Every finding on record at Fair Acres Geriatric Center

Based on review of facility policy, clinical record, facility documentation, and staff interview, it was determined the facility failed to ensure that residents were free from abuse resulting in actual harm of continued nonconsensual sexual contact for one of five sampled residents (Resident 1). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance. Findings include:Review of facility policy, Prohibition of Abuse, reviewed December 2024, revealed that residents, families, and staff are provided with information on how and to whom they may report concerns, and incidents. Any individual observing an incident of abuse, neglect, or misappropriation, or suspecting abuse, neglect, or misappropriation has a responsibility to intervene immediately so that safety of the resident can be ensured. Once the resident is safe, the individual who witnessed the incident of abuse or suspected abuse will immediately report the incident to a Licensed Nurse. Review of Resident 1's significant change MDS (Minimum Data Set - periodic assessment of resident needs) of June 9, 2026, included diagnoses of but not limited to schizophrenia (serious mental health condition that affects how people think, feel, and behave, often leading to hallucinations, delusions, and disorganized thinking). The assessment also revealed that the resident had a BIMS (brief interview for mental status) score of 9, indicating moderate cognitive impairment. Review of Resident 2's annual MDS of June 9, 2026, revealed the resident had a BIMS score of 15, indicating normal cognitive function. Review of Nurse Aide, Employee E4's written statement obtained on June 29, 2026, revealed on June 25, 2026, Resident 1 was heard saying Resident 2 likes to kiss his body. Employee E4 questioned Resident 1 on June 26, 2026, if Resident 2 ever asked Resident 1 to do things he does not want to do and Resident 1 replied yes, he jerks me off and indicated this act happened often. Employee E4 also stated that he/she was not sure what to do and did not feel comfortable talking to anyone but the unit manager, Employee E5. Review of unit manager, Employee E5's written statement obtained on June 29, 2026, revealed; nurse aide, Employee E4 reported the allegation of non-consensual sexual contact which Resident 1 made regarding Resident 2 four days after the initial allegation. Review of Resident 1's verbal statement obtained on June 29, 2026, revealed, [Resident 2] jerks me off, he kisses all over my body, he likes to jerk me off, he grabbed and kissed my ass, I don't like it. Resident 1 further revealed he did not give consent and was unclear of the timeline but stated that it (sexual contact) happened often. Review of Resident 2's verbal statement obtained on June 29, 2026, revealed, I have kissed Resident 1 all over his body, from top to bottom. I touched his private. Resident 2 indicated that two nights ago was the last time (June 27, 2026) sexual contact occurred. Review of hospital emergency department note of June 29, 2026, revealed Resident 1 was assessed for sexual assault. Assessment revealed no injury to genitalia. Resident was discharged on antibiotic for STD (sexual transmitted disease) prophylaxis (treatment to prevent a disease from occurring). Review of information submitted by the facility to the Department on June 29, 2026 at 1 a.m. revealed, [Resident 1], long-term resident of [facility]. He is alert to self, place at times. He has a BIMS of 9. [Resident 1] made the following statement to his aide on 6/25 He likes to kiss my body (referring to his roommate, [Resident 2]). On further questioning, resident reported manual manipulation of his genitals, kissing/licking of his body & anal penetration. Further review of the documentation revealed, CNA [name removed] reported allegation to this writer today, 6/29/26, at 0840. Immediately separated residents & investigation initiated. Review of the facility submitted documentation including PB-22 (Report of Investigation of Alleged Abuse, Neglect, or Misappropriation of Property) initiated June 29, 2026, revealed the facility substantiated the sexual abuse as there was a delay in reporting by nurse aide, Employee E4 of Resident 1's allegation of sexual abuse against Resident 2 (roommate). Review of Employee E4's 2025 mandatory in-service training revealed nurse aide, Employee E4 had received abuse prevention training on August 18, 2025. Based on the above findings, Immediate Jeopardy to the safety of the residents was identified to the Director of Nursing (DON) on July 2, 2026, at 1:25 p.m. for failure to keep a resident free from abuse due to nurse aide's delay in reporting which resulted in actual harm of Resident 1 who was subjected to further nonconsensual sexual contact of Resident 2. The DON was provided with the Immediate Jeopardy template, and an immediate action plan was requested. The facility identified the jeopardy at the time the incident was reported on June 29, 2026, and implemented the following corrective action plan:The residents were immediately separated and 1:1 supervision was implemented.The alleged victim was ordered by the physician to be transferred to the emergency room for further evaluation.Park police (campus police unit) were notified.Employee E4 was placed on paid administrative leave.All residents and previous roommate of alleged perpetrator were interviewed regarding nonconsensual sexually contact or abuse by another resident.Applicable staff were interviewed regarding the allegation of sexual assault/abuse.Prohibition of Abuse policy and procedure was reviewed. All employees were immediately educated on the policy and procedure.The Director of Nursing or designee will audit resident concerns to ensure allegations of sexual assault/abuse are reported immediately to appropriate authorities. Audits will occur weekly x2 and then monthly x2. If trends are identified, corrective action, including a root cause analysis will be reported to the QA (quality assurance) committee. On July 2, 2026, a review was conducted to verify the complete implementation of the facility's corrective action plan. Ten staff were interviewed and confirmed they received the training described in the facility's action plan. All nursing staff were aware of abuse prevention and reporting. All staff training was completed by June 29, 2026. Resident 1 was observed in a room on a different nursing unit from Resident 2 with both on 1:1 supervision. The Immediate Jeopardy existed from June 25, 2026, until June 29, 2026. Verification of all elements of the action plan was completed on July 2, 2026, at 3:00 p.m., and Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on interviews, clinical record review, review of facility policy and the review of facility documentation, it was determined the facility failed to ensure one resident was free from financial exploitation through misappropriation of resident funds for one out of 40 residents reviewed, resulting in actual harm to Resident R186 who lost thousands of dollars. Findings include:Review of the facility policy titled Prohibition of Abuse, approved January 2024, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness, including failure to communicate regarding the plan of care.The policy further defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.Review of Resident R186's clinical record revealed the diagnoses of Vascular Dementia, unspecified severity, with agitation (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain) with a start date of September 12, 2024, altered mental status, and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident R186's Minimum Data Set (federally mandated, standardized, comprehensive clinical assessment tool) dated January 8, 2025, revealed Resident R186 possessed a Brief Interview for Mental Status (BIMS) of 8 out of 15 indicating moderated cognitive impairment.Review of documentation submitted on December 17, 2025, to the State Survey Agency revealed the facility became aware of an allegation of misappropriation of funds when it was contacted by the Department (licensing entity for skilled nursing facilities) on December 17, 2025. Further review of facility submitted information revealed the Durable Power of Attorney (DPOA) for Resident R186 opened a brokerage account at a nearby banking institution to manage Resident R186's funds. The banking institution became concerned after conducting an internal audit and identifying the following transactions:On October 23, 2025, a deposit of $131,298.56 was received from Empower.On October 28, 2025, a withdrawal of $44,160.00 was made.On October 28, 2025, an authorized purchase of $3,332.00 was made to (local company)On October 28, 2025, several ATM withdrawals of $800.00 each were made.On November 5, 2025, four Venmo transactions of $450.00 each were completed to (individual confirmed as not resident).The account balance as of December 12, 2025, was $53,687.05.Further review of facility submitted information revealed, that on 11/10/25 a new brokerage account was opened but was flagged by [NAME] Fargo with concerns related to capacity of (Resident R186) to execute POA from 1/10/25. On 11/21/25 POA documents were submitted to designate (resident friend) as POA for (Resident R186)'s newly opened brokerage IRA along with a letter of incapacitation dated 9/15/25. Per the letter (Resident R186) has been a resident at Fair Acers since 5/26/22. It is not clear if date of incapacitation is May 2022 or [DATE]. Fair Acres has no such letter on file. (Resident) is sole owner on account ending [****] and (resident's friend) is listed as POA.Review of the facility's investigation dated December 17, 2025, revealed the facility referred the matter to the local police department for investigation, but current status is unknown. Review of Resident R186's Pennsylvania Durable Power of Attorney form revealed it was signed by Resident R186 on January 10, 2025, and witnessed by facility staff, Licensed Employee E2 and Unlicensed Employee E4.During an interview conducted with Resident R186 on February 12, 2026, at approximately 10:58 a.m., Resident R186 stated he/she was unaware their Durable Power of Attorney intended to transfer funds to another banking institution. Resident R186 reported knowing his/her Durable Power of Attorney for over 50 years and described him/her as a family friend.During an interview conducted with Licensed Employee E2 on February 13, 2026, at approximately 9:30 a.m., Licensed Employee E2 confirmed Resident R186 signed the POA paperwork on January 10, 2025. Licensed Employee E2 further indicated Resident R186's Brief Interview for Mental Status (BIMS) score at the time the form was signed was 8 out of 15, indicating moderate cognitive impairment. Licensed Employee E2 confirmed Resident R186 did not possess decision-making capacity at that time and, therefore, should not have signed the Pennsylvania Durable Power of Attorney form.During an interview conducted with Unlicensed Employee E4 on February 13, 2026, at approximately 1:27 p.m., Unlicensed Employee E4 reported being asked to witness Resident R186 signing the Pennsylvania Durable Power of Attorney form. Unlicensed Employee E4 stated he/she does not participate in evaluating residents to determine decision-making capacity.During a phone interview conducted with the Social Services Director (SSD) on February 13, 2026, at approximately 1:45 p.m., the SSD confirmed Resident R186 had a BIMS score of 8 and lacked decision-making capacity to sign the Pennsylvania Durable Power of Attorney form. The SSD further reported that if Licensed Employee E2 had reviewed Resident R186's BIMS score prior to the signing, the resident would not have been permitted to designate a Durable Power of Attorney and would have retained control of their funds.Review of Resident R186's clinical medical record revealed in December 2025, the POA was removed and Resident R186 was appointed a legal guardian from a nearby law firm.Resident R186's guardian was unable to be reached by phone.During an interview conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on February 13, 2026, at approximately 2:15 p.m., the investigation was reviewed. The NHA confirmed Resident R186 should not have signed the Pennsylvania Durable Power of Attorney form.The facility failed to protect Resident R186 from financial exploitation through misappropriation of resident funds resulting in actual harm to Resident R186. Resident R186's suffered financial loss when approximately $77, 611.51 was withdrawn from the banking account after Resident R186's signed power of attorney to a friend, while diagnosed with vascular dementia and cognitively impaired as demonstrated with a BIMS of 8.28 Pa. Code 201.18(b)(1)(2)(e)(1) Management28 Pa. Code 201.29 (a)(c) Resident rights28 Pa Code 211.12 (c) Nursing services

