Every finding on record at Delaware Valley Veteran's Home

Based on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for nine of nine residents reviewed (Residents R1, R6, R18, R42, R122, R62, R5, R3, and R2).Findings include: The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability. A Level I PASRR must be completed for all persons considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level I PASRR determines that the person is a targeted individual with mental illness or an intellectual disability. The Level II PASRR determines whether placement or continued stay in the requested or current nursing facility is appropriate. Review of Resident R18's clinical record revealed an admission date of March 31, 2023, with a diagnosis of bipolar disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior). Review of Resident R18's Level 1 PASRR, dated March 31, 2023, revealed that the assessment did not include the resident's diagnosis of bipolar disorder. During an interview on July 9, 2026, at 1:21 p.m., Employee E3, Social Worker Supervisor, confirmed that Resident R18's PASRR assessment was not updated to include the resident's diagnosis of bipolar disorder. Review of Resident R6's clinical record revealed an admission date of June 16, 2021, with diagnoses including schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression), bipolar disorder, and Post Traumatic Stress Disorder (PTSD -a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Review of Resident R6's Level 1 PASRR, dated June 16, 2021, revealed that the assessment did not include the resident's diagnoses of schizoaffective disorder, bipolar disorder, and PTSD. Review of Resident R1's clinical record revealed an admission date of December 8, 2022, with diagnoses including major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities), and PTSD. Review of Resident R1's Level 1 PASRR, dated December 8, 2022, revealed that the assessment did not include the resident's diagnoses of major depressive disorder or PTSD. During an interview on July 9, 2026, at 2:04 p.m., Employee E2, Director of Nursing, confirmed that Resident R1's PASRR assessment was not updated to include the resident's diagnoses of major depressive disorder and PTSD. Review of Resident R42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of anxiety disorder (intense, excessive, persistent worry or fear), major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, and delusional disorder (false beliefs in something that is untrue). Review of Resident R42's Level 1 PASARR, dated May 28, 2020, revealed the only diagnosis listed was major depressive disorder and did not include the resident's other mental health diagnoses. Review of Resident R122's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of schizoaffective disorder, major depressive disorder, anxiety, panic disorder (a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause), and bipolar disorder. Review of Resident R122's Level 1 PASARR, dated March 18, 2022, revealed the resident's diagnoses was not updated to include schizoaffective disorder and anxiety. Review of R62's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of major depressive disorder, bipolar disorder, post-traumatic stress disorder, and generalized anxiety disorder. Review of Resident R62's Level 1 PASRR, dated June 15, 2022, revealed the resident did not have any mental health diagnosis listed. Review of R5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of generalized anxiety disorder, schizophrenia, bipolar disorder, major depressive disorder, adjustment disorder with depressed mood, and post-traumatic stress disorder. Review of Resident R5's Level 1 PASRR, dated August 14, 2019, revealed it was not updated to include the above diagnoses. Review of R3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of borderline personality disorder, bipolar disorder, major depressive disorder, post-traumatic stress disorder, and anxiety. Review of Resident R3's PASRR, dated November 22, 20222, revealed the resident's mental diagnosis only included anxiety, major depressive disorder, and post-traumatic stress disorder. Interview on July 9, 2026, at 9:45 a.m., Employee E2, Director of Nursing, confirmed the facility does not update residents PASRR's with new diagnoses. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of PTSD and a diagnosis of borderline personality disorder added on December 9, 2021. Review of Resident R2's Level 1 PASRR dated April 23, 2020, revealed it was not updated with diagnoses of PTSD and borderline personality disorder. Interview on July 9, 2026, at 10:52 a.m. with the Director of Social Services, Employee E6, confirmed Resident R2's PASRR Level 1 was not updated with the above mental health diagnoses. 28 Pa. Code: 211.10 (c) Resident care policies

Based on review of facility documentation, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of four employees reviewed (Employee E5). Findings Include: Review of Title 42 Code of Federal Regulations S483.35(d) Requirement for facility hiring and use of nurse aides-S483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless-(i) That individual is competent to provide nursing and nursing related services; and(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of S483.151 through S483.154. Review of facility documentation, dated September 30, 2025, revealed on September 30, 2025, it was reported to facility administration that Nurse Aide Trainee, Employee E5, failed to obtain the certified nurse aide within 120 days of working in a nurse aide training and testing program as required. Continued review of facility documentation dated September 30, 2025, revealed Nurse Aide Trainee, Employee E5's, 120 days were up on September 18, 2025. Nurse Aide Trainee, Employee E5, was working as a Nursing Assistant on his/her assigned unit from September 18, 2026, through September 30, 2026. Interview on July 8, 2026, at 11:00 a.m. with Director of Nursing, Employee E2, confirmed Nurse Aide Trainee, Employee E5, failed to become certified within four months and worked past his/her 120 days. 28 Pa Code: 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of clinical records, facility documentation, staff interview and review of facility policy, the facility failed to ensure Resident R3 was free of abuse from Resident R2, who was known to have an aggressive behavior. This failure resulted in actual harm to Resident R3 who was shoved by Resident R2, resulting in a fall sustaining a left eyebrow abrasion, forehead bruising, and a left humeral head fracture for one of six residents reviewed. (Resident R3)Findings include: Review of the facility policy title Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property updated August 7, 2023 revealed It is the purpose of protocol to give guidance to the Department of Military and Veterans Affairs (DMVA), Bureau of Veterans Homes (BVH), State Veterans Homes (SVHs) to provide protections for the health, safety, welfare, and rights of each resident residing in the SVH by prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraints not required to treat a resident's medical condition. Continued review of the policy revealed that ABUSE: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. SERIOUS BODILY INJURY: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as a surgery, hospitalization or physical rehabilitation; or an injury resulting from criminal sexual abuse. SERIOUS PHYSICAL INJURY: An injury that causes a person severe pain or significantly impairs a person's functioning, either permanently or temporarily. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Dementia (progressive disease of the brain) with agitation, Post Traumatic Stress Disorder (condition that may occur after experiencing or witnessing a scary or dangerous event), and Adjustment Disorder with mixed anxiety and depressed mood (condition where someone has both anxiety and sadness in response to a stressful life change or event). Review of Resident R2's MDS, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Review of Resident R2's comprehensive care plan, initiated March 18, 2024, and revised April 2, 2026, revealed Resident R2 had a history of physical and verbal altercations with other residents. The care plan identified, the resident could be impulsive, experience rapid mood changes, become angry or upset with staff, and become verbally abusive when needs were not met promptly. The care plan further indicated the resident exhibited territorial behaviors, including believing other residents' rooms belonged to him/her. Review of information submitted by the facility to the State Survey Agency, dated March 23, 2026, revealed Resident R3 was involved in a resident-to-resident altercation on March 23, 2026, in which Resident R2 pushed Resident R3, causing him/her to fall to the floor. The facility substantiated resident abuse and concluded that both residents were cognitively impaired and that Resident R2 did push Resident R3 due to confusion about the bedroom. Upon assessment, Resident