaluation was blank. There were no wound evaluation forms completed for November 2025. During a staff interview with Employee 6 (Registered Nurse/Wound Nurse) on November 21, 2025, at 9:50 AM, she indicated that if the in-house wound consultant follows a resident's wounds, the wound consultant completes the assessment/measurements of the wound weekly. Employee 6 further indicated that if a resident goes to an off-site wound clinic, then the staff nurses on the units are responsible for completing the weekly assessment/measurements of a resident's wound. Email communication received from the Director of Nursing (DON) on November 21, 2025, at 10:41 AM, she confirmed that there were missing wound evaluations. Review of Resident 8's most recent wound clinic consult dated November 13, 2025, revealed a recommendation for a Roho chair cushion to be utilized. Observation of Resident 8 with Employee 7 (Registered Nurse) on November 21, 2025, at 10:40 AM, revealed that the Resident was sitting in his wheelchair on a gel cushion. During a staff interview with the Nursing Home Administrator and DON on November 21, 2205, at 11:02 AM, the DON indicated that she would follow-up on the Roho cushion not being implemented as recommended by the wound clinic. During a staff interview with the DON on November 21, 2025, at 11:15 AM, she confirmed that she would expect nursing staff to have assessed, measured, and documented the findings accordingly. She also indicated that she would also expect the wound clinic to share their measurements and assessment findings. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon for two of five residents reviewed for unnecessary medications (Residents 5 and 8).Findings include: Review of Facility policy, titled Medication Monitoring, with a last review date of March 17, 2025, revealed, in part, 5. Each resident's medication regimen is reviewed by a licensed pharmacist at designated intervals, and whenever changes in condition that could be related to medications are noted. Irregularities are reported and addressed in accordance with facility policy for medication regimen reviews and addressing irregularities.Review of facility policy, titled Medication Regimen Review, (MRR) with a last review date of March 17, 2025, revealed, in part, 4. The pharmacist, physician or CRNP [Certified Registered Nurse Practitioner] should document, either manually or electronically, that a medication regimen review has been completed. a. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. 5. The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. 6. Written communications from the pharmacist shall become a permanent part of the resident's medical record. 7. Timelines and responsibilities for pharmacist Medication Regimen Review: a. The consultant pharmacist should schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities. b. The pharmacist shall communicate any recommendations and identified irregularities via written communication. f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.Review of Resident 5's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning).Review of Resident 5's physician orders revealed an active order for Sennosides Tablet as needed, with a start date of August 6, 2025.Further review of Resident 5's physician orders revealed an active order for Senna-Docusate Sodium Oral Tablet as needed, with a start date of August 18, 2025.Review of Resident 5's clinical record revealed an MRR on August 31, 2025, that read, in part, A medication regimen review was performed- see report for comments/recommendations(s) noted. Comments: Resident has PRN (as needed) orders for senna and senna/docusate with diagnosis of constipation. Consider discontinuing one of these orders. If both are to remain active, please add more specific directions to help determine when each should be used. Thank you.During an email correspondence with the Director of Nursing (DON) on November 20, 2025, at 1:55 PM, she revealed she was unable to provide a signed copy of the aforementioned MRR to indicate that it was reviewed by the physician. During a follow up interview with the DON on November 21, 2025, at 11:06 PM ?AM, revealed the physician was going to review the aforementioned MRR later that day, as there was no evidence to indicate it was responded to prior. She further revealed her expectation that monthly MRRs should be reviewed by the physician timely and recommendations to be implemented, if applicable.Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and unspecified severe protein-calorie malnutrition (nutritional status in reduced availability of nutrients that leads to changes in body composition and function). Review of Resident 8's clinical record revealed that the facility consultant pharmacist reviewed his medication regimen on July 3, 2025, and made recommendations. Review of facility provided Drug Regimen Review Documentation note for Resident 8's July 3, 2025, medication regimen review revealed that the pharmacist had identified the following concerns: Resident has two active orders for Tylenol PRN [as needed] for pain-650 milligrams every six hours as needed, and 1000 milligrams every eight hours as needed. Please verify which is correct and discontinue the other to avoid possible duplication of therapy. 2. There are active orders for Imodium 2 milligrams TID [three times a day] for diarrhea and Senna 8.6 milligrams daily for constipation. These are conflicting diagnoses. Please evaluate. The note was initialed by Resident 8's Certified Registered Nurse Practitioner (CRNP) on July 7, 2025, with no documentation or orders provided. In addition, the note was initialed by a staff nurse also dated July 7, 2025. Review of Resident 8's physician order history revealed that the Tylenol orders were clarified on July 17, 2025, and that the Imodium and Senna conflicting orders were clarified on August 6, 2025. Further review of Resident 8's clinical record revealed that the facility consultant pharmacist reviewed his medication regimen on July 31, 2025, and noted no irregularities, even though Resident 8 was continuing to receive both the Imodium and Senna daily for the previously identified conflicting diagnoses. During a staff interview with the Nursing Home Administrator and DON on November 21, 2025, at 11:00 AM, the DON confirmed that no clear order was given by the CRNP even though he had initialed the document and, therefore, the Imodium and Senna continued. She further indicated that nursing staff should have followed up with the CRNP when no documentation or order was provided about the Imodium and Senna. She indicated that the pharmacist should have utilized the correct form when making recommendations on July 3, 2025, and confirmed that the pharmacist should have identified on Resident 8's medication regimen review on July 31, 2025, that the diagnoses conflict had not been addressed and should have reissued a report of the irregularity. 28 Pa. Code 211.2(d)(3) Medical director.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services to ensure acceptable parameters of nutrition and hydration for one of 35 residents reviewed (Resident 1). Findings include:Review of facility policy, titled Hemodialysis, dated 2024, revealed in section 5, that a licensed nurse will monitor and communicate a resident's nutritional/fluid management including weights, compliance with food/fluid restrictions, and intake/output measurements as ordered.Review of Resident 1's clinical record revealed diagnoses that included chronic kidney disease (a long-term condition where the kidneys are damaged and can't filter blood properly, leading to a buildup of waste and fluid) and dependence on renal dialysis (a patient's life is sustained by a medical process that artificially filters their blood because their kidneys have failed). Review of Resident 1's physician orders revealed a physician's order for a fluid restriction of 720 ml daily, with a start date of September 4, 2025.Review of Resident 1's TAR (Treatment Administration Record) for November 18, 2025, revealed Resident 1's fluid was being tracked by the medication nurse. Further review of the TAR revealed that Resident 1's fluid consumption was over the 720 ml limit four times in the month of November 2025: on 3, 6, 7, and 13.Review of Resident 1's Task section of the electronic medical record revealed Resident 1's fluid intake was being tracked by nurse aids. Further review revealed that as of November 18, 2025, Resident 1's fluid intake was over the 720 ml limit on 17 times in the month of November 2025: on 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, and 18.Further review and comparison of the Task documentation and Resident 1's TAR for November 2025 revealed that the amount of fluid documented that Resident 1 consumed did not match on any days.Interview with the Director of Nursing on November 21, 2025, at 8:00 AM, revealed that she had reviewed the documented amount of Resident 1's fluid intake with the unit manager and they were unable to determine the amount of fluid consumed by Resident 1.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 35 residents reviewed (Resident 8).Findings include: Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure) and cognitive communication deficit (a group of disorders that affect a person's ability to communicate, which can cause difficulty with understanding or producing language and nonverbal communication skills, such as gestures and facial expressions). Observation of Resident 8's room on November 19, 2025, at 9:35 AM, revealed a pair of shearing scissors that were approximately six to eight inches in length laying on the stand near Resident 8's television. Subsequent observations of Resident 8's room on November 20, 2025, at 10:37 AM, and 12:37 PM, revealed the same findings. During an observation of Resident 8's room on November 20, 2025, at 12:48 PM, with the Nursing Home Administrator (NHA) and Director of Nursing, the NHA acknowledged the presence of the scissors and confirmed that the scissors should not be in Resident 8's room within access of residents. He removed the scissors from Resident 8's room. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, facility documentation review, and resident and staff interviews, it was determined that the facility failed to provide care and services to ensure the residents' highest level of functioning and well-being for two of 35 residents reviewed (Residents 145 and 232). Findings include: Review of Resident 145's clinical record revealed diagnoses that included lymphedema (tissue swelling caused by an accumulation of protein-rich fluid) and hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone). Observation conducted on November 18, 2025, at 10:55 AM, in Resident 145's room, revealed compression wraps lying on the floor on the left side of Resident 145's bed. Interview conducted with Resident 145 on November 18, 2025, at 10:57 AM, revealed that she does not wear the compression wraps and that they have been on her floor for multiple days. Review of Resident 145's clinical record revealed that she was seen by a Certified Lymphedema Specialist on August 19, 2025, with a recommendation for the Resident to wear compression wraps for lymphedema. Further review of Resident 145's clinical record revealed that a compression vendor came to the facility on October 28, 2025, and fitted Resident 145 with full-leg garments. Resident 145's record failed to reveal any physician's orders or care plan regarding the administration of the full-leg garments. Interview conducted with the Nursing Home Administrator (NHA) on November 20, 2025, revealed that it took time to get Resident 145 compression wraps due to their insurance not covering the initial wraps and having to find an outside vendor to come in. The NHA revealed it normally takes a week or two since a resident is trialed for wraps for the vendor to provide them with an order for them to be administered. NHA revealed the vendor fitted Resident 145 on October 28, 2025, and they are waiting for them to provide any order. Review of electronic mail provided by the facility revealing communication between the facility and the vendor on November 20, 2025, at 4:07 PM, stating the prescription for Resident 145's new wraps arrived on that day, will be signed by the physician, and then the new wraps will start being applied to Resident 145. Review of Resident 145's clinical record revealed a compression garment prescription dated November 20, 2025, for four pairs of bilateral compression wraps. Review of Resident 232's clinical record revealed diagnoses that included presence of a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 232's admission MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of September 29, 2025, revealed in Section C. Cognitive Patterns that her score was a 6, indicating severe cognitive impairment. Review of Resident 232's clinical record revealed that she had a pacemaker replacement procedure on October 31, 2025. Review of Resident 232's physician orders revealed an order for bilateral enabler bars to promote independence with bed mobility, transfers and turning/repositioning every shift, dated September 26, 2025; and an order for left arm restrictions of: Do not lift, push or pull more than 2 pounds with left arm. No tub baths or soaking-ok to cleanse with soap and water. No lotions, ointments or powder to incision. Keep L[eft] elbow lower than shoulder height every shift for pacemaker care through December 1, 2025, with an original order date of October 31, 2025. Review of Resident 232's care plan and nurse aide Kardex failed to reveal left arm precautions for staff to follow. Review of Resident 232's nurse aide task documentation for lying to sitting on side of bed and rolling side to side from October 31, 2025, through November 21, 2025, revealed that Resident 232 had been coded as being independent to needing substantial assistance. Review of Resident 232's progress notes revealed a nurses note dated November 4, 2025, at 12:34 PM, indicated, in part, Resident denied pain/discomfort to area during skin assessment. Pushed resident back to dayroom after body assessment in room. While turning resident towards table in wheelchair, resident stated 'I can feel that pulling when you turned me.' Refused pain medication when offered. During a staff interview with the NHA and Director of Nursing (DON) on November 20, 2025, at approximately 2:00 PM, the concern was shared regarding Resident 232's ordered left arm restrictions not being communicated for nurse aides to follow, and potential safety concerns with her cognitive status and the independent use of the enablers possibly exceeding her ordered restrictions. During a staff interview with the NHA and DON on November 21, 2025, at 10:58 AM, the DON indicated that they removed the enablers yesterday after surveyor concerns were shared. She further indicated that the enablers had originally been placed after Resident 232 requested them to help with bed mobility and to help her feel safer in bed. When questioned if the facility had reevaluated Resident 232 for the safe use of the enablers when her restrictions were ordered on October 31, 2025, the DON confirmed that they did not do so. She also indicated that they had not considered utilizing only one enabler on the right side of the bed to limit use of the left arm. She confirmed that Resident 232 does have fluctuating cognition throughout the day and may not have been in adherence with her restrictions and independent use of the enablers. The DON confirmed that Resident 232's left arm restrictions were not care planned for staff to follow but should have been. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, facility policy review, state regulation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 35 residents reviewed (Resident 4). Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. Review facility policy, titled Medication Administration, without date, revealed that after the nurse prepares the medication for a resident, they must observe the resident consuming the medication. Review of Resident 4's clinical record revealed diagnoses that included dementia (a progressive loss of mental functions) and anxiety disorder (a mental health condition characterized by excessive and persistent fear, worry, or dread that can interfere with daily life). Observation of Resident 4 on November 18, 2025, at 10:24 AM, revealed the Resident lying in bed. Beside Resident 4, on the overbed table, was a cup containing 7 tablets in a medication cup. Further observation on November 18, 2025, at 11:12 AM, revealed the medication was still there and Resident 4 refused an interview at that time because she said that she didn't feel good. Review of Resident 4's physician's orders failed to reveal a physician's order for self-administration of medications. Review of Resident 4's care plan failed to reveal a care plan for self-administration of medications. Interview with Employee 1 LPN (Licensed Practical Nurse) on November 20, 2025, at 1:59 PM, revealed that when she was administering Resident 4's morning medications on November 18, 2025, she was interrupted and called away to do another task and left Resident 4's medications with Resident 4. Interview with the Director of Nursing on November 20, 2025, at 9:46 AM, revealed that Resident 4 did not have an evaluation or physician's order for self-administration of medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 35 residents reviewed (Residents 14 and 173).Findings Include: Review of facility policy, titled Comprehensive Care Plans; Dated 2022, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident 14's clinical record revealed diagnoses that included Vitamin D deficiency and osteoporosis (a condition in which the bones become brittle and fragile). Review of Resident 14's care plan revealed a care plan focus for surgical wound related to bilateral femur fractures, with an initiated date of July 3, 2025. Review of Resident 14's clinical record revealed that she no longer had any healing surgical incisions. Email communication received from the Director of Nursing (DON) on November 21, 2025, at 2:07 AM, indicated that Resident 14's care plan was revised to remove the surgical wound. During a staff interview with the Nursing Home Administrator and the DON on November 21, 2025, at 8:36 AM, the DON confirmed that Resident 14's care plan should have been revised when her surgical wounds healed. Review of Resident 173's clinical record revealed diagnoses that included congestive heart failure (a chronic condition where the heart muscle can't pump enough blood to meet the body's needs) and obstructive uropathy (a condition where urine flow is blocked in the urinary tract, which can cause urine to back up and damage the kidneys). Observation of Resident 173 on November 18, 2025, at 9:45 AM, revealed the Resident lying in bed with his nephrostomy (a procedure where a tube is placed through the skin and into the kidney to drain urine) tube and bag lying in bed next to him. Review of current physician orders for Resident 173 revealed a current order for Left Nephrostomy Tube Site: Observe for signs/symptoms of infection, with a start date of October 30, 2025. Review of Resident 173's care plan failed to reveal any indication that Resident 173 had a Nephrostomy tube or required care pertaining to his nephrostomy tube. An interview with the DON on November 21, 2025, at 8:01 AM, revealed that Resident 173 should have a care plan that included nephrostomy care. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, facility admission agreement, closed clinical records, resident account statements, and staff interview, it was determined that the facility failed to convey resident fund account balance and overpayment balance upon discharge in accordance with State law for three of three closed resident records reviewed (Residents 1, 2, and 3). Findings include: A review of the facility policy, titled Resident Personal Funds, last revised [DATE], stated, Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. A review of the facility admission agreement stated the following,10.2 Refunds of Personal Funds. Any personal funds or valuables of Resident held by the Facility will be refunded .within thirty (30) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such entities or persons entitled to the refund under current law.10.3 Refunds of Prepayments or Overpayments. Any prepayments or overpayments made by Resident and held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due the Facility, within thirty (30) days after Resident's discharge or death. In the event of Resident's death, such refund will be made to the duly authorized representative of Resident's estate or to such other entities or persons entitled to the refund under current law. The closed clinical record confirmed that Resident 1 expired on [DATE]. Resident 1's account statement indicated that the Authorized Representative should have received a refund of $180.24 (one hundred eighty dollars and twenty-four cents). A refund check was not issued to the Authorized Representative until [DATE]. The closed clinical record confirmed that Resident 2 was discharged on [DATE]. Resident 2's account statement indicated that the Authorized Representative should have received a refund of $165.38(one hundred sixty-five dollars and thirty-eight cents). A refund check was not issued to the Authorized Representative until [DATE]. The closed clinical record confirmed that Resident 3 expired on [DATE]. Resident 3's Authorized Representative prepaid for the entire month of [DATE]. Resident 3's account statement indicated an overpayment of $4,370.75 (four thousand, three hundred seventy dollars, and seventy-five cents). The facility provided a copy of the canceled check that revealed the facility dated the check [DATE], and the paid date was documented as [DATE]. During an interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 PM, the NHA was aware that refunds on account balances should occur within 30 days. The NHA had to contact the corporate office for details of the refunds because they make the final approval. 28 Pa. Code 211.5(d) Clinical records 28 Pa Code: 201.18(e)(1) Management

Based on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents reviewed for respiratory care (Resident 369). Findings include: Review of facility policy, titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy), undated, revealed, The facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy device and settings from the practitioner. Review of Resident 369's clinical record revealed diagnoses that included congestive heart failure (CHF - weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and obstructive sleep apnea (sleep disorder that causes breathing pauses during sleep due to a blockage of the upper airway). Observation on October 28, 2024, at 1:53 PM, revealed a CPAP machine (delivers a continuous stream of air, preventing airway collapse from obstructive sleep apnea) present on Resident 369's bedside stand. During an immediate interview with Resident 369, she revealed that she uses the machine, but that is has not been cleaned since she resided on another unit a while ago. Review of physician's progress note dated August 13, 2024, revealed notation for Resident 369 to continue using a CPAP machine for sleep apnea. Review of Resident 369's active care plan revealed that she uses a CPAP machine for sleep apnea, initiated on July 18, 2022. Review of Resident 369's physician orders revealed an order for BIPAP at bedtime, starting October 24, 2024, and an order to clean the BIPAP/CPAP tubing, nasal mask and headgear weekly, starting October 24, 2024. Further review of Resident 369's physician orders failed to reveal any order for BIPAP/CPAP use or care since November 13, 2023. During a review of orders in the presence of the Director of Nursing on October 31, 2024, at 1:02 PM, she acknowledged that she was unable to locate any orders for CPAP/BIPAP care or use between November 2023 and October 24, 2024. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from potential for abuse by failing to perform criminal history background checks prior to hire for three of five personnel files reviewed (Employees 3, 4, and 5). Findings Include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated 2022, revealed, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Review of the personnel file for Employee 3 (Registered Nurse) revealed no evidence that a Pennsylvania State Police background check or an FBI background check (for new hires that have not resided in Pennsylvania for two years) was completed prior to her hire on September 4, 2024. Review of personnel file for Employee 4 (Nurse Aide) revealed no evidence that a Pennsylvania State Police background check or an FBI background check (for new hires that have not resided in Pennsylvania for two years) was completed prior to her hire on August 14, 2024. Review of personnel file for Employee 5 (Licensed Practical Nurse) revealed no evidence that a Pennsylvania State Police background check or an FBI background check (for new hires that have not resided in Pennsylvania for two years) was completed prior to her hire on October 10, 2024. During an interview with the Nursing Home Administrator on October 31, 2024, at 1:03 PM, he acknowledged the aforementioned concerns. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.19(8) Personnel policies and procedures

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment for three of 35 residents observed (Residents 156, 167, and 252); and failed to maintain a safe, clean, and home-like environment on one of six nursing units observed (Heritage Harbor). Findings include: Review of facility policy, titled Routine Cleaning and Disinfection, with a last review date of March 26, 2024, revealed, in part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment; Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge; Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: f. toilet seats; h. Resident chairs; Cleaning of walls, blinds, window curtains will be conducted when visibly soiled; and Wheelchairs will be cleaned on a predetermined schedule and when visibly soiled. Observation on the Heritage Harbor unit on October 28, 2024, at 10:21 AM and at 12:49 PM, and on October 29, 2024, at 8:51 AM, revealed a long, dried liquid stain in the hallway extending from the bird cage to the corner of the adjoining hallway near the entrance door. A strong urine odor was present. Observation of the courtyard door curtains in the Heritage Harbor dayroom on October 28, 2024, at 10:38 AM; on October 29, 2024, at 9:15 AM; and on October 30, 2024, at 9:16 AM, revealed several dried reddish stains. During an interview with the Nursing Home Administrator (NHA) on October 31, 2024, at 11:12 AM, he revealed the expectation that the aforementioned concerns would have been cleaned in a timely manner. Observation of Resident 156's room on October 28, 2024, at 11:47 AM, revealed food debris between their bed and nightstand. During an immediate interview with Resident 156, the Resident indicated that housekeeping is sparse and that the debris had been there for a few days. Follow-up observation of Resident 156's room on October 30, 2024, at 10:15 AM, revealed the same observation of food debris between their bed and nightstand. During a staff interview with the NHA and Director of Nursing (DON) on October 31, 2024, at 11:06 AM, the NHA confirmed that he would expect Resident 156's bathroom to have been cleaned of the identified concern with the daily routine cleaning of the room. Observation of Resident 167's wheelchair made on October 28, 2024, at 1:34 PM, revealed a large amount of a brown, clumpy substance covering the left side of the seat and lower bar of the wheelchair. Follow-up observations of Resident 167's wheelchair made on and October 29, 2024, at 8:54 AM and 11:06 AM, revealed the same observation of a brown, clumpy substance covering the left side of the seat and lower bar of the wheelchair. During a staff interview with the NHA and DON on October 30, 2024 at 1:19 PM, the NHA revealed that wheelchairs receive a deep cleaning every six weeks and that Resident 167's wheelchair had been cleaned on October 23, 2024. The NHA also stated that he would expect that if wheelchairs were noticeably soiled, they would be cleaned as needed between scheduled deep cleanings. Observation of Resident 252's bathroom on October 28, 2024, at 12:04 PM, a dried, brown substance was noted to be on the front of the toilet bowl. During an immediate interview with Resident 252, the Resident indicated that this was an ongoing issue and that it has been worse than that on occasion. Follow-up observation of Resident 252's room on October 30, 2024, at 10:16 AM, revealed the same observation of a dried, brown substance was noted to be on the front of the toilet bowl. During a staff interview with the NHA and DON on October 31, 2024, at 11:06 AM, the NHA confirmed that he would expect Resident 252's room to have been cleaned of the identified concerns with the daily routine cleaning of the room. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

Based on policy review, observation, record review, and staff interview, the facility failed to complete a risk-benefit analysis and obtain consent for enabler bar use for one of six residents reviewed for enabler use (Resident 33). Findings include: Review of facility policy, titled Proper Use of Bed Rails, dated 2023, with a last review date of March 26, 2024, revealed, in part, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails; 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. Size and weight; c. Sleep habits; d. Medication(s); e. Acute medical or surgical interventions; f. Underlying medical conditions; g. Existence of delirium; h. Ability to toilet self safely; i. Cognition; j. Communication; k. Mobility (in and out of bed); and l. Risk of falling; 2. The resident assessment must also assess the resident's risk from using bed rails; 5. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails; 6. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: a. What assessed medical needs would be addressed by the use of bed rails; b. The resident's benefits from the use of bed rails and the likelihood of these benefits; c. The resident's risks from the use of bed rails and how these risks will be mitigated; and d. Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate; 7. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.; 11. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan, including, but not limited to, the following information c. Ongoing assessment to assure that the bed rail is used to meet the resident's needs; d. Ongoing evaluation of risks; and 12b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. Review of Resident 33's clinical record revealed diagnoses that included morbid obesity (obesity in which the person weighs 80-100 pounds over their ideal body weight) and chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body). Review of Resident 33's current physician orders revealed an order for occupational Therapy evaluate and treat as indicated-Resident requesting bilateral enablers on bed for positioning, dated January 7, 2024. Further review of Resident 33's current physician orders failed to reveal any other orders regarding bilateral enablers. Review of Resident 33's care plan failed to reveal the use of bilateral enablers. Observation of Resident 33 on October 28, 2024, at 11:23 AM, revealed the presence of bilateral enablers on their bed. Review of Resident 33's clinical record revealed that there were two Bed Safety with Measuring Tool evaluations completed by nursing staff regarding Resident 33's bilateral enabler use; one was dated February 5, 2024, and the other was dated April 22, 2024. Further review of Resident 33's clinical record failed to reveal the presence of an informed consent or documentation of education with Resident 33 regarding the risks versus benefits of the bilateral enabler use. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on October 31, 2024, at 11:02 AM, the DON indicated that she could not provide any Occupational Therapy evaluation from January 2024 that Resident 33 was determined to be safe in the functional use of the bilateral enablers. In addition, she indicated that she could not provide a consent form or documentation to support that Resident 33 was educated on the risks versus benefits of the use of the bilateral enablers. She confirmed that she would have expected the therapy evaluation to have been completed as ordered to determine Resident 33's safe use of the enablers and the consent obtained before the enablers were placed on the bed. She also indicated that she would have expected Resident 33's use of bilateral enablers to have been reassessed for the safe use according to facility policy. 