Every finding on record at Elkins Crest Health & Rehabilitation Center

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include:Review of the facility's policy entitled, Storage of Refrigerated Food Policy, dated July 30, 2026, revealed that foods that were to be prepared and not placed into service were to be covered, labeled, and dated with use by dates. Staff were to check the refrigerator/freezer/dry storage routinely for food items that were expired and they were to be discarded by the use by date.Observations during the tour of the dietary department on August 4, 2026, at 10:45 a.m., revealed the following:In the walk-in refrigerator, there were three containers of fruit salad with best by dates of August 1, 2026, and a container of prepared peppers with a preparation date of July 30, 2026, with no use by date.The following was observed on the cook's table:The lids on bottles of spices were left open as follows: Two containers of ground nutmeg, which was also not labeled with a use by date.One container of celery seeds, which also had a use by date of December 19, 2025.One container of rubbed sage, which was also not labeled with a use by date.One container of ground oregano, which was also not labeled with a use by date.One container of whole basil, which was also not labeled with a use by date.One container of whole thyme, which was also not labeled with a use by date.One container of dill weed, which also had a use by date of August 21, 2025.An opened container of distilled vinegar had no use by date.There were two open boxes of corn starch with no open date or use by date.Small black insects were observed flying throughout the kitchen, including the closed dry storage area.Observation of the emergency eyewash station in the kitchen area revealed the left outlet had no spray cap or dustcover and the right shower head appeared to have white colored flecks embedded in the sprayer holes. In an interview on August 7, 2026, at 1:07 p.m., the Maintenance Director stated that the maintenance department was responsible for checking the eyewash station for functionality and providing maintenance to the equipment.28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation and staff interview, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents on two of three nursing units. (Second and Third Floor Nursing Units) Findings include: Observations in resident rooms throughout the facility from August 4, 2026, at 11:05 a.m. through August 6, 2026, at 3:00 p.m. revealed the following: In room [ROOM NUMBER], there was no privacy curtain for bed one. The curtain for bed two had brown stains. There was a long-handled tool with a metal scraper at the bottom, leaning against a resident's dresser, that was identified by the Housekeeping Director, as a floor scraper used to remove waxy residue from the floor. Additionally, the blind cords were tangled making the blinds non-adjustable, and the pillow on bed two had a large brown stain. In room [ROOM NUMBER], the closet door was hanging off the track and the clock displayed the wrong time. The privacy curtains between beds one, two, and three had brown stains. The blinds were covered with dust and dirt, and the ceiling paint was peeling by the window. In the bathroom, there was chipped paint on the right side of the toilet and the rubber baseboard was caved in, creating a hole. In room [ROOM NUMBER], there was a large stain on the ceiling and an empty cup and crumpled paper under the side-table near bed two. The tray table used by the resident in bed three was peeling. In room [ROOM NUMBER], the privacy curtains were stained between beds one and two. In room [ROOM NUMBER], the dresser near bed two had a broken middle drawer. The privacy curtains between beds one and two were soiled with brown stains. In room [ROOM NUMBER], the metal legs of the tray table were rusted and there was no closet door for bed two. In room [ROOM NUMBER], the privacy curtain between beds one and two had brown stains. In room [ROOM NUMBER], the clock displayed the wrong time. There were black marks on the wall across from the bed. There were brown spots under both sides of the bed. The privacy curtains between beds one and two had brown stains. In room [ROOM NUMBER], the wall behind bed two was marred with several areas of chipped paint. There was a brown substance splattered on the wall between the two televisions. In room [ROOM NUMBER], the wall behind bed two was marred and paint was missing in two areas. In room [ROOM NUMBER], the ceiling tile above bed two was bowed and not flush with the rest of the ceiling. 28 Pa. Code 201.18(e)(2.1) Management.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide feeding assistance in a manner that maintained dignity for four of 29 sampled residents. (Residents 28, 33, 59, 96)Findings include: Clinical record review revealed that Resident 28 had diagnoses that included cognitive communication deficit, down syndrome, need for assistance with personal care, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment and the care plan revealed the resident needed assistance with feeding at mealtimes. On August 4, 2026, at 12:38 p.m., Resident 28 was observed in the dining room with other residents. Registered Nurse (RN) 1 was observed feeding lunch to the resident while standing. Clinical record review revealed that Resident 33 had diagnoses that included a history of traumatic brain injury, unspecified severe protein-calorie malnutrition, and contractures of the left and right hands. Review of the MDS assessment dated [DATE], revealed the resident had moderate cognitive impairment and was dependent on staff for eating meals. On August 5, 2026, at 12:46 p.m., Resident 33 was observed in the dining room with other residents. Licensed Practical Nurse (LPN) 1 was observed feeding lunch to the resident while standing. Clinical record review revealed that Resident 59 had diagnoses that included moderate intellectual disabilities and dysphagia. Review of the MDS assessment dated [DATE], revealed the resident had moderate cognitive impairment and required set-up assistance for meals. The care plan indicated that staff was to provide assistance for eating meals. On August 4, 2026, at 12:42 p.m., Resident 59 was observed in the dining room with other residents. RN 1 was observed feeding lunch to the resident while standing. Clinical record review revealed that Resident 96 had diagnoses that included cognitive communication deficit, ventilator associated pneumonia, and unspecified convulsions. Review of the MDS assessment dated [DATE], revealed the resident had severe cognitive impairment and required set-up assistance for meals. Review of the care plan revealed that the resident required encouragement during meals. On August 4, 2026, at 12:48 p.m., Resident 96 was observed in the dining room with other residents. Rather than encouraging the resident to eat after set-up, RN 1 was observed feeding lunch to the resident while standing. In an interview on August 7, 2026, at 9:50 a.m., the Director of Nursing confirmed that staff were to sit with residents when assisting them to eat. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's ability to self-administer medications for one of 29 sampled residents. (Resident 4) Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed July 30, 2026, revealed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Staff should ensure that the physician's order for self-administration listed the specific medication(s) the resident may self-administer. The facility would provide a locked medication storage compartment and key to the resident. Staff should document the self-administration of medications on the resident's Medication Administration Record according to the medication administration schedule and should document the self-administration and self-storage of medications in the resident's care plan. Clinical record review revealed that Resident 4 had diagnoses that included a traumatic amputation at knee level of the lower right leg, diabetes, allergies due to pollen, and shortness of breath. Review of the Minimum Data Set (MDS) assessment, dated May 18, 2026, revealed that Resident 4 had no cognitive impairment. Observations on August 4, 2026, at 1:20 p.m., August 5, 2026, at 8:30 a.m. and 11:33 a.m., and on August 6, 2026, at 9:55 a.m., revealed that there was one bottle of fluticasone nasal spray (a medication used to treat symptoms caused by allergies), and one Breyna inhaler (budesonide and formoterol; a steroid and muscle relaxing lung agent) unsecured on the bedside table in the resident's room. In an interview on August 4, 2026, at 1:20 p.m., Resident 4 stated that he self-administered the medications twice a day. There was no documentation to indicate that the facility had assessed Resident 4 for the ability to self-administer the fluticasone nasal spray, or Breyna inhaler. The medications were not secured in his room. In an interview on August 7, 2026, at 9:44 a.m., the Director of Nursing confirmed that Resident 4 was not assessed to self-administer the medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to include the resident or resident's responsible party in the comprehensive care planning process and failed to review resident care plans with the required interdisciplinary team for five of 29 sampled residents. (Residents 4, 8, 11, 15, 89)Findings include: Clinical record review revealed that a Minimum Data set (MDS) assessment was completed on May 2, 2026, and May 18, 2026, for Resident 4. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessment. Clinical record review revealed that an MDS assessment was completed on February 24, 2026, for Resident 8. MDS assessments were completed on April 24, 2026, and June 10, 2026. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments. Clinical record review revealed that an MDS assessment was completed on April 19, 2026, for Resident 11. There was a lack of evidence that the facility conducted the required care plan review, that was to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessment. Clinical record review revealed that MDS assessments were completed on January 8, 2026, April 2, 2026, and May 26, 2026, for Resident 15. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments. Clinical record review revealed that MDS assessments were completed on March 15, 2026, and June 15, 2026, for Resident 89. There was a lack of evidence that the facility conducted the required care plan reviews, that were to involve the resident or resident representative and interdisciplinary team, after completion of the MDS assessments. During an interview on August 7, 2026, at 10:48 a.m., the Director of Nursing confirmed that there was no evidence that care conferences were held timely with the residents, resident representatives, and required interdisciplinary team members. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician's orders for one of 29 sampled residents. (Resident 51) Findings include: Clinical record review revealed that Resident 51 had diagnoses that included hypertension, vascular insufficiency (condition where leg veins fail to send blood back to the heart efficiently), peripheral vascular disease (a slow disease of the blood vessels outside the heart and brain that involves narrowed, blocked, or damaged vessels), and localized swelling in both legs. A physician's order dated April 11, 2025, directed staff to apply anti-embolism stockings to both legs while out of bed in the morning and remove them at bedtime. Review of the comprehensive care plan revealed that the resident was at risk for an altered cardiovascular system. Multiple observations on August 4, 5, and 6, 2026, between 9:30 a.m. and 2:00 p.m., revealed Resident 51 was out of bed in a wheelchair and the anti-embolism stockings were not applied. In an interview on August 7, 2026, at 11:21 a.m., the Director of Nursing confirmed that the anti-embolism stockings should have been applied at the times of the observations. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to immediately report an injury of unknown origin to the State Survey Agency for one of six sampled residents. (Resident 2)Findings include: Review of the facility policy entitled, Resident Abuse, last reviewed August 1, 2025, revealed that all incidents and allegations of abuse, including injuries of unknown source were to be reported immediately to the Administrator, Director of Nursing, and to the State Agency. Clinical record review revealed Resident 2 had diagnoses that included hemiplegia (paralysis that affects one side of the body), stroke, and dementia. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, required staff assistance with toileting and personal hygiene, and was dependent on staff for transfers. A review of nursing notes revealed that on November 28, 2025, at 1:19 p.m., a nurse aide observed bruising to Resident 2's right arm and right hip. A registered nurse assessed the bruises and indicated that two faded purple bruises were observed to resident's right hip and right upper arm and that the resident was unable to recall how the bruises occurred. There was a lack of evidence to support that the facility reported the injury of unknown source to the State Survey Agency. In an interview at 1:00 p.m., the Director of Nursing confirmed the facility did not report the incident to the State Survey Agency. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on two of three nursing units. (Floors 2 and 3)Findings include:Findings include:Observations on September 9, 2025, from 9:45 a.m. through 1:00 p.m. and on September 10, 2025, from 10:00 a.m. through 1:00 p.m. revealed the following: Peeling paint was observed on the wall under the fire extinguisher in the hallway by room [ROOM NUMBER].Peeling paint and a dried brown liquid were observed on the floor in front of the closets in room [ROOM NUMBER].The hallway wall between rooms [ROOM NUMBERS] was marred.A bedside tray table in room [ROOM NUMBER] was missing a drawer, another drawer was crooked, and a metal drawer track was observed on the floor. A bed curtain in room [ROOM NUMBER] was off its track. Debris was observed on the floor in room [ROOM NUMBER].Marks were observed on the walls in the second-floor dining room.The handrail in the hallway across from the second-floor nursing station was missing a piece.The handrail next to the elevator was loose.Flies were observed in rooms 208, 224, and at the second-floor nursing station. There was damage to the wall behind the A bed and ceiling tiles were damaged in the bathroom of room [ROOM NUMBER].The radiator cover was damaged, and a sliding closet door was off the tracks in room [ROOM NUMBER].The entrance door and a floor tile were damaged in room [ROOM NUMBER].A sliding closet door was missing in room [ROOM NUMBER].The wall across from bed A was damaged. Floor tiles in the bathroom in 325 were damaged. There was an uncovered electrical outlet with wires exposed on the wall behind bed A in room [ROOM NUMBER].An electrical outlet to the left of the television in the third floor dining room had no cover.Ceiling tiles, the radiator under the television, and the piano in the third floor dining room were damaged.Wheelchair bumper rails in the hallway between rooms 314 and the shower room, and between rooms [ROOM NUMBERS] were damaged. A red substance was observed on the back of the 3rd floor High side med cart.The sharp's container cabinets on both 3rd floor med carts had broken vents on the sides.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the current status of one of 33 sampled residents. (Resident 7)Findings include:Clinical record review revealed that Resident 7 had diagnoses that included cerebrovascular accident (stroke), respiratory failure, and dysphagia (difficulty swallowing). After a change in condition on May 21, 2025, the physician ordered the resident to begin receiving hospice services. The MDS assessments, dated May 21 and August 21, 2025, did not indicate that Resident 7 received hospice services. In an interview on September 12, 2025, at 1:10 p.m., the Director of Nursing confirmed that Residents 7's MDS assessments were inaccurate and the resident was receiving hospice services.