Based on clinical record review and interview with staff, it was determined that the facility failed to inform the resident or resident's representative in advance of treatment risks and benefits, options, and alternatives for one of five residents reviewed (Resident 332).Findings include: Review of Resident 332's clinical record revealed an order on December 12, 2025, for risperidone (antipsychotic medication) 0.25 mg (milligrams) at bedtime for vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), severe, with agitation. An order was received on December 22, 2025, for lorazepam (anti-anxiety medication) 0.5 mg one tablet at bedtime for encounter for palliative care (medical care that relieves pain, symptoms and stress caused by serious illness). An additional order was received on December 30, 2025, for lorazepam 0.5 mg every six hours prn (as needed) for vascular dementia, severe, with agitation. Further review of the clinical record revealed no evidence that the resident or resident's representative was notified in advance of the risk, benefits, options, and alternatives of the use of risperidone or lorazepam. Interview with the Director of Nursing on February 13, 2026, at 1:00 p.m. confirmed that the resident or resident's representative was not made aware of the risks, benefits, options, and alternatives prior to the use of risperidone and lorazepam. 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 resident assessments accurately reflect the residents' status for one of 35 residents reviewed. (Resident 12).Findings include:Review of Resident 12's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 31, 2025, revealed under section P0100 - Physical Restraints, that the resident was marked as using restraints less than daily.Review of Resident 12's physician's orders revealed that the resident did not have an order for any restraints.Interview with the licensed staff, Employee E6, on February 13, 2026, at 1:40 p.m. confirmed that the resident's MDS assessment was marked incorrectly.483.20 Accuracy of Assessments28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan to address the use of psychotropic medications (any drug that affects behavior, mood, thoughts, or perception, which includes medications for anxiety and antipsychotics) for one of 35 residents reviewed (Resident 332).Findings include: Review of Resident 332's clinical record revealed an order on December 12, 2025, for risperidone (antipsychotic medication) 0.25 mg (milligrams) at bedtime for vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), severe, with agitation. An order was received on December 22, 2025, for lorazepam (anti-anxiety medication) 0.5 mg one tablet at bedtime for encounter for palliative care (medical care that relieves pain, symptoms and stress caused by serious illness). An additional order was received on December 30, 2025, for lorazepam 0.5 mg every six hours prn (as needed) for vascular dementia, severe, with agitation.Further review of the clinical record revealed that there was no care plan to address the use of the psychotropic medications risperidone and lorazepam.Interviews with licensed staff, Employee E7, on February 13, 2026, at 11:04 a.m. and licensed staff, Employee E8, on February 13, 2026, at 11:22 a.m. confirmed that there was no care plan addressing the use of the psychotropic medications.28 Pa. Code 201.18(b)(1) Management

Based upon clinical record review it was determined that the facility failed to follow physician orders regarding fluid restriction for one of thirty-five residents reviewed (Resident 388).Findings include:Review of Resident 388's diagnosis list revealed diagnoses including respiratory failure.Review of Resident 388s physician orders revealed an order for fluid restriction 1800 milliliters (ml) daily - Nursing 7-3 - 300 ml; 3-11 - 180 ml; 11-7 - 120 ml; Dietary - Breakfast - 480 ml; Lunch - 360 ml; Dinner - 380 ml.Further review of Resident 388's clinical record failed to reveal evidence that Resident 388's fluid restriction was being monitored on a daily basis to ensure Resident 388 did not exceed the 1800 ml per day. Interview with the Director of Nursing on February 13, 2026, at 1:00 p.m. confirmed that the facility was not monitoring Resident 388's daily fluid consumption. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of one resident reviewed for nutrition (Resident 348).Findings include:Review of facility policy, Fundamental Nursing Care: - Obtaining Resident Height and Weight, dated March 2023, revealed that A weight gain or loss of 4% within one month requires a follow- up.Weight gain or loss of 4% requires a re-weigh of the resident . Review of Resident 348's clinical record revealed recorded weights of 91.8 pounds on August 29, 2025; 90.8 pounds on September 9, 2025; 84.5 pounds on October 31, 2025 (loss of 6.3pounds or -6.94% in one month). There was no evidence of a re-weigh conducted to address the weight loss.Further review of Resident 348's clinical record failed to reveal recommendations to address the weight loss. Interview with Employee E5 on February 13, 2025, at 10:30 a.m. confirmed that further dietary interventions should have been implemented to address Resident 348's weight loss.28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing Service

Based on review of clinical records, facility documentation, resident council minutes, facility policies, and interviews with residents and staff, it was determined that the facility failed to demonstrate evidence that residents are educated on filing grievances and that grievances forms/ boxes were available and accessible for residents on nursing units for five of 5 floors reviewed (Building 8, Floor 3, 4, 5, 6 and 10).Review of facility policy titled Code of Corporate Compliance revealed that Residents are treated in a manner that preserves dignity, autonomy, self-esteem, civil rights and involvement in their own care. Fair Acres Geriatric Center employees receive training about resident rights to clearly understand their role in supporting them. Observation of Building 8, 3rd floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E3, Licensed Practical Nurse, on July 18, 2025 at 10:45 am revealed that there are no grievance forms available and if resident would like to make a complaint they call the phone number posted on the wall. Interview with Employee E4, Unit Secretary, on July 18, 2025 at 10:48am revealed there were no grievance forms available behind the nursing station. Observation of Building 8, 4th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E5, Unit Manager/ Licensed Practical Nurse, on July 18, 2025 at 10:54am revealed that if residents would like to place a grievance we could give them a blank envelope and they could place it in the facility internal mailbox. Confirmed no grievance forms/ drop box available on unit. Observation of Building 8, 5th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit. Interview with Employee E7, Licensed Practical Nurse, on July 18, 2025 at 11:05am confirmed no grievance forms/ drop box available on unit. Employee stated If resident has a complaint or concern they would report it to the unit manager. Observation of Building 8, 6th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit.Interview with Employee E8, Registered Nurse, confirmed no grievance forms or boxes available and accessible for residents on nursing unit.Observation of Building 8, 10th floor, revealed no grievance forms or boxes available and accessible for residents on nursing unit.Interview with Employee E12, Licensed Practical Nurse, confirmed no grievance forms or boxes available and accessible for residents on nursing unit.Observation of Building 8, main lobby, revealed complaint box on receptionist desk. Interview with Employee E13, Utility aide, confirmed no grievance forms available. Residents would just write on a plain piece of paper and put it in the box if they have a complaint. Interview with Employee E1, Director of Nursing confirmed facility has no grievance policy. If residents want to file a grievance then they would either write on a plain piece of paper and drop it in the main lobby complaint box or would call the phone number listed on the Nursing Unit. Review of Resident council minutes dated May 14, 2025 and June 11, 2025 revealed no discussions/ education on the topic of filing a grievance. 28 Pa. Code 201.29(a) Resident rights

Based upon facility policy review, clinical record review, and interviews, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of five residents reviewed (Resident 134). Findings include: Review of facility records revealed a policy titled [NAME] Rx Policy and Procedures Manual, Subject: Medication Regimen Review, dated June 1, 2023, documenting resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the pharmacy's consulting records and reported to the resident's attending physician, the facility's Medical Director and Director of Nursing as appropriate. The physician will accept and document that the irregularity has been reviewed. The attending physician should document his or her rationale in accordance with federal and state regulations. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue D-Mannose (a dietary supplement used to treat or prevent urinary tract infections), as the resident continues to have urinary tract infections (UTIs). Use should also be avoided in patients with diabetes (disease that affects how the body uses blood sugar) due to effects on blood sugar. Review of R134's clinical record failed to reveal that the above recommendation was addressed by the physician. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Melatonin (a hormone that regulates day and night cycles) for insomnia, as the resident is also ordered Trazadone (an antidepressant) for insomnia. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue Glucosamine-Chondroitin (supplement for joint pain) for osteoarthritis, as pain has been uncontrolled with use of this supplement, and it is likely not contributing to pain relief. Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to discontinue PreserVision AREDS 2 (a multivitamin), as resident is already ordered a daily multivitamin with minerals (Centrum Silver Women 50+). Review of R134's Consultation Report for the Medication Regimen Review completed on October 6, 2024, revealed a recommendation to change timing of Omeprazole (a stomach acid reducer), to 30-60- minutes prior to breakfast to optimize effectiveness. Review of R134's clinical record failed to reveal that the above recommendations were addressed by the physician. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 24, 2025, at 1:30 p.m. when the above information was presented, the DON confirmed there was no documented evidence of a response by the physician to the recommendations made by the consulting pharmacist. 483.45 Drug Regimen Review, Report Irregular, Act on 28 Pa. Code 211.5(f) Clinical records