R3 sustained a left eyebrow abrasion, forehead bruising, and complaints of left shoulder pain. Review of nursing documentation from March 23, 2026, through April 1, 2026, revealed Resident R3 received pain medication, neurological monitoring, and x-ray evaluation, which did not identify any acute fracture at that time. Continued review of nursing documentation revealed Resident R3 continued to express complaints of left leg pain, additional imaging was obtained on April 1, 2026. Resident R3 was transferred to the hospital on April 1, 2026, and returned on April 2, 2026, with a diagnosis of a left humeral head fracture. The facility investigation, completed April 3, 2026, determined the allegation was substantiated and confirmed the fracture resulted from the altercation. Interventions implemented following the incident included increased monitoring of Resident R2, staff education on de-escalation and supervision, medication review, and care plan updates. Review of the facility's summary and review for Resident R2 revealed the following events and interventions for Resident R2: The resident has a documented history of confusion, impulsivity, and behavioral disturbances, including multiple resident-to-resident altercations:11/08/24 Incident:Resident reported that he asked (Resident R2) to pick up a fallen picture for him. (Resident R2) refused and an altercation ensued. AP alerted staff to Resident requiring assistance in bedroom but did not indicate any concerns of an altercation. Resident room was changed at Resident request, but Resident also had a history of false allegations. Unsubstantiated.03/03/2025 Incident:The resident was involved in an altercation initiated by (Resident R2) resulting in physical harm and a fall. The incident was substantiated. Interventions: Room change, separation from aggressor, initiation of purposeful rounding, psychiatric evaluation, and medication adjustments. 11/26/2025 Incident:A second substantiated altercation occurred with the same resident (Resident R2), resulting in a confirmed rib fracture. Interventions: Continued monitoring, pain management, reinforced separation strategies, and staff education on supervision during high-risk periods.Recent Incident of March 23, 2026 (Alpha Ave Unit):Resident pushed another resident despite prior interventions, indicating ongoing behavioral escalation and poor impulse control. Review of Resident R2's progress notes revealed Resident R2 was transferred from Delta unit to Alpha Ave (secured, smaller, cognitively supportive environment) on November 21, 2025. During an interview on April 13, 2026, at approximately 1:00 p.m., Employee E3, Administrator, stated the facility believed adequate interventions had been implemented for Resident R2. Email communication with the Director of Nursing, dated April 15, 2026, revealed Resident R2 was on one-hour safety checks prior to the March 23, 2026 incident and was last seen by the nurse in his room at 3:49 p.m. At 4:01 p.m., Resident R3 was at the nurse's station, seen directly by staff through 4:03pm, then Resident R3 walked down the hall. Resident R2 was walking in the hallway; Nurses were at the nursing station at that time. At 4:04 p.m., both parties in room; 4:05pm, Resident R3 falls out of room. Staff responded immediately at 4:05 pm. The facility failed to provide ensure that Resident R3 was free of abuse from Resident R2, who was known to have with an aggressive history. This failure resulted in actual harm to Resident R3 who sustained a fall after being pushed by Resident R2, resulting in a left eyebrow abrasion, forehead bruising, and a left humeral head fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to Resident R1, who was at risk for falls related to decreased mobility, and poor safety awareness, This failure resulted in actual harm, to Resident R1 who sustained a fall and was diagnosed with a hip fracture for one of 30 residents reviewed for one of six residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia (decline in cognitive function that interferes with daily life), Chronic Obstructive Pulmonary Disease (COPD - airway disease that restricts breathing), and Generalized Anxiety disorder. Review of Resident R1's Minimum Data Set (MDS - federally mandated resident assessment and care screening), dated January 21, 2026, revealed a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Review of Resident R1's comprehensive care plan, initiated August 4, 2025, revealed the resident was at risk for falls related to decreased mobility, poor safety awareness, and opioid drug use. Further review of Resident R1's care plan revealed the resident was at risk for activities of daily living (ADL) deficit related to decreased mobility and cognitive impairment. Interventions, dated February 13, 2026, revealed the resident required one person assist for transfers. Review of information submitted by the facility to the State Survey Agency, dated April 06, 2026, revealed during routine care, the nurse aide turned away from the resident to place soiled clothing in a hamper. Upon turning back, the resident was observed sitting on the floor. Further review revealed an x-ray confirmed an acute left subcapital (bone break just below the head of the femur - aka: thigh bone) hip fracture with associated soft tissue swelling. Review of facility's investigation revealed Employee E1, Nurse Aide, had completed a bed bath and dressing, and the resident was seated on the edge of the bed with feet on the floor while preparing for transfer to a wheelchair. During this time, the nurse aide turned away to place soiled linens in a hamper. The resident then attempted to transfer independently and was found on the floor. Review of Employee E1, Nurse Aide, witness statement, dated April 06, 2026, revealed On April 6, 2026, I went into room [XXX] to provide care. I gave resident a bed bath and got (him/her) dressed. The resident is one assist and able to transport with assistance. Resident was sitting on the side of (his/her) bed with both feet on the floor. Wheelchair was locked and facing (him/her). I then turned to place resident dirty clothing in the bin. Upon facing the resident I saw (him/her) sitting on the floor. I asked (resident) if (he/she) was okay, (resident) responded yes. I then proceeded to help (him/her) to (his/her) feet and assisted (resident) in sitting in the wheelchair. I then notified the nurse. Review of facility provided employee education for Employee E1, Nurse Aide, revealed the root cause of the incident was identified as turning away from a high fall-risk resident during care, resulting in lack of supervision. Education provided indicated staff should ensure residents are placed in a safe position prior to stepping away and complete transfers before attending to other tasks. Interview with Employee E2, Occupational Therapist, on April 13, 2026, at approximately 10:25 a.m. confirmed the resident required one-person assistance for transfers for safety. Interview with Resident R1's family representative on April 13, 2026, approximately 11:30 a.m. confirmed the resident had a history of falls and was considered high risk. Interview with Employee E3, Administrator, on April 13, 2026, approximately 11:45 a.m. confirmed the nurse aide turned away from the resident while the resident was seated on the side of the bed in vulnerable position. The facility failed to provide adequate supervision to Resident R1, was at risk for falls related to decreased mobility, and poor safety awareness. This failure resulted in actual harm, to Resident R1 who sustained a fall and diagnosed with a hip fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that residents drug regimen reviews were free from unnecessary drugs related to an increased medication dosage for one out of seven residents reviewed. (Resident R1)Findings Include: Review of facility policy titled, Medication Controlled Drug Administration Record Disposal of Schedule CII-CV Medications with a revision date of July 19, 2024 states, Policy-All schedule CII-CV medications will be counted by the outgoing and incoming nurses responsible for the medication cart at shift change on each unit . Under procedure the policy states, 1. Each medication nurse will complete a narcotic count at the beginning and the end of the shift for their medication cart. The nurse on duty and the relieving nurse will sign off on the Controlled Drugs-Count Record verifying all narcotics are accounted for and that the total for each Controlled Substance Administration Record matches the master Weekly Unit Controls Reports by Resident sheet . Review of the facility policy titled, Medication Administration Protocol with a revision date of December 3, 2024 states, Purpose- It is policy of this facility that all residents shall obtain their prescribed medications from our pharmacy. Exceptions to this will include medications prescribed to our residents and received from outside specialty clinics. All outside prescribed medications will have the approval of our attending physicians and the appropriate physician ' s order will be received prior to starting that medication .Review of facility documentation provided titled, Narcotic Fill Procedure undated states, Tech Duties- 1. Pulls appropriate product 2. Places one label on box or blister-places another label on narcotic administration sheet. Further review states, Pharm Duties- 1. Visually verifies correct selection 2. Brings filled product to narc log folders. 