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan that addressed an individual resident's needs as identified in the comprehensive assessment for two of 33 sampled residents. (Residents 75 and 76)Findings include: Clinical record review revealed that Resident 75 had diagnoses that included senile degeneration of the brain, major depression, and difficulty in walking. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident was occasionally incontinent of urine. The MDS Care Area Assessment (CAA) summary, dated February 13, 2025, indicated that the resident's urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 75's urinary incontinence were addressed in the care plan. Clinical record review revealed that Resident 76 had diagnoses that included dementia, muscle weakness, and difficulty in walking. According to the MDS assessment dated [DATE], the resident was occasionally incontinent of urine. The MDS CAA summary, dated January 2, 2025, revealed the resident's urinary incontinence was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 76's urinary incontinence were addressed in the care plan. In an interview on September 12, 2025, at 10:10 a.m., the Director of Nursing confirmed the identified care areas were not addressed in the care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide necessary treatment and services to promote healing and to prevent new pressure sores from developing for one of two sampled residents with pressure sores. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included anoxic brain injury (lack of oxygen to the brain), respiratory failure, and diabetes. The Minimum Data Set assessment dated [DATE], indicated that the resident was non-verbal, dependent on staff for activities of daily living, had a pressure sore, and was at risk for developing additional pressure sores. On July 22, 2025, a physician's order directed staff to keep the resident's ears floating using a supportive neck pillow every shift. A review of the wound care physician's note, dated August 21, 2025, indicated the resident had bilateral open ear wounds. The care plan indicated that the resident had bilateral ear wounds and was at risk for worsening skin problems due to reduced mobility. Interventions included keeping the resident's ears floating by applying a neck support pillow with turning and repositioning every two hours. On September 9, 2025, at 11:05 a.m. and on September 11, 2025, at 11:30 a.m., 12:30 p.m., and 2:25 p.m., the resident was observed lying in bed without the neck pillow in place. The resident's right ear was in direct contact with the bed pillow. On September 12, 2025, at 8:48 a.m., the resident was observed lying in bed without the neck pillow in place with his head facing forward. Bilateral ear wounds were observed. On September 12, 2025, at 10:10 a.m., the Director of Nursing confirmed that the neck pillow was supposed to be in place, and that it was not at the time of the observations. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide routine and emergency dental services for one of 33 sampled residents. (Resident 67)Findings include: Clinical record review revealed that Resident 67 was admitted on [DATE], and had diagnoses that included spinal stenosis, nutritional deficiency, and chronic inflammatory demyelinating polyneuritis (an autoimmune disorder that damages nerve cells).During an interview on September 9, 2025, at 11:00 a.m. Resident 67 stated some of her teeth were damaged while she was hospitalized in October 2024. A dentist had referred her to an oral surgeon for extractions but no appointment had been made. On May 21, 2025, a dentist examined the resident and noted that she needed the damaged teeth removed by an oral surgeon. There was no documentation in the clinical record to support that the facility scheduled an examination with the oral surgeon to meet the needs of the resident.During an interview on September 12, 2025, at 9:45 a.m., the Director of Nursing, confirmed that the facility had failed to provide recommended dental services to Resident 67.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa Code 211.15 Dental services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the State Ombudsman's office in writing of the transfer from the facility for six of six sampled residents who were transferred to the hospital. (Residents 2, 4, 6, 15, 16, 155)Findings include: Clinical record review revealed that Resident 2 was transferred to the hospital on May 12, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 4 was transferred to the hospital on June 17, 2025, and on August 11, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 6 was transferred to the hospital on October 23, 2024, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 15 was transferred to the hospital on June 14, 2025, and on June 27, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 16 was transferred to the hospital on April 2, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 155 was transferred to the hospital on July 8, 2025, after a significant change in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on September 12, 2025, at 9:45 a.m., the Director of Nursing confirmed that the written copies of the discharge or transfer notices were not sent to the Office of the State Long Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on observation and staff interview, it was determined that the facility failed to ensure that current and accurate nurse staffing information was posted in the facility at the beginning of each shift.Findings include: Observations during a tour of the facility conducted on September 9, 2025, at 9:45 a.m., revealed that staffing information posted in the lobby was dated for September 5, 2025. In an interview on September 12, 2025, at 10:15 a.m., the Director of Nursing confirmed that the correct staffing information should have been posted. 28 Pa. Code 201.18(b)(3) Management.

Based on observation, it was determined that the facility failed to dispose of trash and refuse properly. Findings include: Observation of the dumpster area on September 9, 2025, at 10:30 a.m., revealed the side door of the dumpster was open. The grassy area adjacent to the dumpster had multiple pieces of plastic and paper debris. There were two dumpster lids laying on the ground next to the dumpster. 28 Pa Code 201.18(b)(3) Management.

Based on clinical record review, policy review, review of facility documentation, observation, and staff interview, it was determined that the facility failed to provide necessary supervision to monitor a resident's whereabouts and prevent an elopement (unauthorized departure from the facility) which resulted in actual harm for one of 10 sampled residents at risk for elopement. (Resident 1) The incident has been identified as past non-compliance. Findings include: Review of the facility policy entitled, Elopement/Unauthorized Absence Policy, last reviewed on August 2, 2024, revealed that staff was to identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included vascular dementia (impaired cognition, or a disease that causes progressive cognitive impairment that includes memory loss and personality changes), anxiety, and dissociative and conversion disorder (causes a person to be disconnected from their thoughts, memories, consciousness, and identity, and causes physical symptoms that a person can't control). According to the Admission/Readmission assessment, dated November 8, 2024, the resident could walk without assistance and was identified as a potential elopement risk. According to the care plan, the facility identified that the resident was at risk for elopement since admission to the facility and interventions implemented were for staff to place a Wanderguard (a security apparatus worn by an at risk resident that prevents doors from opening to prevent elopement when the resident is nearby) on the resident's left wrist and to place the resident on the third floor of the facility. Review of the nursing notes revealed that Resident 1 did not express any desire to leave the facility or exhibit exit-seeking behaviors from admission on November 8, 2024, through November 9, 2024. On November 9, 2024, a nurse noted that at approximately 7:15 p.m., Resident 1 was observed lying on the ground outside the perimeter of the building. His personal belongings were scattered on the ground around him. A blanket/sheet was observed hanging from the window of Resident 1's room above him. According to the facility investigation into the incident, the resident was last seen at approximately 6:35 p.m. seated in the dining room. The investigation indicated that the resident broke the window safety device and used bed sheets to climb out the third story window, experiencing a fall and sustaining a dislocated knee (disruption of the knee joint), subarachnoid hemorrhage (bleeding in the space between the brain and tissue covering the brain), and a vertebrae fracture (broken spine). In a interview on November 14, 2024, at 11:31 a.m., the Administrator stated that the resident broke the chain device on the window, and then tied bed sheets and hospital gowns together and climbed out the window. As a result, the resident was able to leave the facility unattended and sustained serious injuries. Information available to the Department included the following corrective actions implemented by the facility in response to Resident 1's elopement: 1. Resident 1 was sent for immediate medical attention. 2. The facility conducted an immediate head count of all residents in the facility to ensure that facility accounted for all residents. 3. The facility audited all residents' records to ensure their elopement risk assessments were current and accurately reflected resident risk. 4. All windows were checked by maintenance and were further secured (permanently affixed closed). 5. Secured doors and the alarm system also checked for proper function. 6. The facility educated all staff in the facility on the facility's elopement policy. 7. Elopement drills were completed. On November 14, 2024, a review was conducted to verify the complete implementation of the facility corrective action plan. Licensed employee LPN 1, and non-licensed employees NA 1, housekeeper E 1, and activities assistant E 2, were interviewed regarding education provided to prevent elopement. All staff interviewed confirmed that they received the training described in the facility action plan. All nursing staff were aware of the requirements for supervising residents who were at risk for elopement. All facility windows, doors, and safety devices (Wanderguards) were checked and were functioning properly. All sampled resident were being supervised by staff when needed. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 212.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the main kitchen and on two of three nursing unit pantries. (First floor and Second floor) Findings include: Observation of the kitchen on October 6, 2024, at 9:20 a.m., revealed the following: In the walk-in freezer, there was an opened box of chicken leg quarters on the bottom shelf with an accumulation of ice. There was an opened bag of hamburgers that was not dated. There were two opened packages of mixed vegetables that were not dated. On the freezer shelf there was pepperoni wrapped in plastic wrap that had a use-by date of August 7, 2024. In the walk-in refrigerator, there was an opened bag of shredded cheese that had no date and miniature butter cups on the floor underneath the shelves. In dry storage, there was a pack of taco shells removed from the original packaging that was not dated. There were five bags of hot dog buns on a shelf that had a use-by date of August 22, 2024. There was one bag of hot dog buns that had a hole with an insect inside. There were three bags of dinner rolls and one bag of hamburger rolls that were opened and were not dated. On the storage shelf there was a box of sprinkles with a use-by date of July 18, 2024. Observation of the first floor unit pantry on October 6, 2024, at 10:55 a.m., revealed that in the freezer, there was a package of sausage, egg, and cheese croissant with no name or date. There was an unknown item wrapped in aluminum foil with no name or date. Observation of the second floor unit panty on October 6, 2024, at 11:28 a.m., revealed that in the freezer, there was an unlabeled clear food storage bag of vegetables and an unknown item inside a black bag with no name or date. In the refrigerator, there was a bottle of soda that was opened with no name or date. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary. Previously cited 9/22/23. 28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a Minimum Data Set assessment for a signifcant change in condition was completed for one of 28 sampled residents. (Resident 39) Findings include: Clinical record review revealed that Resident 39 experienced a decline in his overall status and hospice services began on April 9, 2024. There was no Minimum Data Set (MDS) assessment completed to reflect the significant change in the resident's condition. In an interview on October 8, 2024, at 10:00 a.m., the Director of Nursing confirmed that a significant change in status MDS assessment was not completed upon a change in the resident's condition.