Based on facility policy, clinical record, and facility documentation reviews, it was determined that the facility failed to provide preventative wound treatments which resulted in actual harm to Resident 111 when the venous ulcer opened after Licensed Nurse Employees E5 and E6 failed to administer wound treatments for four days for one of 35 residents reviewed (Resident 111). Findings include: Review of facility policy titles, Prohibition of Abuse, last revised August 2019, revealed neglect is defined as failure to provide goods and services necessary to avoid physical harm. Review of Resident 111's clinical record revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 111's wound notes revealed a March 3, 2021 wound nursing note regarding the right shin venous ulcer which indicated; this area has re-opened chronically, but with current treatment the re-opening is much less frequent. Further review of Resident 111's wound notes revealed a note regarding the resident's right shin venous ulcer from the wound nurse dated March 9, 2021, which indicated, Injury has resolved, but this does re-open at times. Will recommend current treatment plan of [MEDICATION(S)] [(antibiotic cream]) and hydrocortisone and ABD [(absorbent dressing)] pad continue every Monday, Wednesday, and Friday, with moisture barrier ointment and ABD pad every Sat, Sun, Tues, Thursday. Review of Resident 111's March 2021 Treatment Administration Record (TAR) revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 111's March 2021 TAR revealed the treatment was signed out by License Nurse Employee E6 on March 17, 2021 and March 19, 2021. Further review of Resident 111's March 2021 TAR revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 111's March 2021 TAR revealed the treatment was signed as administered by Licensed Nurse Employee E5 on March 16, 2021 and Licensed Nurse Employee E6 on March 18, 2021. Review of Resident 111's progress notes revealed a late entry nursing note from March 20, 2021, which stated, Nurse caring for resident called to resident room to show this writer dressing to right shin dated 3/15/21. A follow up late entry nurse's note from March 20, 2021, revealed During treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation revealed that on March 20, 2021, when Licensed Nurse Employee E9 went to do the treatment to Resident 111's right shin, it was discovered dressing in place was dated March 15, 2021. At that time, the area to Resident 111's right shin was discovered to have reopened; measuring 8.0 centimeters (cm) x 5.0 cm x 0.1 cm. Review of facility documentation revealed a witness statement from Licensed Nurse Employee E9 on March 20, 2021, which stated, This nurse went to do a treatment on [Resident 111's right] shin. Upon removing skin sleeve, a dressing dated 3/15/21 7-3 was observed on resident [right] shin. [Licensed Nurse Employee E10] on unit and notified immediately. This nurse proceeded to change the dressing as per order. Further review of facility documentation revealed a witness statement from Licensed Nurse Employee E10 on March 20, 2021, which stated, At [2:00 p.m.] called to room by [Licensed Nurse Employee E9] who was assigned to [Resident 111.] [Employee E9 ] asked me to witness her changing [Resident 111's right] shin dressing as per MD order, both myself and [Employee E9] noted the date on the dressing was 3/15/21. The dressing order was for a daily treatment change .Area had been previously resolved and was noted to show deterioration at dressing site. Area was re-measured, cleansed, documented, new dressing applied, and investigation initiated .Upon investigation it was found that [Licensed Nurses Employees E5 and E6] had signed out treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Both nurses suspended pending investigation as per protocol. Review of witness statement from Licensed Nurse Employee E5 on March 22, 2021, revealed: I do not remember doing a [treatment] on [Resident 111] on 3/16/21. I know that I had treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of witness statement from Licensed Nurse Employee E6 on March 22, 2021, revealed: I do not have any knowledge of [Resident 111's] treatment not done. Review of Resident 111's wound notes revealed a note regarding the resident's right shin venous ulcer on March 22, 2021, which stated, This is a reopening of a chronic area. Preventative treatments in place which have been effective in treating and preventing reopening. Review of the facility's investigation of neglect revealed both investigations for Licensed Nurses Employee E5 and E6 were substantiated for neglect for the failure to do Resident 111's treatment to the right shin. Employee E5 was given a final written warning and educated on abuse and wound care. Employee E6 was terminated. Attempts to interview Resident 111 throughout full health survey dates were unsuccessful due to resident refusal to answer surveyor questions. The above findings were discussed and confirmed with the Nursing Home Administrator and Director of Nursing on March 24, 2022 at approximately 1:50 p.m. The facility failed to ensure Resident 111 was free from neglect when Licensed Nurses Employees E5 and E6 failed to treat Resident 111's venous ulcer for four days which resulted in the wound reopening. 483.13 Resident behavior and facility practices 10-01-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 6/18/2020 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services Previously cited 7/10/2020 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 3/11/2021, 7/10/2020, 6/18/2020

Based on observation, clinical record review, and staff interviews it was determined that the facility failed to ensure that infection prevention and control was maintained during [CONDITION(S)] care for one of two residents reviewed (Resident 197). Findings include: Review of Resident 197's clinical records revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] care observation was conducted on March 24, 2022, at 10:22 a.m., with Licensed nurse Employee E7, assisted by Registered nurse, Employee E8. Observation revealed the following: Employee E7 opened the sterile package of the [CONDITION(S)] kit, picked up and assembled the sterile gauze, cotton tip, and brush with bare hands, and assembled it on top of a sterile sheet. Employee E7 put on a non-sterile glove on both hands and cleaned the surrounding of the stoma with gauze and cotton tips that were previously touched with bare hands. After cleaning the non-disposable inner cannula, Employee E7 placed it on sterile water, then later picked it up wearing a non-sterile glove, wiped the other and inside part of the tube with the gauze and cotton tip stick that was previously touched with bare hands then placed it back on the resident's [CONDITION(S)] cannula. An interview with Employee E8 on March 24, 2022, at 10:35 a.m., was conducted. Employee E8 informed the surveyor that the facility does a clean technique when performing [CONDITION(S)] care. Employee E8 informed the surveyor that a sterile technique/glove is done only when touching the inner cannula. The facility failed to ensure that infection prevention and control were maintained when handling the resident's inner cannula and caring for the surrounding of the [CONDITION(S)] cannula/stoma. The above information was discussed with the Director of Nursing on March 24, 2022, at 1:30 p.m. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/11/2021

Based on clinical record review and staff interview it was determined the facility failed to provided therapy services to prevent a decline in Activity of Daily Living performance for one of 2 residents reviewed. (Resident 371) Findings Include: Review of Resident 371's clinical record revealed the resident was readmitted from the hospital on November 16, 2021, and receiving therapy services from November 17, 2021, until December 22, 2021. Review of the Physical Therapy Discharge Summary dated December 22, 2021, revealed Resident 371 was able to ambulate (walk) with a walker and needing only supervision. Resident was able to transfer from a sitting to standing position independently when discharged from therapy. Review of the Physical Therapy Discharge Summary dated March 17, 2022, revealed the resident was started on physical therapy on February 28, 2022, and the initial assessments showed Resident needed assistance for transfers and walking with his/her walker indicating a decline since the therapy discharge on December 22, 2021. Review of Resident 371's progress notes revealed a Certified Registered Nurse Practitioner (CRNP) note dated February 2, 2022, indicated in the plan section; CRNP wanted a PT (physical Therapy) eval (evaluation) for ambulatory dysfunction (difficulty walking). Interview with Employee E3 on March 24, 2022, at 11:45 a.m. revealed there was no documentation of request for a therapy evaluation on February 2, 2022 sent to the therapy department. On February 9, 2022, there was a request for the resident to receive restorative nursing services, which were not inititated. On Feburary 28, 2022; there was a request for therapy evaluation and therapy was inititated. Interview with Employee E4 on March 24, 2022, at 12:00 p.m. confirmed there was no communication form between nursing staff and the therapy department that Resident 371 indicating a therapy evaluation was ordered on February 2, 2022, and the resident didn't start therapy until February 28, 2022. The facility failed to obtain a therapy evaluation when requested by the CRNP on February 2, 2022, after the resident had a decline in ambulation ability resulting in a delay of a return to ambulation ability. 28 Pa. Code: 211.12 (d)(1)(3) Nursing services 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on clinical record and facility documentation review, it was determined that the facility failed to ensure complete and accurate clinical records for one of 35 residents reviewed (Resident 111). Findings include: Review of Resident 111's March 2021 Treatment Administration Record (TAR) revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 111's March 2021 TAR revealed the treatment was signed out by License Nurse Employee E6 on March 17, 2021 and March 19, 2021. Additional review of Resident 111's March 2021 TAR revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident 111's March 2021 TAR revealed the treatment was signed out by License Nurse Employee E5 on March 16, 2021 and Licensed Nurse Employee E6 on March 18, 2021. Review of Resident 111's progress notes revealed a late entry nurse's note from March 20, 2021, which stated, Nurse caring for resident called to resident room to show this writer dressing to right shin dated 3/15/21. Review of facility documentation revealed a witness statement from Licensed Nurse Employee E10 on March 20, 2021, which stated, At [2:00 p.m.] called to room by [Licensed Nurse Employee E9] who was assigned to [Resident 111]. [Employee E9] asked me to witness her changing [Resident 111's right] shin dressing as per MD order, both myself and [Employee E9] noted the date on the dressing was 3/15/21. The dressing order was for a daily treatment change . Upon investigation it was found that [Licensed Nurses Employees E5 and E6] had signed out treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The above findings were discussed and confirmed with the Nursing Home Administrator and Director of Nursing on March 24, 2022 at approximately 1:50 p.m. The facility failed to ensure Resident 111's clinical record was complete and accurate, as Licensed Nurse Employees E5 and E6 signed for treatments that they did not complete. 28 Pa. Code 211.5 (f) Clinical records Previously cited 3/11/2021 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 3/11/2021, 7/10/2020, 6/18/2020