3. Looks up record sheet and re-verifies product against log sheet item details. 4. Deduction of product on appropriate log sheet is done and resident details written as place holder awaiting return receipt label. 5. Initials sign/receipt label 6. After round signed receipt label is placed on log sheet . Review of Resident R s clinical record revealed the resident was re-admitted to the facility on [DATE] after hospitalization with the following diagnoses: Unspecified seizures, Opioid use disorder in remission, Hypertension (high blood pressure), and Major Depressive Disorder. Review of facility witness statement from Chief Pharmacist, Employee E8 states, A fax request for Suboxone 2 milligrams (mg) was received on September 19, 2025. The label was generated, and the technician labeled the incorrect Suboxone package (Suboxone 8mg package). Unfortunately, it slipped the pharmacist verification process. The receiving nurse who signed off on the Suboxone did not catch the order as well. The resident was on hospital leave on September 19, 2025, and per protocol narcotic was stored until the patient returned. Resident returned approximately October 4, 2025 and when previous order re-activated, the incorrect fill was started. Interview on October 21, 2024 with the Director of Nursing Employee E2 and the Nursing Home Administrator Employee E1 revealed the resident was sent out to the emergency room for evaluation to the suboxone clinic being closed at the time of the medication dose increase discovery. After evaluation it was found that Resident R1 had no adverse effects from the medication dose increase. After being seen in the emergency room Resident R1 was given a taper dose as follows: Suboxone Day 1 to Day 5: 12mg/day Day 6 to Day 10: 8mg/day Day 11:4 mg/day.On October 21, 2021 at 1:03 p.m. it was confirmed by the Director of Nursing Employee E2 and the Chief Pharmacist Employee E8 that there were errors on dose verification from several staff including the pharmacist and nurses.28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility documentation, review of clinical record, observation and staff interviews, it was determined that the facility failed to provide adequate supervision for one of one resident observed who utilized outdoor relaxation time. (Resident R21). Findings:A review of the facility policy titled Outdoor Relaxation for Nursing Care Residents, revised July 2025, revealed: Residents who are not at risk for elopement/wandering will be able to enjoy the outdoor areas that are within the boundaries between daylight hours, from sunrise to sunset, for safety purposes.A review of the clinical record revealed that Resident R21 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, psychotic disturbance, mood disturbance and anxiety, unspecified sensorineural hearing loss, and major depressive disorder, single episode.On July 21, 2025, at 9:00 a.m. and 3:01 p.m., observations showed that three to four residents were sitting outside with no staff supervision.On July 22, 2025, at 10:30 a.m., an observation was conducted with Employee E8, during which Resident R21 was seen coming onto the porch, passing the cones that were set up to designate a safe zone for sitting outside, and propelling himself in his wheelchair around the oval road independently. During this time, three cars were entering the facility grounds, and Resident R21 began propelling toward the curb instead of remaining in the designated area. Employee E8 confirmed that it was not safe for Resident R21 to be propelling himself such a distance without supervision.On July 22, 2025, at 10:47 a.m., an interview was conducted with Resident R21, who reported that he completes four laps around the oval road in the morning and two in the afternoon, totaling approximately one mile per day. The resident is hard of hearing and was not wearing his hearing aids during his time outside. He reported feeling safe while taking his daily wheelchair walks but suggested that having a flag on his wheelchair or wearing a safety vest would make him more visible to oncoming traffic and improve his safety.On July 22, 2025, at 2:45 p.m., a meeting was held with the Administrator, Employee E1, and the Director of Nursing, Employee E2, who confirmed that it was unsafe for Resident R21 to propel himself around the oval road without supervision and in the presence of oncoming traffic.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 review of clinical record, observations, and staff interview, it was determined that the facility failed to ensure the proper care of a resident with an indwelling urinary catheter for one of three residents observed with urinary catheters. (Resident R143) Findings include:Review of Resident R143's clinical record revealed Resident R143 was admitted to the facility on December17, 2024 with a diagnosis that included hemiplegia (total paralysis on one side of body) and hemiparesis (partial weakness on one side of body), obstructive and reflux uropathy (urine can't flow normally through urinary tract due to blockage), edema (swelling caused by too much fluid trapped in the body's tissue). Observation on July 21, 2025 at 11:25 revealed Resident R143 in his/her wheelchair in the hallway with his/her urinary catheter bag (collects urine from at tube inserted into the bladder) dragging on the floor.28 Pa. Code 211.12(d)(1) Nursing services Observation on July 21, 2025 at 11:35 p.m. revealed Resident R143 in the dining room with his/her urinary catheter on the floor. Interview on July 21, 2025 at 11:39 p.m. with Employee E5, Licensed Practical Nurse, confirmed Resident R143's urinary catheter should be properly secured and not on the floor.

Based on a review of clinical records, observations, facility policy and staff interviews, it was determined that the facility failed to identify that a resident was free from physical restraint due to locking the wheelchair as a restraint for one of the one resident reviewed. (Resident R70)Findings include:A review of the facility policy titled, Restrain Management Protocol revised August 2023 revealed The purpose of this protocol is to provide guidance to the Department of Military and Veterans Affairs (DMVA), Bureau of Veterans Homes (BVH), State Veterans Homes (SVHs) to maintain the resident's right to be free from any physical or chemical restraints that are implemented for discipline or convenience and not required to treat a medical condition.A review of the clinical record revealed that Resident R70 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. (Hemiplegia refers to complete paralysis of one side of the body, while hemiparesis indicates weakness on one side.)On July 21, 2025, at 11:36 a.m., Resident R70 was sitting in the dining room waiting for his meal to be served. During the interview, Resident R70 revealed that his left hand is contracted, and he is unable to reach the wheelchair lock to move himself closer to the dining table with his right hand. Resident R70 reported, I can't do anything, can you please unlock my wheelchair?On July 21, 2025, at 11:46 a.m., nurse aide, Employee E6 brought lunch to Resident R70. The resident requested, Can you please unlock my wheelchair so I can sit closer to the dining table and propel myself with my feet? Employee E6 unlocked the wheelchair and left it unlocked while Resident R70 ate his lunch. After finishing, Resident R70 propelled himself with his feet and exited the dining room. When asked how often staff lock his wheelchair from the back, Resident R70 responded, Too often.On July 22, 2025, at 9:19 a.m., an interview was held with the Director of Nursing, Employee E2, and the Therapy Director, Employee E7, who confirmed that the resident's left hand is contracted, and the right hand is nonfunctional, preventing him from unlocking the wheelchair brakes located on the sides of the wheelchair. On June 24, 2025, Resident R70 was assessed for a Broda pedal wheelchair with a pressure relief cushion for functional mobility; however, his inability to reach and unlock the wheelchair brakes was not assessed. Resident R70 depends on staff to lock and unlock his wheelchair. Employee E2 reported that staff should only be locking the wheelchair during transfers, and that for the remainder of the time, Resident R70 should be independent and able to propel himself freely. Employees E3 and E7 reported that they will update the order to reflect that Resident R70's wheelchair should not be locked restraining him from being mobile unless he is being transferred.28 Pa. Code 211.8(c)(1) Use of Restraints.28 Pa. Code:211.12(d)(1)(5) Nursing services.