Based on review of the Resident Assessment Instrument (RAI) Users Manual, clinical record review, and staff interview, it was determined that the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one of 28 sampled residents. (Resident 119) Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing required MDS assessments (mandated assessments of a resident's abilities and care needs), revised October 2023, indicates that quarterly assessments must be no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, and the assessment was to have a completion date that was no later than the ARD plus 14 calendar days. Clinical record review revealed that Resident 119 had a quarterly MDS assessment completed on February 18, 2024. There was no evidence that any MDS assessment, including a quarterly assessment, had been completed until August 16, 2024. In an interview on October 8, 2024, at 11:21 a.m., the Director of Nursing stated that the MDS quarterly assessment had not been completed in a timely manner as required by the RAI manual.

Based on observation, clinical record review, and review of manufacturer's drug usage recommendations, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for two of four residents observed on medication administration. (Residents 28, 47) Findings include: Observations of medication administration on October 6, 2024, from 9:30 a.m. to 10:15 a.m., revealed that two medication errors occured during 30 medication administration opportunities, resulting in a medication administration error rate of 6.67%. Clinical record review revealed that Resident 28 had diagnoses that included chronic obstructive pulmonary disease. A review of physician's order dated November 15, 2022, revealed that staff was to administer one puff of a fluticasone furoate-vilanterol (Breo Ellipta) inhaler every day. A review of the manufacturer's instructions for use of the inhaler revealed that users of the inhaler were to rinse their mouth with water after inhalation to help reduce the risk of developing an infection in the mouth or throat. Observation of the medication pass on October 6, 2024, at 9:40 a.m., revealed that Resident 28 was not directed to rinse her mouth after using the inhaler. Clinical record review revealed that Resident 47 had diagnoses that included asthma and shortness of breath. A review of physician's order dated February 5, 2024, revealed that staff were to administer one puff of a fluticasone furoate (Arnuity Ellipta) inhaler. A review of the manufacturer's prescribing information revealed that users were to rinse their mouth with water after using the inhaler to help reduce the chance of getting an infection in the mouth or throat. Observation of the medication pass on October 6, 2024, at 9:50 a.m., revealed that Resident 47 was not directed to rinse her mouth after using the inhaler. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and facility documentation, and interviews with residents and staff, it was determined that the facility failed to follow physician's orders [REDACTED]. Findings include: Resident R50's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set assessment (MDS-a periodic assessment of needs) dated February 3, 2017, for Resident R50 revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15 indicating that the resident was cognitively intact. Review of Resident R50's clinical record revealed that the resident was ordered the following medications, [MEDICATION NAME] (an opioid pain medication) 10 mg every eight hours as needed for pain, APAP ([MEDICATION NAME] - a pain medication) 650 mg every six hours as needed for pain, [MEDICATION NAME] (a medication for pain) 800 mg four times a day, Bengay Patch (used for pain) to the right shoulder and bilateral (both) knees as needed. Review of the facility's Omni Inventory record revealed that [MEDICATION NAME] was a medication that was kept in the facilty's Omni emergency drug supply and was a medication that was available to any resident once an authorization number was received from the facility's contracted pharmacy. Review of the Omnicare Request for Removal of Controlled Medication from Contingency Supply form revealed that the form was utilized to request a Controlled Medication to include [MEDICATION NAME] from the facility's emergency supply. Review of Resident R50's Medication Administration Record (MAR) revealed that the resident was administered [MEDICATION NAME] 10 mg on March 27, 2017, and not again until March 29, 2017, at 11:00 a.m. Review of the Facility's Controlled Medication Utilization Record revealed that the resident's supply of [MEDICATION NAME] 10 mg's was at a zero balance on March 26, 2017. During the initial tour of the Second Floor Nursing unit on Wednesday, March 29, 2017, at 10:08 a.m. Resident R50 was observed sitting in a chair in her room. Resident R50 stated that she was in pain all day/night from Tuesday, March 28, 2017, to the present time on Wednesday, March 29, 2017. The resident stated that she has [MEDICAL CONDITION] and her pain medications had run out on Monday and she hasn't received her [MEDICATION NAME] since Monday night. An interview with Resident R50 on March 29, 2017, at 11:00 a.m. revealed that Resident R50 was laying in her bed and that she still had not received her [MEDICATION NAME] pain medication. The resident stated that, I'm in pain so bad that my body is cold and I had to ask for two blankets last night. The resident stated that she was in pain all over her body. The resident stated that she was given a Bengay patch for her knees and that the Bengay patch does not help with the other pain that she experiences, nor does Tylenol. The resident stated that the facility staff, saw that I didn't have any more ([MEDICATION NAME]) and they were supposed to order more ([MEDICATION NAME]). When surveyors asked the resident stated that no other alternatives were offered regarding the pain, besides the Bengay patch to her knees and Tylenol. The resident stated that she asked about the emergency kit (an emergency supply of medications to include [MEDICATION NAME]) and the facility staff said, no, they (facility staff) can't do it and the facility staff gave no other reason why the [MEDICATION NAME] was not available. Resident R50 stated that the pain right now its like a 12 (on a pain scale of 1-10 with 0 being no pain and 10 being excruciating pain) and nothing else relieves the pain besides the [MEDICATION NAME]. The resident stated that the pain started Monday night (March 27, 2017) and she was administered the [MEDICATION NAME] on Monday night and felt fine. The resident stated that when she woke up on Tuesday, March 28, 2017, I hurt and requested [MEDICATION NAME] and was told that the [MEDICATION NAME] was not available. The resident stated that she was not offered a warm bath or shower and no other type of diversional activities were offered to the resident to try to reduce the pain. The resident stated that what she experiences is a nasty disease . the pain never goes away Oxy ([MEDICATION NAME]) makes the pain more bearable. The facility failed to follow physician's orders [REDACTED]. Further interview with Resident R50 on March 29, 2017, at 2:00 p.m. revealed that the resident was laying in her bed. Resident R50 stated that she had received her [MEDICATION NAME] and that she was feeling much better and that she got some rest. The resident stated that she woke up on Tuesday morning, March 28, 2017, and the first thing she asked for from the facility staff was the [MEDICATION NAME] related to her [MEDICAL CONDITION]. The Resident stated that the facility staff said that she didn't have anymore of the [MEDICATION NAME]. The resident stated that she was at the Nurses station and observed a facility staff member call the doctor at the Nurses station and the resident was told that the [MEDICATION NAME] would be available on March 28, 2017, at 6:00 p.m The resident stated that at 6:00 p.m. she approached the facility staff and was told the [MEDICATION NAME] had not arrived and was told the medication may arrive on March 29, 2017, at 12:00 a.m The resident stated that the medication had not arrived on March 29, 2017, at 12:00 a.m The resident stated that she woke up on March 29, 2017, and when she woke up she stated that she was hurting and the resident stated that she requested that she needed [MEDICATION NAME] to facility staff and was told by facility staff that the [MEDICATION NAME] had not come in yet. Resident R50 stated that regarding the Bengay patch to her knees on March 28, 2017, that the patch was fine just on the knee area but its hard to explain [MEDICAL CONDITION] - it is in my muscles and Bengay is for my knees. I was cold all over from not having the [MEDICATION NAME]. I was in pain all over on the 28th. Bengay and Oxy ([MEDICATION NAME]) are two different things. Review of facility policy, Infusion Maintenance Table dated 2016, indicated that The nurse is responsible for reviewing the complete procedure for indicated therapies before performing infusion therapy. Additionally, the policy indicated that for all [MEDICAL CONDITION] (Central Venous Access Device-PICC - Peripherally Inserted Central Catheter-soft flexible catheter designed for long term staff use) must confirm the location of the tip of the catheter prior to use in the facility. Review of additional facility policy 5.2 Central Venous Access Device ([MEDICAL CONDITION]) Dressing Change, dated revised May 1, 2015, revealed that Central Vascular Access Devices ([MEDICAL CONDITION]) include: 1.1 Peripherally Inserted Central Catheters (PICC) and that 2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. The policy further indicated that the . 