Every finding on record at Concordia at RP Home

Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to properly maintain sanitary conditions which created the potential for cross contamination. (Main Kitchen) Findings include:Review of facility policy Food Safety and Sanitation dated 7/15/26, indicated all local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. During an observation with Food Service Director Employee E5 in the main kitchen on 8/11/26, at 9:15 a.m., revealed five kitchen ceiling fans with brown debris. During an observation with Food Service Director Employee E5 in the main kitchen on 8/11/26, at 10:00 a.m. revealed brown debris covering wall in the dishwasher area. During an interview on 8/11/26, at 10:30 a.m., Dietary Manager Employee E5 confirmed that the facility failed to maintain sanitary conditions creating the potential for cross contamination. 28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of the facility policy and staff interviews, it was determined that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (June 2025 to May 2026). Findings include: Review of facility Antibiotic Stewardship Program policy last reviewed 7/15/26, indicated the facility implements an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose if the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Review of the facility's Infection Control Program from June 2025 to May 2026, failed to include documented evidence that antibiotic (medications used to treat infections) monitoring was completed timely. The previous month antibiotic report was utilized for tracking. During an interview on 8/11/26, at 2:26 p.m. Registered Nurse (RN) Infection preventionist (IP) Employee E1 revealed antibiotic stewardship was completed after each month from June 2025 to May 2026. IP, Employee E1 stated every first of the month, the previous month antibiotic report were reviewed and residents who were prescribed antibiotics were tracked for length of time they received the antibiotic and indication for use. IP, Employee E1 stated the facility started daily tracking in June 2026. IP, Employee E1 confirmed the facility failed to timely conduct antibiotic stewardship. During an interview completed on 8/12/26, at 10:38 a.m. the Nursing Home Administration and Director of Nursing confirmed that the facility failed to implement an antibiotic stewardship program for 12 of 12 months (June 2025 to May 2026). 28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a pneumococcal immunization for one of five residents reviewed (Residents R11).Findings include: A review of facility policy, Infection Prevention and Control Program, dated 7/15/26, indicated residents will be offered the pneumococcal vaccines recommended by the CDC upon admission unless contraindicated or received the vaccines elsewhere. Documentation will reflect the education was provided and details regarding whether or not the resident received the immunizations. A review of the clinical record indicated Resident R11 was admitted to the facility on [DATE], with diagnoses that included cancer, high blood pressure, and anxiety. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/9/26, indicated the diagnoses were current. Section O0300 Pneumococcal Vaccine revealed the resident was not up to date and the resident was not offered the pneumococcal vaccine. A review of R11's electronic clinical record Immunizations documentation on 8/12/26, at 11:00 a.m., did not include information that the pneumococcal vaccine was offered or declined. During an interview on 8/12/26 at 1:19 p.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered pneumococcal immunization for Residents R11. 28 Pa. Code 211.5(f)(i)-(xi) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical record review, and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of six residents (Residents R54).Findings include: Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/8/26, indicated diagnoses of chronic respiratory disease, dysphagia (difficulty swallowing) and depression. Review of the clinical record indicated Resident R54 was transferred to the hospital on 6/22/26, and returned did not return to the facility. Review of Resident R54's clinical record, the facility failed to include documented evidence that the facility provided a written notification to the Office of Long-Term Care Ombudsman for the hospitalization on 6/22/26. During an interview on 8/13/26, at 2:00 p.m. the Director of Social Services Employee E9 confirmed that the facility failed to provide written transfer notice to a representative of the Office of Long-Term Care Ombudsman for two of six residents as required (Resident R54). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on a review of Resident Assessments Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to conduct a Significant Change Minimum Data Set assessments for one of six samples residents (Resident R2). Findings include: Review of Resident Assessment Instrument (RAI) 3.0 User's Manual (reference used to complete an MDS) dated [DATE], indicated the significant change assessments (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes in hospice providers and remains a resident at the nursing home. The assessment reference date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). Review of Resident R2's MDS assessment dated [DATE], indicated the following diagnosis: pulmonary hypertension, dysuria and heart failure. Review of Resident R2's physician orders dated 7/24/26 indicated that she was ordered hospice care services. Review of Resident R2's MDS assessments did not include a significant change MDS assessments that included hospice services for Resident R2. During an interview on 8/13/26, at 1:30 p.m. RNAC (Registered Nurse Assessment Coordinator) Employee E4 confirmed that the facility failed to conduct a Significant Change Minimum Data Set assessment for Resident R2 as required. 28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing Services

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan for a resident within 48 hours of a resident's admission for one of six residents reviewed (Resident R27).Findings include: Review of the facility policy Care Plan-Baseline last reviewed 7/15/26, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care. Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE], with diagnoses of dementia, depression, and cerebral infarction. Review of Resident R27's progress note dated 7/30/26, revealed the resident's ability to hear was highly impaired. Review of Resident R27's progress note dated 7/30/26, revealed the resident arrived with a pocket talker. Review of the Resident R27s Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/4/26, indicated the diagnoses were current. Section B0200. Hearing revealed the resident ability to hear (with hearing aid or hearing appliances of normally used) was highly impaired. Resident R27's clinical record lacked evidence that a baseline care plan was implemented for Resident R27's difficulty hearing. During an interview on 8/12/26, at 1:37 p.m. Registered Nurse Supervisor, Employee E3 stated if resident's are hard of hearing, a care plan with interventions related to the difficulty hearing should be implemented. During an interview completed on 8/12/26, at 1:46 p.m. the Registered Nurse Assessment Coordinator, Employee E4 confirmed the facility failed to implement a baseline care plan within 48 hours for Resident R27's hearing difficulty. 28 Pa Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of eight residents (Resident R7).Findings include: Review of facility's policy Comprehensive Care Plans dated 7/15/26, indicated the facility will 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. Review of admission record indicated Resident R7 was admitted to the facility on [DATE], with diagnoses of right foot drop, depression, and high blood pressure. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/23/26, indicated the diagnoses were current. Review of Resident R7's care plan dated 5/28/26, indicated to apply brace the resident's right lower extremity. It was indicated to apply on with morning care and off with evening care or as tolerated. During an interview on 8/12/26, at 1:22 p.m. Resident R7 was observed without a right lower extremity brace. The resident's brace was observed sitting on the chair in the resident's room. Resident R7 stated no one had offered to put it on. During an interview on 8/12/26, at 1:24 p.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R7's right lower extremity brace was not applied as care planned. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy, clinical records, staff and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of eight sampled residents (Resident R17).Findings include: The facility Activities of Daily (ADLs) policy dated 7/15/26, indicated it is the facility policy to set goals with the resident make the goals specific to what is important to the resident. Review of the clinical record revealed Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's care plan dated 5/28/26, indicated to assist with ADL completion as needed. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/20/26, indicated diagnoses coronary artery disease (CAD- narrowing of the arteries that reduce blood flow to the heart), hypertension (high blood pressure) and depression. Review of Resident R17's clinical nurse notes and ADL documentation did not indicate that he received a haircut or was offered for his beard to be shaved. During an interview and observation on 8/11/26, at 10:05 a.m. Resident R17 was observed with disheveled long hair and a long beard. Resident R17 stated I'd like to get it cut someday and typically likes it shorter when asked if he prefers his long hair and beard. During an interview on 8/12/26, at 11:12 p.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R17 needed hair services. During an interview on 8/12/26, at 3:13 p.m. the Director of Nursing confirmed the facility failed to provide Activity of Daily Living (ADL) assistance to Resident R17. 28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on review of facility policy, clinical records, observations, and interviews with staff, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent pressure ulcers (PU/PIs -to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (Resident R50).Findings include: Review of facility policy Pressure Injury Prevention and Management dated 7/15/26, indicated the facility is committed to the prevention of avoidable pressure ulcers, and to provide treatment and services to heal the pressure ulcer, and prevent infection and the development of additional pressure ulcers. Interventions wil be based on specific factors identified will be implemented. Review of Resident R50's admission record indicated he was admitted on [DATE]. Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses high blood pressure, depression, and chronic obstructive pulmonary disease (COPD- is a progressive lung disease that makes it difficult to breathe). Section M-Skin Conditions indicated the resident had a stage III pressure ulcer. Review of Resident R50's current physician orders dated 6/25/26, indicated to turn and repositioned every two hours. Review of Resident R50's current physician orders dated 7/27/26, indicated to use wedge cushion to position resident form side to side. During an observation on 8/11/26, at 10;14 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning. During an observation on 8/12/26, at 11;13 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning. During an observation on 8/13/26, at 8;50 a.m. Resident R50 was observed laying in bed supine, with no wedge or pillow in place for positioning. During an interview on 8/13/26, at 9:34 a.m. Licensed Practical Nurse, Employee E? was asked if Resident R50 had a wedge to be turned and repositioned. LPN, Employee E2 stated I haven't seen one. During an interview on 8/13/26, at 9:35 a.m. Registered Nurse Supervisor, Employee E3 confirmed Resident R50 does not have a wedge and not turned and repositioned as ordered. During an interview on 8/13/26, at 2:36 a.m., the Director of Nursing confirmed that the facility failed to make certain Residents R50 was provided necessary treatment and services for pressure ulcers. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of two residents (Resident R6).Findings include: Review of the facility policy Enteral Feeding Procedure last reviewed 7/15/26, indicated enteral feedings may be prescribed for residents who are physically or psychologically unable to take food by mouth in amounts that will support minimum nutrition. Enteral feedings should be administered under the close supervision of a physician and monitored by a Registered Dietitian and/or physician. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/14/26, indicated diagnoses of adult failure to thrive, gastroesophageal reflux disease (GERD), and dysphagia (difficulty swallowing). Section K-Swallowing/Nutritional Status- revealed the resident had a feeding tube while a resident. Review of Resident R6's care plan dated 7/14/26, indicated the resident received enteral feedings and to administer diet as ordered. Review of Resident R6's physician order dated 4/21/26, indicated Enteral Feed (delivers liquid nutrition directly into digestive system using a flexible tube that bypasses normal swallowing) every shift Glucerna 1.2 (formula type) to run 24 hours continuous at 70 milliliter (ml) per hour. Free water flushes with 50 ml every six hours. During an observation completed on 8/11/26, at 10:09 a.m. the enteral feeding pump was observed to be beeping. A hold error message was observed on the screen. 700 ml of Glucerna was observed in the bottle. During an observation on 8/12/26, at 11:08 a.m. Resident R6's enteral feeding pump was paused. Resume in 24 minutes was observed on the screen. During an interview on 8/12/26, at 11:15 a.m. Registered Nurse, Employee E3 stated Resident R6 is on a continuous tube feed. It was indicated staff pause the tube feed for an hour each shift. Nurses are responsible for placing the tube feed pump on hold, and responsible for restarting. It was indicated the nurse aides are not allowed to touch the pump, disconnect, or hold the enteral feeding. RN, Employee E3 stated she was the resident's nurse and was assigned the resident for day shift on 8/12/26. During an interview on 8/12/26, at 11:25 a.m. Resident R6's enteral feeding was on hold. During an interview on 8/12/26, at 11:34 a.m. RN, Employee E3 confirmed Resident R6's enteral feeding was on hold. RN, Employee E3 confirmed she did not place the enteral feeding on hold and was not aware it was placed on hold. RN, Employee E3 restarted the resident's enteral feeding. During an interview on 8/12/26, at approximately 3:00 p.m. information was disseminated to the Director of Nursing that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services for one of two residents (Resident R6). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, observations, and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for one of three sampled residents (Residents R50).Findings include: Review of Resident R50's admission record indicated he was admitted on [DATE]. Review of Resident R50's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/29/26, indicated the diagnoses of high blood pressure, depression, and chronic obstructive pulmonary disease (COPD- is a progressive lung disease that makes it difficult to breathe). Review of Resident R50's current physician orders dated 6/5/26, indicated to check every week on Sunday evening, if humidifier has been changed. Review of Resident R50's current physician orders dated 6/5/26, indicated to apply 2 liters of oxygen each shift. Review of Resident R50's current physician orders dated 6/6/26, indicated to check oxygen humidification every shift and change/fill as needed. During an observations on 8/11/26, at 10:14 a.m., Resident R50's humidification bottle dated 8/2/26, was observed empty. During an observations on 8/12/26, at 11:00 a.m., Resident R50's humidification bottle dated 8/2/26, was observed empty. Resident R50 was not utilizing oxygen and the nasal cannula was observed hanging over the oxygen concentrator without a bag. During an interview and observation on 8/12/26, at 11:13 a.m. Registered nurse Supervisor, Employee E3 confirmed Resident R50's humidification bottle was empty. RN Supervisor, Employee E3 confirmed Resident R50 was not receiving oxygen as ordered and the nasal cannula tubing was not stored properly when in use. During an interview on 8/12/26, at 2:23 p.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment. 28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records, hospital records, physician orders, and staff interviews, it was determined the facility failed to ensure physician-ordered laboratory services were obtained in a timely manner and failed to follow through on ordered laboratory testing for one of six residents reviewed (Resident R10). Findings include: Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses of dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), anxiety, and depression. Review of the Resident R10's Minimum Data Set (MDS- a periodic assessment of care needs) dated 6/30/26, indicated the diagnoses were current. Review of Resident R10's progress note dated 8/8/26, revealed the resident had increased confusion, hallucinating and combative. The physician was notified and an order for a urinalysis was obtained. Review of Resident R10's physician order dated 8/8/26, indicated to obtain urinalysis with culture one time only related to dementia without behavior disturbance. There was no documented evidence that the facility obtained the physician-ordered urinalysis and culture and sensitivity or implemented alternative measures to ensure timely completion of the ordered laboratory testing between 8/8/26, to 8/12/26. During an interview on 8/12/26, at 1:30 p.m. Registered Nurse Supervisor, Employee E3 stated when a urinalysis and culture is ordered, it is transcribed to alert of the clinical record as a task that needs to be completed. All supplies are located in the utility room. The order must be signed off in the clinical record when the specimen is obtained. The results are followed up and if any abnormal findings the physician is notified. RN, Supervisor, Employee E3 confirmed the facility failed to obtain Resident R10's urinalysis as ordered. During an interview conducted on 8/12/26, at 3:13 PM, the Director of Nursing confirmed there was a delay in obtaining the physician-ordered urine specimen. 28 Pa. Code 211.12 (3)(5) Nursing services.

