Every finding on record at Fairview Rehab and Care Center

Based observations of the physical environment of the main kitchen and first floor dining room, reviews of pest control reports, interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program to ensure that the building was free of pests and rodents. Findings include: Observations of the main kitchen at 11:30 a.m., on April 6, 2026, revealed that the tiled flooring throughout the main kitchen contained areas of worn away and missing grouting. The flooring in areas of high-water usage: the dish room, three compartment sinks and food preparation and cooking areas contained an accumulation of food debris. The missing grouting between the tiles on the flooring evidenced moist food debris. The unrepaired flooring was not easily cleanable for dietary staff. The entire perimeter of the main kitchen evidenced a heavy accumulation of food debris with multiple holes along the baseboard of the flooring. A build-up of food debris was observed underneath large pieces of food service equipment (stove, tray-line, refrigeration and steamtable). The dining room area on the first floor that was located across from the main kitchen contained a small serving area for foods and beverages. The area also had an ice machine. The working mechanisms of the ice machine (pipes for draining excess water and sink) were located behind this machine and inside the cabinets. Upon opening the cabinets holes were noted around the pipes and mice droppings were observed inside the cabinets. Interviews with Residents R1 and R2 at 1:00 p.m., on April 9, 2026, revealed that these residents eat in the dining area on the first floor regular. Residents R1 and R2 reported that they had eaten lunch in the first-floor dining area on April 6, 2026, the residents stated that while they were seated in the dining room, they observed a live mouse scurrying across the floor and behind the curtains and cardboard boxes stored inside the first-floor dining area. Interviews with Residents R9 and R10 who both live on the first-floor nursing unit revealed that they have observed pests and rodents in their room (116). Observations of room [ROOM NUMBER] revealed Resident R10 stores food uncontained (opened box of cereal) and directly on the floor. Interview with Employee E4, registered nurse, at 1:30 p.m., on April 6, 2026, who was familiar with the care of Resident R10 revealed that this resident's family likes to bring in foods (cereal cupcakes, crackers) from the outside, for Resident R10, when they come in to visit with the resident. A review of the pest control operator's service reports for the facility revealed that room (115) located across the hallway from room (116) was treated of roaches and rodents on March 31, 2026. The pest control operator noted that there was a large amount of clutter in room (115); which provides places for pests to harbor and breed. Observations of room [ROOM NUMBER] on April 6, 2026, revealed several cardboard boxes filled with resident belongings stored directly on the floor in this room. The area was not easily cleanable for housekeeping staff. A review of the pest control operator's service report for the facility revealed that the main kitchen where foods and fluids are prepared stored and assembled for delivery for the residents was treated for pests and rodents (roaches and mice on March 31, 2026). The pest control operator removed a dead mouse near the walk-in cooler and listed multiple holes throughout the perimeter of the kitchen at the base board of the flooring that have voids/holes in the structure that needed sealing to prevent pest and rodent harborage. The pest control operator noted observing mice droppings in the dry food storge area of the main kitchen on March 31, 2026. A review of the pest control operator's service report for the facility revealed mice were found near the walk-in cooler on March 29, 2026. The pest control operator requested the facility to repair the large gap/void underneath the sink located in the main kitchen. The pest control operator observed roaches on the dishwasher and its' electrical mechanisms on March 29, 2026. A review of the pest control operator's service report for the facility dated March 18, 2026, revealed that the pest control operator noted that dietary staff are leaving the back door of the main kitchen propped open and that this would allow easy access to the building for pests and rodents. The back door of the main kitchen leads directly outdoors to the garbage and refuse area of the facility. Interview with the Nursing Home Administrator, Employee E1 at 2:30 p.m., on April 6, 2026, confirmed the pest control problems on the first floor of the facility that included the main kitchen and the first-floor nursing unit. The administrator reported that work was scheduled to install a coded door alarm for the door that opens and leads out of the main kitchen onto the loading and receiving dock. The Nursing Home Administrator said that the dietary staff would not have to prop the door open any longer. Further interview with the Nursing Home Administrator and the Director of Maintenance, Employee E3 at 3:00 p.m., on April 6, 2026, confirmed the necessary repairs of the main kitchen flooring and voids/ holes in the baseboards and walls throughout the perimeter of the main kitchen to prevent pests and rodents from entering the building to live and breed. 28 PA. Code 201.14(a) Responsibility of licensee 28 PA. Code 201.18(b)(1)(3)(d)(e)(1)(2.1) Management