7. Length of external catheter is obtained upon admission. and . 8. for PICC's, upper arm circumference is obtained . Upon admission if no insertion measurement available, then weekly Review of Resident R61's clinical record revealed that the resident had been admitted to the facility on [DATE], with diagnoses, including but not limited to, endometrial (endometrium- inner lining of the uterus) cancer and [MEDICAL CONDITION] (reduced red blood cell count). Further review of the clinical record for Resident R61 revealed that upon admission the resident was noted with a PICC line present in the resident's right forearm. The physcian's admission orders [REDACTED]. Nursing progress notes dated March 27, 2017, at 8:00 p.m. revealed that upon admission the nursing staff had flushed Resident R61's PICC line. Further review of Resident R61's clinical record revealed no documentation that the resident's PICC placement had been verified at the time of admission, no documentation that the external length of the catheter had been measured and no documentation in the March Medication Administration Record (MAR) and Treatment Administration Record (TAR) that the resident's PICC line had been flushed as ordered. An interview with Employee E10, the Unit Manager on April 3, 2017, at approximately 10:15 a.m. confirmed that there was no documentation in the clinical record including the MAR and TAR for Resident R61 that the placement of the PICC line had been verified prior to use, that the external length and arm circumference had been measured weekly or that the PICC line had been flushed in March as ordered. Review of the clinical record for Resident CL3 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Further review of the clinical record and MAR and TAR for Resident CL3 revealed no documentation that the location of the PICC line had been verified prior to access or that the external catheter and arm circumference had been measured weekly, as per facility policy. Review of the clinical record for Resident R99 revealed a MDS dated [DATE], which indicated that the resident had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) dated February and March, 2017 revealed that the results of Resident R99's Accu-check was less than 110 on February 7, and 17, 2017. Further review of the MAR revealed that staff had administered the Humalog Insulin to Resident R99 on February 7 and 17, 2017, when the physician's orders [REDACTED]. Continued review of Resident R99's MAR dated March 2017 revealed that the resident's Accu-check results were less than 110 on March 5, 6, 8, 15, 19 and 30, 2017. It was further documented that staff had failed to hold Resident R99' s Humalog insulin as ordered on those dates. Additionally, it was noted on Resident R99's February and March MAR that on at least six occasions (02/11/17, 02/19/17, 03/11/17, 03/20/17, 03/24/17 and 03/25/17) the resident had refused to have her morning Accu-check completed and the nursing staff had administered her Humalog Insulin to her without verifying her blood sugar level first. An interview with Employee E10, the Unit Manager, on March 30, 2017, at 11:00 a.m. confirmed that the staff had failed to follow the physician's orders [REDACTED]. The facility failed to follow physician's orders [REDACTED]. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 05/18/15, 06/10/16, 10/21/16, 12/20/16 28 Pa. Code 211.5(f) Clinical records Previously cited 05/18/15, 06/10/16, 10/21/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 05/18/15, 06/10/16, 10/21/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/10/16, 10/21/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 05/18/15, 06/10/16, 10/21/16, 12/20/16

Based on observations and interviews with residents and facility staff, it was determined that the facility failed to adequately monitor and maintain safe and comfortable air temperatures for all residents of the facility placing all of the residents in Immediate Jeopardy due to the danger of significant adverse consequences (135 residents.) Findings Include: An initial tour of the facility on July 25, 2016, at 5:00 p.m. with Employee E6, Evening Nursing Supervisor, revealed that the first floor nurses' station was noted to be 84.0 degrees Fahrenheit (F.). The temperature in the elevator was noted to be 82.4 degrees F. The temperature obtained on the third floor low side hallway was 85.0 degrees F. at approximately 5:15 p.m. The residents' rooms were observed to have individual heating/cooling units installed just under the windows. An observation at approximately 5:30 p.m., accompanied by Employee E6, revealed the door to room [ROOM NUMBER] was noted to be 3/4 closed. Resident R9 was observed seated in a chair that faced the foot of the bed and the resident was going through the trash can. The temperature of room [ROOM NUMBER] was 91.0 degrees F. A second temperature obtained in room [ROOM NUMBER], at approximately 6:45 p.m. while accompanied by the Nursing Home Administrator (NHA), was observed to be 90.1 degrees F. The Director of Nursing stated in an interview at approximately 7:30 p.m. that Resident R9 was severely demented (loss of a sense of reality), that staff had obtained a temperature of 89.0 degrees F. in the room, that the room had been closed and the resident had been moved to another room. Resident R3 who resided in room [ROOM NUMBER] stated it was, very hot, and the temperature in that room was 82 degrees F. Resident R2 who was visiting from the second floor agreed and stated that his room was, not as hot as this. The temperature at that time was noted to be 85.8 degrees F. in the low side hallway. The temperature in room [ROOM NUMBER], a two bed room, was 85.8 degrees F. Resident R10 was observed in bed in room [ROOM NUMBER] and was nonverbal. The temperature in that room was noted to be 83.6 degrees F. Resident R7 who resided in room [ROOM NUMBER] stated that it was, warm. The temperature was noted to be 88.1 degrees F. On July 25, 2016, at approximately 6:00 p.m. the NHA returned to the facility and continued with the tour of the third floor. Between approximately 6:00 p.m. and 6:45 p.m. observations revealed the following: The air conditioner in room [ROOM NUMBER] was noted to be set at 70.0 degrees F. and the temperature obtained in the room was 83.4 degrees F. The temperature obtained in room [ROOM NUMBER] was 86.1 degrees F. The temperature obtained in room [ROOM NUMBER], was 89.0 degrees F. The temperature obtained in room [ROOM NUMBER] was 84.3 degrees F. The temperature obtained in room [ROOM NUMBER] was 82.5 degrees F. The temperature obtained in room [ROOM NUMBER] was 82.4 degrees F. Observation of resident room [ROOM NUMBER] revealed that the air conditioner was not turned on, the temperature obtained was 83.4 degrees F. The temperature obtained in room [ROOM NUMBER] was 82.9 degrees F. Observations of room [ROOM NUMBER] where Resident R4 resided, he/she stated, it is hot in here, The air conditioning unit was set at 74 degrees F. and the room temperature was 84.9 degrees F. The resident was moved to a room on the first floor at approximately 7:45 p.m. Temperatures continued to be observed on July 25, 2016, with the NHA as follows: The temperature obtained in room [ROOM NUMBER] was 86.0 degrees F. The temperature obtained in room [ROOM NUMBER] was 86.1 degrees F. Resident R11 in room [ROOM