Based on facility policy, review of clinical and hospital records, and staff interviews it was determined that the facility failed to ensure proper communication with the [CONDITION(S)] center which resulted in harm for one out of two residents (Resident 327). Findings include: Review of the facility policy labeled, Care of the resident with a vascular access for hemodialysis and communication with [CONDITION(S)] centers' dated June 2011, states the facility should report any abnormal findings to the resident's physician and to the [CONDITION(S)] center. Abnormal findings or complications can include clotted shunts, dislodgement, infection, and any unusual assessment findings. Review of Resident 327's clinical record revealed the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed, the resident had a physician's order to receive [CONDITION(S)] on Tuesday, Thursday, and Saturday every week. Further review revealed on Wednesday January 19, 2022, the resident received a COVID19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) test. On Friday January 21, 2022 at 2:51 p.m. the facility received a fax that Resident 327 tested positive for COVID19 and isolation precautions were put into place. There is no documentation that the facility notified the physician or the [CONDITION(S)] center of this infection. Additional review of Resident 327's clinical record notes for Saturday January 22, 2022; revealed the resident returned from [CONDITION(S)] at 5:30 a.m. The ambulance crew stated that the [CONDITION(S)] center would not allow the resident in the facility because she is COVID positive. The [CONDITION(S)] center is trying to get the resident into their special [CONDITION(S)] COVID unit and awaiting their return call. The physician was made aware that resident did not receive [CONDITION(S)] and needed to wait until Tuesday (January 25, 2022) for the COVID positive center and ordered resident sent to the emergency room for [CONDITION(S)] if the resident started to have symptoms. Further review of the clinical record revealed that on January 24, 2022, Resident 327 had a sudden change in mental status, complaints of SOB (shortness of breathe), heaviness in lifting both arms and legs, difficulty in making speech, and shivering with hand tremors. The resident was transferred to the emergency room . Review of Resident 327's hospital records revealed on January 24, 2022; resident presented with respiratory distress, confusion, and increased dyspnea (labored breathing) that required [CONDITION(S)] (a device that helps with breathing). Resident was found to be hyperkalemic (high potassium) with a potassium level of 7.4 (typical potassium level for an adult falls between 3.5 and 5.0 millimoles per liter (mmol/L) and underwent emergent [CONDITION(S)]. The resident was quickly weaned off [CONDITION(S)] after [CONDITION(S)]. Further review of the hospital discharge summary states in the assessment, found to be hypoxic in the setting of Covid infection and missed [CONDITION(S)] session. Interview with resident was unsuccessful as resident either was unavailable due to [CONDITION(S)] treatment, sleeping or refused request for interview. An interview with the Director of Nursing on March 24, 2022, at 11:15 a.m. revealed that the facility assumed that when the resident tested positive for COVID the [CONDITION(S)] center would automatically send the resident to the COVID positive center. The Director of Nursing confirmed that they did not notify the center or the physician prior to resident arriving at [CONDITION(S)] of the resident's COVID positive status. The facility failed to communicate with the [CONDITION(S)] center regarding resident's medical condition which resulted in a missed [CONDITION(S)] session that resulted in hospitalization for Resident 327. 28 PA Code 211.12 d (1)(3)(5) Nursing Services

Based on observation, review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to follow bowel management protocol for one of 40 residents reviewed (Resident R327) Findings include: Review of facility documentation revealed a policy, Bowel Protocol, approved in February 2020, stating residents without bowel movement for six shifts need to be evaluated/medicated for potential constipation or fecal impaction and offer/give PRN (as needed) [MEDICATION(S)], if no results from first dose in 24 hours perform a bowel evaluation and administer second dose of Milk of Magnesia (MOM) as ordered [MEDICATION(S)] unless signs and symptoms of bowel obstruction. If no results from second dose of ordered MOM in 24 hours perform a bowel evaluation and administer Fleets enema. Further review of facility policy, Bowel Protocol, revealed if signs and symptoms of bowel obstruction, do not administer a [MEDICATION(S)] and notify the physician immediately and notify physician of resident with repeated abnormal stool. Further review of facility policy revealed symptoms of bowel obstruction include but not limited to nausea/vomiting. Review of clinical documentation for Resident R327 revealed an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of clinical documentation for Resident R327 revealed an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical documentation for Resident R327 revealed a Minimum Data Set (MDS) dated [DATE], revealed Resident R327 is total dependence for toilet use. Further review of clinical documentation for Resident R327 revealed a Minimum Data Set (MDS) dated [DATE], revealed Resident R327 has a Brief Interview for Mental Status (BIMS) of 14 indicating cognition is intact. Review of clinical documentation for Resident R327 revealed a Bowel and Bladder report revealed resident had a small bowel movement on March 4, 2021. Further review of clinical documentation for resident R327 revealed resident did not have any bowel movements from March 4, 2021, at 4:12 a.m. until March 11, 2021. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of MAR failed to reveal any additional doses bowel protocol medications had been administered to Resident R327 between March 6, 2021, and March 11, 2021. Observation of Resident R327 on March 9, 2021, in the presence of licensed employee E3 revealed resident had vomit on his bed and in his trash can. Observation of Resident R327 on March 10, 2021, at 12:37 p.m. reviewed small amount of vomit in his trash can. Interview with Resident R327 on March 10, 2021, at 12:38 p.m. resident confirmed he vomited once into his trash can. Interview with Employee E4 on March 10, 2021, at 12:40 p.m. confirmed vomit was in the trashcan. Review of clinical documentation on March 11, 2021, at 11:00 a.m. failed to reveal notification to physician about Resident R327 without bowel movement in five days or the two episodes of vomiting. Interview with the Assistance Director of Nursing on March 11, 2021, at 12:40 p.m. confirmed facility bowel protocol was not followed for Resident R327. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to ensure that infection prevention and control was maintained during [CONDITION(S)] care on one of two residents reviewed (Resident 250). Findings include: A review of Resident 250's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes dated January 14, 2021, at 6:39 p.m. revealed that Resident 250 was admitted to the facility with a [CONDITION(S)] (A surgical procedure that consist of making an incision on the front aspect of the neck and opening a direct airway through an incision in the windpipe). Further review of the same note revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of the [CONDITION(S)] care was conducted on March 11, 2021, at 8:40 a.m. with licensed Employee E8. The observation revealed that after Employee E8 checked Resident 250's oxygen saturation (Measures the number of red blood cells), Employee E8 cleaned the bedside table, removed his gloves, and set up the dressing, gloves, and other things that will be used for suctioning and [CONDITION(S)] care. Employee E8 opened a sterile glove package, picked up the sterile gloves with bare hands, stretched it then put them on. Employee E8 used his left hand to touch unsterile areas/surfaces which includes the suction knob while suctioning and used his right hand to touch the suction tube. At 8:52 a.m. Employee E8 used his left hand to insert the tip of the suction tube inside the cannula then proceeded with suctioning the resident. After suctioning, Employee E8 changed gloves, removed the gauze with phlegm on the resident's [CONDITION(S)] site then threw it on the garbage receptacle then changed gloves. Employee E8 cleaned the surrounding of the resident's [CONDITION(S)] site with gauze, changed gloves then cleaned it again with a Qtip. After changing gloves, Employee E8 picked up the sterile disposable inner cannula and placed it on the resident's [CONDITION(S)] then cleaned the phlegm of the [CONDITION(S)] mask then placed it on the resident's neck. After changing gloves, Employee E8 rechecked the resident's oxygen saturation, removed all used dressings and packages then performed handwashing. During the entire observation of suctioning and [CONDITION(S)] care, Employee E8 was observed changing gloves a total of six times but did not observed performing any hand hygiene in between changing of the gloves. An interview was conducted With Employee E8 on March 11, 2021, at 9:00 a.m. and was made aware of contaminating the sterile gloves used for suctioning and the tip of the suction tube. Employee E8 was also made aware of the missed hand hygiene in between changing gloves, the employee acknowledged the surveyor. The above was conveyed to the Assistant Director of Nursing on March 11, 2021, at 1:00 p.m. The facility failed to ensure that infection control and prevention were maintained during Resident 250's [CONDITION(S)] care. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 7/10/20, 6/18/20, 5/7/19.

Based on a review of the facility's policy, clinical record review, resident interview and staff interview, it was determined that the facility failed to ensure that narcotic pain medications were administered with adequate indications for use for one of 35 residents reviewed (Resident 54). Findings include: A review of the facility policy titled, Pain Management, with an approval date of February 2020, it was revealed that a physician's orders for pain medication must specify PRN (As needed) pain medication along with corresponding pain scale. Pain scale to be used: 0- no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain. A separate pain evaluation is to be completed with the A.M. and P.M medication pass and once on 11-7 if the resident is awake. Ask the resident if they are experiencing pain, or observe for non-verbal signs of pain, use pain evaluation scales. If the answer is yes, utilize scale, assign a number value for pain intensity. A review of Resident 53's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 53's Quarterly Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated December 15, 2020, revealed that the resident was cognitively intact. An interview with Resident 53 on March 10, 2021, at 8:30 a.m. revealed that she/he had periods of generalized pain but denied any pain during the interview. A review of Resident 53's Physician's Order Sheet (POS) revealed an order on January 10, 2021, for Oxycodone (A narcotic medication used to treat moderate to severe pain) five mg tablet, take one tablet by mouth every six hours as needed for moderate pain (Pain scale of 4-6). The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 53's January 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with licensed nurse Employee E6 on March 11, 2021, at 9:00 a.m. revealed that before administering PRN pain medications, the nurse will assess the resident's pain which includes intensity, The pain scale will be completed and the ordered PRN medication will be administered for moderate pain. Employee E6 was unable to provide an answer as to why a PRN oxycodone was administered for a pain scale of zero on the dates mentioned above. An interview with the Unit Manager Employee E7 on March 11, 2021, at 9:15 a.m. revealed that the pain scale for moderate pain was four, five, and six. Employee E7 confirmed that Resident 53 should have not administered with PRN oxycodone for a pain scale of zero. The facility failed to ensure that Resident 53 was administered with PRN oxycodone as indicated for use (moderate pain). 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 7/10/20, 5/7/19 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 7/10/20,6/18/20, 5/7/19

Based on review of clinical records, facility policies and staff interviews, it was determined that the facility failed to notify the resident's responsible party of the need to initiate a new treatment, for one resident out of three sampled (Resident R1). Findings include: A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment completed at specific times to identify resident care needs) completed on August 6, 2020, revealed that Resident R1 was severely impaired. A review of Resident R1's clinical record revealed that on September 9, 2020, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident R1's clinical record revealed that the resident's responsible party was not notified of the new treatment until September 29, 2020, after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Assistant Director of Nursing (ADON) on September 29, 2020, at 2:30 p.m., confirmed that nursing failed to notify Resident R1's responsible party in a timely manner. 28 Pa Code 211.12(a)(c) Nursing services 28 Pa Code 201.29(a) Resident Rights 28 Pa Code 207.2(a) Administrator's responsibility