Based on observations, review of facility's menu and staff interviews, it was determined that the facility failed to meet resident's food preference for three of three residents reviewed. (Residents R111, R89, R98).Findings include:On July 21, 2025, at 11:50 a.m., an interview with Resident R111 stated, This is the second time this week we only have salads to choose from for dinner, no hot food.On July 21, 2025, at 12:24 p.m., an interview with Resident R89 revealed that, based on the current menu, only cold items would be available for dinner. Resident R89 took the menu off the table and reported that cold salads would be served for dinner, and that residents, including himself, would prefer one hot meal to be offered. A review of the grievance form for Resident R98, filed on June 9, 2025, revealed a concern related to the dinner menu on that date. Resident R98 reported that there were two cold options on the dinner menu and stated he/she spoke with someone from dietary, who explained that the menu comes from headquarters. The resolution, completed on June 12, 2025, was to ensure that at least one hot entree item would be available for dinner. However, on July 22, 2025, there were still two cold options listed on the dinner menu.On July 22, 2025, at approximately 9:15 a.m. the Dietary Director, Employee E3, confirmed that based on the current Week 2 menu for Monday's dinner on July 21, 2025, the facility served egg salad sandwiches and chicken salad on wheat. The Week 1 menu showed that Monday's dinner included ham and Swiss sandwiches and egg salad sandwiches. This same week Thursday's dinner included seafood salad on a croissant and egg salad on wheat. There was no hot dinner meal available to residents.28 Pa Code 201.14(a) Responsibility of licensee

Based on resident interviews, meal tray observations, and staff interviews, it was determined that the facility failed to provide palatable, appealing and attractive meals during lunch for one of one meal observations (lunch meal).Findings include:On July 21, 2025, at 12:31 p.m., observation and interview with Resident R52 revealed that he was served three pierogies with kielbasa for lunch and was unable to cut through the skin of the kielbasa. Resident R52 also reported that the pierogies appeared dry and were difficult to cut. He stated, The kielbasa is overcooked, and the pierogies are too hard to cut. Resident R52 only attempted to scoop out the soft potatoes from one pierogi and appeared visibly upset.On July 21, 2025, at 12:54 p.m., a test tray was conducted by the Dietary Director, Employee E3, to assess the palatability of the pierogies and kielbasa. The kielbasa was too hard to cut, and the pierogies were dry and difficult to cut through. Employee E3 reported that the facility could improve the meal by cutting the kielbasa into smaller pieces and adding more butter or margarine to soften the pierogies. The meal was also not visually appealing, as the kielbasa and pierogies were served with wax beans, all of which were a similar beige color, making the plate look bland and unappetizing.28 PA. Code 211.10(a)(b)(c)(d) Resident care policies28 PA. Code 201.18(b)(1)(3) Management28 PA. Code 201.14(a) Responsibility of licensee

Based on observation, policy review, and staff interviews, it was determined the facility failed to develop and implement a water management program for the prevention, detection, and control of waterborne contaminants such as Legionella (a bacteria that may cause [legionnaires disease, a serious type of pneumonia).Findings include: Review of Centers for Disease Control and Prevention (CDC) guideline for “Water Management and Healthcare Facilities” Revealed “Legionella water management programs identify hazardous conditions and include taking steps to minimize the growth and spread of Legionella in the building water system. Having a water management program is now an industry standard for large buildings in the United States” Review of Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo titled “ Requirement to reduce legionella risk in healthcare facility water systems to prevent cases and outbreaks of legionella disease” Dated July 6 2018, Revealed “ Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. This policy memorandum applies to hospitals, critical access hospitals CAHS and long term care LTC. However, this policy memorandum is also intended to provide general awareness for all healthcare organizations facilities must have water management plans and documentation that at minimum ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (eg: Pneumonias, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - Develops and implements a water management program that considers the ASHRAE Industry standards and the CDC Toolkit - Specifies testing protocols in acceptable ranges for control measures, and documents the results of testing and corrective action taken when control limits are not maintained - Maintains compliance and other acceptable federal, state and local requirements. Interview with Employee 1 July 24, 2025, at 10:00 AM confirm the facility failed to ensure water testing and compliance of water management plan. The facility was not able to provide documented evidence that water testing was completed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services. 28 Pa. Code 201. 14 (a) Responsibility of licensee

Based on review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to follow and or clarify physician's orders relating to advance directives for one of eight residents reviewed. (resident r 168)Findings include:Review of the facility document Advanced Healthcare Directives dated [DATE], revealed the purpose of this protocol is to provide guidance for the facility, regarding honoring the resident's choice and self-determination related to their advanced healthcare directives. The components of this policy are defined as the following: The Pa. POLST, Pennsylvania physician orders for life sustaining treatment, a voluntary, portable medical order designed to support individuals transitioning between health care facilities or living in the community by communicating choices for care at the end of life. It is a document designed to help health care providers honor the wishes of their patients. A do not resuscitate, DNR order is a legally recognized order that means a person has decided not to have cardiopulmonary resuscitation CPR attempted on them if their heart or breathing stops. A resident's wishes including DNR and DNI (Do not intubate) preference are conveyed as a medical order in a POLST form and a legal representative refers to an individual who has been appointed as the resident's guardian by a court, has been appointed as the president's health care agent pursuant to a health care power of attorney, or is the resident health care representative pursuant to 20 Pa. C.S. 5461. Review of facility reported to the State Agency dated [DATE], revealed that on [DATE], at approximately 04:00 am. a nurse aide entered the resident's room and discovered that Resident R168 was unresponsive. The nursing assistant then notified nurse who immediately followed protocol; airway, breathing, and circulation were checked, vitals were unable to be obtained, code cart brought into the room, oxygen was administered, and chest compression were started. Nurse supervisor arrived in room as question Resident R168's code status, Resident R168's code status was officially do not resuscitated (DNR). Review of Resident R168's clinical record revealed Resident 168's POLST form dated [DATE], signed by Resident R168 power of attorney, resident's son. Interview with NHA Employee E1, on [DATE], at 09:40 a.m. confirmed that there was a miscommunication regarding the resident code status. - 28 Pa. Code 201.18(a)(b)(1)(3) Management28 Pa. Code 211.12 (d) (1)(5) Nursing Services

Based on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision during a planned out-of-facility activities outing to a theater, for one of six residents reviewed who were at risk for elopement. This resulted in Resident R138 exiting the theater and was unable to be located for one hour and 45 minutes. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R138) Findings include: Review of facility policy, Policies and Procedures Related to Wandering and Elopement dated May 20, 2014, revealed that the purpose of the policy is to assess residents for the purpose of assuring their safety and determine the risk for wandering and/or elopement within or out of the home. Continued review revealed that all staff must maintain a heightened awareness of their surroundings, the residents in our care, and environmental issues that might lead to a resident's elopement. Review of Resident R138's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 30, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 11, which indicated that the resident was moderately cognitively impaired and that he had behaviors of inattentiveness. Further review revealed that the resident was able to walk independently without an assistive device. Review of Resident R138's Elopement Evaluation, dated July 29, 2024, revealed that the resident was identified by the facility as being at risk for elopement, related to ambulation status, cognitive impairment and history of exit seeking behaviors. The evaluation noted that an elopement care plan was initiated. Review of Resident R138's care plan, dated initiated March 8, 2023, revealed that the resident was at risk for elopement and has exhibited exit seeking behaviors. Interventions included to encourage the resident to look for a staff member if he feels lost, confused or needs assistance, to redirect and reorient the resident as needed, and to maintain safety. Continued review of Resident R138's care plan, dated initiated July 26, 2024, revealed that the resident had memory deficits, requiring reminders and invitations for consistent activity participation. Interventions included that the resident will be invited to community outings to enhance life enrichment. Review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 3:33 p.m. which indicated that the resident went on an out-of-facility activities outing to a theater. The note continued that, At 3pm staff notified security desk resident had eloped and police were called. Police arrived at 3:15 p.m. and began searching the area for the resident. Continued review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 4:15 p.m. that nursing staff confirmed that the resident was located. Further review of progress notes for Resident R138 revealed a nurses note, dated August 25, 2024, at 5:10 p.m. that the resident returned to the facility. The resident was noted to be at his baseline and was placed on every fifteen-minute checks. Review of facility documentation reported to the Pennsylvania Department of Health on August 26, 2024, at 4:09 p.m. revealed that Resident R138 was on an out-of-facility activities outing to a theater on August 25, 2024, and that at 2:15 p.m. it was discovered that the resident was unable to be located. The resident was located at 4:00 p.m. at a river toll bridge commission building and subsequently returned to the facility. Review of Google Maps revealed that the river toll bridge commission building was 0.2 miles, approximately a four minute walk, from the theater, in a busy [NAME] area along a waterfront. Interview on October 17, 2024, at 1:27 p.m. Employee E10, activities aide, stated that on the day of the planned activities outing to the theater, two residents cancelled, so Resident R138 was added to the trip roster the morning of the outing. Employee E10, activities aide, stated that six residents were accompanied to the theater by one other activities aide and himself. Employee E10, activities aide, stated that Resident R138 was seated by his coworker and that he periodically checked on all of the residents during the theater performance. Near the end of the first act, Employee E10, activities aide, stated that he noticed that Resident R138 was not in his seat and that he got up and checked the area for the resident as well as asked theater staff if they had seen the resident. Employee E10, activities aide, immediately initiated elopement protocol and notified the local police. Employee E10, activities aide, stated that additional facility staff arrived to assist with the search and that the police received a call from the river toll bridge commission building with a description matching Resident R138. Facility staff went to identify the resident and brought him back to the facility. Employee E10, activities aide, stated that prior to the elopement incident with Resident R138, that the facility did not have an official protocol in place for screening residents signed up for out-of-facility events to identify their care needs, such as for elopement risk identification. Review of facility documentation revealed a witness statement, dated August 25, 2024, from Employee E11, activities aide. Employee E11, activities aide, noted that Employee E10, activities aide, asked her where Resident R138 was and that she did not see the resident. Continued review of facility documentation revealed another witness statement, dated August 27, 2024, from Employee E11, activities aide. The employee indicated that two residents were seated completely behind both her and the other activities aide and that she periodically checked on the residents. Employee E11, activities aide, indicated that she did not know which residents on the outing were elopement risks. Review of facility documentation, Elopement Preparedness and Response, dated September 3, 2024, revealed that the facility determined that the root cause of Resident R138's elopement was due to the seating arrangement at the theater. Resident R138 was seated out of sight of staff and therefore staff were unable to supervise and redirect the resident to remain in a safe location throughout the outing. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. Resident R138 was unable to be located during an out-of-facility activities outing to a theater on August 25, 2024, from 2:15 p.m. until he was found at a river toll bridge commission building at 4:00 p.m. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on October 17, 2024, at 1:58 p.m. On August 25, 2024, the facility initiated a plan of correction to address the failure of ensuring that a resident was adequately supervised to prevent elopement. The facility plan of correction included the following: 1. [Resident R138[ was assessed on August 25, 2024, at 5:10 p.m. A full assessment was completed of [Resident R138[ by Registered Nurse Supervisor. No adverse effects or injuries noted. Increased supervision initiated with 15-minute checks upon return to the building and continued through August 29, 2024.[ Resident R138[ placed on purposeful rounding every hour as of August 29, 2024, and rounds continue. 2. All residents with wander guards [device that is placed on resident's wrist or ankle which sound alarms or prevent doors to be open for exit] were verified to ensure electronic wander guards in place and functioning. Audit completed by Registered Nurse Supervisor including verification of orders, placement and function of wander guard; review of care plans updated and noted in clinical record. Wander guard master list updated, reviewed and provided to Interdisciplinary team on August 26, 2024. 3. Facility off premise policy was created August 30, 2024, pertaining to off premises activities. New procedure developed to include staff education and evaluation of residents prior to attending an outing to ensure each resident's appropriate supervision and needs are met to include review of elopement risk, mobility needs, hygiene, toileting, meal and hydration intake, as well as other ADL [activities of daily living] needs related to staffing and/or volunteer support. Activity trip form is reviewed and approved by activities supervisor and clinical service manager for all residents prior to attending an outside activity; any deviations from the roster are reviewed by activities supervisor prior to leaving the premises. Nursing and security staff are updated regarding residents who are participating in event off premises. Resident profile binder in place with instruction for every off premises outing which is provided to staff prior to leaving for the activity that includes elopement risk, safety needs and medical needs. During the off premises outing all residents will be required to stay within the facility group under the supervision of a responsible party as per policy. 4. Activities staff involved in the incident received immediate education on escorting residents to outside activities and the requirement that residents will not be left unattended at any time. All activities staff education completed on August 28, 2024, on outings protocol. No additional off-site activities were held from August 25, 2024, through August 27, 2024. 5. On August 27, 2024, facility activity form updated to reflect a review by nursing and activities to ensure sufficient staff and supplies are available for the outings including a review of elopement risk, dietary needs, personal care needs and medical needs. Audits of forms completed with final review by activities supervisor and clinical service manager. All outings forms will continue to be reviewed and approved by activities supervisor and clinical service manager prior to any outings. 