NUMBER] was noted to have a tracheostomy tube (a breathing tube). The temperature obtained in the room was noted to be 82 degrees F. The NHA stated at that time that Resident R11's family prefers the room warm. Employee E4, a member of the nursing staff stated in an interview at that time, thank you, it is hot. In room [ROOM NUMBER] Resident R5 was noted to be screaming. The air conditioning unit was noted to have little airflow. The temperature obtained was 86.3 degrees F. The NHA stated at that time that the resident was on hospice. In room [ROOM NUMBER] Resident R6 was observed with a wash cloth on her forehead. The NHA asked what the wash cloth was for and the resident stated, It's hot. At the time of the observation the temperature was 77.5 degrees F. Employee E6 stated in an interview at 6:30 p.m., it's like this all the time. The temperature obtained in room [ROOM NUMBER] was 83.6 degrees F. The air conditioning unit in room [ROOM NUMBER] was set at 66 degrees F. The temperature obtained was noted to be 76.4 degrees F. On July 25, 2016, at approximately 6:45 p.m. at the completion of the tour, the NHA stated that he was not told it was hot, that the residents turn off the units and that he could not be in the building all the time. On July 25, 2016, at 7:15 p.m. the NHA was notified that Immediate Jeopardy had been identified related to air temperatures in the resident's rooms and common areas being greater than 81 degrees F. causing the residents unnecessary discomfort and placing the health and safety of the residents in Immediate Jeopardy. The NHA was then asked to provide a corrective action plan. During an interview with Resident R8, a resident on the first floor, on July 25, 2016, at approximately 8:00 p.m. the resident stated, It had been hot for a while, not to believe what anybody said. The corrective action plan was reviewed and included that the maintenance crew would be in the building and replace as many air conditioning units as they could from other administrative areas. The residents would be offered to move to other areas. Additional air conditioning units would be ordered with overnight delivery requested and the facility would continue to monitor temperatures on the 3rd floor every 60 minutes. On July 26, 2016, at 1:55 p.m. a tour of the facility was conducted. Temperatures were obtained of the previously identified rooms that were over the required 81 degrees F. with the NHA. This tour revealed the following temperatures: The hallway on the third floor low side revealed a temperature of 86.1 degrees F. room [ROOM NUMBER] was 86.1 degrees F. room [ROOM NUMBER] was 84.7 degrees F. room [ROOM NUMBER] was 82.7 degrees F. room [ROOM NUMBER] was 82.7 degrees F. room [ROOM NUMBER] was 82.0 degrees F. room [ROOM NUMBER] was 84.0 degrees F. The activities room on the third floor was 87.9 degrees F. The NHA confirmed these temperatures during an interview on July 26, 2016, at 2:30 p.m. and further stated that the new air conditioning units had not yet arrived but should be at the facility and installed by the next day, July 27, 2016 by noon. The NHA further stated that one of the two large air conditioning units on the roof was down and it needed to be repaired. The NHA could not confirm when that would occur. The Immediate Jeopardy continued due to the rooms not being below the required 81 degrees F. On July 27, 2016, at 2:15 p.m. a tour of the facility was conducted. Temperatures were obtained of the previously identified rooms that were over the required 81 degrees F. with the NHA. Six new air conditioning units had been delivered and installed at the time of the tour. This tour revealed the following temperatures: The hallway on the third floor low side revealed a temperature of 84.1 degrees F. room [ROOM NUMBER] was 82.0 degrees F. room [ROOM NUMBER] was 84.0 degrees F. room [ROOM NUMBER] was 82.0 degrees F. The activities room on the third floor was closed off. The NHA stated that it required a new roof top unit that was ordered and would be installed within 2 weeks. The Immediate Jeopardy continued due to the rooms not being under the required 81 degrees F. On July 28, 2016, at 8:45 a.m. a tour of the facility was conducted. Observations of the outside of the facility revealed a portable generator running a portable air conditioning unit with 2 larger hoses going from the ground to the 3rd floor window. Temperatures were obtained of the previously identified rooms that were over the required 81 degrees F. with the NHA. This tour revealed the following temperatures: The hallway on the third floor low side revealed a temperature of 71.5 degrees F. room [ROOM NUMBER] was 72.5 degrees F. room [ROOM NUMBER] was 73.0 degrees F. room [ROOM NUMBER] was 72.5 degrees F. room [ROOM NUMBER] was 71.0 degrees F. room [ROOM NUMBER] was 75.0 degrees F. room [ROOM NUMBER] was 72.5 degrees F. room [ROOM NUMBER] was 78.0 degrees F. The Immediate Jeopardy for the temperatures was lifted on July 28, 2016, at 9:00 a.m. The facility failed to monitor and maintain temperatures of less than 81 degrees F. and to make timely interventions related to extreme air temperatures, placing residents at risk for health consequences from extreme temperatures placing all the residents in Immediate Jeopardy. 42 CFR 483.15(h)(6) Comfortable & Safe Temperature Levels 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/10/16, 04/13/16, 05/18/15 28 Pa. Code 201.18(b)(1) Management Previously cited 06/10/16, 04/13/16, 05/18/15 28 Pa. Code 201.18(b)(3) Management Previously cited 06/10/16, 05/18/15 28 Pa. Code 201.18(e)(1) Management Previously cited 06/10/16 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 06/10/16, 04/13/16, 05/18/15

Based on observations, review of clinical records, facility documentation, facility policies and procedures and interviews with staff, it was determined that the facility failed to provide an environment that was free of accident hazards related to a lack of supervision of residents during meal time for one out of 31 residents reviewed (Resident 56) which resulted in actual harm to one resident. The facility also failed to ensure that hot water temperatures for bathing and grooming were maintained at a safe level for 2 out of 3 units observed (Units 1 and 2) and failed to provide adequate supervision to prevent the elopement of residents from the building for one out of 31 residents reviewed (Residents R110). Findings include: Review of Resident R56's clinical record revealed an Occupational Therapy assessment dated [DATE], which indicated that Resident R56 required supervision (oversight, encouragement or cueing) with self feeding. Further review of Resident R56's clinical record revealed an admission Minimum Data Set assessment (MDS - a periodic assessment of needs) dated February 4, 2016, which indicated that for eating (section G & H), Resident R56 required supervision and set up help. Further review of Resident R56's clinical record revealed nursing progress notes dated April 18, 2016, which indicated that Resident R56 was being transferred to a local hospital for treatment and evaluation related to a burn sustained from coffee. There was no evidence of a facility investigation. Review of the hospital General history and physical examination [REDACTED]. Review of the hospital documention by a hospital burn center dated April 19, 2016, indicated that 8% of Resident R56's total body surface was affected. An interview with the Director of Nursing on June 9, 2016 at 2:50 p.m., confirmed information about the total body surface affected by the burn, as documented in the hospital record. Review of facility documentation titled, Skin Grid - Other Skin Problems, indicated that Resident R56, on April 22, 2016, returned from the hospital burn center with a wound on the right inner thigh related to sustaining a second degree burn (Involves the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.) that measured 9.0 cm (centimeters) x 9.0 cm and the wound on the left inner thigh measured 8.0 cm x 8.0 cm. Review of the treatment record for Resident R56 on June 9, 2016 at 1:30 p.m., in the presence of Employee E13, a Licensed Nurse, revealed that the last wound evaluation related to the burn for Resident R56 was on June 7, 2016, which indicated that the wound on the left inner thigh measured 7.0 cm x 7.0 cm and the wound on the right inner thigh measured 7.0 cm x 7.0 cm. Further review of the treatment record indicated that the treatment to the burn areas continued with Medihoney (an ointment for