Based on a review of the Pennsylvania Professional Nursing Practice Act, facility policy, clinical record review, facility documentation, staff interview, and guidelines from the American Heart Association, it was determined that the facility failed to ensure that staff met the professional standards for a licensed nurse (Employee E4) for one of five residents reviewed (Resident CL1). This resulted in Resident CL1 not being immediately checked for responsiveness and vital signs by Employee E4, and a delay in receiving Cardiopulmonary Resuscitation (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating), when the resident was found with the cord from an over-the -bed light around their neck. Findings include: The Professional Code, Title 49, Professional and Vocational Standards (Pennsylvania Professional Nursing Practice Act), Chapter 21.145(a) states that the Licensed Practical Nurse (LPN) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, and experience in nursing competency. The LPN participates in the planning, implementation, and evaluation of nursing care, using focused assessment in settings where nursing takes place. Chapter 21.145 (3) states, a LPN shall follow the written, established policies and procedures of the facility that are consistent with the Act. Review of the facility policy and procedure 15.01a titled, CPR and AED [(automated external defibrillator - a device used to shock the heart back into rhythm)] use in Adult Residents, last reviewed [DATE], revealed CPR and AED use should be promptly instituted for residents in [CONDITION(S)] with these important exceptions: (1) DNR [(Do Not Resuscitate)] order and Code Status Form States DNR; (2) reliable criteria for determination of death - which include rigor mortis, lividity, tissue decomposition or obvious fatal trauma. Further review of the facility policy revealed it was the responsibility of the physician, registered nurse, licensed practical nurse, supervisors, park police, and medical management to follow the policy. An additional review of the facility procedure revealed The Professional Nurse/CPR Team member assesses responsiveness. If no pulse or respirations are obtained, prepare to initiate CPR .direct staff to bring resident's chart and equipment (backboard, ambu bag [(a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately)], and AED.) Determine DNR status. If the chart is not immediately available, and the resident's DNR status is unknown, begin CPR. Review of Resident CL1's clinical record revealed a physician's order dated [DATE], for Resident CL1 to be a full code (to perform all life sustaining measures). Review of Resident CL1's progress notes revealed a nurse's note dated [DATE], at 7:12 a.m., from licensed nurse Employee E4 which stated this writer @ 0200 walked around back hallway [to] check on resident and saw her feet coming off the bed, repositioned resident in bed and asked 'where are you going' resident stated. 'I am looking for sugar.' this writer made resident aware it was after midnight. @ 0230 this writer made rounds and resident was in bed awake @ 304 went to check resident on B/T Q 30 min [(safety checks done every 30 minutes)], resident is fall risk, resident not in bed saw resident kneeling on floor asked resident are you mopping the floor resident did not answered went closer to resident and noticed resident's face was pale in color and light cord around resident's neck, tried to move resident's unable at time, immediately called supervisor, supervisor immediately responded, arrived on floor and immediately went into resident's room. Further review of Resident CL1's progress notes revealed a nurse's note dated [DATE], at 9:39 a.m., from licensed nurse Employee E5 which stated At approx. 0307 I was called by [Employee E4] to come see the resident right away. The resident was found at approx. 0309 with the overhead light cord wrapped around her neck faced down on the [NAME] pad [(floor mat)]. I called [licensed nurse Employee E6] for assistance with CPR. I immediately broke the cord with my hands, turned the resident face side up and initiated CPR. Resident is a full code. Employee E6 applied the AED and the resident was shocked four times prior to 911 arriving. [Employee E4] was instructed to call a Rapid Response and 911. When 911 arrived they initiated standard ACLS protocol and transferred the resident to [hospital] via stretcher at 0339. My co-worker notified [physician] @ 0320 & DON @ 0321. [Licensed nurse from hospital] spoke with my colleague and informed her that the resident expired @ 0403. Review of witness statement written on [DATE], by licensed nurse Employee E4, revealed that at 3:04 a.m., Employee E4 went to check on Resident CL1 and saw resident kneeling, asked are you mopping the floor, did not answered (sic) walked closer to resident and saw light cord around her neck, touched her feet, it was lifeless, face pale, staff not around/close to room @ time, left room to call [licensed nurse Employee E5.] [Employee E5] removed cord from resident's neck and started CPR. [Licensed nurse Employee E6] came immediately on unit and helped [with] CPR. I went and checked code status, called 911 and park police. Review of witness statement written on [DATE], by licensed nurse Employee E5, revealed I was called by [Employee E4] to come see the resident right away at approximately 0306. When I came on the unit [Employee E4] was standing at the nurse's station. She was trembling and frazzled. I asked her where is the emergency and she couldn't get it together to tell me. I had to tell [Employee E4] to focus and tell me who the resident is and she finally told me. The resident was found unresponsive with the overhead light cord wrapped around her neck faced down on the [NAME] pad on the floor between the bed and window. I called [licensed nurse Employee E6] for help from the resident's room because [Employee E4] did not help with CPR. I immediately broke the cord with my hands, turned the resident face up, and initiated CPR. Resident was pale and had secretions coming from her mouth. Shortly after [Employee E6] arrived to assist me with CPR. The AED was applied and the resident was shocked 4 times before 911 arrived. [Employee E4] was instructed to call a Rapid Response and 911. Neither [Employee E6] or myself heard an overhead page for a Rapid Response. Later [Employee E4] reported to us she mistakenly told the Park Police that it was a Code Red. So [Employee E6] called Park Police again @ 0310 for a Rapid Response from the room. We yelled out that we need more help and [nurse aide Employee E9] notified other nurses on different unit. Three nurses (licensed nurses Employees E10, E11, and E12) came to the unit to assist with CPR. Review of witness statement written on [DATE], by licensed nurse Employee E6, revealed that at 3:09 a.m., received a call from [Employee E5] that a resident was found hanging in her room and that she needed help. I arrived on the unit and yelled out for [Employee E5's] name and she responded back that she was in [Resident CL1's room.] I arrived to the room and saw [Employee E5] turning the resident over and CPR began, I yelled out to call a Rapid Response and ran for the necessary equipment with the assistance of [nursing aide Employee E9], and after not hearing the Rapid Response overhead, this RN called at [3:10 a.m.] to Park Police Rapid Response [Resident CL1's room] now. This RN placed AED on resident and began to bag resident and [Employee E5] was doing chest compression (resident shocked [four times], This RN and [Employee E5] yelled out for additional help and that we did not hear the Rapid Response. [Employee E4] came to the room and said she was doing the paperwork; this RN told her paperwork can wait and to get us some help now. Help ([Employees E10, E11, and E12]) arrived in the room to assist. CPR continued until paramedics arrived to assist. Resident placed on paramedic's AED and ACLS protocol began. Resident left unit at 0339. Interview with licensed nurse Employee E5 on [DATE], at 12:42 p.m., revealed that upon being notified by Employee E4 that Resident CL1 was found unresponsive with a cord around the neck, Employee E5 went to the room and found the resident lying face down on the [NAME] pad (fall mat) with the cord around the resident's neck. Employee E5 stated that the cord was taut, and she immediately broke the cord from the light, rolled the resident over on her back, removed the cord, and initiated CPR. Interview with licensed nurse Employee E4 on [DATE], at 9:45 a.m., revealed that when Employee E4 discovered Resident CL1, the resident was kneeling on the floor on the [NAME] pad. Employee E4 initially thought the resident had put herself on the floor, typical of her behavior of cleaning the floor. Employee E4 then noticed the light cord was around the front of the resident's neck. Employee E4 stated that the cord was taut, that the resident had an extension to the cord in order to better reach it, and that the cord was stuck in the resident's side rail. Employee E4 stated that she should have stayed with and helped Resident CL1 upon discovering the resident unresponsive. Review of licensed nurse Employee E4's personnel record revealed that Employee E4 was certified through a providing agency (CPR and AED) program on [DATE], through [DATE]. Review of information provided by the providing agency revealed: The first step in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . When a bystander witnesses the sudden collapse of a victim or finds someone who appears lifeless, the bystander should: Ensure the scene is safe Check for responsiveness (tap shoulder and shout, Are you all right?) If victim doesn't respond, activate emergency response system. The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start CPR beginning with chest compressions. Ideally, the healthcare provider performs a pulse check at the same time as the check for no breathing or only gasping, to minimize delay in detection of [CONDITION(S)] and initiation of CPR. Interview with the Director of Nursing on [DATE], at 9:00 a.m., confirmed that licensed nurse Employee E4 was currently suspended for failing to assess Resident CL1 and render aid to Resident CL1. Licensed nurse Employee E4's failure to follow professional nursing standards was conveyed to and confirmed with the Nursing Home Administrator on [DATE], at 11:00 a.m. 28 Pa. 211.10(c) Resident care policies 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on review of guidance from the Centers for Disease Control and the Pennsylvania Department of Health, as well as observations and staff interviews, it was determined that the facility failed to ensure that staff performed proper hand hygiene and wore appropriate personal protective equipment when providing care on two of five designated COVID-19 units observed (Building Six - First and Second Floor). Findings include: Guidance from the Centers for Disease Control (CDC - a national health protection agency) regarding the use of Personal Protective Equipment (PPE - protective garments and/or equipment designed to protect the body from infection or injury) for Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by [MEDICAL CONDITION], that can cause fever, cough, fatigue and/or breathing problems), dated May 22, 2020, included that when caring for a person with confirmed or suspected COVID-19, the caretaker was to use an N-95 respirator (a face mask designed to achieve a very close facial fit and very efficient filtration of airborne particles), gloves, an isolation gown and eye protection, and that the preferred PPE for eye protection was a face shield or goggles. The Pennsylvania Department of Health - Health Alert Network (PAHAN) 509, updated May 29, 2020, included that residents with a positive COVID test, who are within the parameters for transmission-based precautions, were to be placed in a Red Zone and that full PPE was to be worn when caring for these residents. Interview with Employee E3 on June 18, 2020, at 9:40 a.m. revealed that the first and second floors of Building Six were designated as COVID-19 units and all residents residing on the two floors had tested positive for COVID-19, and all staff entering the COVID-19 units were required to wear an N-95 mask, an isolation gown and eye protection, and that gloves were required when entering a resident's room. Employee E3 also stated that both units had residents with dementia (progressive [MEDICAL CONDITION] disease of the brain). Observations on the first floor of Building Six on June 18, 2020, at 9:45 a.m. revealed that one resident was walking in the hallway, there were seven residents in the dining room and eight residents in the activity room. At 9:45 a.m. Employee E4 was standing in the hallway, documenting on the wall kiosk, while wearing an isolation gown and a red cloth facemask. Interview with Employee E4 at that time revealed that the facility provided him/her with training regarding what PPE to wear in a COVID unit (an N-95 mask, isolation gown, and eye protection) and provided him/her with an N-95 mask, but he/she had not been using it because he/she had a problem with it (gestured, pointing to his/her nose). Observations on the first floor of Building Six on June 18, 2020, at 10:15 a.m. revealed that Employee E5 was mopping the floor of the dining room. There were seven residents seated in the dining room (appropriately distanced). Employee E5 was wearing a blue cloth facemask and gloves, and was not wearing a gown and eye protection. Interview with Employee E5 at that time revealed that he/she was wearing complete PPE earlier, but had to remove it because it got hot. Employee E5 stated that he/she would put it back on after he/she was done mopping the floor. Observations on the first floor of Building Six on June 18, 2020, at 10:30 a.m. revealed that Employee E6 was standing in front of the activity room while wearing an isolation gown and a black printed cloth mask with an air valve. Interview with Employee E3 on June 18, 2020, at 10:33 p.m. revealed that Employee E6 informed him/her that the mask he/she was wearing was an N-95 mask. Observations on the second floor of Building Six on June 18, 2020, at 10:40 a.m. revealed that two residents were seated in front of the nursing station and one resident was wandering in the hallway approaching staff. Employee E7 approached the surveyor to introduce himself/herself. Employee E7 was wearing an N-95 mask, but was not wearing a gown and eye protection. Interview with Employee E7 on June 18, 2020, at 10:41 a.m. confirmed that staff in the COVID unit were required to wear a gown and eye protection. Observations on the second floor of Building Six on June 18, 2020, at 10:50 a.m. revealed that Employee E8 was seated in the nursing station with a surgical mask on. Employee E8 was not wearing an N-95 mask, a gown and eye protection. Interview with Employee E8 at that time revealed that from his/her understanding, complete PPE (N-95 mask, gown, eye protection and gloves) were to be worn only when inside a resident's room, due to close contact with the resident. The surveyor asked Employee E8 if the resident seated by the nursing station in front of Employee E8 was considered a close contact, and Employee E8 responded, I guess, I should have, I don't know. Observations on the second floor of Building Six on June 18, 2020, at 10:59 a.m. revealed that Employee E9 was in the hallway pushing an activity cart while wearing a black cloth mask. Employee E9 was not wearing a gown and eye protection. Interview with Employee E9 at that time revealed that he/she was wearing complete PPE earlier when he/she entered a resident's room, but he/she took it off upon leaving the room. While interviewing Employee E9, a confused resident who was wandering in the hallway approached both Employee E9 and the surveyor and started talking to Employee E9. The employee stroked the resident's left arm then continued to pat the resident's back with his/her left hand. Without performing hand hygiene, Employee E9 then wiped his/her left face with the same hand he/she used to touch the resident. Interview with Employee E3 on June 18, 2020, at 11:10 a.m. confirmed that the staff should have worn complete and correct PPE when entering the first and second floors of Building Six. 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 facility policy, clinical record review, review of facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure residents were free of accidents during a transfer via a mechanical lift to one of three residents reviewed, resulting in actual harm to Resident R1 sustaining a fall, and required a transfer to the hospital with a [DIAGNOSES REDACTED]. Findings include: Review of facility policy labeled, Mechanical Lift, Slings and Battery Charging, dated (MONTH) (YEAR), lists Points of Emphasis, #5 states, always check that all sling attachment clips are fully in position before and during the lifting cycle, and in tension as the patient's weight is gradually taken up. The facility policy continues with, General Information: Before Use: The slings should be checked before and after use with each patient and it is essential that the slings, their straps and attachment slips are carefully inspected before each and every use. The facility policy continues with During Use: Always assure that the straps connecting the sling to the attachment clips are not twisted when the attachment clips are connected to the spreader bar. Review of Resident R1's clinical record revealed the following [DIAGNOSES REDACTED]. Further review of the physician orders [REDACTED]. Further review of Resident R1's clinical record review revealed a quarterly Minimal Data Set assessment (MDS- assessment of resident care needs) dated (MONTH) 10, (YEAR), in which the resident's BIMS (Brief Interview of Mental Status) was five out of 15 which identified the resident with severe cognitive impairment. Further review of the MDS revealed that the resident was an extensive assist with one person for bed mobility, total dependence with two persons, and Resident R1 did not walk in the last seven days. Review of Resident R1's nursing note dated (MONTH) 12, (YEAR), revealed that Resident R1 fell while being assisted from the stretcher to the chair. A laceration was noted at the occipital head (the area located at the rear of the head) with bleeding and slight indentation to the back of the head. The physician was notified and Resident R1 was sent to the hospital at 5:15 a.m. Review of the facility investigation of Resident R1's fall incident written statement revealed that Nurse Aide, Employee E3, noted that the other nurse aide had clipped both clips on the left side and thought the clips were secure but the clips became detached on the lower left side of the Hoyer (a type of mechanical lift) pad during the transfer process and the resident rolled out and fell to the floor. A second written statement from Nurse Aide, Employee E4, hooked the upper left shoulder strap and thought the other aide did the other three. The left strap popped off. A final written statement from Licensed Employee E5 stated checked the hoyer lift and found the leg part had the sling attached on one side and the other part was not. 911 called as per Physician's verbal order. Review of the hospital inpatient discharge summary report for Resident R1 confirmed the [DIAGNOSES REDACTED]. Review of the Mechanical Lift companies report dated (MONTH) 19, (YEAR), revealed that the lift was inspected and stated, all lift functions were operating correctly. Review of the facility documentation of the, summary of the incident, dated (MONTH) 12, (YEAR), revealed that both nursing assistants reported seeing all four clips attached prior to the fall. The left leg strap became detached during the transfer. The mechanical lift was checked and found to be in working order. The passive clip sling used by the facility was removed from service, checked and was intact and functioning properly. It was determined this was not a mechanical issue. Interview with the Nursing Home Administrator on (MONTH) 25, (YEAR), at 2:30 p.m. confirmed that the staff did not assure that the transfer was free from accidents by checking that the attachment clips were fully in position during the lifting cycle as stated in the facility policy. The facility failed to ensure that Resident R1 was free of accidents while being transfer via the use of a mechanical lift which resulted in harm to Residents R1 who sustained a fall, requiring transfer to the hospital and a [DIAGNOSES REDACTED]. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 10/24/17, 04/22/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/25/18, 10/24/17, 09/15/16, 04/22/16 28 Pa. Code 201.18(b)(1) Management Previously cited 10/24/17, 09/15/16, 04/22/16 28 Pa. Code 201.18(b)(3) Management Previously cited 10/24/17, 05/11/17, 04/22/16 28 Pa. Code 201.18(e)(1) Management Previously cited: 04/27/18, 10/24/17, 04/22/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 04/27/18, 05/11/17, 01/31/17, 04/22/16 28 Pa. Code 211.12(c) Nursing services Previously cited: 04/27/18, 10/24/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 05/29/18, 04/27/18, 10/24/17, 05/11/17, 04/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 04/27/18, 10/24/17, 05/11/17, 01/31/17, 04/22/16