6. QAPI [Quality Assurance Performance Improvement] meeting held September 27, 2024, and education, audits and policy reviewed by IDT [Interdisciplinary Team]. Next QAPI meeting scheduled for October 25, 2024. A review was conducted of staff education, wander guard and activity forms audits and off-premise activities policy that was created related to Resident R138's elopement. Interviews with facility staff were conducted on October 17, 2024. Facility staff provided extensive feedback and understanding of the facility's new off-premise policy and process. Facility staff verbalized that all residents and staff assignments are reviewed prior to all outings to ensure that supervision and resident care needs can be met. All residents who have been identified as at risk for elopement receive one-to-one supervision during outings. All residents who attend the outing have information, including their supervision and care needs, in a binder that is taken along on the outing. Facility staff verbalized that all residents are assigned to specific staff during all outings and that no residents are ever left alone. Facility audits were reviewed and residents who were identified by the facility as being at risk for elopement had appropriate elopement prevention measures in place. Facility activity forms were reviewed and indicated that all residents and staff were reviewed for appropriateness and care needs prior to all out-of-facility activities. Review of facility documentation revealed that the corrective action plan was immediately initiated on August 25, 2024. The facility's action plan was accepted on October 17, 2024, at 4:48 p.m. and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for four of four sampled residents (Resident R128, R24, R74 and R106 ). Findings include: Review of facility policy Culturally Competent Trauma Informed Care dated July, 2024, revealed that The (FACILITY NAME) will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment, and others. The United States Department of Veterans Affairs sanctions the PCL-5 checklist, as a screening tool for the purpose of quantifying and monitoring symptoms, screening individuals for PTSD and assisting 1n making a provisional diagnosis of PTSD. The assessment will be conducted in a private setting and will use a multi-pronged approach to identify a resident's history of trauma and will include a review of the resident's admission records for recent or past involvement in a traumatic event (i.e., natural disaster, accidents, war, physical, emotional, or sexual abuse at any age, rape, unexpected life events such as death of a child or personal illness). The Social Worker/designee will assess the resident to identify if they are culturally diverse and will evaluate the resident for their ability to effectively communicate and the potential need for language assistance services; if indicated language assistance services will be arranged for the resident. If a history of trauma and or trauma related symptoms are identified a Medical Provider order will be requested for a referral by a mental health professional who is experienced in working with those exposed to trauma. Upon receipt of Medical Provider order the Social Worker/designee will place the referral to the mental health professional. The resident's care plan will be implemented with individualized interventions that include trigger specific interventions addressing ways to decrease re-traumatization, as well as identifying ways to mitigate or decrease the effect of the trigger on the resident. In situations where a trauma survivor is reluctant to share their history, the (FACILITY NAME) will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. The (FACILITY NAME) will evaluate the resident's care plan at least quarterly to review if interventions, needs and problems are identified and have the desired effect to achieve the residents' goals for care, a. The Social Worker or designee will include the resident's family or resident representative in the evaluation to ensure clear and open discussion and to better understand if intervention need to be changed. The (FACILITY NAME) will engage the services of an interpreter to monitor or evaluate the effect of cultural interventions for non-English speaking residents. A review of the clinical record revealed that Resident R128 was admitted to the facility, with diagnoses to include anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Further review of the clinical record for Resident R128 revealed that the resident served in the military. Resident R128's current care plan-initiated May 11, 2023, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. A review of the clinical record revealed that Resident R24 was admitted to the facility, with diagnoses to include major depressive disorder, and post-traumatic stress disorder (PTSD). Further review of the clinical record for Resident R24 revealed that the resident served in the military. Resident R24's current care plan-initiated February 27, 2023, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. A review of the clinical record revealed that Resident R74 was admitted to the facility, with diagnoses to include bipolar disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Further review of the clinical record for Resident R74 revealed that the resident served in the air force. Resident R74's current care plan-initiated April 4, 2023, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. A review of the clinical record revealed that Resident R106 was admitted to the facility, with diagnoses to include bipolar disorder, dementia, major depressive disorder, and post-traumatic stress disorder (PTSD). Further review of the clinical record for Resident R106 revealed that the resident served in the army. Resident R106's current care plan-initiated March 15, 2023, revealed a care plan for PTSD. Further review of the care plan did not address resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. Interview with the Director of Nursing, Employee E1, on October 18, 2024, at 11:00 a.m. confirmed that Residents 124's, R24s, R74s and R 106s plan of care for PTSD did not include resident's actual diagnoses/condition of PTSD, identifying the resident's past experiences and possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on observations and interviews with staff, it was determined that the facility failed to ensure that garbage was disposed of properly. Findings include: Observation in the receiving area and the garbage disposal area on July 9, 2024, at 10:30 a.m. with Employee E13 Food Service Manager, revealed that the dumpster which contained garbage from the kitchen and general trash from the resident care area with no lid. The open dumpsters revealed the contents, which included open or untied garbage. There were flies observed around the opening of the dumpster. An interview with Administrator, Employee E1, on October 16, 2024, at 2:00 p.m. confirmed that there was lid to the dumpster which the maintenance made to close the dumpster which was not placed appropriately. Administrator also confirmed that the dumpster is designed to push the trash inside without exposing the content, however the dumpster was over filled. 29 Pa. Code 201.18 (b)(1) Management

Based on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to a resident eloping during a planned out-of-facility activities outing to a theater, for one of six residents reviewed related to elopement risk. This failure placed Resident R138 at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. Findings include: Review of the job description for the Nursing Home Administrator (NHA) revealed that the NHA is responsible for managing, directing and controlling all health-care activities and management functions. Continued review revealed that the NHA is responsible for enforcing the regulations relative to the level of health care and safety of residents and to the protection of their personal and property rights. Review of the job description for the Director of Nursing (DON) revealed that the DON directs all nursing care activities and participates in the administration of the multidisciplinary and nonclinical aspects of a veterans' extended care facility's overall operations. Continued review revealed that the DON directs the operations of various departmentalized disciplines within the facility to include, but not limited to, Nursing, Pharmacy, Physical and Recreational Therapy, and Therapeutic Activities. Review of Resident R138's Elopement Evaluation, dated July 29, 2024, revealed that the resident was identified by the facility as being at risk for elopement, related to ambulation status, cognitive impairment and history of exit seeking behaviors. The evaluation noted that an elopement care plan was initiated. Review of Resident R138's care plan, dated initiated March 8, 2023, revealed that the resident was at risk for elopement and has exhibited exit seeking behaviors. Interventions included to encourage the resident to look for a staff member if he feels lost, confused or needs assistance, to redirect and reorient the resident as needed, and to maintain safety. Continued review of Resident R138's care plan, dated initiated July 26, 2024, revealed that the resident had memory deficits, requiring reminders and invitations for consistent activity participation. Interventions included that the resident will be invited to community outings to enhance life enrichment. Review of facility documentation reported to the Pennsylvania Department of Health on August 26, 2024, at 4:09 p.m. revealed that Resident R138 was on an out-of-facility activities outing to a theater on August 25, 2024, and that at 2:15 p.m. it was discovered that the resident was unable to be located. The resident was located at 4:00 p.m. at a river toll bridge commission building and subsequently returned to the facility. Interview on October 17, 2024, at 1:27 p.m. Employee E10, activities aide, stated that on the day of the planned activities outing to the theater, two residents cancelled, so Resident R138 was added to the trip roster the morning of the outing. Employee E10, activities aide, stated that six residents were accompanied to the theater by one other activities aide and himself. Employee E10, activities aide, stated that Resident R138 was seated by his coworker and that he periodically checked on all of the residents during the theater performance. Near the end of the first act, Employee E10, activities aide, stated that he noticed that Resident R138 was not in his seat and that he got up and checked the area for the resident as well as asked theater staff if they had seen the resident. Employee E10, activities aide, immediately initiated elopement protocol and notified the local police. Employee E10, activities aide, stated that additional facility staff