burns the to skin), which was to be applied twice a day with a clean dressing. An interview with Employee E13, a Licensed Nurse, on June 9, 2016 at 1:45 p.m., confirmed that the wounds to Resident R56 were the result of a coffee burn sustained on April 18, 2016. An interview with Employee E6, the Director of Dietary Services, on June 9, 2016 at 2:05 p.m., confirmed that hot beverage temperatures on April 18, 2016, were above the allowable temperature set by the facility. However, a random review of food temperature logs between the time period of April 17, 2016, (one day before Resident R56 sustained a burn from hot coffee) through June 4, 2016, revealed numerous blanks on the food temperature logs for coffee, which included April 18, 2016, the day the burn was obtained. During the same interview with Employee E6 on June 9, 2016 at 2:05 p.m., it was confirmed that the temperatures are not accurately taken or recorded, per the facility policy and procedure, as related to hot beverages. An interview with the Director of Nursing on June 10, 2016 at 10:15 a.m., confirmed that the facility did not provide a safe environment for Resident R56 in regards to hot coffee. The facility failed to provide adequate supervision and monitoring of hot beverages that were provided to the residents that required supervision with meals, which resulted in actual harm to Resident R56. The facility failed to complete a thorough investigation into how the burn occurred. During the initial tour of the First Floor Nursing Unit on June 7, 2016 at 6:40 a.m., an interview with Employee E3, the Director of Maintenance, revealed that the First Floor Nursing Unit staff did not have thermometers to obtain water temperatures, and the thermometer that Employee E3 was using, was not properly calibrated. The following temperatures were recorded by the use of the surveyor's thermometer in the presence of Employee E3: 117 degrees Fahrenheit from the sink and shower in the shower room 117 degrees Fahrenheit from the shower in the individual shower room During the initial tour of the facility on June 7, 2016 at approximately 6:45 a.m., revealed that bathroom sinks in resident rooms 201, 202, 204 and 213 on the Second Floor Nursing Unit were registering 118, 118, 117 and 118 degrees Fahrenheit, respectively. Observation of the Second Floor Shower Room revealed a shower water temperature of 118 degrees Fahrenheit and the shower room sink registered at 119.8 degrees Fahrenheit. The facility thermometer in the shower room stall registered the water temperature at 120 degrees Fahrenheit. On June 7, 2016 at 7:35 a.m., Employee E3 was alerted to come to the Second Floor Nursing Unit to evaluate the water temperatures with the facility's thermometer. Observation of temperatures taken by Employee E3 on June 7, 2016 at 7:35 a.m., with a facility thermometer, revealed that the shower room temperature registered at 116.1 degrees Fahrenheit and the facility's thermometer in the shower stall registered at 120 degrees Fahrenheit. Interview with Employee E3 on June 7, 2016 at 7:40 a.m., and when asked what should the facility water temperatures register, Employee E3 stated that water temperatures should register between 110 and 120 degrees Fahrenheit. It was observed while obtaining temperature readings with the facility staff, that Employee E3 was using a laser beam thermometer. Water was not identified as a temperature target. Documentation provided by the Nursing Home Administrator also revealed a TELS (Senior Living Building Management System Procedure) documentation that revealed to test water temperatures to ensure that patient room water temperatures were to be 120 degrees Fahrenheit (or as specified by state requirements). There was no facility policy provided regarding acceptable hot water temperatures that revealed 110 degrees Fahrenheit or below were acceptable temperatures for residents during bathing and grooming. After a policy was requested, a policy was received and dated June 7, 2016. Observation of the boiler room with Employee E3 on June 7, 2016 at 8:00 a.m., revealed three hot water heaters. Interview with Employee E3 at the time of this observation, revealed that one of the three hot water heaters was out of service for approximately two weeks, and in order to maintain adequate water temperature to accommodate the Third Floor Nursing Unit, the remaining two hot water heaters were adjusted so the water was leaving the tanks at a higher temperature. Further observation of the two functional hot water heaters revealed a dial on a metal plate, with temperature numbers indicated on the metal plate, which Employee E3 manually turned to demonstrate how the water temperature was increased or lowered. Observation of the industrial glass thermometers attached to each of the two functioning hot water heaters revealed the red liquid in both thermometers was dissipated and dispersed throughout the glass, indicating the thermometers were not operational. Further interview with Employee E3 revealed that the facility's process was if the nursing staff reported the water was too hot or too cold, Employee E3 would manually adjust the dial on each of the two hot water tanks, and then have another maintenance employee take a water temperature with a thermometer on the nursing floors to ensure the water temperature was adequate. Employee E3 confirmed that the facility did not calibrate their own thermometers to assess accuracy to ensure safe water temperature, and it was confirmed that both thermometers were broken since Employee E3's date of hire with the facility, and there was no accurate way to determine the exact water temperature when leaving each of the two functioning water heaters. Review of the personnel file for Employee E3 revealed that the employee's date of hire was December 14, 2015. Observation of the three hot water heaters with the Nursing Home Administrator (NHA) on June 7, 2016 at 12:30 p.m., confirmed both thermometers on each of the two functioning hot water heaters were inoperable. An interview at the time of the observation with the NHA revealed that a certified plumber was called into the facility to evaluate the hot water heating system. Documentation was provided on June 8, 2016, from a TELS Service Request that revealed a new thermocouple would need to be ordered. Observation on the second day of the survey, June 8, 2016, at 9:12 a.m., in the presence of Employee E3, Director of Maintance, and the NHA revealed the following hot water temperatures were recorded using the facilities thermometer: 111.6 degrees Fahrenheit in the sink of the first floor handicap bathroom. 113.2 degrees Fahrenheit in the sink of the first floor visitor/staff bathroom. 112 degrees Fahrenheit in the sink of resident room 109 During these observations, Employee E3 indicated that the hot water temperatures exceeded the facility's guidelines in regards to hot water. At the end of the third observation, Employee E3 was directed by the NHA to turn down the dials on the hot water tanks. Review of the facility policy, Elopement Prevention and Management Program, dated as revised October 2008, defined adequate supervision as the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment. The policy further revealed that the facility would assess the security of potential internal environmental hazards including, but not limited to, exit doors, and would identify and manage potential external environmental hazards including, but not limited to, busy streets. Review of the clinical record for Resident R110 revealed a quarterly MDS dated [DATE], indicated the resident had [DIAGNOSES REDACTED]. The MDS revealed that the resident had a BIMS (Brief Interview for Mental Status-screening assessment to aid in determining cognitive impairment) score of 13 (score of 13 to 15 means the resident is cognitively intact) and the resident required supervision (oversight, encouragement or cueing) for independent ambulation (walking) in the resident's room, in the corridor, and on or off the unit. Review of the recapitulation (summary) of the physician's orders dated July 2015, revealed Resident R110 required nursing facility services. Review of the information dated July 31, 2015 submitted by the facility revealed that Resident R110 had an additional [DIAGNOSES REDACTED]. The information revealed that Resident R110 was found by an off-duty employee at 1:32 p.m. on July 31, 2015, approximately 2.5 miles away from the facility. Review of facility investigation documentation dated July 31, 