Based on observation, and interview with residents and staff, the facility failed to ensure safe, clean, comfortable and homelike environment on one of two nursing floors. (Second floor)Findings Include: Review of facility policy titled Homelike Environment with a revised dated of February 2021 state, Policy Statement- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy states, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. Observations of the Second floor on March 31, 2026, between 10:15 a.m. - 10:40a.m. revealed the following: -room [ROOM NUMBER] revealed two top corners of the wall had wallpaper peeling. Behind the (window) bed was an outlet exposed due to the wall bubbling up and pushing out. Further observation of the room revealed two brown stained ceiling tiles in the room and one brown stained ceiling tile in the bathroom. -room [ROOM NUMBER] revealed one black and a brown stained ceiling tile over by the window area. -Common room revealed one ceiling tile missing and one brown stained ceiling tile. There was one large area about four inches high by two feet wide of the wall that had been patched with white spackle. The area had not been painted over. At the back of the door there was a space about seven inches high by seven inches wide that had been patched with white spackle. The area had not been painted over. During interview held with Resident R2 at 10:00 a.m. on March 31, 2026, birds kept appearing at the resident's window. When asked about it, Resident R2 said he/she has a deal with the maintenance director Employee E3 to not close up the whole she created in the screen. Resident R2 showed the surveyor an area in the screen of the window approximately three inches by three inches that was torn. Resident R2 explained that (she/he) likes to feed to the birds and the squirrels. The window was open about two inches, and the resident had a [NAME] weight blocked part of the whole in the screen. There were scrambled eggs and cereal that was on the windowsill and the outside window ledge. An interview was held with the Maintenance Director Employee E3 at 11:13 a.m. about Resident R2 having a hole in the screen of his/her window. Employee E3 stated he was unaware. The whole in the screen was observed and confirmed by the Maintenance Director Employee E3 on March 31. 2026 at 11:16 a.m. An interview was held with the Nursing Home Administrator, Employee E1 at 11:32 a.m. confirmed that he knew about a whole in the screen window of Resident R2's window and that was small so that the resident would feed the animals through. Observation was made of the second-floor nurse's station and the lighting at the nurse's station was blinking constantly. Outside of the shower room there was a piece of baseboard on the floor next to the nurse's station. There were several areas in the hallway on the walls and ceiling that had been repaired with white spackle but had not yet been painted. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on the three of three nursing units. (First, Second, and Third Floors).Findings include:A review of the Facility Policy titled Frequency of Meals last revised, March 2017 revealed Each resident shall receive at least three meals daily, at times comparable to typical mealtime in the community or in accordance with resident need, preferences and requests and the plan of care. The facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than a fourteen-hour span between the evening meal and breakfast. Under bulletin #5 & 6 further revealed Nourishing snacks will be available for residents who need or desire additional food between meals. Evening snack will be offered routinely to all residents. Timing of the snack will consider relevant factors. Residents will also be offered nourishing snack if the time span between the evening meal and the next day's breakfsast exceeds fourteen hours. Nourishing snacks are items from the basic food groups, offered either separately or with each other.On January 7, 2026, at 10:30 a.m., a resident council meeting was held with alert and oriented residents (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, and R146). The residents reported that they rarely, or never, receive a night snack. They stated that when snacks are provided, there are often not enough for everyone, or they do not receive them at all. Residents reported feeling hungry, indicating that the food provided at dinner is insufficient to sustain them until breakfast.On January 8, 2026, at 10:16 a.m., an interview was conducted with Resident R25, who reported that he/she did not receive a snack