Based on facility policy, review of facility documents, and staff interviews, it was determined that the facility failed implement enhanced barrier precautions for one of three residents (Resident R6), and provide evidence control measures were implemented and the facility water management plan included remedial process for control limits for 14 of 14 months (June 2025 to August 2026). Findings include: Review of the facility's Enhanced Barrier Precautions policy dated 7/15/26, indicated it is the facility's policy to implement enhanced barrier precautions for the prevention of transmission of multi-drug resistance organisms. Enhanced barrier precautions (EBP-refers to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown and gloves use during high contact resident care activities. EBP will be implemented for residents with wounds and indwelling medical devices such as a feeding tube. Gowns and gloves will be made available immediately near or outside of the residents' room. PPE is necessary when performing high-contact care activities such as dressing, bathing, and providing hygiene, changing briefs or assisting with toileting. Review of the facility's Water Management Policy, Monitoring, and Response last reviewed 7/15/26, revealed it is the facility's policy to reduce legionellosis and other opportunistic pathogens in the facility's water system based on nationally accepted standards. Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measure being monitored to reduce the risk of Legionella growth and spread. Control measures are things done in the building water systems to limit growth and spread of legionella such as heating, adding disinfectant, cleaning, or circulation and dead spot elimination. A further review of the facility's water management plan failed to include remedial procedure for if the control limits are not met. Review of facility documentation on 8/12/26, at 11:00 a.m. failed to include evidence the control measures were implemented. During an interview on 8/13/26, at 10:52 a.m. Maintenance Director, Employee E2 stated the facility does not keep daily logs when asked to provide evidence of the control measures the facility implemented. Maintenance Director, Employee E2 stated he's been working at the facility for fours years and I haven't kept any logs. Maintenance Director, Employee E2 confirmed the facility's plan failed to include a remedial process if control limits are not met and stated 'Yes, I agree we have to measure and have instructions if things go awry. During an interview on 8/13/26, at 2:36 p.m. Nursing Home Administrator confirmed the facility failed to implement their water management plan to prevent the growth of legionella by failing to conduct weekly flushes for the closed unit located on 2 [NAME] from April 2025, to April 2026. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/14/26, indicated diagnoses of adult failure to thrive, gastroesophageal reflux disease (GERD), and dysphagia (difficulty swallowing). Section K-Swallowing/Nutritional Status- revealed the resident had a feeding tube while a resident. Review of Resident R6's care plan dated 7/27/26, indicated the resident required isolation for their wounds and enteral feeding. The resident isolation type was enhanced barrier precautions. During observations conducted on the following dates and times, no signage was posted at the entrance of the resident's door indicating the resident was in enhanced barrier precautions.-8/11/26m at 10:09 a.m.-8/12/26, at 11:25 a.m. A review of the resident's clinical record on 8/13/26, failed to include a physician order for enhanced barrier precautions. During an observation and interview on 8/13/26, at 10:13 a.m. Nurse Aide (NA), Employee E7 and NA, Employee E8 were providing direct care to Resident R6 without gown or gloves. NA, Employee E7 and NA, Employee E8 stated they were unaware Resident R6 was in EBP and confirmed no signage was posted at the entrance. During an interview on 8/13/26, at 10:21 a.m. Registered Nurse, Employee E6 confirmed Resident R6 failed to have isolation signage posted at the entrance of the door and the resident did not have a physician order for enhanced barrier precautions. During an interview on 8/13/26, at 12:34 p.m. information was disseminated to the Director of Nursing that the facility failed to implement enhanced barrier precautions as required for Resident R6. 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)(2)(5) Nursing services.

Based on a review of facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a COVID-19 vaccine for one of five residents reviewed (Residents R1). Findings include: A review of facility policy, Infection Prevention and Control Program, dated 7/15/26, indicated residents will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. Residents will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination. The resident's medical record includes documentation that indicates at a minimum, the following:-The resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. -Each dose of COVID-19 vaccine administered to the resident, or if the resident did not receive the vaccine due to medication contradiction or refusal. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cancer, high blood pressure, and insomnia (difficulty staying or falling asleep). A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/29/26, indicated the diagnoses were current. Section O0350 Resident's COVID-19 vaccination is up to date revealed the resident was not up to date. A review of R1's electronic clinical record Immunizations documentation on 8/12/26, at 11:00 a.m., did not include information that the COVID-19 vaccine was offered or declined. During an interview on 8/12/26 at 1:19 p.m., the Director of Nursing confirmed the above findings, and that the facility failed to document each resident was offered COVID-19 vaccine for Residents R1. 28 Pa. Code 211.5(f)(i)-(xi) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for wheelchair transport to prevent accidents which resulted in actual harm of a hematoma to right forehead, patella (kneecap) fracture, and ankle sprain for one of three residents (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy Fall Prevention dated 7/15/25, indicated a Fall Risk Assessment will be used to screen residents for fall risk on admission, quarterly, annually, and significant change. The nurse will complete the following:Review and complete the variables on the Morse Fall Scale by assigning the corresponding score which best describes the resident. Add the column of numbers to obtain the total score. Scoring as follows:-Hight Risk: 45 and higher-Moderate Risk: 25 - 44-Low Risk 0 - 24.Initiate an intervention(s) as appropriate. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/26, indicated diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure, and depression. Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting cognitive impairment) score of 12 - moderately impaired cognition. Section GG - Functional Abilities - Mobility, Question GG0170R indicated the resident was coded at a 03 partial/moderate assistance. Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for wheeling self 50 feet in a wheelchair and making two turns. Review of Resident R1's Morse Fall Risk Screening dated 4/20/26, indicated a score of 65 - high risk. Review of Resident R1's care plan dated 4/19/26, indicated to provide assistance for ADL's (activities of daily living) as needed. Resident is at risk for falls and related injury due to weakness and history of falling. Goal indicated that resident will not fall, but if a fall occurs, resident will not sustain significant injury through next review. Review of Resident R1's clinical record nursing progress note dated 4/24/26, at 6:57 p.m., indicated writer was alerted by a Nurse Aide (NA) that Resident R1 had fallen from the wheelchair. When approached the resident was found lying on the head with the lower torso up by the wheelchair seat. The NA behind the chair stated they were trying to assist resident through the doors and the resident fell forward. Resident was assessed and noted to have a hematoma (collection of blood outside of the vessels causing swelling, pain and inflammation) to the right forehead. Measured 2.5 centimeters (cm) long by 6 cm wide. Site was bleeding. Resident also had an abrasion to the right knee that was bleeding 2cm long