28 PA code 201.18(b)(1) Management 28 PA code 211.10(d) Resident care policies 28 PA code 211.12(d)(2)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of 35 residents reviewed (Residents 25 and 136). Findings include: Review of facility policy, titled Skin Assessment, undated, with the last review date of March 26, 2024, revealed, in part, A full body, or head to toe, skin assessment should be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review of Resident 25's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and edema (swelling caused by excess fluid accumulation in the body tissues). Review of Resident 25's October 2024 TAR (Treatment Administration Record - form used to document physician orders as well as when and how treatments are administered to a resident) revealed a physician order for Ace wraps (elastic bandage that applies pressure to control swelling) to be applied in the morning and removed at bedtime daily for edema, starting September 28, 2024. Observations on October 28, 2024, at 11:58 AM and at 1:26 PM; on October 29, 2024, at 9:04 AM; and on October 30, 2024, at 9:17 AM and at 12:25 PM, revealed that no ace wraps had been applied to Resident 25. Further review of Resident 25's October 2024 TAR revealed that it was documented that the ace wraps were applied as ordered on each of the aforementioned dates. During an interview with the Director of Nursing (DON) on October 31, 2024, at 11:07 AM, she revealed she did not have any further information regarding the absence of Resident 25's ace wraps. She also revealed the expectation that the ace wraps should have been applied as ordered. Review of Resident 136's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), and protein-calorie malnutrition (the state of inadequate food intake). Observation of Resident 136 on October 28, 2024, at 11:53 AM, revealed the presence of two dressings to their left elbow. Neither dressing was dated and there were two small areas of dark brown-black discoloration on the dressings. Review of Resident 136's current physician orders revealed an order for Conduct full body assessment weekly on Thursday - Evening shift. Document findings in assessments (weekly skin observation tool) dated June 7, 2024, but failed to reveal any ordered treatment for their left elbow. Review or Resident 136's order history revealed an order to Cleanse left elbow with wound cleanser. Apply Xeroform gauze. Cover with ABD pad. Secure with conforming roll gauze and tape. Discontinue order once healed. Every day shift for Wound Care with a start date of September 16, 2024, and discontinuation date of October 2, 2024. Review of Resident 136's clinical record progress notes failed to reveal any documentation regarding a current skin issue to their left elbow. Review of a progress note dated October 1, 2024, indicated the wound to their left elbow was resolved. Review of Resident 136's September Treatment Administration Record revealed that their weekly full body assessment was coded N on September 5, 12, 19, and 26, 2024. Review of Resident 136's October Treatment Administration Record revealed that their weekly full body assessment was coded Y on October 3, 2024, and N on October 10, 17, and 24, 2024. Review of Resident 136's assessments in the clinical record failed to reveal that a weekly skin observation tool had been completed since August 22, 2024. Follow-up observations of Resident 136 on October 29, 2024, at 1:33 PM, and on October 30, 2024, at 10:18 AM and 12:15 PM, revealed the presence of one dressing to their elbow, which had a small area dark brown-black discoloration and was not dated. Email communication received from the DON on October 31, 2024, at 8:27 AM, indicated that she had investigated the aforementioned observations and findings. She revealed that nurses were interviewed and declined putting bandage on resident. The nurse said that the hospice nurse was in the past few days. The UM [Unit Manager] contacted hospice nurse who stated that she put the bandage on him because it was scabbed over and she didn't want it to open up. She stated she did not tell the nurse or the unit manager and didn't send over a recommendation. She apologized and said she'd fax over a recommendation. This morning, I [DON] did receive a verbal order for a foam bordered dressing to left elbow for protection and to change every 3 days and PRN [as needed]. I [DON] will be putting the order in the computer today. During an interview with the DON and the Assistant DON on October 31, 2024, at 9:08 AM, the concern of Resident 136 having no documented weekly skin observation tool since August 22, 2024, and Treatment Administration Records being coded as N was shared. The DON indicated that the coding was to indicate that the weekly observation tool was (Y) or was not completed (N). She confirmed that the coding of N would indicate that the skin check was not completed. She said she would look at it but, at that point, would have to agree that the documentation to support weekly skin checks was lacking. During a final interview with the Nursing Home Administrator (NHA) and DON on October 31, 2024, at 11:04 AM, the DON confirmed that she had no additional documentation to provide that would show that Resident 136 had a weekly skin assessment. She said the hospice nurse should have communicated her intervention to facility at time of occurrence. The DON further indicated that facility nurses may not necessarily have noted that Resident 136 had a bandage on their elbow if a treatment was not ordered for their shift. The NHA and DON both confirmed that Resident 136 should have received a weekly skin assessment as ordered and that they would expect this to have been documented accordingly. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and assistive devices to maintain vision abilities for one of one resident reviewed for vision (Resident 240). Findings include: Review of Resident 240's clinical record revealed diagnoses that included chronic kidney disease (CKD - a long-term condition that occurs when the kidneys are damaged and cannot filter blood properly) and hypertension (high blood pressure). During an interview with Resident 240 on October 28, 2024, at 10:53 AM, revealed he was on the list to get his eyes examined in the beginning of this month (October 2024) but that did not occur, and Resident 240 was never told why or if it was rescheduled. Review of Resident 240's clinical record revealed a nursing progress note dated October 4, 2024, at 1:41 PM, with the following text: Resident to see by the optometrist on October 1, 2024. Will be seen on next visit due to time constraint. Observation at the third-floor nurses' station on October 29, 2024, at 12:43 PM, revealed a list of residents to be seen by the optometrist on October 29, 2024, which included Resident 240 on the list. During an interview with Resident 240 on October 30, 2024, at 10:25 AM, revealed the Resident saw their name was on the list to been seen by the optometrist on October 29, 2024, however, that did not occur. During an interview with the Nursing Home Administrator (NHA) on October 31, 2024, at 12:21 PM, he confirmed that Resident 240 did not see the optometrist on October 1 or 29, 2024, as scheduled due to a time constraint on October 1, 2024, and a miscommunication between the doctor and staff on October 29, 2024. NHA revealed he would have expected Resident 240 to have been seen as scheduled by the optometrist on October 1 or 29, 2024. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on observations, facility policy review, and staff interview, it was determined that the facility failed to provide appropriate care and services to residents receiving tube feedings for one of five residents with tube feedings reviewed (Resident 2). Findings include: Review of facility policy, titled Appropriate Use of Feeding Tubes, revised 2023, revealed the interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the initiation, continuation, or discontinuation of a feeding tube. Review of Resident 2's clinical record revealed diagnoses that included aphagia (a severe condition characterized by the inability to swallow, leading to persistent drooling and the inability to eat or drink) and dysphagia (difficulties swallowing). Observation of Resident 2 on October 21, 2024, at 11:25 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding and water flush hanging. The tube feeding was infusing at 60 cc per hour and the water was infusing at 55 cc per hour. Observation of Resident 2 on October 22, 2024, at 11:54 AM, revealed that the Resident was lying in bed. Beside the Resident's bed was a pole with tube feeding and water flush hanging. The tube feeding was infusing at 60 cc per hour and the water was infusing at 55 cc per hour. Review of current physician orders for Resident 2 on October 21, 2024, revealed a current order for Resident 2 to receive enteral feeding, Osmolite 1.5cal (type of enteral feeding) at 60 cc per hour a water flush of 60cc per hour for 20 hours per day. Review of Resident 2's plan of care revealed a focus area of the Resident requires tube feeding, with a revision date of May 15, 2024, and an intervention of the Resident is dependent with tube feeding and water flushes. See MD orders for current orders, with a date initiated of June 22, 2022. Interview with the Director of Nursing on October 31, 2024, at 12:33 PM, revealed that she would expect the Resident to be receiving the water flushes as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon in a timely manner for two of five residents reviewed for unnecessary medications (Residents 100 and 147). Findings include: Review of facility policy, titled Medication Regimen Review, undated, revealed, The consultant pharmacist should schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Review of Resident 100's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). Review of Resident 100's Note to Attending Physician/Prescriber forms dated June 24, 2024, and September 4, 2024, revealed the following recommendation: The resident is receiving the antipsychotic agent Seroquel, but lacks an allowable diagnosis to support its use .Please document applicable diagnosis. Further review revealed the physician did not respond to either recommendations until October 30, 2024. During an interview with the Director of Nursing (DON) on October 31, 2024, at 12:17 PM, she acknowledged that the physician did not respond to Resident 100's aforementioned pharmacy reviews in a timely manner. Review of Resident 147's clinical record revealed diagnoses that included dementia with psychotic disturbance and depression. Review of Resident 147's monthly pharmacy medication regimen reviews failed to reveal that one was completed by the pharmacist in April 2024. Review of Resident 147's Note to Attending Physician/Prescriber form dated June 24, 2024, revealed the following recommendation: The resident is receiving the antipsychotic agent Seroquel, but lacks an allowable diagnosis to support its use .Please document applicable diagnosis. Further review revealed the physician did not respond to the recommendation until October 30, 2024. During an interview with the DON on October 31, 2024, at 11:07 AM, she revealed she did not have any additional information about Resident 147's April 2024 medication regimen review. She also acknowledged that the physician did not respond in a timely manner to Resident 147's June 2024 pharmacy recommendation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice related to wound assessments for one of six residents reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included atherosclerosis (buildup of plaque in the walls of arteries causing reduced blood flow) and type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should). Review of Resident 5's nursing progress notes revealed a note dated June 2, 2024, at 10:44 PM, that stated, called Gentiva Hospice RN [Registered Nurse] about resident wound deterioration to LLE (left lower extremity) who stated to refer to wound team asap on Monday, covering dressing applied for now, area cleansed as ordered, MD notified, left message for Family member. Review of progress note dated June 3, 2024, at 10:35 PM, stated, Resident started on doxycycline 100 mg for left shin wound. No adverse effect noted, tolerated well. Vitals stable. Took all meds without difficulty and fluids. Pain management effective. Review of Resident 5's wound and skin note dated June 3, 2024, revealed the wound consultant nurse practitioner documented maggots were present in Resident 5's left anterior shin wound and ordered the wound to be cleansed with 0.125% dakins solution (diluted bleach wound cleansing solution), dakins moistened fluffed gauze to the base of the wound and secured with bordered gauze twice daily and as needed. A wound and skin note dated June 5, 2024, from the wound consultant nurse practitioner documented no live maggots were present in Resident 5's left anterior shin wound. Review of Resident 5's clinical record revealed no assessment of the wound and no documentation of maggots present in the wound in the progress notes. Further review of Resident 5's clinical record failed to reveal evidence that the facility nursing staff continued to monitor or assess Resident 5's wound after the maggots were identified. A staff interview on July 11, 2024, at 10:35 AM, with Employee 2 (Registered Nurse) revealed, Employee 2 was one of the registered nurse supervisors for the building the evening of June 2, 2024. Employee 2 stated that she was notified around 9:30 PM - 10:00 PM by the licensed practical nurse on the floor that Resident 5's wound looked different than it had previously. Employee 2 stated she went and assessed it (she said she had never seen it prior). Resident 5's left shin wound was shiny black with something moving deep down in it. A staff interview on July 11, 2024, at 12:37 PM, with Employee 1 (Nurse Practitioner) revealed Employee 1 arrived at the facility June 3, 2024, for wound rounds. The wound nurse at the facility informed Employee 1 that there was a concern of possible maggots in Resident 5's wound. Employee 1 immediately assessed Resident 5's wound and confirmed there were maggots in the wound. A staff interview on July 10, 2024 at 12:30 PM, with the Director of Nursing revealed Resident 5 did have maggots in his left shin wound. She stated the physician was notified and orders were initiated to cleanse the wound with dakins solution several times a day and keep the wound covered. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, staff interview, and facility policy review, it was determined that the facility failed to provide interventions to ensure resident safety after an identified change in condition resulting in harm as evidenced by a repeated fall and fracture for one of 13 residents reviewed (Resident 71). Findings include: Review of facility policy titled, Fall Prevention Program, last reviewed March 28, 2023, revealed it stated the facility's policy was, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the aforementioned policy's, Policy Explanation and Compliance Guidelines, revealed that subsection 6 stated, Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .Interventions will be monitored for effectiveness .The plan of care will be revised as needed. The policy continued in subsection 7 which stated, When any resident experiences a fall, the facility will .Complete a post-fall assessment .Complete an incident report .Review the resident's care plan and update as indicated .Document all assessments and actions .Obtain witness statements in the case of injury. Review of Resident 71's clinical record on June 5, 2023, at approximately 11:30 AM, revealed diagnoses including history of breast cancer and diabetes mellitus type 2 (decreased ability of the body to utilize insulin for the use of transport of glucose from the blood stream into the cells for nourishment). Review of Resident 71's comprehensive plan of care revealed the plan of care for, .