the previous night.On January 8, 2026, at 10:18 a.m., an interview was conducted with Resident R156 who reported that the last time he/she received a snack was the previous Sunday. Last night, the resident went to the nursing station to request a snack and was informed that no snacks were available.On January 8, 2026, at 10:20 a.m., an interview was conducted with Resident R154, who reported that he/she did not receive a snack the previous night.On January 8, 2026, at 10:21 a.m., an interview was conducted with Nursing Assistant Employee E9, who reported that residents are not provided snacks at night. The employee stated that if residents request additional portions after a meal, they are not available. Employee E9 also reported that food portions are small scoops of each food item served.On January 8, 2026, at 10:25 a.m., an interview was conducted with Licensed Nurse Employee E11, who works the evening shift. Employee E11 reported that during a recent evening shift, there were not enough snacks available for every resident on the floor.On January 8, 2026, at 10:31 a.m., an interview was conducted with the Dietary Director, Employee E8, who confirmed that, based on the scheduled meal times, there is a total of 14 hours and 25 minutes between residents' last dinner, served at 4:50 p.m., and the next breakfast, served at 7:05 a.m., on the first-floor nursing unit. Employee E8 stated that this time interval requires the facility to provide a nutritious snack to each resident. During the observation, dry storage contained items such as sugar cookies, fudge rounds, saltine crackers, Goldfish, and some chips, which were the items available for resident consumption at that time.The Dietary Director, Employee E8, reported that when snacks are delivered to the nursing units, a sign-off sheet is completed by nursing staff to document receipt of the snacks. A review of the snack documentation revealed no documentation indicating that snacks were delivered on the following dates: November 2, 3, 5, 8, 11, 13, 14, 15, 18, 20, 21, 25, 26, and 27, 2025. Additionally, there were no nursing staff signatures documented for the evening shift on November 6, 2025 ; December 1, 5, 13, 17, 19, 22, 25, and 26, 2025; and January 1, 3, 4, and 6, 2026.28 Pa. Code: 201.14(a) Responsibility of license

Based on clinical record review, and interviews with staff and residents, it was determined that the facility did not ensure that medication was administered according to the physician's order for one of 32 residents reviewed (R65).During an interview on January 6, 2026, at 11:30 a.m., resident R65 stated that she had recently been on antibiotic drops for an ear infection, but that she had not received multiple doses. She stated that one of the nurses informed her that the drops could not be located, but the nurse had requested a pharmacy refill. The resident stated that no one ever came back and gave her the missing doses.Review of clinical documentation revealed that resident R65 was admitted to the facility on [DATE], with diagnoses including, but not limited to, asthma, hypertension, and arthritis. Revie of clinical documents revealed that the resident was prescribed Neomycin-polymyxin-HC otic solution 3.5-10,000-1.instill 3 drop[s] in right ear four times a day for Ear Infection for 10 days, indicating a total of 40 doses of the antibiotic drops. The medication was scheduled to be given at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. starting at 5:00 p.m. on December 24, 2025, with the final dose to be given at 1:00 p.m. on January 3, 2026.Review of the Medication Administration Records (MAR) for December 2025 and January 2026 revealed that the initial two doses of the medication, December 24, at 5:00 p.m. and 9:00 p.m., had not been signed out in the MAR. Additionally, the final two doses, 9:00 a.m. and 1:00 p.m. on January 3, had been signed in the MAR with the numeric code 5, which the MAR identifies as Hold/See Progress Note.Review of the progress notes for resident R65, revealed that licensed nurse, employee E18, entered a note on January 3, 2026, at 11:00 a.m. which stated Medication on HOLD, until pharmacy delivers.Interview with the assistant Director of Nursing, employee E3, on January 9, 2026, at 10:30 a.m. confirmed that the resident had missed four doses of the antibiotic ear drops.28 Pa Code 211.9(a)(1) Pharmacy services28 Pa Code 211.12(d)(5) Nursing services