by 2cm wide. Resident complained of head pain. 911 was called and resident was transferred to the emergency room. Further review of Resident R1's clinical record nursing progress note dated 4/25/26, at 1:05 a.m., resident returned from the emergency room with a large hematoma with abrasions to the forehead and a diagnosis of left patella fracture and ankle sprain. Review of Registered Nurse (RN) Employee E1's signed witness statement dated 4/24/26, indicated writer was notified by NA that Resident R1 fell from the wheelchair while being pushed through the door by another NA. Review of NA Employee E2's signed witness statement dated 4/24/26, indicated around 6:00 p.m. as they were coming out of a resident room, the double doors down the middle hallway were opening and NA Employee E3 was pushing Resident R1 through the door and the resident went head down landing on right side of head and neck. Review of NA Employee E3's signed witness statement dated 4/24/26, indicated Resident R1 was wandering around the ice machine and doorway while writer was getting ice for ice water. All the alarms were going off by the ice machine all the way to the east back hallway. This was the second time writer redirected Resident R1 away from the area to prevent resident from going outside. The last time, the writer redirected Resident R1 they helped to push resident to get to their room. No leg lifts on feet, very hard to push. Resident fell right through the door as writer opened it. Writer indicated they were trying to keep the resident safe from going outside. Review of facility provided report dated 4/24/26, at 6:00 p.m. indicated employee was attempting to redirect resident who was self-propelling in the hallway when they pushed the resident in the wheelchair and the resident fell forward out of the wheelchair. Leg rests were not present on the wheelchair at the time of the indecent. Review of Resident Occurrence Report Fall Investigation dated 4/24/26, indicated recommendations to reduce fall or injury in the future: Physical therapy to evaluate for leg rests. Interview on 5/5/26, at 9:00 a.m. NA Employee E4 indicated residents should never be pushed by staff without footrests on the chair. Interview on 5/5/26, at 9:10 a.m. Licensed Practical Nurse (LPN) Employee E5 indicated residents in wheelchairs should always have footrests in place if they are being pushed by staff. Interview on 5/5/26, at 9:15 a.m. NA Employee E6 indicated a resident who self-propels and needs help, staff should go to the resident's room and get the footrests before pushing them. Interview on 5/5/26, at 9:30 a.m. Occupational Therapist Employee E7 indicated when the department provides a resident a wheelchair, they always provide footrests with the chair. Interview on 5/5/26, at 9:45 a.m. NA Employee E8 indicated residents need footrests on the wheelchair before staff can push them. Interview on 5/5/26, at 10:00 a.m. NA Employee E9 indicated staff are not permitted to push a resident in a wheelchair without footrests. Interview on 5/5/26, at 10:10 a.m. RN Employee E1 confirmed NA Employee E3 failed to provide adequate supervision and assistance by not placing foot rests on the wheelchair at the time of the incident on 4/24/26, at 6:00 p.m. when they were pushing the resident through the door, as required which resulted in actual harm of a hematoma to right forehead, left patella fracture, and ankle sprain for Resident R1. Telephonic interview on 5/5/26, at 11:37 a.m. NA Employee E3 indicated Resident R1 maneuvers themselves all over the place in the wheelchair. NA Employee E3 indicated they redirected Resident R1 three times due to the wander guard alarm (device that alerts staff if a resident with a wander bracelet is near an unauthorized area) going off. They pushed Resident R1 back twice while trying to also care for other residents and pass ice water. They reported they were scared because the alarms were going off and they were trying to protect the resident from getting outside. The resident was hard to push, and they opened the door pushing resident through the door and resident fell right on their head. They had to turn all the alarms off and admitted the resident did not have footrests on at the time they pushed the resident through the door. This deficiency is cited as past non-compliance. On 4/24/26, at 8:30 p.m. the facility initiated a plan of correction that included: -The resident involved was immediately assessed following the incident, and appropriate medical evaluation and monitoring were conducted until emergency medics arrived.-The involved staff member received immediate re-education and was sent home during the investigation.-The incident was immediately investigated by the Charge nurse and the Nursing Home Administrator.-Nursing staff have been re-educated on neglect and pushing a resident in a wheelchair must always have footrests in place prior to staff assisting.-All residents were audited and had wheelchair leg rests available and present, at the time of the incident on 4/24/26, at 9:00 p.m. the Shift Supervisor confirmed via verbal report to the Nursing Home Administrator.-All staff were re-educated on wheelchair safety and neglect starting at the time of the incident on 4/24/26.-Education signature sheets were reviewed with staff signatures for 43 of the facility's total 50 employees by 4/27/26.-Wheelchair leg rest bags were ordered to trial with residents who self-propel. -Leg rest bags delivered and applied to resident wheelchairs on 5/1/26.-Weekly observation audits conducted to observe compliance with wheelchair transport safety. Results on file with the Nursing Home Administrator reviewed and intact.-Continue with audits to ensure resident safety weekly until 100% (percent) compliance for three months and then will move to monthly observations.-Therapy to continue to monitor Resident R1 for wheelchair seating and option for custom wheelchair.-Observation Audits communicated and provided to QAPI (Quality Assurance and Performance Improvement) Committee. The facility was back in compliance on 4/27/26. Interviews with seven of seven facility staff present on 5/5/26, indicated they received education on neglect and pushing a resident in a wheelchair must always have footrests in place prior to staff assisting. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, facility provided documents and clinical records, and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of a hematoma to right forehead, patella (kneecap) fracture, and ankle sprain for one of three residents (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy Prevention of Abuse and Response dated 7/15/25, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the admission record indicated that Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/5/26, indicated diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure, and depression. Section C0500 indicated a Brief Interview for Mental Status (BIMS- is a screening test that aids in detecting cognitive impairment) score of 12 - moderately impaired cognition. Section GG - Functional Abilities - Mobility, Question GG0170R indicated the resident was coded at a 03 partial/moderate assistance. Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for wheeling self 50 feet in a wheelchair and making two turns. Review of Resident R1's care plan dated 4/19/26, indicated to provide assistance for ADL's (activities of daily living) as needed. Resident is at risk for falls and related injury due to weakness and history of falling. Goal indicated that resident will not fall, but if a fall occurs, resident will not sustain significant injury through next review. Review of Resident R1's clinical record nursing progress note dated 4/24/26, at 6:57 p.m., indicated writer was alerted by a Nurse Aide (NA) that Resident R1 had fallen from the wheelchair. When approached the resident was found lying on the head with the lower torso up by the wheelchair seat. The NA behind the chair stated they were trying to assist resident through the doors and the resident fell forward. Resident was assessed and noted to have a hematoma (collection of blood outside of the vessels causing swelling, pain and inflammation) to the right forehead. Measured 2.5 centimeters (cm) long by 6 cm wide. Site was bleeding. Resident also had an abrasion to the right knee that was bleeding 2cm long by 2cm wide. Resident complained of head pain. 911 was called and resident was transferred to the emergency room. Further review of Resident R1's clinical record nursing progress note dated 4/25/26, at 1:05 a.m., resident returned from the emergency room with a large hematoma with abrasions to the forehead and a diagnosis of left patella fracture and ankle sprain. Review of Registered Nurse (RN) Employee E1's signed witness statement dated 4/24/26, indicated writer was notified by NA that Resident R1 fell from the wheelchair while being pushed through the door by another NA. Review of NA Employee E2's signed witness statement dated 4/24/26, indicated around 6:00 p.m. as they were coming out of a resident room, the double doors down the middle hallway were opening and NA Employee E3 was pushing Resident R1 through the door and the resident went head down landing on right side of head and neck. Review of NA Employee E3's signed witness statement dated 4/24/26, indicated Resident R1 was wandering around the ice machine and doorway while writer was getting ice for ice water. All the alarms were going off by the ice machine all the way to the East back hallway. This was the second time writer redirected Resident R1 away from the area to prevent resident from going outside. The last time, the writer redirected Resident R1 they helped to push resident to get to their room. No leg lifts on feet, very hard to push. Resident fell right through the door as writer opened it. Writer indicated they were trying to keep the resident safe from going outside. Review of facility provided report dated 4/24/26, at 6:00 p.m. indicated employee was attempting to redirect resident who was self-propelling in the hallway when they pushed the resident in the wheelchair and the resident fell forward out of the wheelchair. Leg rests were not present on the wheelchair at the time of the incident. Review of Resident Occurrence Report Fall Investigation dated 4/24/26, indicated recommendations to reduce fall or injury in the future: Physical therapy to evaluate for leg rests. Interview on 5/5/26, at 9:00 a.m. NA Employee E4 indicated residents should never be pushed by staff without footrests on the chair. Interview on 5/5/26, at 9:10 a.m. Licensed Practical Nurse (LPN) Employee E5 indicated residents in wheelchairs should always have footrests in place if they are being pushed by staff. Interview on 5/5/26, at 9:15 a.m. NA Employee E6 indicated a resident who self-propels and needs help, staff should go to the resident's room and get the footrests before pushing them. Interview on 5/5/26, at 9:30 a.m. Occupational Therapist Employee E7 indicated when the department provides a resident a wheelchair, they always provide footrests with the chair. Interview on 5/5/26, at 9:45 a.m. NA Employee E8 indicated residents need footrests on the wheelchair before staff can push them. Interview on 5/5/26, at 10:00 a.m. NA Employee E9 indicated staff are not permitted to push a resident in a wheelchair without footrests. Interview on 5/5/26, at 10:42 a.m. RN Employee E1 confirmed NA Employee E3 neglected to place footrests on the wheelchair at the time of the incident on 4/24/26, at 6:00 p.m. while NA Employee E3 was pushing resident through the door, as required which resulted in actual harm of a hematoma to right forehead, left patella fracture, and ankle sprain for Resident R1. Telephonic interview on 5/5/26, at 11:37 a.m. NA Employee E3 indicated Resident R1 maneuvers themselves all over the place in the wheelchair. NA Employee E3 indicated they redirected Resident R1 three times due to the wander guard alarm (device that alerts staff if a resident with a wander bracelet is near an unauthorized area) going off. They pushed Resident R1 back twice while trying to also care for other residents and pass ice water. They reported they were scared because the alarms were going off and they were trying to protect the resident from getting outside. The resident was hard to push, and they opened the door pushing resident through the door and resident fell right on their head. They had to turn all the alarms off and admitted the resident did not have footrests on at the time they pushed the resident through the door. This deficiency is cited as past non-compliance. On 4/24/26, at 8:30 p.m. the facility initiated a plan of correction that included: -The resident involved was immediately assessed following the incident, and appropriate medical evaluation and monitoring were conducted until emergency medics arrived.-The involved staff member received immediate re-education and was sent home during the investigation.-The incident was immediately investigated by the Charge nurse and the Nursing Home Administrator.-Nursing staff have been re-educated on neglect and pushing a resident in a wheelchair must always have footrests in place prior to staff assisting.-All residents were audited and had wheelchair leg rests available and present, at the time of the incident on 4/24/26, at 9:00 p.m. the Shift Supervisor confirmed via verbal report to the Nursing Home Administrator.-All staff were re-educated on wheelchair safety and neglect starting at the time of the incident on 4/24/26.-Education signature sheets were reviewed with staff signatures for 43 of the facility's total 50 employees by 4/27/26.-Wheelchair leg rest bags were ordered to trial with residents who self-propel. Leg rest bags delivered and applied to resident wheelchairs on 5/1/26.-Weekly observation audits conducted to observe compliance with wheelchair transport safety. Results on file with the Nursing Home Administrator reviewed and intact.-Continue with audits to ensure resident safety weekly until 100% (percent) compliance for three months and then will move to monthly observations.-Therapy to continue to monitor Resident R1 for wheelchair seating and option for custom wheelchair.-Observation Audits communicated and provided to QAPI (Quality Assurance and Performance Improvement) Committee. The facility was back in compliance on 4/27/26. Interviews with seven of seven facility staff present on 5/5/26, indicated they received education on neglect and pushing a resident in a wheelchair must always have footrests in place prior to staff assisting. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, review of facility documentation, observations, and staff and resident interviews, it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for three of three residents reviewed (Resident CR1, R2, and R3).Findings include: Review of facility policy, Activities of Daily Living (ADLs), dated 7/15/25, revealed ADL tasks include toileting and feeding. It is the facility policy to provide a resident the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The nurse aides must document all ADL support and performance using the electronic health record. Proper position is maintained for eating and an elimination schedule is maintained for regularity. Clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses of heart failure, stroke, and diabetes mellitus. Review of physician orders dated 10/24/26, indicated to consult hospice. Review of Resident CR1's hospice Initial Comprehensive assessment dated [DATE], revealed the resident needs complete care of all adls including feeding. Review of Resident CR1's progress note dated 11/14/25, revealed the resident requires assistance from staff with meals and all aspects of care. It was revealed the resident had worsening symptoms in hands since return from the hospital; difficulty with fine motor movements, feeding self. Review of Resident CR1's clinical record from 10/28/25, to 12/21/26, failed to include an order to assist the resident with feeding. Review of physician orders dated 12/22/26, indicated the resident requires assistances with meals. Review of Resident CR1's Documentation Survey Report V2 Dec-25 revealed on 12/23/25, 12/24/25, and 12/25/25, at 7:00 a.m. and 12:00 p.m. the resident was not provided help or staff oversight at anytime while eating. A further review failed to include any documentation of the percentage of fluid intake at meals and food eaten. Resident CR1's Documentation Survey Report V2 Dec-25 failed to include evidence the resident was assisted with toilet use for a total of 18 shifts in the month of December. Clinical record review revealed Resident R2 was admitted to the facility on [DATE], with diagnosis to include heart failure, high blood pressure, and malnutrition. During