[Activities of Daily Living] self-care performance deficient [related to] Activity Intolerance, Confusion, Fatigue, Limited Mobility, included an intervention of, TRANSFER: Transfers [with] 2 [staff] assist and mechanical lift in and out of [wheel chair], which was initiated on July 23, 2022, and revised on May 25, 2023. Review of Resident 71's Quarterly Minimum Data Set (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) with an assessment reference date of May 15, 2023, revealed section G. Functional Status, subsection B, Transfer - How residents moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), was assessed as Resident 71 requiring extensive assistance of two or more staff physically assisting the Resident. Review of facility incident report revealed that on May 20, 2023, Resident 71 suffered a witnessed fall. Further review of the incident report revealed it stated, Resident was on toilet when [Resident 71] began to slide off .[Nurse Aide] then lowered resident to the floor for safety. Review of the incident report's Injuries Observed at Time of Incident section, revealed no injury was observed at the time of the incident. Review of the incident report revealed that subsection, Notes, which was documented by the Director of Nursing, stated, Root cause: resident has been recently hospitalized for encephalopathy, [pneumonia], [diabetes mellitus]. [Resident 71] has overall displayed a condition change related to strength and conditioning. Resident does not have the trunk strength/control to stab[a]lize self on toilet independently. P[l] to have therapy assess for toileting modalities. Staff to assist resident with check and change in bed until therapy approves toileting . Review of provided documentation revealed no witness statements were obtained by the facility regarding Resident 71's May 20, 2023 fall from the toilet. Review of Resident 71's interdisciplinary progress notes revealed that on May 21, 2023, a day after the fall from the toilet, a note was entered at 10:46 AM, which stated, Assessment of resident due to [complaints of] pain in right lower extremity [status post] fall 5/20/23. Resident right knee is swollen, no bruising noted. Right ankle, swollen with bruising noted on lateral aspect. [Range of motion] impaired to knee and ankle. Resident rates pain at 6 out of 10, [Licensed Practical Nurse] notified and will give resident PRN [as needed] Tylenol. [Attending physician] notified, x-ray of knee and ankle ordered. Will update [Representative Party] . According to the interdisciplinary notes, on May 21, 2023, at 11:45 AM, the facility received an authorization for the ordered x-ray to Resident 71's right knee and ankle. Review of the interdisciplinary progress notes revealed that on May 21, 2023, at 8:52 PM, the facility was notified that an x-ray technician would be at the facility the following day, May 22, 2023, to perform an x-ray. Review of Resident 71's clinical record and provided documentation revealed the facility did not alter resident's plan of care, including transfer status assistance, in response to the injury to Resident 71's right knee and ankle. Review of the interdisciplinary notes revealed that on May 22, 2023, an incident note was entered, which stated, [Registered Nurse] was called to the [sic] shower room for a fall. Resident [71] was lying on the floor by the grab bar to the right of the sink. There was a [wheel chair] along the wall. [Resident 71] was fully dressed and had gripper socks on. [Nurse Aide] reports that the resident was lowered to the floor and did not hit her head. [Nurse Aide] states immediately before the resident became weak and fell she [Nurse Aide] was drying the residents bottom and pulling up her pants when the residents legs went weak and the resident started to go down. Resident states 'My ankle hurts and it gave out on me.' Resident was assessed and states her right ankle hurts and she would like an xray . Review of the facility incident report for the fall in the shower room dated May 22, 2023, at 7:45 AM, revealed, Other Info, stated, Resident was having right knee and ankle pain during transfer from shower chair to [wheel chair]. Resident was holding the grab bar while the [Nurse Aide] was pulling up the residents pants. Review of facility incident report revealed that, Resident Description, stated, My ankle hurts and it gave out on me. Review of the incident reports Notes section revealed that on May 22, 2023, Director of Nursing (DON) documented, Reviewed resident fall from 5/22/23 with [Interdisciplinary Team]: resident [71] was in the shower chair with [Nurse Aide] in the shower room. Assisted her to stand at the grab bar and resident ankles gave out and bowed inwards and resident was lowered to the floor by [Nurse Aide] .Root cause: resident lowered to floor after unable to stand at grab bar with staff assistance. Resident is a 2 person mechanical lift for transfers and had 1 staff with her. The information that the staff member had to assist with transfers was incorrect. Therapy confirmed resident on 5/22/23 to be 2 assist with transfers. Staff education on how to obtain resident transfer status. Remove resident transfer status on all report sheets for staff. Review of witness stated by Employee 6 (Licensed Practical Nurse [LPN]), revealed that Employee 6 documented, On 5/22/23 at the start of my shift I received no information that [Resident 71] had a recent fall and there was an x-ray pending completion for her right ankle/lower leg. There was no neuro-check sheet in place because the fall was witnessed and there was no order in the system for fall monitoring to alert of recent incident [which occurred on May 20, 2023]. The [Nurse Aide] caring for patient asked me if resident [71] [was to be][out of bed] to shower or received a bed bath, I told her that yes, she did go into the shower room per her usual routine. Review of facility fall witness statement completed and signed on May 22, 2023, by Employee 5 (Nurse Aide [NA]) revealed Employee 5 documented a response to form question, What do you think caused the fall? as, Her [Resident 71] ankles were hurting her. Further, Employee 5 included a written statement of, I was assisting [Resident 71] to pull her pants up after the shower when her ankles gave out so I [sic] assist her to the floor[.] I moved the shower chair out of the way made [Resident 71] comfortable and called for help; she only complained of ankle pain no other injury[.] Before I performed her shower I went to the charge nurse to make sure she was 1 assist to transfer the nurse informed me she was. [Resident 71] did complaint of ankle [pain] before the transfer to the shower chair, she also informed me she had a fall prior to this incident. Review of interdisciplinary note dated May 22, 2023, at 3:15 PM, revealed it stated, [Resident 71] had a 1-2 view [xray] of the right knee and a 2 view [x-ray] of the right ankle today by [X-ray company] around noon. Right knee shows no fracture, right ankle shows a distal fibula fracture with mild displacement. No significant joint malalignment. Mild soft tissue swelling. Resident states she is having 10/10 pain at this time right outer ankle is swollen and purple .[Certified Registered Nurse Practitioner][sic] was updated and recommends the resident be[sic] seen in [orthopedic] urgent care or ER today. New order placed to send resident to ER for eval and treatment [related to] right ankle injury . Review of facility fall assessment for Resident 71, effective date May 22, 2023 at 8:27 AM, revealed Resident 71 scored a 55 indicating that resident was, High Risk for Falling. Review of all available clinical documentation for Resident 71 revealed the facility did not alter Resident 71's plan of care to prevent further accidents or possible injury after the fall on May 20, 2023, and subsequent assessment of increased pain, swelling, and bruising to the right leg and ankle that was observed by facility staff on May 21, 2023. Further, the facility did not change Resident 71's transfer status pending an x-ray of Resident 71's right knee and ankle. During a staff interview on June 8, 2023, at approximately 12:20 PM, Director of Nursing stated that after Resident 71's fall on May 20, 2023 at 12:30 PM, and prior to the fall sustained on May 22, 2023 at 7:45 AM, Resident 71 was assessed by therapy for trunk and bilateral lower extremity strength. Further, Director of Nursing stated that therapy had determined that Resident 71 did not require a change in care. However; review of Physical Therapy Treatment Encounter note revealed it was dated and signed by the Physical Therapist Assistant 1 on May 22, 2023 at 5:02 PM, after the second fall. Director of Nursing stated that the time was not accurate on the Physical Therapy Treatment Encounter note. During the staff interview the Director of Nursing was asked to provide a statement from the Physical Therapy Aide attesting to the time that the assessment was conducted. No statement was provided as of June 8, 2023 at approximately 3:00 PM. Review of the Physical Therapy Treatment Encounter note revealed section, Response to [Treatment], stated, [Patient] stated [right] ankle hurt, [patient] to receive x-ray today for previous report of pain following earlier fall (the one before fall during toilet transfer). As of June 8, 2023, at approximately 1:30 PM, the facility had no further information to provide. In an electronic response received June 12, 2023 at 9:46 AM, Director of Nursing confirmed that Resident 71 should have had two staff assistance while standing to dress and subsequent fall on May 22, 2023. The facility failed to initiate interventions to ensure the resident's safety following a change in condition and a fall which resulted in a subsequent fall requiring transfer to the hospital for a distal fibula fracture. 28 Pa code 211.11(d) Resident care plan 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record reviews, review of facility deployment sheets, and resident and staff interviews, it was determined that the facility failed to provide adequate and sufficient nursing staff to provide medication administration in accordance with professional standards of practice and physician orders for 14 out of 14 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) on the Transitions Unit. These staffing failures resulted in 269 missed medication doses including insulins, antipsychotics, antibiotics, antihypertensives, seizure medications, heart medications, and pain medications. These missed medications had the potential to cause the residents discomfort or pain, to exacerbate medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety resulting in Immediate Jeopardy. Findings include: Review of medication administration records revealed the following: Resident 1: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of nine doses each date); Resident 2: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of six doses each date); Resident 3: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of eight doses each date); Resident 4: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 12 doses on November 6, 2022, and 15 doses on November 24, 2022); Resident 5: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 10 doses each date); Resident 6: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 11 doses each date); Resident 7: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 11 doses on November 6, 2022, and 12 doses on November 24, 2022); Resident 8: day shift medications were not signed as administered on November 24, 2022 (total of 10 medication doses each date); Resident 9: day shift medications were not signed as administered on November 24, 2022 (total of eight medication doses each date); Resident 10: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 10 medication doses each date); Resident 11: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 20 doses on November 6, 2022, and 16 doses on November 24, 2022); Resident 12: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of nine doses each date); Resident 13: day shift medications were not signed as administered on November 6, 2022 (total of 14 medication doses); and Resident 14: day shift medications were not signed as administered on November 6, 2022 (total of seven medication doses). The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the concern identified on November 28, 2022, at approximately 1:05 PM. The DON indicated that she was not aware that medications were not given. She indicated that she would look into it. During an interview with Employee 4 conducted on November 28, 2022, at approximately 1:44 PM, Employee 4 stated that the majority of the aides working are agency staff and it is difficult to manage them at times. Employee 4 indicated that it is difficult to get the agency aides to do their work and they are often disrespectful of supervising nurses. Email communication received from NHA on November 29, 2022, at 4:10 PM, stated that they had interviewed the Employee 2 (Nurse), who was on duty on November 6, 2022, and they indicated that they administered the medications. The email also stated that on November 24, 2022, the Nurse had to leave the shift unexpectedly and that the Registered Nurse (RN) Supervisor took over the unit. Additional email communication received from NHA on November 29, 2022, at 4:43 PM, stated that the Nurse that worked on November 6, 2022 has not worked since that date and she was not able to provide an explanation for not documenting the medication administration. Review of census reports and deployment sheets revealed that for day shift on November 6, 2022, Transitions had a census of 32 residents with one LPN assigned was responsible for medications and treatments and was responsible for two medication carts. Review of census reports and deployment sheets revealed that for day shift on November 24, 2022, Transitions had a census of 28 residents with one LPN that was responsible for medications and treatments. This LPN was responsible for two medication carts. It was also noted that on the evening shift the RN House Supervisor was assigned to the Transitions Unit and responsible for medications and treatments and was responsible for two medication carts. During an interview on November 30, 2022, at approximately 10:30 AM with Employee 1 (Registered Nurse Supervisor) that was working on November 24, 2022, Employee 1 indicated that Employee 3 (LPN) came to her around 1:00 PM, and said he had to go now. She said she went to the unit to complete the narcotic counts. During this process, Employee 3 stated to her that he had not passed any medications to the residents on the second cart for the day. No reason was provided. She then started to pass the medications. She said that she administered medications to Resident 13 and 14, but then she got a call from another unit indicating that a Resident was having an acute change in condition. She said she was the supervisor and had to go to assess the other Resident and follow-up with physician. She indicated that she ended up having to send that Resident to the hospital and, by the time she had completed all those tasks, it was too late to give the medications. She indicated that she contacted the Nursing Home Administrator and updated him on what had occurred. She also contacted the physicians of the residents at approximately 4:40 PM and informed them of what had occurred. She indicated that the physicians gave no new orders and said to resume medications at the next scheduled time. Interview with Resident 11 on November 30, 2022, at approximately 12:15 PM, the Resident confirmed that she did not receive her medications on Thanksgiving Day during the day shift hours. Resident 11 said she kept mentioning it to the nurse aide who said they kept telling the nurse, but the nurse never came. Resident 11 further shared that there was another day that they did not get their medications on day shift, but that they could not recall the exact date. During an interview with Resident 15 completed on November 30, 2022, at 1:40 PM. Resident stated, they don't have enough staff to take care of us. We shouldn't have to go without showers or care. I don't want to go somewhere else, but I may have to so I can get the care I need. During an interview with Resident 17 completed on November 30, 2022, at 1:45 PM, Resident revealed that they had finally gotten a good unit manager for her wing, but now she's leaving. They can't keep staff here and the residents are the ones that suffer for it. During an interview with NHA and DON on November 30, 2022, at approximately 2:20 PM, the above information was shared. During a telephone interview with Employee 2 on December 1, 2022, at 11:19 AM, Employee 2 indicated that on November 6, 2022, she was only assigned to the east wing of the unit and that she passed all her resident's medications. She said she cannot speak as to what happened on the west wing portion. Review of deployment sheet for November 6, 2022, indicated that Employee 2 was the only nurse assigned to the whole unit. During a phone interview with NHA and DON on December 1, 2022, at approximately 2:00 PM, they were informed of the conversation with Employee 2 and that, according to the deployment sheet, was the only nurse assigned that date/shift. NHA confirmed that he would expect that there would be enough staff to meet the needs of the residents and that all residents would receive their medications as ordered by the physician. The facility's census (amount of residents residing in the facility) on November 24, 2022 was 169 with four bed holds (residents currently out of the building). On November 27, 2022 the census was 172 with two bed holds. On December 6, 2022 the census was 177 with two bed holds. Despite their known staffing challenges, the facility continued to admit new residents. The NHA was provided the immediate jeopardy template on December 6, 2022, at 4:15 PM, and an immediate action plan was requested. On December 6, 2022, at 6:47 PM, the facility's immediate action plan was accepted which included: 1) Claremont executed a new agency agreement for direct care staff on December 5, 2022. 