arrived to assist with the search and that the police received a call from the river toll bridge commission building with a description matching Resident R138. Facility staff went to identify the resident and brought him back to the facility. Employee E10, activities aide, stated that prior to the elopement incident with Resident R138, that the facility did not have an official protocol in place for screening residents signed up for out-of-facility events to identify their care needs, such as for elopement risk identification. Review of facility documentation revealed a witness statement, dated August 25, 2024, from Employee E11, activities aide. Employee E11, activities aide, noted that Employee E10, activities aide, asked her where Resident R138 was and that she did not see the resident. Continued review of facility documentation revealed another witness statement, dated August 27, 2024, from Employee E11, activities aide. The employee indicated that two residents were seated completely behind both her and the other activities aide and that she periodically checked on the residents. Employee E11, activities aide, indicated that she did not know which residents on the outing were elopement risks. Review of facility documentation, Elopement Preparedness and Response, dated September 3, 2024, revealed that the facility determined that the root cause of Resident R138's elopement was due to the seating arrangement at the theater. Resident R138 was seated out of sight of staff and therefore staff were unable to supervise and redirect the resident to remain in a safe location throughout the outing. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. Refer to F689. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store drugs and biologicals in a locked compartment on one of two nursing carts reviewed. (D unit high cart) Findings include: Review of policy titled Medication Storage and Refrigerator Temperatures revealed that medications and biologicals in rooms, carts, boxes and refrigerators are maintained with in secured locations accessible only to designated staff. Based on drugs.com website updated (updated 10 [DATE]) reveled Insulin is a hormone that is produced naturally in our bodies. Its main role is to allow cells throughout the body to uptake glucose (sugar) and convert it into a form that can be used by these cells for energy. Naturally occurring human insulin is made by beta cells within the pancreas, but people with diabetes have little or no natural insulin release. Insulin is available as synthetic human insulin (made in a laboratory but resembles naturally occurring human insulin), insulin analogs (human insulin that has been genetically modified), and biosimilars. Insulin analogs are better than standard human insulin at mimicking natural insulin release. Based on the American diabetes association recommendation of safe storage for insulin revealed. For the people with diabetes who use it, insulin is a vital need. It's important to store insulin as directed so that it remains usable by those who need it. Follow these tips to ensure effective insulin storage. 1. Keep It Cool According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36 F to 46 F. If you are using ice, avoid freezing the insulin. Do not use insulin that has been frozen. 2. Know Its Expiration Date Unopened insulin refrigerated in the ranges described above maintains potency until Based on the Department of health and Human Services Centers for Medicare and Medicaid Services titled Medication Storage and Labeling revealed S483.45 (h) (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Observation of medication administration pass with Licensed nurse, Employee E5 on October 16, 2024, at 8:30 a.m. revealed the medication cart stored a container consisting of sixteen vials of insulin on top of the cart for complete access to the insulin for anybody to obtain. Interview with Employee E5 at time of observation revealed the container was supplied to her by the supervisor prior to med pass, it was originally stored in the medication room in the refrigerator. Employee E5 stated that she intended to return the container of insulin to the medication room after med pass. Interview with Licensed nurse, unit manager, Employee E4 on October 16, 2024, at 8:41 a.m. at the medication cart D unit high cart, revealed that according to this employee, the container consisting of 16 bottles of insulin is acceptable to leave on top of the cart. Interview with Licensed nurse Employee E6 on October 16, 2024, at 9:05a.m. at Medication cart Low side revealed the insuling is taken from the medication room refrigerator prior to med pass, then placed in a drawer in the medication cart during med pass. The medication cart is locked when unattended. After Employee E6 completes medication pass for the unit, the container of insulin will be brought back to the medication room. Interview with the director of nursing , employee E 2 on October 17, 2024 at 2:10pm.m. confirmed the insulin is to be store inside the medication cart and locked. 28 Pa. Code 211.9(a)(1)Pharmacy services 28 pa code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to ensure medications were dispensed and administered in according to professional standards of practice relating to medication administration for one of 3 residents reviewed. (Resident R125) Findings include: Review of facility policy titled Medication Administration Protocol dated May 2022, revealed that every medication will have a physicians order, including the order route and dose of med and will be transcribed into medication administration record (MAR). Review of Resident R125's physician orders revealed that Resident R125 had an order for Methadone 20 milligrams (mg). U.D. ( unit dose) bottle once a day due to opioid dependence. Special Instructions: DRINK THE WHOLE BOTTLE, THEN FILL WITH WATER AND DRINK TO RINSE OUT REMAINING DRUG. NURSE AND PATIENT SIGN ASSOCIATED SHEET AFTER EACH ADMINISTRATION. DO NOT DISCARD BOTTLE. DX: OPIOD DEPENDENCE Once A Day Review of Drugs.com last updated on [DATE]. revealed Methadone is a long-acting opioid medication that is used to reduce withdrawal symptoms in people addicted to heroin or other narcotic drugs, and it can also used as a pain reliever. When methadone is used for Opioid Use Disorder (OUD) it reduces withdrawal symptoms and drug cravings, but does not cause the high associated with the drug addiction. Methadone is highly regulated medication (Schedule 2 Controlled Substances Act) and when used for OUD is only available through approved opioid treatment programs (OTP) that involves regular monitoring, counseling, and drug testing to make sure that patients are making progress in their recovery. Use this medicine exactly as prescribed by your doctor. Follow the directions on your prescription label and read all medication guides or instruction sheets. Never use this medicine in larger amounts, or for longer than prescribed. Tell your doctor if you feel an increased urge to use more of this medicine. Observation of medication administration on October 16, 2024, at 8:45 a.m. revealed Licensed nurse, Employee E5 preparing to administer Residents R125's medications. Observation revealed that Employee E5 prepared all the medication and placed them in a small medication cup. She then unlocked the narcotic box of medication and pulled a small bottle of methadone prescribed to Resident R125. After Resident 125 consumed the pills Employee E5 then pour orange juice into the small bottle and the resident swallowed the liquid from the mouth of the bottle. Resident R125 then handed back the bottle (for counting purposes, the bottles must be returned. The bottle contained a small amount of fluid approximately 3-5 ml remained). Interview with Licensed nurse, unit manager Employee E4 on October 16, 2024, at 8:41 a.m. revealed that Employee E4 stated t hat the bottle of methadone does not need to be refilled with water. The resident fills the medication with water or orange juice. Interview with Director of Nursing Employee E2 on October 17, 2024, at 2:20 p.m. confirmed that the orders stated to fill the bottle with water and drink, these instructions of adminstration must be followed as prescribed. 28 Pa Code 211.9 (a)Pharmacy Services 28 Pa. Code 211.12(d)(1) Nursing Services