an interview on 3/18/26, at 9:23 a.m. Resident R2 stated sometimes there are issues getting changed and indicated she can wait a while to be assisted with toileting. Resident R2's Documentation Survey Report V2 Dec-25 failed to include evidence the resident was assisted with toilet use for a total of six shifts in the month of December. Clinical record review revealed Resident R3 was admitted to the facility on [DATE], with diagnosis to include dementia, malnutrition, adult failure to thrive, and dysphagia (difficulty swallowing). Review of Resident R3's physician order dated 8/12/25, indicated the resident was ordered a pureed texture, thin consistency diet. Directions included an upright posture, slow rate, small bites/sips, set-up and feed from staff as needed. Review of Resident R3's care plan on 3/18/26, indicated to assist to an upright position for all meals as tolerated, set up and assist with eating as needed, monitor/document/report as needed any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusal to eat, appears concerned during meals. During an interview on 3/18/26, at 9:30 a.m. RN Supervisor, Employee E1 provided this writer with an undated document titled Residents that need assistance with meals. Resident R3 was included. During an observation on 3/18/26, at 11:58 a.m. Nurse Aide, Employee E4 set up Resident R1's tray and exited the room. During an observation on 3/18/26 , at 11:59 a.m. Resident R3 was observed eating in bed, not in an upright position. The resident was observed eating rapidly. During an interview and observation of Resident R3 eating on 3/18/26, at 12:02 p.m. Registered Nurse, Employee E5 stated the resident was eating at her normal rate and confirmed the resident was not sitting in an upright position or being assisted with meals. During an interview on 3/18/26, at 12:32 p.m. NA, Employee E3, stated all staff must document at least each shift for feeding and toileting. NA, Employee E3 stated if not documented not done, it has to be done. Interview on 3/18/26, at 12:50 p.m. the Director of Nursing (DON), stated staff are expected to check on residents every one to two hours. The DON stated for toileting, the assistance level, size of bowel movement, and support provided must be documented. For eating it was indicated the percentage of amount eaten and amount of fluids as well as assistance provided is documented in the clinical record. The DON confirmed the facility failed to document ADL care was documented and provided for Resident CR1, R2, and R3. Interview on 3/18/26, at 1:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility to provide Activities of Daily Living (ADL) assistance for three of three residents reviewed (Resident CR1, R2, and R3). 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on a review of resident clinical records, and staff interview, it was determined the facility failed to ensure the coordination of hospice services (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) with facility services to meet the needs for end of life care for one of two residents (Resident CRR2).Findings include: Review of the clinical record revealed that Resident CRR2 was admitted to the facility on [DATE]. Review of Resident CRR2's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/30/25, indicated diagnoses of anxiety, depression, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairment). Section O- Special treatments, procedures and programs section K1 coded yes for hospice services while a resident. Review of Resident CRR2's physician order dated 9/13/24, indicated assessment and admitted to hospice. Further review of Resident CRR2's physician orders failed to include a diagnosis for the hospice care and indicate which hospice provider was providing this service and the hospice providers contact information. Review of Resident CRR2's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 1/22/26, at 2:25 p.m. the Director of Nursing confirmed that the facility failed to include a diagnosis for hospice care and contact information for the hospice agency and how to access the hospice's 24 hour on-call system and that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of Residents CRR2. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (CRR2).Findings include: Review of facility policy Wound Management Program, last reviewed 7/15/25, indicated the facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individuals' clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and prevention of infection unless a resident's preferences and medical condition necessitates palliative care as the primary focus. A commitment to the Wound Management Program is demonstrated by implementation of the processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. A visual skin assessment is completed by the nurse upon admission, re-admission and as needed by the nurse aide / therapy report or nurse identification. Results are documented in the Nursing admission Screening and/or Skin Observation Tool in Point Click Care. Review of the clinical record revealed that Resident CRR2 was admitted to the facility on [DATE]. Review of Resident CRR2's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 11/30/25, indicated diagnoses of anxiety, depression, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairment). Review of Resident CRR2's physician order dated 8/23/24, indicated Skin assessment weekly (from head to toe) at bedtime every Thursday. Review of Resident CRR2's clinical record on 1/22/26, failed to indicate documentation that the skin observation tool was completed between 9/15/25, through 12/20/25. Review of Resident CRR2's physician orders dated 12/20/25, at 8:26 a.m. indicated sacrum wound: Clean with normal saline, apply Medi honey, calcium alginate and boarder gauze one time a day. Further review of Resident CRR2's December treatment administration record indicated that the dressing was not documented completed until 12/22/25. Review of Resident CRR2's physician orders dated 12/22/25, at 3:14 p.m. indicated treatment to sacrum: Cleanse wound with soap & water and cover with dry dressing daily and as needed every night shift for wound care. Further review of Resident CRR2's December treatment administration record indicated that the dressing was not documented as completed on 12/30/25. During an interview completed on 1/22/26, at 2:25 p.m. the Director of Nursing (DON) confirmed that Resident CRR2's skin observation tool was not completed between 9/15/25, through 12/20/25, and that a treatment ordered on 12/20/25, was not documented as completed until 12/22/25. The DON also confirmed that the treatment orders dated 12/22/25, for Resident CRR2 were also not documented as completed on 12/30/25, and that the facility failed to ensure residents were assessed, and provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three residents (CRR2). 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 review of facility policy, facility submitted documents, clinical records and staff interviews, it was determined that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for one of three residents reviewed (Resident R2).Findings include:Review of facility policy Prevention of Abuse and Response dated 7/15/25, indicated neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs on an individual basis when a resident does not receive care in one or more areas (e.g., absence of frequent monitoring for a resident known to be incontinent, resulting in being left to lie in urine or feces). Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/6/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and arthritis (inflammation of one or more joints, causing pain and stiffness).Review of a physician order dated 10/2/25, indicated to transfer resident with full body lift (a mechanical lift).Review of Resident R2's Kardex (a snapshot of resident care needs) dated 10/8/25, indicated the resident transfers with Hoyer/full lift and assist of two staff.Review of a progress note dated 10/8/25, stated, Resident was being transferred to bed to the w/c (wheelchair). During the transfer the Hoyer lift tilted so the CNA (Certified Nurse Aide) had to lower her to the floor. Resident was assessed. She states that she hit her head and left shoulder. When her husband came in she requested to go to the ER (emergency room) for head pain. Physician and DON (Director of Nursing) notified.Review of a witness statement dated 10/8/25, completed by Nurse Aide (NA) Employee E1 stated, On October 8th around 1:30 p.m. I got Resident R2 all cleaned up changed to get her up in the Hoyer. She was holding on and when I went to turn it towards her chair it tilted and it was falling, so I held it to slowly lower to ground.During an interview on 11/24/25, at 1:11 p.m. the Nursing Home Administrator (NHA) stated, Resident R2's spouse was pressuring NA Employee E1 to get the resident into her chair because they wanted to go outside to smoke. During an interview on 11/24/25, at 2:15 p.m. the NHA and DON confirmed that the facility failed to make certain each resident was free from neglect by not ensuring adequate supervision and assistance for transfers for Resident R2. 