2015, revealed that: Resident R110 was observed exiting the building as per video footage at 10:32 a.m.; was reported to be missing by a charge nurse at 12:00 p.m.; the unit manager was informed of the resident's absence between 12:30 p.m. to 12:45 p.m.; a search for the resident was initiated at 12:45 p.m.; the police were contacted at 12:55 p.m.; the resident was found at 1:35 p.m., and was returned to the facility at 1:45 p.m. on July 31, 2015. Further review of the facility investigation documentation revealed that the resident was missing approximately 90 minutes before the facility staff knew the resident was not in the building and had initiated a search. Review of an employee witness statement from Employee E8, the former Receptionist, revealed at the time Resident R110 exited the building on July 31, 2015, the employee was in the copier room making photocopies (away from the reception desk/front entrance to the building). Review of another employee witness statement from Employee E9, the former Risk Manager, dated July 31, 2015, revealed that upon interview with Resident R110 about the elopement, the resident stated, Im (sic) not going anywhere mam (sic), I got lost. I was hypnotized that's (sic) what I'm being treated here for. Interview with the NHA on June 10, 2016 at approximately 1:30 p.m., revealed that during the facility's investigation into the circumstances around Resident R110's elopement from the facility on July 31, 2015, the investigation determined that the resident exited through the main entrance while the receptionist was in an adjacent room making photocopies. Further interview with the NHA confirmed that Resident R110 eloped from the facility without the staff knowledge and was missing for approximately 90 minutes before the staff realized the resident was missing. The facility failed to ensure hot water temperatures were maintained at safe levels, and failed to appropriately supervise residents to prevent elopements, resulting in actual harm to Resident R56. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 05/18/15 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/13/16, 05/18/15, 06/17/14 28 Pa. Code 201.18(b)(1) Management Previously cited 04/13/16, 05/18/15, 06/17/14 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 205.37(e) Equipment for bathrooms 28 Pa. Code 211.10(d) Resident care policies Previously cited 05/18/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/18/15, 06/17/14

Based on the review of a closed clinical record, facility documentation and interview with staff, it was determined that the facility failed to consistently monitor, assess and develop interventions to address the psychosocial needs of one resident, resulting in actual harm to that resident (Resident CL1). Findings include: Review of facility policy "Suicide Prevention" revised July 2008, stated that staff, "monitor residents closely that display the following warning signs: change in eating or sleeping habits, apathy about previous interests or activities, sudden disinterest in surroundings, withdrawal from friends, family or social activities, preoccupation with death, body and physical complaints-not necessarily verbalized, making final arrangements, will, funeral plans, insurance changes, giving away prized possessions, previous suicide attempts and extreme fatigue." Review of Resident CL1's closed clinical record revealed that the resident was [AGE] years old and had been admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. Review of Resident CL1's Minimum Data Set Assessment (MDS-periodic assessment of needs), dated February 15, 2013, revealed that the resident, was free of cognitive impairment, did not ambulate or transfer and noted that the resident had suicide ideation, anxiety disorder and depression. physician's orders [REDACTED]. Employee E5, a Licensed Nurse, stated in an interview on March 20, 2013, at approximately 9:00 a.m., that the resident had been very withdrawn, would not come out of his room, was "upset about things like his Foley catheter (tube inserted into bladder to drain urine), that it might get blocked." Employee E4, a member of the nursing staff, stated that, "The resident always stayed in his room but did not know why". The Director of Nursing stated in an interview on March 20, 2013, at approximately 12:30 p.m., that it was decided to take the resident off of every 30 minute checks at the last care conference because, "he had no more symptoms, like depression" and that Resident CL1 did not want to get out of bed, that he liked staying in bed. The Director of Social Services stated in an interview on March 20, 2013, at approximately 1:30 p.m., that the resident was never out of bed and that she did not know the reason the resident stayed in bed, the resident did not want to get out of bed, that he just liked staying in bed. Employee E7, a Registered Nurse, stated in an interview on March 20, 2013, at approximately 12:45 p.m., that the resident had an electric wheelchair, was very controlling and did not know why he stayed in bed. Employee E2, Registered Nurse Manager, stated in an interview on March 20, 2013, at approximately 1:45 p.m., that, "The resident did not get out of bed, that he did not get out of bed to shower and did not know why he did not get out of bed, that he was his own person". A review of nursing notes January 2013 through March 5, 2013, revealed that the resident had refused meals, wound treatments and turning and repositioning in the bed. Review of physician progress notes [REDACTED]. Entries on February 15, 2013 and March 8, 2013, stated that, "the resident remains fixated on his Foley catheter (tube inserted into the bladder to drain urine)". The March 2013, note also stated, "await urology consult due to frequent bleeding (although suspect Foley trauma, self inflicted)". Psychiatric consultation notes dated January 2, January 28, and February 25, 2013, reported that the resident was alert and pleasant, good or decent mood, denied depressive mood, continue current medication and supportive visits. Facility documentation dated March 14, 2013, stated that nursing staff doing morning rounds at approximately 7:20 a.m. had entered the resident's room and noted he was pale, diaphoretic (profuse sweating), had a bounding (forceful) pulse of 90 beats per minute, "with a safety pin impaled in the chest along with a paperclip that had been straightened out and was pulled out of the residents chest when the shirt was pulled up." He had also cut open his right upper arm. 911 was alerted and the resident was transferred to the emergency room . Hospital documentation noted that Resident CL1's vital signs upon arrival at the emergency room , at approximately 8:20 a.m., were noted to be a heart rate of 138 beats per minute (60-100 normal), respirations 41 per minute (elevated) and an very elevated blood pressure of 176/112 mmHg (millimeters of mercury). A chest X-ray completed in the emergency room noted evidence of a safety pin entering the left lower chest with extensive consolidation (firmness) of the left lower lobe suggesting [MEDICAL CONDITION] contusion/hemorrhage (bruising and bleeding), a moderate left pneumothorax (abnormal collection of air in the space around the lungs) for which a chest tube was inserted. Further, the chest X-ray showed penetration approximately 10 centimeters (approximately 4 inches) and a foreign body once removed measured 11 (approximately 4 1/2 inches) centimeters. Documentation from the emergency room noted final Diagnosis: [REDACTED]. A psychiatric consultation completed at the hospital on March 14, 2013, reported that the resident had stated he had, "thought about it for several days, wanted to die" and noted a [DIAGNOSES REDACTED]. The facility failed to provide ongoing monitoring, assessment and development of interventions to address depression and suicidal thoughts in this resident. In addition, the facility failed to plan any increase in supervision despite his behaviors of continued self imposed isolation, noncompliance with care and preoccupation with the indwelling catheter as indicated in the facility policy. Employee E7, stated in an interview on March 20, 2013, that, "he must have been plotting this for a long time". This failure to assess, monitor and develop appropriate interventions resulted in actual harm. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 06/21/12. 28 Pa. Code 201.18(b)(1) Management. Previously cited 06/21/12. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 06/21/12.