2) Administrator, scheduler, nursing leadership, and Human Resources will conduct a staffing meeting to audit actual and projected hours and validate adequacy daily for three weeks and then monthly for three months. Issues identified will be corrected at the time of discovery. 3) Facility has communicated vacant shifts to agencies through January 1, 2023, on December 4, 2022. 4) Facility has signed three block agreements with agency nurses through the month of December on December 6, 2022. 5) Facility will continue to communicate vacant shifts to employees with bonus offerings and execute a comprehensive recruitment and retention plan that includes sign-on and referral bonus offerings. 6) RN Supervisors will be re-educated to communicate unforeseen staffing emergencies that would be impactful to the Director of Nursing and Nursing Home Administrator for further intervention. Interventions may include asking employed volunteers to stay, enhancing premium offerings to employees and agency staff to pick up shifts or supplementing staffing with nursing leadership team members or traveling agency staff to ensure care delivery. 7) Licensed Nurses will be educated to check in with the RN Supervisor at beginning of shift to verify assignment. 8) Licensed Nurses will be educated that, in the event of an emergency and after assumption of a new cart, they should begin medication administration based on red/ non-administered medications in the MAR. 9) Facility will hold new admissions temporarily, until such time as the Quality Assurance Performance Improvement Committee deems actual licensed staffing supports resumption. On December 7, 2022, at 3:18 PM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12 (a)(c)(d)(1)(4)(5) Nursing Services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, as well as resident and staff interviews, it was determined that the facility failed to follow accepted professional standards and principles for administering medications and ensure the prevention of significant medication errors for 13 out of 14 residents sampled (Residents 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14) on the Transitions Unit. This resulted in an Immediate Jeopardy situation because the missed medications had the potential to cause the residents discomfort or pain, to exacerbate medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety of 13 out of 14 residents reviewed. Findings include: Review of Resident 1's clinical record revealed diagnoses that included atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow and can result in blood clot formation) and hypertensive chronic kidney disease (medical condition referring to damage to the kidneys due to chronic high blood pressure). Orders included amlodipine 10mg give one tablet by mouth every day (medication used to treat high blood pressure and coronary artery disease which is damage or disease in the heart's major blood vessels which causes limited blood flow to the heart). Review of medication administration record revealed that Resident 1 was not administered this medication on November 6, 2022, and November 24, 2022. Review of Resident 2's clinical record revealed diagnoses that included chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Orders included phoslo capsule 667 mg one capsule three times a day with meals (a medication used to reduce phosphorus in the blood of people with end stage renal disease). Review of medication administration record revealed that Resident 2 was not administered this medication at breakfast and lunch on November 6, 2022, and November 24, 2022. Review of Resident 3's clinical record revealed diagnoses that included prostate cancer and pneumonia. Orders included: Lactulose Encephalopathy Solution 10gm/ml Give 30ml by mouth daily (medication derived from lactose that is used to treat liver disease by lowering ammonia levels); Levaquin 500mg by mouth daily for 7 days (an antibiotic used to treat infections); and MS Contin ER (morphine) 15mg one tablet by mouth every 12 hours (a narcotic pain medication). Review of medication administration record revealed that Resident 3 was not administered the morning dose of lactulose and MS Contin on November 6, 2022, and November 24, 2022. In addition, medication administration record revealed that Resident 3 was not administered the daily dose of Levaquin on November 24, 2022, which was the last dose of the seven day course of antibiotic. Review of Resident 4's clinical record revealed diagnoses that included type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar; either the body doesn't produce enough insulin or it resists insulin). Orders included Insulin Lispro 100 units/ml inject three units three times a day and blood sugar check with each meal (a rapid acting insulin taken with meals used to lower levels of glucose in the blood). Review of medication administration record revealed that Resident 4 did not have their blood sugar checked at breakfast and lunch and was not administered the breakfast and lunch doses of insulin on November 6, 2022, and November 24, 2022. Review of Resident 5's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). Orders included lasix (furosemide) 40mg give one tablet by mouth daily (a medication used to fluid retention or edema caused by congestive heart failure) and lisinopril 30mg give one tablet by mouth daily (a medication used to treat high blood pressure and heart failure). Review of medication administration record revealed that Resident 5 was not administered the aforementioned medications on November 6, 2022, and November 24, 2022. Review of Resident 6's clinical record revealed diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and human immunodeficiency virus (virus that damages the immune system and interferes with the body's ability to fight infection and disease). Orders included Genvoya Tablet 150-150-200-10 mg (Elviteg-Cobic-Emtricit-TenofAF), Give one tablet by mouth in the morning (a combination of 4 medications into one used to treat human immunodeficiency virus); and divalproex sodium tablet delayed release 500 mg one tablet by mouth in the morning and at bedtime (a medication used to treat seizures). Review of medication administration record revealed that Resident 6 was not administered the Genvoya on November 6, 2022, or November 24, 2022. It also revealed that Resident 6 was not administered the Divalproex Sodium in the morning on November 6, 2022, and November 24, 2022, and was not administered the evening dose on November 25, 2022. Review of Resident 8's clinical record revealed diagnoses that included hypertension (high blood pressure). Orders included amlodipine besylate tablet 10 mg give one tablet by mouth one time a day (medication used to treat high blood pressure); and tramadol tablet 50 mg give one tablet by mouth two times a day (a narcotic medication used to treat pain). Review of medication administration record revealed that Resident 8 was not administered the amlodipine on November 24, 2022, and was not administered the morning dose of tramadol on November 24, 2022. Review of Resident 9's clinical record revealed diagnoses that included type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar; either the body doesn ' t produce enough insulin or it resists insulin) and cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain). Orders included clopidogrel bisulfate tablet 75 mg give one tablet by mouth daily (medication used to prevent formation of blood clots); and Insulin Aspart FlexPen Solution Pen-injector 100 units/ml (Insulin Aspart) Inject as per sliding scale: if Less than 70 notify MD; if 131 - 180 = two units 181 - 240 = four units; 241 - 300 = six units; 301 - 350 = eight units; 351 - 400 = 10 units; 401 - 599 = 12 units; Call MD if greater than 400, subcutaneously with meals (a rapid acting insulin taken with meals to lower levels of glucose in the blood). Review of medication administration record revealed that Resident 9 was not administered the clopidogrel on November 24, 2022. It also revealed that Resident 9 did not have their blood sugar checked on November 24, 2022, at 8:00 AM and 12:00 PM. Review of Resident 10's clinical record revealed diagnoses that included hypertensive heart disease with heart failure (heart failure that is a result of heart problems that occur because of high blood pressure that is present over a long time) and deep vein thrombosis (condition that occurs when a blood clot forms in a vein deep inside a part of the body). Orders included: amlodipine besylate tablet 10 mg give one tablet by mouth one time a day (medication used to treat high blood pressure); isosorbide mononitrate extended release tablet 24 Hour 30 mg give one tablet by mouth one time a day (medication used to treat heart disease and prevent chest pain); and heparin sodium (porcine) solution 5000 units/ml inject 1 ml subcutaneously every eight hours (a blood thinner used to prevent blood clot formation). Review of medication administration record revealed that Resident 10 was not administered the amlodipine besylate and isosorbide mononitrate on November 6, 2022, and November 24, 2022. It also revealed that Resident 10 was not administered the heparin on November 6, 2022, at 8:00 AM. Review of Resident 11's clinical record revealed diagnoses that included Parkinson's (a long term degenerative disorder of the central nervous system that mainly affects the motor system) and bacteremia (the presence of bacteria in the bloodstream). Orders included pramipexole dihydrochloride tab 0.25 mg give one tablet at bedtime (medication used to treat Parkinson's); heparin sodium 5000 units/ml inject 5000 units subcutaneously twice a day (a blood thinner used to prevent blood clot formation); cefazolin sodium solution reconstituted 2 gm intravenously every eight hours (an antibiotic used to treat infections); hydralazine tablet 50 mg give one tablet by mouth three times a day (medication used to treat high blood pressure); and Medrol Dose Pack give as directed (a steroid medication used to treat inflammation). Review of medication administration record revealed the following: the pramipexole dihydrochloride was not administered on the night of November 25, 2022; the heparin sodium was not administered on the morning of November 6, 2022, and November 24, 2022, or the evening of November 25, 2022; the cefazolin was not administered at 8:00 AM on November 6, 2022; the hydralazine was not administered at 8:00 AM and 2:00 PM on November 6, 2022, and November 24, 2022; and the medrol dose pack was not administered at 8:00 AM, 12:00 PM, or 5:00 PM on November 6, 2022. Review of Resident 12's clinical record revealed diagnoses that included atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow and can result in blood clot formation). Orders included Eliquis 5 mg one tablet by mouth twice a day (blood thinning medication used to prevent blood clot formation). Review of medication administration record revealed that Resident 12 was not administered the morning dose of Eliquis on November 6, 2022, and November 24, 2022. Review of Resident 13's clinical record revealed diagnoses that included hypertension, angina pectoris, and borderline personality disorder. Orders included: isosorbide mononitrate tablet 30 mg give one tablet by mouth daily(medication used to treat heart disease and prevent chest pain); lasix (furosemide) tablet 40 mg give one tablet by mouth in the morning and in the afternoon (a medication used to fluid retention or edema); lisinopril tablet 5 mg give one tablet by mouth one time a day (medication used to treat high blood pressure); olanzapine tablet 2.5 mg give one tablet by mouth in the afternoon (medication used to treat mental disorders); and olanzapine tablet 5 mg give one tablet by mouth one time a day. Review of medication administration record revealed that Resident 13 was not administered the isosorbide, lasix, lisinopril, or olanzapine on the morning of November 6, 2022. In addition, Resident 13 was not administered the afternoon dose of lasix or olanzapine on November 6, 2022. Review of Resident 14's clinical record revealed diagnoses that included atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow and can result in blood clot formation) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) . Orders included apixaban 5 mg one tablet by mouth twice a day (blood thinning medication used to prevent blood clot formation); and levetiracetam (Keppra) Tabs 1000 mg one tablet by mouth twice a day (medication used to treat seizures). Review of medication administration record revealed that Resident 14 was not administered the morning dose of apixaban and levetiracetam on November 6, 2022. Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of concerns identified on November 28, 2022, at approximately 1:05 PM. DON indicated that she was not aware that medications were not given and that she thought medication administration had improved. Email communication received from the DON on November 29, 2022, at 2:34 PM, revealed that there were notes dated November 7, 2022 (the day after the missed medications). There were also notes dated November 24, 2022 notifying the physician(s) of each Resident's missed doses of medications. Email communication received from NHA on November 29, 2022, at 4:43 PM, indicated that the nurse that worked on November 6, 2022 has not worked since that date and she was not able to provide an explanation for not documenting the medication administration. He further indicated that with November 6, 2022, being a Sunday he believed this documentation omission would have been noted during an AM clinical meeting and addressed upon discovery on Monday, November 7, 2022, which was why the notes were dated for November 7, 2022. These notes were timed for 11:45 AM. Email communication received from NHA on November 29, 2022, at 4:10 PM, indicated that they had interviewed Employee 2 (Nurse) who was on duty on November 6, 2022, and he indicated that the nurse administered the medications. The email also included that on November 24, 2022, the nurse had to leave the shift unexpectedly and that the Registered Nurse (RN) Supervisor took over the unit. During a telephone interview with Employee 2 on December 1, 2022, at 11:19 AM, Employee 2 indicated that on November 6, 2022, she was only assigned to the east wing of the unit and that she passed all of her resident's medications. She said she cannot speak as to what happened on the west wing portion. Review of deployment sheet for November 6, 2022, indicated that Employee 2 was the only nurse assigned to the whole unit. During a phone interview with NHA and DON on December 1, 2022, at approximately 2:00 PM, they were made aware of the conversation with Employee 2 and that, according to the deployment sheet, she was the only nurse assigned that date/shift. No further information was provided. The NHA confirmed that he would expect that there would be enough staff to meet the needs of the residents and that all residents would receive their medications as ordered by the physician. During an interview on November 30, 2022, at approximately 10:30 AM with Employee 1 (Registered Nurse Supervisor) who was working on November 24, 2022, Employee 1 indicated that Employee 4 (Licensed Practical Nurse) came to her at around 1:00 PM, and said they had to go now. She said she went to the unit to complete the narcotic counts. During this process, Employee 4 indicated to her that he had not passed any meds to the residents on the second cart for the day. He provided no reason as to why he had not administered the medications. She indicated that she then started to pass the medications. She said that she administered medications to Resident 13 and 14, but then she got a call from another unit indicating that a Resident was having an acute change in condition. She said she was the supervisor and had to go to assess the other Resident and follow-up with physician. She indicated that she ended up having to send that Resident to the hospital and, by the time she had completed all those tasks, it was too late to give the medications. She indicated that at that time she notified the NHA of what had occurred. She also contacted the physicians of the Residents and informed them of what had occurred. She indicated that the physicians gave no new orders and said to resume meds at the next scheduled time. Review of the progress notes revealed that the physician was notified at 4:40 PM. Phone interview with Employee 4 was attempted on December 1, 2022, at 10:32 AM. At the time of survey exit on December 1, 2022, at 2:00 PM, Employee 4 had not returned the call. Interview with Resident 11 on November 30, 2022, at approximately 12:15 PM, the Resident confirmed that they did not receive her medications on Thanksgiving Day during the day shift hours. Resident 11 said they kept mentioning it to the nurse aide who said they kept telling the nurse, but the nurse never came. Resident 11 further shared that there was another day that they did not get their meds on day shift, but that they could not recall the exact date. During an interview with the NHA and DON on November 30, 2022, at approximately 2:20 PM, the above information was shared. The NHA was provided the immediate jeopardy template on December 6, 2022, at 4:15 PM, and an immediate action plan was requested. On December 6, 2022, at 6:05 PM, the facility's immediate action plan was accepted, which included: 1) Physicians were notified upon discovery concerning medication administration observations of November 6, 2022 and November 24, 2022, and did not provide new orders at that those times 2) Agency Employees 1 and 2 have not worked since November 6, 2022, and November 24, 2022, respectively, and will not be utilized by the facility. 3) Licensed Nurses were re-educated concerning the expectation to administer medications as ordered on November 30, 2022. 4) NHA and DON initiated a review of performance and charting expectations with individual agencies for additional review with oncoming staff on December 5, 2022. 5) Registered Nurse Unit Managers or designee will complete an audit of medication administration documentation weekly for three weeks and monthly for three months to validate compliance with each shift included. Issues will be corrected upon discovery. 6) Registered Nurse Unit Managers or designee will complete a random medication administration observational audit for five residents weekly for three weeks and monthly for three months to validate compliance with each shift included. Issues will be corrected upon discovery. 7) NHA and DON will review facility policies concerning medication administration and medication administration documentation, update as necessary by December 7, 2022, and initiate staff education based on updates if required. On December 7, 2022, at 3:18 PM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.9(d) Pharmacy services

Based on facility policy review, clinical record review, review of the American Heart Association (AHA) information, and staff interviews, it was determined that the facility failed to immediately provide Cardiopulmonary Resuscitation (CPR - emergency life-saving procedure performed when the heart stops beating) as required for one of one residents reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident 1 became unresponsive and pulseless, and the facility staff did not immediately administer CPR to Resident 1 as required. Resident 1 was pronounced dead at the facility. This failure placed 64 of 180 residents (Residents ,d+[DATE]) that had requested to have CPR administered if they became unresponsive and pulseless, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy, titled Emergency Procedure- Cardiopulmonary Resuscitation, revised [DATE], revealed If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Basic Life Support] shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) (Rigor mortis is the stiffening of the joints and muscles of a body a few hours after death). According to the American Heart Association (AHA), immediate CPR can double or triple chances of survival after cardiac arrest. The AHA has established evidenced-based decision making guidelines for initiating CPR when cardiac or respiratory arrest occurs. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the resident's advance directives and any related physician order, such as code status, or in the absence of advance directives or a DNR order. Review of Resident 1's clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included asthma, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of Resident 1's POLST (Pennsylvania Orders for Life-Sustaining Treatment) form, revealed that, in the event Resident 1 has no pulse and is not breathing, Resident 1 checked that he wanted CPR/Attempt Resuscitation. Resident 1 signed the POLST form on [DATE]. Review of Resident 1's physician order, dated [DATE], revealed Resident 1 was a Full Code (meaning that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of Resident 1's care plan revealed a care plan in place for Full Code, initiated [DATE]. The goal stated In the event of cardiac arrest or unresponsive episode staff will honor the code status of FULL CODE and attempt resuscitation. Review of Resident 1's nursing progress note revealed a note written by Employee 3 (Registered Nurse), dated [DATE]. The note stated that the nurse entered Resident 1's room at approximately 8:10 PM to administer medications to Resident 1's Roommate. The nurse observed Resident 1 to be mottled (a bluish-red, lace-like pattern under the skin which happens when deoxygenated blood pools beneath the skin's surface) and without spontaneous respirations. There was no response to vigorous tactile stimuli and Resident 1 was noted with blue lips and fingertips, and Resident 1 did not have a carotid pulse. Skin remained warm and dry. POLST was confirmed that Resident 1 was a Full Code and a rapid response request was made overhead for all available licensed staff. The note further states that resuscitation efforts were initiated, AED (automated external defibrillator) was put into place and advised no shock. CPR continued and Resident 1's Responsible Party was notified of Resident 1's condition and the overt clinical signs of irreversible death. Resident 1's Responsible Party wished for efforts to cease as EMS arrived and took over CPR. The physician at the hospital was contacted and made aware of Resident 1's condition and the wishes of the Responsible Party. An order was received to cease all efforts and the Registered Nurse (RN) pronounced Resident 1 deceased at 8:34 PM. During an interview with Employee 1 (Registered Nurse) on [DATE], at 11:45 AM, she stated that Employee 3 (RN) told her to call 911, Resident 1 is dead. Employee 1 stated she went into Resident 1's room to assess him and noted that he was cyanotic (bluish or grayish color of the skin), mottled, pulseless, and had no rise and fall of his chest. Employee 1 stated she was made aware that Resident 1 was a Full Code but felt that he was too far gone based on her experience as a critical care nurse. Employee 1 stated she was told by another nurse that they needed to do CPR because Resident 1 was a Full Code. Employee 1 stated that Employee 2 (RN) was the one who started the chest compressions. Employee 1 was unable to say how much time had passed between Resident 1 being confirmed a Full Code and then starting CPR. Employee 1 also stated that the prior RN stated she was in Resident 1's room not long before Resident 1 was found unresponsive, and that Resident 1 had just finished dinner and his plate was pushed off to the side. Employee 1 stated Resident 1's pupils were not blown and she was unsure what happened for Resident 1 to go unresponsive and pulseless. During an interview with Employee 2, on [DATE], at 1:40 PM, she stated that she was working downstairs when she heard the code being called. She stated she came upstairs (via the elevator) and found Resident 1 with no pulse and no signs of life. Employee 2 initiated chest compressions. Employee 2 stated that Resident 1 still felt a little warm and Employee 2 stated that Resident 1 was not stiff. Employee 2 was unable to say exactly how long it took her to arrive upstairs after the code was called, but she stated it was barely five minutes. Employee 2 stated that she was the first person to do any chest compressions. During an interview with Employee 3 on [DATE], at 1:46 PM, she stated that, when she was giving medications to Resident 1's Roommate, Employee 3 saw Resident 1 was slumped over with mottled arms and did not appear to be breathing. Employee 3 approached Resident 1 and touched him. Employee 3 stated he felt warm. Employee 3 stated she looked in the computer for Resident 1's code status, which was listed as Full Code. Employee 3 then went to the nurses station, at the opposite end of the hallway, to obtain the chart and confirm the Full Code status with Resident 1's POLST. Employee 3 called the code overhead and Employee 3 stated she approached Employee 1 at the nurses' station and informed her that there was a code, that Resident 1 was a Full Code, and to go to Resident 1's room while she got the crash cart and AED. Employee 3 stated that Employee 1 went to Resident 1's room and stated that Employee 1 was the first RN in the room. Employee 3 called EMS and went downstairs to get the AED. Employee 3 stated that as she was going to get the AED, she passed Employee 2 getting off of the elevator. Employee 3 stated that Resident 1 had no signs of rigor mortis. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) 1 and ADON 2 on [DATE], at 1:00 PM, they stated that the code was reviewed during morning meeting on Monday, [DATE], but they were not made aware of any issues. Review of facility provided document listing the current code status of current Residents, as well as review of the clinical records for Residents ,d+[DATE], revealed that Residents ,d+[DATE] were all listed as Full Codes (if their heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) including CPR. The facility failed to promptly initiate CPR in accordance with the Resident's wishes and professional standards of nursing to a resident who had requested CPR during the admission process, had a physician's order for CPR, and had been identified as a FULL CODE, when finding the Resident unresponsive, without a pulse or breathing, and without clear clinical signs of death; placing 64 other residents who had requested CPR be administered in the event that they were to suddenly become unresponsive and pulseless in Immediate Jeopardy. The NHA and ADON 1 and ADON 2 were notified of the immediate jeopardy situation on [DATE], at 2:39 PM, based on the failure of Employee 1 to start CPR on Resident 1. The NHA was provided the immediate jeopardy template on [DATE], at 2:43 PM, and an immediate action plan was requested. On [DATE], at 4:28 PM, the facility's immediate action plan was accepted which included: 1) Day shift RN Supervisor has been re-educated concerning the facility Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes. 2) Registered Nurse Staff Educator immediately initiated re-education of licensed nurses concerning the Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes. 3) Resident Nurse Unit Managers or designee will complete an audit of EMR code status to POLST by [DATE], to validate consistency of records for staff reference. 4) ADON or designee will conduct a code drill for additional training of facility staff. Drills will be conducted initially on [DATE], weekly for four weeks and monthly thereafter. Timing of drills will vary so that each shift may participate. 5) NHA and Director of Nursing will review facility policies concerning CPR, AED use/care/storage, update as necessary by [DATE], and initiate staff education based on updates if required. On [DATE], at 12:15 PM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(2)(3)(e)(1) Management 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections (UTI) in two of two residents reviewed for foley catheter (Residents 2 and 3) which resulted in harm and, subsequent transfer and admission of Residents 2 and 3 to an acute care hospital Intensive Care Unit with an admission diagnosis of sepsis (life threatening complication of an infection where chemicals released in the blood to fight an infection trigger inflammation throughout the body) secondary to UTI; further, prior to the transfer and admission to the hospital, the facility failed to follow physician orders related to collecting a urine sample and labs for one of two Residents reviewed (Resident 2). Findings include: Review of Resident 2's clinical record revealed diagnoses that included urinary retention (difficulty urinating and completely emptying the bladder) and a Pressure Ulcer. Review of Resident 2's current physician orders revealed the following for foley catheter for diagnosis of urinary retention neurogenic bladder (condition in which the nerves that carry messages back and forth between the bladder, spinal cord, and brain don't work as they should), and/or wound healing secondary to incontinence (inability to control one's urine flow); and change catheter monthly on the 13th on the evening shift, dated July 13, 2022. Review of Resident 2's current care plan revealed a care plan focus for an indwelling foley catheter related to extensive skin breakdown, Stage IV Pressure Injury to the Sacrum, initiated on June 10, 2022. Interventions included: position catheter bag and tubing below the level of the bladder and away from entrance room door; check tubing for kinks each shift, monitor for signs and symptoms of discomfort on urination and frequency; monitor and document for pain/discomfort due to catheter; monitor/record/report to MD for signs and symptoms of urinary tract infection: including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident 2's Treatment Administration Records from May 2022, through August 2, 2022, revealed no documentation of providing catheter care to the Resident prior to August 2, 2022. Review of nurse aide task documentation from July 17, 2022, through August 2, 2022, for catheter output revealed that on 17 occasions staff coded output (urine output from the catheter) as Non-Applicable; and on four occasions there is no output documented. On July 30, 2022, Resident 2 had no documented output for the entire 24 hours. Review of Resident 2's progress note dated for July 5, 2022, indicated that the Resident was reporting complaints of urinary discomfort, urgency, and pressure. The note also indicated that the Resident's urine was cloudy with moderate sediment. The physician was notified and an order was given to obtain an urinalysis (urine sample used to detect medical conditions) and urine culture (used to identify the type of microorganism that is causing an infection). Review of urinalysis and culture results dated July 8, 2022, indicated that there was mixed genital flora isolated; these superficial bacteria are not indicative of a urinary tract infection; and that no further organism identification was warranted on this specimen. If clinically indicated, recollect a mid-stream, clean-catch urine, and transfer immediately to urine culture transport tube. The urinalysis results revealed the following abnormal results: leukocyte esterase 3+ (normal result is negative); White Blood Cells packed (normal is less than or equal to 5); Red Blood Cells 3-10 (normal is less than or equal to 2), and bacteria was moderate (normal is none). Although, the Resident was experiencing clinical indicators of an urinary tract infection and the urinalysis results revealed the aforementioned abnormal results, no repeat urine culture was ordered. In addition, there was no documentation that these results were reviewed with the physician when received on July 8, 2022, and the results were not signed by the physician until July 13, 2022. Review of Resident 2's routine lab work, dated July 13, 2022, revealed the following abnormal results: glucose was 202 (normal is 65-99); BUN (test that measures the amount of urea nitrogen in the blood) was 35 (normal is 6-22); calcium was 11 (normal is 8.6-10.4); and sedimentation rate (test which helps to detect inflammation in the body) was 65 (normal is less than or equal to 30). There was no documentation that these abnormal results were reviewed with the physician when received on July 13, 2022. There was a notation written on the lab results which indicated the physician was not notified of the lab results until on August 9, 2022, while the Resident was admitted to the hospital. Review of Resident 2's progress note dated July 26, 2022, at 3:12 PM, indicated that the Resident's Daughter called and stated she wanted blood work and urinalysis done due to Resident 2's increased confusion. The note further indicated that the physician was made aware of the Daughter's request, and that orders were given to obtain a CBC, BMP, and Urinalysis with Culture and Sensitivity in the morning. There was no documentation by the nurse of an assessment of the Resident. Review of the physician's orders noted an order dated July 26, 2022, for a urinalysis with culture and sensitivity. The facility could not provide any documentation that these labs were obtained as ordered. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 15, 2022, at approximately 2:20 PM, the DON confirmed that the labs ordered on July 26, 2022, were not obtained. A physician's progress note dated July 27, 2022, at 4:28 PM, revealed that the Resident was seen by the physician for transfer of care to their service, and that earlier the Resident's daughter complained reviewed possible confusion and patient had UA [urinalysis] and CBC BMP ordered. Further review of the physician's physical exam notes, there was no documentation present that indicated the Resident's genitourinary system was assessed. It was also noted that the physician referred to labs that were obtained on May 24, 2022, and not the Resident's most current labs. Review of Resident 2's progress note dated August 1, 2022, at 2:45 PM, revealed that the Resident complained of occasional leaking around the catheter. There was no documentation that a full assessment of the Resident's urinary system was completed, or that the physician was made aware of the leaking around the catheter. Review of Resident 2's progress note dated August 2, 2022, at 12:48 PM, revealed that the Resident was complaining of pain due to the foley and asked if it could be changed. The note further indicated that: the nurse checked the foley catheter and noted it was draining yellowish colored urine; secured foley on thigh; and encouraged the Resident to drink more fluid. The nurse also indicated that the Resident's Daughter was notified of the concerns. The nurse then notified the physician and an order was received to change the foley catheter 24 French that day, and then monthly. In addition, the physician ordered a CBC, BMP, and urinalysis with C&S for the next morning, and to start Cipro (antibitoc) 500 mg twice daily for seven days. Review of Resident 2's progress note dated August 2, 2022, at 6:51 PM, indicated that the Resident continued with confusion and had an altered mental status. Vital signs were obtained. Resident's temperature was noted to be 97.8 Fahrenheit (F). Resident's Daughter was present at bedside and concerned that Resident 2 was not their normal self and that the Resident looked flushed. Nurse notified physician and order was given to transport the Resident to the hospital for evaluation. Review of Resident 2's History and Physical Report from the hospital dated August 2, 2022, revealed admitting diagnoses of sepsis (life threatening complication of an infection where chemicals released in the blood to fight an infection trigger inflammation throughout the body); acute kidney injury (an abrupt decrease in kidney function), labs on admission indicated a creatinine level of 1.57, with a baseline lab value of 0.5-0.6; and urinary tract infection, lab results were grossly indicative of infection in setting of chronic Foley. Urinalysis showed presence of white blood cells (WBC, help the body fight infection) with a value of too numerous to count. Further review of hospital notes stated that there were no signs of infection to wounds; and clinical suspicion for source of bacteremia (presence of bacteria in the bloodstream) and septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) were UTI. Infectious Disease was consulted. On August 3, 2022, Resident 2 was transferred to the Intensive Care Unit. Resident 2 was started on three antibiotics, administered IV (intravenously). Resident 2's white blood cell (WBC) count (blood test used to measure the number of WBCs which help fight infections) on August 2, 2022, was 15.9 (normal is 3.8-10.8); Blood Urea Nitrogen (BUN) was 40 (normal is 7-25); and Creatinine 1.57 (normal is .6-1.2). BUN and creatinine are tests used together to determine kidney function. Resident 2 had a temperature recorded at the hospital of 103.5 F. The Daughter reported to hospital staff that Resident 2 had fevers and altered mental status for two days prior to hospitalization . No fevers were noted in facility documentation. Review of Resident 2's Infectious Diseases Consult dated August 3, 2022, indicated the following: Diagnosis of Septic Shock (life threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention); and was noted to have a positive urine culture and, therefore, the clinical suspicion for source of bacteremia and septic shock were determined to be from an urinary tract infection. Review of Resident 3's clinical record revealed diagnoses that included obstructive and reflux uropathy (condition where urine flows backwards to the kidney instead of to the bladder because of some type of obstruction). Review of Resident 3's physician orders revealed a foley catheter related to obstructive uropathy; change Foley catheter every 30 days on the 27th of each month on evening shift; irrigate Foley catheter with sterile water for blockage/leaking as needed. Review of Resident 3's care plan revealed a focus for indwelling catheter, initiated on July 13, 2022, with interventions that included: Monitor/record/report to physician any signs and/or symptoms of an UTI: including pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, with initiated date of July 13, 2022. Resident 3 also had a care plan focus for antibiotic therapy related to UTI prophylaxis, initiated on July 13, 2022, with interventions that included: Administer antibiotic medications as ordered by physician, and monitor/document side effects and effectiveness every shift, with initiated date of July 13, 2022. Review of Resident 3's Treatment Administration Records from May 2022, through August 9, 2022, revealed no documentation of providing catheter care to the Resident. Review of nurse aide task documentation and revision history of the tasks revealed that catheter care and catheter output were added on August 8, 2022. Review of Resident 3's progress notes revealed a note on July 20, 2022, at 6:22 AM, which noted the Resident was noted to have a small amount of blood in his foley catheter drainage bag. There was no documentation that the physician was made aware. Review of Resident 3's progress note dated July 21, 2022, at 9:25 AM, revealed that the Resident was complaining of pain and discomfort in the bladder/genital area. Nurse was unable to reposition catheter, and removed catheter and Resident experienced immediate relief. A new catheter was reinserted with clear yellow urine noted. There was no documentation that the physician was made aware of the discomfort the Resident 3 was experiencing. On August 4, 2022, at 12:52 PM, nursing note by Licensed Practical Nurse stated that Resident 3 was complaining of urinary tract pain, had a catheter in place that was fully patent and draining urine. The note further indicated that the Nurse checked the Resident's temperature, which was 97.9 F degrees, and that the Registered Nurse Supervisor was made aware and Resident would continue to be monitored. There was no documentation noted by a Registered Nurse. There were no other notes regarding the monitoring of the Resident's urinary complaints until August 9, 2022, or documentation that the physician was made aware. Review of nursing note dated August 9, 2022, at 1:32 PM, revealed that Resident 3 was complaining about catheter bag not draining properly, and slight discomfort in the pelvic area. Urine was noted to be: whitish in color with sediments and foul odor. Physician was made aware, and new orders were subsequently obtained to change the catheter and get a urine sample for urinalysis and urine culture. Further review of nusing notes revealed that Resident 3 was noted with blood in their urine on July 20, 2022, complained of discomfort in the bladder/genital area on July 21, 2022; and complained of urinary tract pain on August 4, 2022. There is no documentation noted in the Resident's clinical record that the physician was ever made aware of the Resident's blood in urine or the complaints of urinary discomfort until August 9, 2022. On August 9, 2022, nursing notes revealed that Resident 3 got out of bed, unassisted, resulting in increase in blood in catheter. The physician was notified and orders obtained to send the resident to the ER. Review of Resident 3's hospital records revealed that, upon arrival to emergency room , the Resident was complaining of hematuria (blood in urine) and ureteral pain around a chronic indwelling foley catheter. It was also noted that the Resident indicated that the symptoms had been going on for a couple of weeks. Further hospital record review, upon hospital admission, initial diagnosis was Urosepsis (sepsis caused by infection of the urinary tract). Resident 3 was noted to have a temperature of 103.7 F upon evaluation at the hospital, and had grossly infected urine on urinalysis. Resident became hypotensive (low blood pressure) on August 10, 2022, and had to be transferred to the Intensive Care Unit. Initial urine culture grew gram negative rods (type of bacteria resistant to several antibiotics); and blood culture also grew gram negative rods and staph aureus (bacteria that can cause various infections). Infectious disease was consulted. Urology was consulted and completed diagnostic testing, and indicated that there was no obvious pathology to explain hematuria. Resident was being treated with two intravenous antibiotics and continuous bladder irrigation (medical procedure that flushes the bladder with sterile liquid) for the hematuria. Further review of Resident 3's hospital records revealed that, by August 11, 2022, the Resident met sepsis criteria with temperature, tachycardia, and that the urine was the source of the infection. Urine was noted to be bloody with White Blood Cells (WBC's help the body fight infection), large amount of bacteria, nitrites (nitrites in urine indicate an infection), and leukocyte esterase (test used to detect presence of white blood cells in the urine which would indicate an infection). Blood cultures were growing multiple organisms- E. coli (bacteria found in the environment, food, and intestines), Providencia (a type of bacteria that can occur in urinary tract infections), Methicillin Susceptible Staphylococcus Aureus (MSSA-type of bacteria that is not resistant to certain antibiotics), and Pseudomonas aeruginosa (type of bacteria that causes infections). Urine culture growing Pseudomonas aeruginosa and E coli. Final conclusion was noted to be sepsis due to urinary tract infection in the setting of chronic indwelling Foley catheter. Email communication received from the NHA on August 15, 2022, at 9:34 AM, indicated the documentation of catheter care was added to Treatment Administration Records as part of their plan of correction for a recent deficiency citation. During an interview with the NHA and DON on August 15, 2022, at approximately 2:20 PM, the DON indicated that the facility had started educating staff on the importance of notifying physician's in a timely manner of Resident concerns. The NHA and DON both confirmed that physician orders should be followed and that physicians should be notified in a timely manner of Resident condition changes and lab results. Email communication received from the DON on August 16, 2022, at 10:50 AM, indicated that, although the care plan states to Monitor/record/report to MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, Resident has chronic urinary tract infections, a foley, and has been on prophylactic antibiotics since May 18, 2022, as infection and hematuria are ongoing issues. An additional review of Resident 3's diagnoses revealed that hematuria nor chronic urinary tract infection were listed as diagnoses. An additional review of physician orders revealed that the diagnosis for the antibiotic was prophylactic care, and not chronic urinary tract infections. An additional review of the care plan revealed that hematuria nor chronic urinary infections were noted as concerns on the care plan. In addition, the care plan indicated to monitor for effectiveness of the antibiotic and document every shift. Review of the clinical record revealed that the concerns that were documented on July 20, 2022, July 21, 2022, and August 4, 2022, staff failed to identify these concerns as signs indicative of an UTI and report them to the physician. Review of the physician's progress note dated August 3, 2022, revealed that there was no specific documentation regarding the Resident's urinary system or foley catheter; nor did the note indicate that the physician was aware of the events the Resident had experienced July 20, 2022, or July 21, 2022. Although the note indicated that the Resident denied nausea, vomiting, diarrhea, chest pain, or shortness of breath, there was no documentation that the Resident was asked about their urinary status or foley. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of medical records, observations, and staff and resident interviews, it was determined that the facility failed to ensure residents received proper care of indwelling catheters for two of two residents reviewed (Resident 2 and 7), and failed to provide appropriate interventions to promote continence in one of ten residents reviewed (Resident 8). Findings include: Review of Resident 2's medical record revealed the Resident was admitted on [DATE], with diagnoses that include malignant neoplasm of the prostate (cancer of the prostate) and retention of urine requiring a foley catheter. Review of Resident 2's physician orders revealed an order for Foley Catheter, 16 French with 10 CC balloon silicone catheter for urinary retention, neurogenic bladder, and/or wound healing secondary to incontinence, with a start date of July 7, 2022; an order to irrigate the catheter with 200 CC of sterile water every shift, with a start date of July 10, 2022; and an order for foley catheter care every shift, with a start date of July 6, 2022. During an interview with Resident 2 on July 28, 2022, at 1:15 PM, the Resident stated that they do not empty his catheter bag often enough. The Resident further stated that, on one occasion, the bag was so full it burst, and the contents spilled all over the floor. Review of Resident 2's Treatment Administration Report for July 2022, revealed the Resident was missing the ordered foley catheter care on July 8, 2022, July 16, 2022, and July 20, 2022. Further review revealed the Resident is missing the ordered sterile water irrigation on July 13, 2022, July 16, 2022, July 20, 2022, and July 21, 2022. Review of Resident 7's medical record revealed the Resident was admitted on [DATE], with diagnoses that include Multiple Sclerosis (a disease that affects central nervous system, making it difficult for the brain to send signals to rest of the body) and Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Review of Resident 7's physician orders revealed an order for Foley Catheter, 18 French with 10 CC balloon silicone catheter for urinary retention, neurogenic bladder, and/or wound healing secondary to incontinence, with a start date of May 31, 2022. Further review revealed the Resident is not ordered any foley catheter care to be completed. Review of Resident 7's Treatment Administration Report for July 2022, failed to reveal any evidence that the Resident has had foley catheter care or sterile water irrigation completed in the month. Review of Resident 8's medical record revealed the Resident was admitted [DATE], with diagnoses that include Hemiplegia (paralysis of one side) and Hemiparesis (paralysis or weakness of one side) following cerebral infarction, affecting left side and generalized muscle weakness. An observation on July 27, 2022, at 2:00 PM, revealed Resident 8 notifying Employee 3 that he needed his brief changed. Employee 3 then notified the Resident that they did not have the proper fitting briefs to use. Employee 3 then obtained supplies to change the Resident. During an interview with Resident 8, 2022, at 2:02 PM, it was revealed that he has not had the proper fitting brief for some time, and that he feels it isn't right. The Resident further stated that the briefs they use are very cheap and leak and tear very easily. During an interview with Employee 3, on July 27, 2022, at 2:05 PM, it was revealed that she does not have the Resident's proper size of brief available, and she has been using a bariatric brief on him because that is all she has to use. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, clinical record review, review of facility policies, and staff interviews, it was determined that the facility failed to secure the stairway and elevators and failed to provide adequate supervision and interventions to prevent accident hazards for wandering residents on two of four nursing units (Floors 1 and 2). This failure placed the facility in an Immediate Jeopardy situation. Findings include: Review of the facility policy titled, Elopement Policy/Procedure last revised October 2020, outlines the following: defines wandering as aimless moving about without a desire to leave the facility; defines exit seeking behavior as the process of a resident endeavoring to leave the facility without authorization; and defines elopement as a resident who has left the facility unauthorized or unwitnessed, or an unauthorized absence of a resident. The policy further states that residents who have risk for elopement will be monitored for safety as part of their plan of care and placed on the elopement list. The interdisciplinary team will assess and develop appropriate interventions and approaches to prevent the resident from eloping. Residents at risk for elopement will have an elopement risk care plan that will include the interventions in place for prevention of elopement. Observations on June 9, 2022, at 10:24 AM on the first-floor nursing care unit, revealed a door that opened to a stairwell. The door was unlocked and freely accessible, with a push bar that opens the door into the stairwell. The stairwell went down to the ground floor and went up to the second and third floors. Further observation revealed two elevators present that provide access to the third, second, and ground floors. The third floor is currently vacant, and the ground floor stairwell has an alarmed emergency door located inside the stairwell. Observations on June 9, 2022, at 10:30 AM on the second-floor nursing care unit, revealed a door that opened to a stairwell. The door was unlocked and freely accessible with a push bar that opens the door into the stairwell. The stairwell went down to the first and ground floors and went up to the third floor. Further observation revealed two elevators located in the center of the unit in front of the nurse's station. The elevators give access to the third, first, and ground floors. Review of resident's clinical records revealed 43 residents residing on the first floor, of those 43 residents, 21 residents are capable of ambulating independently by walking without assistive devices, walking with a cane or walker, or using a wheelchair, and 4 of those also has a diagnosis of Dementia. Further review revealed 13 residents residing on the second floor, of those 13 residents, 6 residents are capable of ambulating independently by walking without assistive devices, walking with a walker, or moving independently while in a wheelchair, and 1 of those also has a diagnosis of dementia. Observation on June 9, 2022, at 10:35 AM, revealed Resident 1 walking back and forth with a walker in the halls and in front of the elevators. Interview with Employee 1 on June 9, 2022, at 10:38 AM, revealed Resident 1 has been wandering while residing on that unit. Employee 1 stated Resident 1 should have a Wanderguard (a security bracelet / anklet that prevents the elevator from departing the unit and activates an alarm) present to prevent him from getting on the elevators. The Employee checked the Resident's ankle to see if a Wanderguard was present and identified he did not have one. Review of Resident 1's medical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include schizophrenia (a mental disorder with cognitive symptoms that may include problems in attention, concentration, and memory, and psychotic symptoms that may include hallucinations, delusions, thought disorders, and movement disorders) and Parkinson's Disease (a chronic and progressive a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Resident 1 was admitted to the facility following knee surgery. Review of Resident 1's progress notes revealed a note dated June 6, 2022, at 12:51 AM, stating Resident 1 wandered out of his room and was speaking to himself in the hallway most of the shift. An additional note dated June 6, 2022, at 12:25 PM, revealed Resident walking in and out of bedroom and walking through hallway naked. Resident attempted to use elevator multiple times. Review of Resident 1's admission assessment dated [DATE], revealed resident is independently ambulatory and walks frequently and is a current smoker. The assessment further revealed the resident does not have normal gait/balance, has problems balancing when standing, has problems balancing while walking, and requires use of assistance device (cane, walker, wheelchair, furniture). Review of the facility assessment titled, Wandering Risk Scale revealed resident are scored on abilities in multiple categories to identify their risk of wandering. If a resident scores 0-8 points they are considered low risk, 9-10 points is considered at risk to wander, and 11-and above is considered high risk to wander. Review of Resident 1's wandering risk assessment dated [DATE], revealed the resident is identified as a high risk to wander. The assessment revealed the resident was marked as can move without assistance while in a wheelchair (1 point), the resident was not marked for ambulatory (3 Points). The resident is also marked for having a history of wandering (2 points), has medical diagnosis of dementia/cognitive impairment, diagnosis impacting gait/mobility or strength (5 points), has history of wandering (2 points), has wandered within the home without leaving the grounds (1 point), has wandered in the past month (1 point), can follow instructions (1 point). The Resident was given a score of 12 which categorizes as a high risk to wander. Interview with the Director of Nursing (DON) on June 10, at 10:40 am, revealed that the wandering risk assessment for Resident 1, dated June 6, 2022, was coded incorrectly. The DON revealed the resident was marked for having a medical diagnosis of dementia/cognitive impairment, diagnosis impacting gait/mobility or strength and should not have been. The DON stated this change would change the resident to a low risk to wander. Review of Resident 1's updated wandering risk assessment submitted on June 10, 2022, revealed the resident was marked as can move without assistance while in a wheelchair (1 point) and not marked as ambulatory (3 points), has a history of wandering (2 points), has wandered within the home without leaving the grounds (1 point), has wandered in the past month (2 points), and can follow instructions (1 point). The assessment was updated to show resident does not have a medical diagnosis of dementia/cognitive impairment, diagnosis impacting gait/mobility or strength, The resident was given a score of 7 which categorizes as a low risk to wander. Observation on June 9, 2022, at 1:40 PM on the second-floor nursing care unit, revealed no staff present at the nurse's station or in view of elevators or stairwell door. Review of Resident 2's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that include adjustment disorder with disturbance of conduct and conversion disorder with seizures or convulsions (a mental condition in which a person experiences blindness, paralysis, or other nervous system [neurologic] symptoms that cannot be explained by illness or injury). Interview with Employee 2 on June 9, 2022, at approximately 4:00 PM, revealed Resident 2 was admitted the day prior and has been upset due to being in a new environment. The Employee confirmed that Resident 2 could get to the stairs. Review of Resident 2's Functional Abilities and Goals assessment completed on June 9, 2022, revealed the resident is able to walk. Review of Resident 2's wandering risk assessment dated [DATE], revealed the resident was marked as able to move without assistance while in a wheelchair (1 point), and was not marked for ambulatory (3 points), however documentation in the clinical record shows Resident 2 walks. The assessment further revealed the resident can follow instructions (1 point). The resident was given a score of 2 which categorizes as a low risk to wander. Review of Resident 3's medical record revealed resident was admitted to the facility on [DATE], with diagnoses that include schizoaffective disorder bipolar type (symptoms of schizophrenia-like delusions and paranoia, while also having periods of mania) and epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors). Review or Resident 3's Minimum Data Set, dated dated [DATE], revealed under the functional status section that resident ambulates using a walker and a wheelchair. Review of Resident 3's wandering risk assessment dated [DATE], revealed the resident was not marked for the section regarding movement, the options are: can move without assistance while in a wheelchair (1 point) or ambulatory (3 points), an additional 1-3 points would be added to score if completed. The assessment revealed the resident can follow instructions (1 point) and has a medical diagnosis of dementia/cognitive impairment, diagnosis impacting gait/mobility or strength (5 points). The resident was given a score of 6 which categorizes as a low risk to wander. An Immediate Jeopardy situation was identified, and the immediate Jeopardy template was provided to the Nursing Home Administrator on June 9, 2022, at 4:20 PM, for failing to ensure adequate supervision and interventions to prevent accident hazards for wandering / elopement risk residents. An immediate corrective action plan was requested on June 9, 2022, at 4:25 PM, to ensure the stairway and elevators were properly secured to prevent injury or elopement of residents. The facility provided an immediate corrective action plan on June 9, 2022, at 6:35 PM, which indicated: A Wanderguard transmitter was placed on Resident 1 upon discovery, which triggers an alarm on the elevator and renders in unable to run until overridden with a code. Resident 1's care plan was updated to incorporate the approach. A motion-censored local alarm was placed on the first and second floor stairwell. The facility reviewed elopement assessments of remaining residents and did not discover additional residents at risk for elopement. The facility initiated immediate education of second floor nursing staff regarding Resident 1's assessment, wandering risk, and care plan approaches, including the Wanderguard transmitter. Facility initiated immediate education of facility staff concerning local alarms on first and second floor stairwell doors. The facility engaged a contracted service company to provide a proposal to incorporate the two stairwell doors into an existing alarm notification annunciator at the nurse's station. The Immediate Jeopardy was removed on June 10, 2022, at 11:09 AM, following confirmation the corrective action plan was implemented. Free of Accident Hazards/Supervision/Devices CFR 483.25(d)(1)(2) 28 Pa. Code 210.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility records and staff interviews, it was determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident 1). Findings include: Review of Resident 1's September 2014 physician orders [REDACTED]. Review of Resident 1's clinical record revealed a Behavior Plan dated May 30, 2014. According to the Plan, Resident 1 is non-compliant with safety for himself and others. "When staff instructs him to do something for his safety he often refuses (thickened liquids, asking for assistance with transfers, sitting outside in high heat for long periods, hydration)". Approaches listed on the Behavior Plan included to make Resident 1 aware of why staff are instructing him on safety and potential issues that could come from his non-compliance. Review of Resident 1's nursing notes revealed on August 26, 2014 at approximtely 3:48 p.m. there was a call from the receptionist to Resident 1's nursing unit; "Resident is on the patio and not responding. Resident sitting in chair outside on patio with head down, chin to chest and drooling and unresponsive to verbal and tactile stimuli; sent to ER. Oxygen started via canula mask, body temperature was 106.3". Further review of nursing notes revealed Resident 1 was admitted to Intensive Care unit for neurogenic shock and severe hypothermia. Written staff statements regarding the incident with Resident 1 revealed: Staff member (SM) 1 saw Resident 1 in his room listening to music at approximately 2:00 p.m. Social Worker (SW) 1 was on the elevator with the resident at approximately 2:00 p.m.; Resident 1 stated he was going to go work on his tan. RN 1 observed Resident 1 sitting in his wheelchair at approximately 2:30 p.m.; nothing appeared out of the ordinary. Staff member (SM) 2 observed Resident 1 on the patio sitting in his wheelchair with his shirt off at 3:00 p.m. Staff member (SM) 3 observed Resident 1 at approximately 3:00 p.m. on the patio with his shirt off, hands in his lap, head slightly tilted down; he appeared to be sleeping. LPN 1 observed Resident 1 sitting in the sun taking an afternoon snooze at approximately 3:10 p.m.; nothing seemed out of the ordinary, breathing was normal. CNA 1 reported Resident 1 was observed after lunch, but she did not see him again until after 3:45 p.m.; he typically comes to the unit numerous times throughout the day, but she could not confirm his activities on August 26, 2014 because she was not assigned to him. Review of the facility's care tracker report revealed Resident 1 was provided with bladder/bowel care on August 26, 2014 at 1:57 p.m. There is no other documented evidence of staff interaction with Resident 1 until he was found unresponsive at 3:45 p.m. Resident 1 exited the building to sit in the sun at approximately 2:00 p.m. While several staff members observed him while tanning on the patio, there is no evidence that he was encouraged to come in out of the sun as per his Behavior Plan, between 2:00 p.m. and 3:45 p.m., when he was found unresponsive by a visitor. There was no evidence of direct supervision to ensure his well-being by nursing staff between 2:00 p.m. and 3:45 p.m. At the time of the incident, there was no policy in place for staff to monitor/check on independent residents on hot days. During an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2014 at 1:30 p.m. it was confirmed that the facility has developed a heat advisory/outdoor policy, effective September 2, 2014, in response to this incident with Resident 1. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3) Nursing services.