28 Pa. Code: 201.14(a) Responsibility of licensee28 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 review of facility policy, facility provided documents, resident clinical record, observation, and staff interviews, it was determined the facility failed to ensure resident safety and to prevent the elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge) of a resident which resulted in an Immediate Jeopardy situation for one of 55 residents (Resident R1). Findings include: Based on a review of facility policy titled Elopement Prevention and Response last reviewed 9/9/22, informed the [facility] strives to promote resident safety and protect the rights and dignity of residents. The facility maintains a process to assess all residents for risk for elopement; implement prevention strategies for those identified as elopement risk, and follow a missing resident procedure. A facility approved risk assessment form will be used to evaluate the resident's physical, behavioral, psychological, and cognitive functions. If the assessment determines the resident scores a high risk of elopement, a physician's order will be secured for an ankle wander bracelet and the care plan updated accordingly. Staff will observe the resident and facility environment and report when a resident is at risk for elopement or has eloped. Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included neoplasm of the brain (brain cancer), diabetes, alcohol abuse, moderate intellectual disabilities (diminished abilities in intellectual and adaptive functioning), anxiety, autistic disorder (challenges with social skills, repetitive behaviors, speech and non-verbal communication), and chronic kidney disease (the kidneys inability to filter waste and excess fluid from the blood). Review of Resident R1's Minimum Data Set (MDS - a periodic federally mandated assessment that guides a resident's care) dated 2/26/23, indicated the diagnoses remained current. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's BIMS score dated 2/26/23, recorded a score of 10, indicating moderate impairment. Review of Resident R1's Nursing Admission Screening dated 2/22/23, indicated resident was confused and had a flat affect (low, or lack of emotional expression when the situation may merit a more evident reaction). Review of the facility's Wandering Risk Assessment scoring indicated the following: 0-8 Low risk 9-10 At risk to wander 11-above High risk to wander Review of Resident R1's Wandering Risk Assessment at admission, dated 2/22/23, recorded a score of 9, indicating the resident was at risk to wander. Review of Resident R1's care plan initiated 2/23/23, included the focus of impaired memory and intellectual disability with interventions of: anticipate needs, provide appropriate activities and provide re-orientation aides. The care plan did not address the resident was at risk for wandering. Review of Resident R1's progress note dated 3/9/23, at 18:00 (6:00 p.m.), documented the resident wandered off, wheeled self to the elevator and went to the first floor where [resident] ask receptionist to call an Uber so they can go to Blawnox (a [NAME] in the Greater Pittsburgh area). The resident was redirected back to the third floor (skilled nursing unit in the building). Review of Resident R1's progress note dated 3/9/23, at 19:07 (7:07 p.m.), documented the resident continues to exit seek and cry throughout the unit. Wanderguard (electronic monitoring device placed on/with the resident for residents at risk for wandering/elopement) functioning properly when close or attempting to go through the doors off unit. Resident R1 continues to ask multiple staff, residents and family members to help get out of here. Very difficult to redirect. Review of Resident R1's current physician orders dated revealed an order on 3/10/23, for a Wanderguard for resident safety related to wandering and/or exit seeking behaviors. The April 2023 recapitulation reveled that order has remained unchanged since onset. Review of Resident R1's progress note dated 4/13/23, at 9:00 p.m, documented the resident took off Wanderguard got on elevator and went out front door. Resident R1 made onto driveway but did not make it to sidewalk. Review of a facility provided document dated 4/14/23, indicated bystanders saw Resident R1 in w/c (wheelchair) at entry of facility called facility to report resident was outside. Resident removed Wanderguard which was found in the trash. Resident exited the third floor onto the elevator at 20:03 (8:03 p.m.) then got off at reception area (closed for the night thus [NAME] [sic] at the desk) and sat at the door inside reception until 20:08 (8:08 p.m.) when resident opened the door to the vestibule where [resident] sat until 20:11 (8:11 p.m.) when Resident R1 opened the door to the outside and sat on the sit [sic] walk in w/c. Visitor approached resident at 20:29 (8:29 p.m.) and the visitor called facility and notified the nursing facility that resident was outside. This area includes a small sidewalk with some parking spaces and a circular driveway to the public sidewalk, the entrance and exit to the driveway both have an incline leading down to the sidewalk with a curb to the main road running in front of the facility. Review of The Weather Channel's forecast for Pittsburgh, PA. on 4/13/23, revealed the high was 84 degrees and the low was 51 degrees. Review of the Nursing Home Administrator's (NHA) witness statement dated 4/19/23, documented staff returned the resident to the building at 20:31 (8:31 p.m.). The witness statement did not include a description of Resident R1's clothing at the time of the elopement. Review of Registered Nurse Employee E1's witness statement, not dated, documented the resident was seen after dinner in the hallway roaming by the common area near the nurse's station. Resident R1's alarm was going off near door earlier in the shift. During an interview on 4/26/23, at 11:40 a.m., Nursing Assistant (NA) Employee E2 reported Resident R1 was very smart and knew how to take off the Wanderguard bracelet. The employee also reported it is difficult to watch residents when evening care is being provided and there is not enough staff to provide evening care. The employee presented a paper of seven resident photographs with names that were the residents with Wanderguard bracelets. During an observation on 4/26/23, at 11:50 a.m., Resident R1's room was located on the section of the hall furthest from the common area/nurse's station area, opposite two closed double doors, and closest to the elevator that lead to the reception area and main entrance on the first floor. The main entrance led out to a sidewalk, parallel to the front of the building. In front of the sidewalk was a small parking area for picking up or returning residents. Parallel to the small parking lot and sidewalk was the facility driveway. At the corner of the facility driveway and side street was a public transportation stop. During an interview on 4/26/23, at 2:00 p.m., Registered Nurse (RN) Employee E4 reported Resident R1 kept removing the Wanderguard bracelet and that the band could be stretched or torn. The employee reported Resident R1 knew the Wanderguard set off the alarm. The resident verbalized wanting to go to Blawnox for beer and vodka. During an interview on 4/26/23, at 2:18 p.m., the NHA reported the facility had five residents that were elopement risks. During an interview on 4/27/23, at 12:15 p.m., NA Employee E2 reported Resident R1 would comment about wanting to go to a hockey game, have a beer and a shot of vodka, and would cry if unable to go out. The elopement happened when