Based on clinical record review and resident and staff interview, it was determined to ensure sufficient staff was available to accompany one of three sampled residents to a medical appointment. (Residents R1) Findings include: Review of clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis including Quadriplegia (a person affected by paralysis of all four limbs ) and type 2 diabetes mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). The Minimum Data Set (MDS-Assessment of resident care needs) assessment dated [DATE], indicated that the resident had impaired range of motion on both of his upper and [NAME] extremities. Further review of the MDS revealed that the resident was dependent on the staff for eating, toileting, transfers, mobility except one placed in a motorized wheelchair. Review of care plan for Resident R1 dated June 16, 2022, revealed that the resident controlled the wheelchair with his chin. Resident was quadriplegic and required total assist to fasten and unfasten seatbelt. Review of facility grievance dated September 3, 2024, revealed a complaint from resident I was sent out on an appointment to (Outside Provider) by myself with no aid, the DON (Director of Nursing) and supervisory reported that they had no staff was available to escort me to this appointment. Myself being a quad (quadriplegia-a person affected by paralysis of all four limbs) patient should never not have someone with me during these appointments. I am unable to do many things for myself and having someone with me makes me feel more secure. I needed assistance with my personal wheelchair and operating the elevator during my appointment. I felt dizzy and ended up in the ER (emergency room ) where my sugar had dropped to 59 and they provided me with a snack and drink. This could have been avoided had I had been accompanied by a staff member during this appointment. I was out the building from 8am to 1:30 p.m. and missed lunch and had a light breakfast. Further review of the grievance revealed that I want a staff member to be provided to me for all of my future appointments, and because am a diabetic, I should also leave with e snack and drink especially since i was out from 730 am and did not return until after lunch. Interview with Resident R1 on September 10, 2024, at 10:00 a.m. revealed that he went to an appointment in the center city approximately has 2 hours of travel time which may take longer depending on traffic on September 3, 2024. Resident stated after the appointment he had to call for the transport to get back to the appointment center to pick him back to the facility. Resident stated the transport driver dropped him in front of the appointment place. He stated his appointment was on the second floor which required him to use the elevator and press the elevator button which he could not do. He stated he had to wait for someone to press the elevator button for him to go to the doctor's office on the second floor. Resident stated he experienced the same issue when he was coming back from the appointment. Interview with the Transportation Clerk, Employee E3 on September 10, 2024, at 10:30 a.m. stated facility set up a stretcher transportation for Resident R1 but a wheelchair van showed up to take the resident to the appointment which required the facility to send a staff member. However, facility send the resident without a staff member. Interview with the Director of Nursing, Employee E2 on September 10, 2024, at 11:30 a.m. stated Resident R1 should have a staff member to accompany him to assist him at the appointment. Employee E2 stated facility did not have enough staff on September 3, 2024 to send with Resident R1 for the appointment. 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 provide care and services for a resident with a diagnosis of diabetes and to assess a resident for hypoglycemia for one of three residents reviewed (Resident R1). Findings Include: Review of facility grievance dated September 3, 2024, revealed a complaint from resident I was sent out on an appointment to (Outside Provider) by myself with no aid, the DON (Director of Nursing) and supervisory reported that they had no staff was available to escort me to this appointment. Myself being a quad (quadriplegia-a person affected by paralysis of all four limbs) patient should never not have someone with me during these appointments. I am unable to do many things for myself and having someone with me makes me feel more secure. I needed assistance with my personal wheelchair and operating the elevator during my appointment. I felt dizzy and ended up in the ER (emergency room ) where my sugar had dropped to 59 and they provided me with a snack and drink. This could have been avoided had I had been accompanied by a staff member during this appointment. I was out the building from 8am to 1:30 p.m. and missed lunch and had a light breakfast. Further review of the grievance revealed that I want a staff member to be provided to me for all of my future appointments, and because am a diabetic, I should also leave with a snack and drink especially since i was out from 730 am and did not return until after lunch. Review of clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis including Quadriplegia and type 2 diabetes mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of physician order for Resident R1 dated July 15, 2024, to check blood sugar as needed. Review of physician order for Resident R1 dated August 2, 2024, for insulin Lispro with blood sugar check and hold for blood sugar less than 130. Review of Medication Administration Record for September 3, 2024, revealed that resident's blood sugar was 181 at 7 a.m. and he received 16 units of insulin Lispro, Repaglinide tablet (antidiabetic medication) 1 mg on September 3, 2024, prior to the appointment which affected the blood sugar level. Resident also received 14 units of long acting on September 2, 2024, at bedtime which had a potential to affect the blood sugar. Review of care plan for Resident R1 dated February 21, 2023, revealed that potential for hypo/hyperglycemia related to the diagnosis of Diabetes, episodes of non-compliance with blood sugar checks and with receiving insulin. Interventions included, check with medical provider to hold insulin and/or medication for skipped meals. Document if insulin or medication refused and notify medical provider. Monitor for adequate meal consumption and evening snacks. Interview with Resident R1 on September 10, 2024, at 10:00 a.m. revealed that he went to an appointment in the center city approximately has 2 hours of travel time which may take longer depending on traffic on September 3, 2024. Resident stated after the appointment he had to call for the transport to get back to the appointment center to pick him back to the facility. Resident stated he left for the appointment after eating a light breakfast. Resident stated he did not have any facility staff that accompanied him for the appointment which he stated he always needed. Resident stated facility did not send any snack or lunch for the appointment and did not have any estimate of when he would return back from appointment. Resident stated he waited after the appointment for transport back to the facility, when he was waiting his blood sugar dropped, and he was taken to emergency room with a blood sugar of 59. He stated they gave him juice and snack which bought the blood sugar back, but he did not know how much the was blood sugar. Resident stated when he returned back to the facility, he told the staff that about the low blood sugar episode. Resident stated facility did not recheck his blood sugar or gave him food when he returned. He stated the facility lunch time was 11:30 a.m. and he returned from the appointment around 1:30 p.m. Review of clinical record for Resident R1 revealed no evidence that the facility checked resident's blood sugar or gave him food when he returned from the appointment. Interview with the Director of Nursing, Employee E2 on September 10, 2024, at 11:30 a.m. stated Resident R1 should have blood sugar checked when he returned from the appointment and offered him lunch when he returned. Resident should have packed food to take for the appointment. Employee E2 confirmed that facility staff did not check his blood sugar when resident returned even after he notified the staff that his blood sugar was 59 at the appointment. Employee E2 stated residents' blood sugar check order and insulin order was not administered at the lunch time or when he returned to the facility. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of facility documentation, and staff interviews, it was determined that the facility failed to adequately monitor and supervise one resident, identified as a high fall risk, who sustained a fall with injuries and direct harm and did and failed to follow physician orders for this resident resulting in actual harm to Resident R1. Findings include: Review of Resident R1's clinical record indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was also currently receiving psychotropic medications for treatment of [REDACTED]. The resident had been assessed as moderately impaired on the Minimum Date Set ( an assessment tool to determine resident needs ) on December 9, 2013 and also identified as a high fall risk since June 26, 2013 and as recent as December 6, 2013. Additionally, a review of nursing care plans dated December 18, 2013 revealed the resident had potential for falls and required extensive assistance with Activities of Daily Living given the psychotropic drug use for treatment of [REDACTED]. A review of the facility policy entitled Bathing-Shower/Tub dated 6/04 under "Procedure" requires the resident "never to be left alone while bathing". A review of nursing documentation revealed that on December 25, 2013 @ 6:55 a.m. the resident was being assisted with getting a shower and sustained a fall. The nurse aide reported turning to put certain shower items down and the resident walked from the shower and fell . The resident fell face down to the floor. The physician was notified and ordered Resident R1 be sent to the hospital. The resident was transferred and later admitted to the hospital with [REDACTED]. These findings were all validated by the Director of Nursing in an interview at 12:15 p.m. on December 25, 2013. The facility failed to adequately monitor and supervise the resident in order to avoid accidents with the resident sustaining a fall causing serious injury and actual harm. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services