Based on review of a reportable event, clinical record review and review of facility documentation, it was determined that the facility failed to ensure the safety of residents during a transfer resulting in actual harm to Resident Q7 sustaining a fractured tibia and fibula for one of ten residents reviewed (Resident Q7). Findings include: Review of Resident Q7's [DIAGNOSES REDACTED].) and heart disease. Review of Resident Q7's Significant Change Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated June 20, 2017, revealed Resident Q7 required complete dependence of two staff persons for transfer in and out of bed and between surfaces. Review of the resident's plan of care dated February 14, 2017, identified the resident with impaired mobility. The interventions included for the resident to be transferred utilizing a mechanical lift with the assistance of two people. Review of the facility's Friendly Accurate Information about our Residents documentation (information regarding the resident's care needs to be utilized by the nursing staff) for Resident Q7 revealed that the resident was to be transfered with the assistance of two staff persons via a Hoyer lift (mechanical lift use to transfer a resident from one surface to another). Review of Resident Q7's nurses' notes dated August 14, 2017, at 9:39 p.m. revealed Resident Q7 showed, signs of pain and discomfort to right leg. The Hospice nursing assistant communicated to the nursing staff that the resident was complaining of pain during morning care. Further review of the nurses' notes dated August 14, 2017, revealed, writer assessed right shin to find that resident had reddened area with purple area within the redness area is slightly swollen and warm to touch. On August 14, 2017, at 10:00 p.m. a nursing note stated that the resident stayed in bed, and the resident continued to have pain with turning. Review of a nursing note on August 16, 2017, written as a late entry on August 15, 2017, at 3:00 p.m. revealed that the resident's physician assessed the resident's right leg for a second time and gave orders for an X-ray to be completed. A nursing note dated August 16, 2017, at 2:00 p.m. noted that an X-ray of the resident's lower leg was completed and the results were sent immediately to the resident's physician which revealed a, broken/fractured tibia (shinbone) and fibula (the two bones in lower leg). The note was indicated the physician was notified at 12:15 p.m. on August 16, 2017 and gave orders for an orthopedic consult as soon as possible. The facility obtained a consult with the orthopedic physician for an appointment on August 16, 2017, at 1:30 p.m. Further review of nursing notes dated August 16, 2017, at 10:00 p.m. revealed that the resident returned to the facility from the orthopedic consultation at 3:45 p.m. with a cast to the right leg fractured tibia and fibula. Review of the facility's investigation report dated August 18, 2017, confirmed that the nursing assistant improperly transferred Resident Q7 from her chair by one staff person and not with the assistance of two staff persons. Interview with the Director of Nursing on October 24, 2017, at approximately 1:00 p.m. confirmed that an improper transfer occurred on August 14, 2017. The facility failed to ensure that Resident Q7 was transferred out of her chair by the nursing staff with the assistance of two staff persons which resulted in actual harm to Resident Q7 sustaining a fractured tibia and fibula. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 04/22/16 (At 42 CFR 483.25(h)) 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/15/16, 04/22/16 28 Pa. Code 201.18(b)(1) Management Previously cited 09/15/16, 04/22/16 28 Pa. Code 201.18(b)(3) Management previously cited 05/11/17, 04/22/16 28 Pa. Code 201.18(e)(1) Management Previously cited 04/22/16 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 05/11/17, 04/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 05/11/17, 01/31/17, 04/22/16