staff were doing rounds, and Resident R1 was savvy enough to leave during rounds. During an interview on 4/27/23, at 11:20 a.m., RN Employee E3 reported Resident R1 was smart, always wanted to go somewhere, knew the band triggered the alarm. Friends took Resident R1 out of the building, [resident] knew the path to the front door. Resident R1 left at prime time during P.M. care. On 4/26/23, at 3:03 p.m., the NHA was made aware Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called as the facility failed to ensure resident safety for one of 55 residents and failed to prevent the elopement of Resident R1. The Immediate Jeopardy template was provided at that time and a corrective action plan was requested. On 4/26/23, at 9:02 p.m. an Immediate Action Plan was accepted with the following actions: - All residents will have Elopement Assessments Screenings completed. Elopement Risk residents will have updated physician orders, care plans, and any other necessary medical record documents. - Care plans will be updated for elopement risk residents to include interventions specific to the resident. - Policies will be updated: Elopement Risk Guidelines - to include assessment frequency, environmental intervention (door alarms, wanderguards), and resident interventions and redirection strategies; and Elopement and Missing Persons. - Staff education to include elopement prevention guidelines, recognizing signs and symptoms of wandering for at risk residents, elopement and missing residents response protocol, and rounding techniques to include frequency, observation of resident and behaviors, and interventions to meet resident needs before unsafe behaviors occur. - Front desk notification to include updated photograph list with names of at risk residents. Also applicable to nursing staff and facility managers. - New admission elopement risk screenings conducted and audited weekly. - Quality Assurance and Performance Improvement (QAPI) notification and reviews. - Daily documentation for signs and symptoms of elopement risk residents for 3 months, then quarterly thereafter. During observations and interviews on 4/28/23, at 1:30 p.m., fifty-five residents had elopement screening and assessments completed, resident records were updated physician orders, care plans, and other necessary medical records documentations as appropriate, the facility had trained 93% of it's staff on the Elopement Policies, prevention guidelines, recognizing signs and symptoms of at risk residents, elopement and missing resident protocol, and rounding techniques, 14 staff interviews were conducted and confirmed receiving training on the content of the trainings, updated policies were reviewed for content, front desk notification of at risk wander residents, as well as the nursing office and staff kitchenette room was completed, two new admission elopement risk screenings were conducted, QAPI was notified on 4/26/23, at 6:45 p.m., and daily documentation for signs and symptoms of elopement risk behaviors were documented for 4/27/23, and 4/28/23. On 4/28/23, at 1:43 p.m. the Nursing Home Administrator was made aware the Immediate Jeopardy was lifted. During an interview on 4/26/23, at 12:35 p.m. the Nursing Home Administrator confirmed the facility failed to ensure resident safety and to prevent the elopement of a resident which resulted in an Immediate Jeopardy situation for one of 55 residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, manufacturer's guidelines and clinical record review and staff interview, it was determined that the facility failed to provide adequate monitoring and supervision to prevent a fall which resulted in injuries for one of two residents reviewed who were utilizing a Merry Walker (Resident R1) and the facility failed to identify the hazardous status of an unalarmed door on one of three corridors on the skilled nursing units (Northeast corridor). Findings include: The facility policy "Ambulation Devices" dated 3/3/11, indicated that formalized therapy should be involved with fitting the Merry Walker (an enclosed framed wheeled walker designed to assist residents with walking) and instructing the staff on the use of the Merry Walker for the individualized needs of each resident. The Minimum Data Set (MDS, a periodic assessment of care needs) assessment dated [DATE], for Resident R1 indicated that the resident had [DIAGNOSES REDACTED]. Review of Resident R1's "Fall Risk" care plan, originally dated 10/13/10, and updated 7/12/11, indicated that Occupational Therapy evaluated the resident and placed the resident in a Merry Walker and would monitor the resident for any ongoing safety concerns. Review of the facility submitted Event Reporting System (ERS) entry to the State Agency dated 7/5/11, at 5:45 p.m., indicated that Resident R1 was noted to be missing around 4:30 p.m. to 4:35 p.m. Facility staff started a search of the nursing (resident) rooms. When they were unable to locate the resident, the staff expanded the search. A nurse aide went to the chapel and bathrooms near the dining room and opened the door (the northeast door) to the stairwell and found Resident R1 at the bottom of the first flight of stairs, on the landing with the Merry Walker on top of the resident. Review of facility's "Resident Accident/Incident" report dated 7/5/11, at 4:45 p.m., indicated that the resident was found with their head on the floor, abrasions (superficial damage to the skin) on both shins, a fractured right clavicle (collarbone) and the resident was sent to the emergency room . The report included "other information," that indicated the resident's ankle alarm (Secure Care System bracelet) was on but the signal malfunctioned at the door (the northeast door to the stairwell). Review of Resident R1's emergency room report dated 7/5/11, indicated the resident was noted to "have two abrasions along the shins, had a chest x-ray, a CT scan (computerized tomography) of the head, neck, chest, abdomen, and pelvis and the injury sustained was a comminuted right clavicle fracture (a fracture in which the bone is crushed or broken into pieces)." Review of the facility submitted Event Reporting System (ERS) entry to the State Agency dated 7/5/11, at 5:45 p.m., indicated the facility investigated as to why the door (the northeast door) did not alarm and it was discovered a circuit board was not working (there was a loose wire above the ceiling ). A removable panic bar lock (a bar which prevented the door from opening ) was put in place by the maintenance staff immediately, and a new circuit board was ordered. Review of the facility "Secure Care System" policy dated 3/3/11, indicated that the facility will maintain a security system for the protection of the cognitively impaired residents who might wander off the unit. Three doors on the third floor (Northeast stairway door and two doors to the Northwest stair landing) will lock when a resident wearing an ankle bracelet comes within four feet of the door (Smart Lock System). If the doors are held open for a period of 30 seconds, an alarm will sound both at the door and on the annunciator panel (an electrical signaling device used to indicate the sources of calls) at the nurses' station on the third floor and in the administrative offices. Review of the "Secure Care System" manufacturer's guidelines dated 5/16/11, recommended weekly testing to verify that all wiring connections are completed and that the door is armed. Review of a "Secure Care Service Report" dated 7/12/11, indicated "a contact was broken on the dining room door panel (circuit board - northeast door) and was replaced." During an interview on 7/28/11, at 8:40 a.m., Occupational Therapist, Employee E1, confirmed that the facility failed to provide adequate monitoring and supervision to prevent Resident R1, with impaired cognition, using a Merry Walker, from falling to the bottom of the first flight of stairs in the northeast stairwell on 7/5/11. During an interview on 7/28/11, at 10:40 a.m., Maintenance Director Employee E2 confirmed that the facility failed to maintain the safe operating condition of the Secure Care System for Resident R1 by checking / testing weekly that the Secure Care System was functioning on the northeast door, "We tested for fire safety but not for resident safety." 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.12(d)(5) Nursing services. 28 Pa. Code: 211.10(d) Resident care policies.