Based on clinical record review and staff interviews, it was determined that the facility failed to correctly administer a medication in accordance with physician's orders [REDACTED]. Findings include: Review of Resident WW19s February 2016 physician orders [REDACTED]. Further review of phsycian's orders revealed an order for [REDACTED]. The facility administered the wrong insulin medication to the resident which caused the resident to be transferreed to the hospital via emergency transportation. The aforementioned information was reported to the administrator, assistant administrator, director of nursing and two assistant directors of nursing on April 22, 2016 at approximately 2:30 p.m. 28 PA Code 201.14(a) Responsibility of licensee 28 PA Code 201.18(b)(1) Management Previously cited 8/11/2015; 7/29/2015; 5/21/2015; 2/19/2015 28 PA Code 211.10(c)(d) Resident care policies Previously cited 7/29/2015; 5/21/2015; 2/19/2015; 11/20/2014 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 2/19/2016; 12/14/2015; 7/29/2015; 5/21/2015; 2/19/2015; 11/20/2014; 4/14/2014

Based on clinical record review, observation, and staff interviews, it was determined that the facility was not free of a significant medication error requiring a resident to be hospitalized for [REDACTED]. (Resident Q17) Findings include: Review of Resident Q17's clinical medical record revealed tha the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation of Resident Q17 on July 29, 2015 revealed a frail looking, middle aged man, wearing glasses's, making no eye contact,who was in his bed and had a one to one caregiver present in the room. The resident had limited ability to communicate verbally and did not answer any questions asked by the surveyor. Review of the quarterly MDS (Minimum Data Set-an assessment of resident needs and needs) completed on July 14, 2015, identified the resident as total dependent for all ADL (activities of daily living) needs and his BIMS (Brief Interview for Mental Status-an assessment of a resident cognitive level) indicated that the resident could not completed the assessment and input from staff into the assessment indicated that the resident was moderately impaired in his cognitive abilities. Review of Resident Q17's clinical medical record revealed that there was a nursing progress note dated July 4, 2015 stating, Nursing Order, send out 911 to local hospital emergency room for evaluation, placed on oxygen 2 liters per minute. Another nursing note dated July 7, 2015 stated that the resident returned back to the facility from the hospital. A physician note dated July 8, 2015 stated, post accidental overdose of narcotics. Review of the discharge documentation from the hospital revealed that the resident was admitted to the hospital from July 4, 2015 to July 7, 2015 and the stated the reason for the admission was accidental drug overdose. Observation of a medication pass on July 29, 2015 with Employee E8 and another licensed nurse revealed that the medication pass system included an electronic medication system that included a picture of the resident on the computer so the resident can be identified, and also a bar scanning system that when medications are pulled from the medication cart for a resident the medication pack needs to be scanned prior to giving the medication it ensure the correct medications were present. This scanning of medications also include narcotic medications. Also, part of the facility's medication pass process was to have the medication cart, with the computer on top of the cart used to access the medication administration records for the resident, is to be located outside of the resident's room when giving medications to the resident in that particular room. Employee E8 also indicated that the residents were supposed to wear identification bands that were on the residents wrists which was also scanned to verify that the correct resident was being administered the medications that were scanned. Employee E8 also stated that Resident Q17 did not comply with keeping the identification band on his wrists and tears them off after application. Interview with Employee E8 on July 29, 2015 approximately at 10:30 a.m. revealed that the night nurse on the night shift of July 4, 2015 gave Resident Q17 medications that were ordered for Resident Q20 who resided two rooms away from Resident Q17. Employee E8 stated that the night nurse gave Resident Q17 [MEDICATION NAME] ER 45mg (a 30 mg tablet and a 15 mg tablet) ([MEDICATION NAME] is a controlled narcotic medication used to treat pain) at 6:00 a.m. on July 4, 2015 that was not ordered for Resident Q17, but was for Resident Q20. According to the facility's investigation, the licensed practical nurse failed to follow the 5 rules of medication administration, which includes following the concept of the right resident, right route, right drug, right time, and the right dose of the medication. According to the statement given from the licensed practical nurse to the facility's administration, she was rushing through her medication pass and took the wrong drug into the wrong room and gave the wrong medication to the wrong resident. Interview with the Director of Nursing and Employee E3 on July 28, 2015 approximately at 11:30 a.m. revealed that the licensed practical nurse did not initiate or complete the medication pass correctly on July 4, 2015 and the the wrong medication to Resident Q17 causing the needed hospitalization to stabilize the accidental ingestion of the narcotic medication. Interview with Employee E4 on July 29, 2015 at 3:15 p.m. revealed that the licensed practical nurse did not even take the medication cart or the computer with her to the bedside when she administered the medication, indicating that she prepoured the medication in the medication room and took the medication to the wrong room and then administering the wrong medication to the wrong resident. The facility adminstered the wrong medication to the wrong resident which resulted in Resident Q17 to become sedated causing the resident to ultimately be hospitalize for a drug overdose, resulting in actual harm to Resident Q17. 28 Pa Code 201.18(b)(1)(e)(1) Management Previously cited: 11/20/2014, 02/19/2015, 03/11/2015, 05/21/2015 28 Pa Code 211.10(d) Resident Care Policies Previously cited: 11/20/2014, 02/19/2015, 05/21/2015 28 Pa Code 211.12(d)(3)(c)(d)(1)(2)(5) Nursing Services Previously cited: 11/20/2014, 02/19/2015, 5/21/2015

Based on clinical record review, staff and resident interviews, and observations, it was determined that the facility failed to ensure that the hot liquids were provided to residents at safe temperatures and that the residents environment was free of accident hazards for one of 5 residents reviewed, resulting in actual harm to Resident Q27. Findings include: Review of Resident Q27's clinical medical record revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident annual MDS (Minimum Data Set-a periodic assessment of needs) completed on May 26, 2015 identified the resident need to for a wheelchair for all her mobility needs. Review of Resident Q27's clinical medical record revealed a nursing progress note dated July 10, 2015 stating the resident spilled coffee on the resident causing a 12 cm by 12 cm burn on the face and chest area. A physician note dated July 10, 2015 and July 12, 2015 stated the resident received extensive burns on the face, chest and that the face burn did blister. Interview with employee E8 on July 29, 2015 revealed that Resident Q27 used a wheelchair for mobility in her room and within the facility. Employee E8 stated that the resident self-propelled the wheelchair with her feet throughout the unit and in other parts of the facility. The resident was independent in her ability to feed self and in attending to her activities of daily living (ADL's). Employee E8 confirmed that Resident Q27 received a 2nd degree burn on the left side of her face, her chest area and her left breast on July 10, 2015 after being hit by a yellow Wet Floor sign by a housekeeper who was waving the sign in the air while walking backwards to help dry the wet floor. The resident was self-propelling herself to her room after receiving a plastic blue cup with a plastic lid which contained hot coffee that was obtained by a staff member who warmed up her coffee at the resident's request. The staff member who warmed the coffee in the unit microwave did not get a temperature of the coffee prior to giving it to the resident. The resident was self-propelling herself to the resident's room carrying the coffee in the resident's hand when the housekeeper hit the resident with the yellow Wet Floor sign causing the coffee to open and spill over the resident causing burns to the face, chest and left breast. Interview with Resident Q27 on July 29, 2015, revealed that the resident was able to stated the name of the housekeeper who hit the resident with the sign and caused the coffee to spill on the face and chest area of the resident. The resident proceeded to show the surveyor the areas that were burned. Observation of the burned areas at the time of the interview, revealed some redness on her middle chest area surrounding a gauze pad and tape present. The resident also revealed a large gauze pad covering the entire left breast. Interview with the Administrator and Director of Nursing on July 29, 2015 confirmed that on July 10, 2015 the resident obtained second degree burns on the face, chest and left breast area from being hit by a staff member who should of not been doing the activity she was doing causing an unsafe environment for the resident. The facility failed to ensure that a hot beverage provided by facility's staff to Resident Q27 was at a safe temperature which resulted in actual harm to Resident Q27. 29 Pa Code 201.18(b)(1)(e)(1) Management Previously cited: 11/20/2014 02/19/2015, 03/11/2015, 05/21/2015 28 Pa Code 211.10(d) Resident Care Policies Previously cited: 11/20/2014, 02/19/2015, 05/21/2015 28 Pa Code 211.12(d)(3) Nursing Services Previously cited: 11/20/2014, 02/19/2015, 05/21/2015

Based on observation, review of facility policy and documentation and staff and resident interviews, it was determined that the facility failed to provide a safe environment for residents who smoke which resulted in actual harm to one resident out of three residents reviewed. (R1) Findings include: Review of Resident R1's quarterly resident assessment Minimum Data Set (MDS - assessment of resident care needs and status) dated November 25, 2014 revealed [DIAGNOSES REDACTED]. Further review of the quarterly MDS revealed that the resident required the supervision and setup of one person for eating and the limited assistance of one person for dressing, toileting and personal hygiene. Review of the facility reported event submitted to the state agency on February 17, 2015 related that Resident R1, a resident on the 9th floor of building 8 was noted to be smoking on the balcony of the building 8 on February 17, 2015 and had caught his clothing on fire. Review of the resident incident investigation report dated February 17, 2015 at 12:50 p.m., related Resident R1 was smoking cigarettes on the balcony when staff noted flames coming from the balcony. Flames were coming off the resident. Staff attempted to control the fames by patting the resident and removing clothing. The resident had removed his shirt by himself. Resident was wearing his clothing protector (paper product with plastic on the back to protect clothing when the resident eats meals) prior to the incident which is believed to be the cause of the fire. Review of facility interview statements report form dated February 17, 2015 with licensed nurse Employee E1 regarding the incident with Resident R1 revealed that Resident R1 was upright in the wheelchair with his sweatshirt off with varying degree of burns noted on the resident's neck, ears and face. Employee E1 further reported that a large amount of debris was noted on Resident R1's scalp and covering his body. The resident's pants were also noted to have large burn holes. Review of the facility interview statement from nursing Employee E2 dated February 17, 2015 related that Employee E2 was in a room adjacent to the porch and " saw flames out of the corner of my eye. When I looked out on the balcony, Resident R1 was on fire. I yelled for help and went to resident. The Resident had taken his sweatshirt off and I took it off his lap. " Review of the facility interview statement from nursing Employee E3 related she yelled for help and got a sheet and put out the flames on his lap, feet and hair. Review of the facility interview statement from Resident 3 confirmed that Resident R1 was on the balcony February 17,2015 smoking and there was flames around his neck and face. He pulled his sweatshirt off over his head. Staff went to help. During the on-site survey on February 19, 2015 an interview with licensed nurse, Employee E1 at 1:45 p.m. revealed that she heard staff yelling for help while she was in her office in building 8, 9th floor nursing unit. Employee E1 ran to assist Resident R1 on 9th floor nursing unit ' s porch/balcony where she observed smoke in the air. Two nursing staffs that were present on the porch with Resident R1and told her that Resident R1 had been on fire and they had extinguished the fire. Interview on February 19, 2015 with nursing Employee E2 and nursing Employee E3 stated that on February 17, 2015 they were having lunch in the room adjacent to the balcony/porch and Employee E2 observed flames out of the corner of her eye and realized that Resident R1 was on fire. Employee E2 related that she yelled out for help and went to help Resident R1 by using his sweatshirt to put out the flames. Employee E3 related that when she arrived on the porch, she threw the resident ' s sweatshirt that was on his lap on the floor and used the sheet to put out the flames. Interview with both employees on February 19, 2015 related that they think that on February 17, 2015 at approximately 12:45 p.m., after the completion of the noon meal, Resident R1 left the dining area by wheelchair and preceded to the porch with the paper/plastic backed clothing protector still in place. Both employees stated that they smelled burnt plastic and could see it melted on the resident's neck and surmised that the resident ignited the clothing protector with a lighter or lite cigarette. Employee E2 did observe a lighter on the porch/balcony table after the incident but did not know where it came from. Facility interviews with staff after the incident on February 17, 2015 failed to determine how the resident obtained a lighter found on the porch table and a cigarette that was later found in his room. Documentation obtained from the hospital emergency room dated February 17, 2015 revealed [DIAGNOSES REDACTED]. The resident related to hospital staff at that time, approximately 1:00 p.m., that his pain level was 10 out of 10. Review of Resident R1's Smoking Annual Safety assessment dated [DATE], revealed that the resident was determined not to be safe to smoke independently. Review of the resident care plan note dated September 2, 2014 revealed that staff had observed burns on his fingers on August 25, 2014 and the resident had decided to stop smoking. However, the resident became a supervised smoker on September 2, 2014 according to the care plan notes of that date. The quarterly Smoking Safety Assessment completed December 2, 2014 indicated that the resident could smoke independently although there was no indication what had changed to avoid the injury observed to the resident's fingers in August, 2014 since the resident's Parkinson's disease had continued to advance. The physician progress notes [REDACTED]. An interview on February 19, 2015 at approximately 1:45 p.m. with the Nursing Home Administrator revealed that the facility was allowing residents to smoke on each unit on the porch in Building 8 secondary to an outbreak of Norovirus. The usual procedure was for residents to smoke in a special area on the main ground floor where independent smokers can light their own cigarettes from a wall mounted cigarette style lighter. Supervised smokers were allowed smoking after each meal and before bed. Independent smokers were allowed to smoke anytime. Licensed nurses Employee E1 and E4 confirmed during interview on February 19, 2015 at approximately 1:45 p.m. and 2:00 p.m. that this was the previous smoking policy and how smoking was currently being handled with the Norovirus. During an interview on February 19, 2015 at approximately 2:15 p.m., licensed nurse, Employee E5 was unsure of the current policy. Interview with Resident R2, a resident from building 8, 3rd floor on February 19, 2015 at 2:30 p.m. revealed that ashtrays were observed on the porch until early afternoon that day. The nursing home administration did not provide a written policy for guidance to staff to address the change in smoking procedure during the Norovirus illness reported in Building 8. The facility failed to provide a safe environment by ensuring that that smoking materials were not in the possession of Resident R1 per the facility's policy in order to ensure resident safety. The facility failed to ensure staff in building 8 were aware of the revised smoking policy during the Norovirus outbreak resulting in residents smoking on unit porches rather than the common area. The ground floor common smoking area had wall mounted lighters for cigarettes. In addition, the facility failed to prevent Resident R1 from being burned by not supervising him and putting revised systems in place for this resident who was assessed as requiring supervision while eating and limited assistance of a staff member to accomplish activities of daily living including dressing, personal hygiene and toileting and who had previously been assessed as at risk for smoking independently which resulted in actual harm and hospital admission to a burn unit. F 323 483.25(h) Accidents and Supervision Previously cited 4/15/14 28 Pa. Code 201.18(b)(3) Management. Previously cited 4/15/14 28 Pa Code: 211.5(f) Clinical records Previously cited 11/20/14 28 Pa Code: 211.10(d) Resident care policies Previously cited 11/20/14 28 Pa Code: 211.12(c)(d)(1)(5) Nursing services Previously cited 4/15/14

Based on facility documentation review, clinical record review, and staff interviews it was determined that the facility failed to provide adequate supervision for one resident who was at high risk for choking which resulted in actual harm to the resident (Resident R1). Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's Nutrition Progress Report dated June 26, 2013, revealed the resident was on a pureed diet (consistency of a soft creamy paste or thick liquid) with no added salt and honey thickened liquids (liquid sticks to the sides of a cup like honey). Review of Resident R1's physician orders [REDACTED]. Review of Resident R1's Fair Facts information Kardex (card-filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care) revealed that the resident was on a pureed diet and required total dependence on staff for set-up and feeding and was on honey thickened liquids. Review of the facility reported event dated August 26, 2013, revealed that the resident was described as alert. The event report revealed that on August 24, 2013, at 11:40 p.m., the resident was fed by his consistent Nurse Aide, Employee E3, a peanut butter and jelly sandwich "per his request". The resident was noted to be choking on the sandwich. The Heimlich Maneuver (standing behind a patient and using the hands to exert pressure on the bottom of the lungs) was attempted but was unsuccessful. When the Nursing Supervisor, Employee E4 arrived on the unit at 11:46 p.m., the resident was unresponsive, diaphoretic (sweating) and there were no breath sounds or heartbeat. The resident was pronounced dead at 11:55 p.m. Review of the facility incident report revealed Employee E3 grabbed a peanut butter and jelly sandwich and started breaking off small pieces of the sandwich and by the fourth piece the resident started to choke. Another statement taken from Employee E4 revealed that upon arrival to the unit at 11:46 p.m., the resident was unresponsive, diaphoretic, cold, clammy and with skin discoloration with no vital signs, no breath sounds, and the heart sound was inaudible. The resident was pronounced dead at 11:55 p.m. Review of the findings of the medical examiner report dated August 25, 2013, revealed that the findings of a partial autopsy were that the cause of death was asphyxiation (a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally) as a result of obstruction of the proximal (central) airway by a food bolus (a mass of chewed food). An interview on August 27, 2013, with the Assistant Nursing Home Administrator and the Director of Nursing confirmed that the peanut butter and jelly sandwich was not on the resident's ordered diet and should not have been given to the resident. The peanut butter and jelly sandwich that was given to the resident went against the speech therapist recommendations and the physician orders. The facility's failure to follow the physician's orders [REDACTED]. 483.25(h) Accidents. Previously cited 5/10/13, 4/30/12 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/10/13, 6/22/12, 4/30/12 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 5/10/13, 6/22/12, 4/30/12 28 Pa. Code 201.18(e)(1) Management. Previously cited 5/10/13, 6/22/13, 4/30/12 28 Pa. Code 211.10(a) Resident care policies. Previously cited 5/10/13 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 5/10/13, 4/30/12 28 Pa. Code 211.12(c) Nursing services. Previously cited 5/10/13 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 5/10/13, 4/30/12

Based on a review of facility policy and procedure, clinical records, observations, and interviews with facility staff, it was determined that the facility failed to assure that physician orders were implemented to prevent further breakdown of pressure ulcers for one out of 3 residents reviewed, resulting in actual harm to the resident. (Resident: R2) Findings include: A review of the facility policy and procedure for Guidelines for the treatment of [REDACTED]. A review of Resident R2's cumulative [DIAGNOSES REDACTED]. A Braden Risk Assessment (tool used to identify the residents risk for skin breakdown) dated July 13, 2011, indicated that the resident was at a high risk for skin breakdown. Review of a Wound Assessment and Documentation Sheet completed on the resident on September 30, 2011 indicated that the resident was noted to have a 0.8 x 0.6 centimeter area to the right heel that was intact and noted to be a suspected deep tissue injury(purple or very deep areas that are surrounded by profound redness or swelling). Review of physician orders gave no evidence that the wound was communicated to the physician, or that a treatment was ordered for that site on September 30, 2011. Further review of the Wound Assessment and Documentation sheet indicated that the area was again assessed on October 9, 2011. The site was noted at that time to be two open areas one 1.5 centimeters by 1.5 centimeters that was entirely pink, and the other area in the same located was 0.5 by 0.7 centimeters, and noted to be entirely pink. Further review of physician orders indicated that no treatment was ordered to the site until October 12, 2011 when the physician wrote an order for [REDACTED]. Interview with the Director of Nursing on October 17, 2011 at 12:00 p.m. indicated that there was no physician orders for treatment until this date. Observation of the area on October 17, 2011 at 2:15 p.m. indicated that the area on the right heel was about 4 x 4 centimeters round with a border of yellow material, and a purplish area to the right lateral side of the wound. The facility failed to assure that the physician was notified and treatments were ordered and documented as administered, resulting in a decline of the residents wound, and actual harm to the resident. 483.25(c) PRESSURE SORES Previously cited 5/26/2011 28 Pa. Code: 201.18(e)(1) Management. Previously cited deficiency 5/26/2011, 4/19/2010 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 5/26/2011, 4/19/2010; 4/02/2010, 3/29/2010 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited 5/26/2011, 1/21/2011, 4/19/2010, 4/02/2010, 3/29/2010 28 Pa. Code: 211.5(f) Clinical records. Previously cited 5/26/2011, 4/19/2010 28 Pa. Code: 211.10(c)(d) Resident care policies Previously cited 5/26/2011