Based on observations, facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that the first floor nursing unit was adequately equipped with a functional resident call bell system for one out of the three units observed. (First Nursing Unit).Findings include:A review of the Facility Policy titled Call System, Residents last revised on September 2023revelaed Resident are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.On January 7, 2026, at 9:34 a.m., an interview was conducted with Resident R156, who reported that her call bell was not working. The surveyor tested the call bell and observed that no light was activated at her bedside or outside the room. The call bell for her roommate, Resident R25, was also tested and found not to be functioning. Nursing Assistant Employee E7 confirmed that these call bells were not working. Additional testing revealed that call bells in Rooms 125, 126, 127, 128, 130, and 131 were also not functioning.On January 7, 2026, at 9:53 a.m., an interview was conducted with Licensed Nurse Employee E7, who reported that the call bell at Bed 128B had not been working for the past two months and that the Administrator had provided a small black call bell receiver for temporary use.On January 7, 2026, at 9:58 a.m., an interview with the Unit Manager, Employee E4, revealed that she was not aware that the call bells were not functioning in Rooms 125, 126, 127, 128, 130, and 131. The Unit Manager validated that the call bells were not activating lights or delivering signals to the nursing station to notify staff.On January 7, 2026, at 10:02 a.m., an interview was conducted on the unit with the Administrator, who reported that there had been an issue with some call bells a while ago. He stated that a black call bell receiver had been provided to room [ROOM NUMBER]B until the issue could be resolved. The Administrator further reported that this was the first time he had learned of a major issue with the call bells on the first-floor nursing unit.The maintenance log for the past three months was requested and showed only three tickets related to a call bell issue in room [ROOM NUMBER] on the first floor. The Administrator stated that he plans to shut down the entire call bell system on the first floor and provide separate call bell push buttons connected to a separate black notification box at the nursing station, so staff will be notified when activated. Additionally, nursing staff will conduct 10-minute checks in every room.Further review of the call bell audits revealed that the most recent audit was conducted on September 26, 2025.On January 7, 2026, at 10:30 a.m., a resident council meeting was held with alert and oriented residents (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, and R146) who reported that call bell issues have been happening for the past a year and half and been functioning on and off.On January 8, 2026, at 10:36 a.m., an interview was conducted with Resident R156, who reported that she was given a small black call bell. However, the call bell was labeled as #17, not with her room number and bed designation. She stated that the nurses on the previous night did not have a key list to identify which resident was assigned to which call bell. As a result, her call was not answered. She also reported that she contacted the receptionist and asked to be transferred to the first-floor nursing station, but her call to the nursing station was never answered.On January 8, 2026, at 10:40 a.m., an interview was conducted with the Administrator, who reported that the nursing station does have a list indicating which residents were assigned alternative call bells. The Administrator stated that when a call bell is activated, nursing staff can identify that call bell #17 is assigned to room [ROOM NUMBER]B. The surveyor and Administrator tested several call bells to ensure they were functioning properly until the main call bell system is repaired. The Administrator also reported that the building is currently being sold to a different company and that resolution of the call bell issues, including any necessary replacements, will be deferred until the new company takes over.On January 9, 2026, at 10:58 a.m., an interview was conducted with Resident R156, who reported that the previous night she used her call bell and it was not answered. She stated that she had to call the receptionist, who then transferred her to the nursing unit desk, where her call was finally answered.On January 9, 2026, at 11:05 a.m., an interview was conducted with the Administrator and the call bell vendor, who had visited the facility a few days earlier to repair the call bell system. The vendor reported that the main call bell box currently needs to be replaced. Once the replacement is completed, they will determine whether the system will function properly or if additional repairs are required.28 Pa. Code 205.28(c)(1) Nurses' station

Based on observation, review of facility records, and interviews with staff and residents, it was determined that the facility did not maintain an adequate pest control program related to insects for three of three units reviewed (1st floor, 2nd floor, and 3rd floor). Findings Include: Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnosis including, but not limited to, malignant neoplasm (cancer) of the rectum and colon, and hypertension. Review of his most recent comprehensive MDS (Minimum Data Set- a periodic assessment of resident needs) completed on September 25, 2025, revealed the resident to have a BIMS score (Brief Interview for Mental Status- an assessment of the resident's cognitive state) of 15 out of a possible 15, indicating that he was cognitively intact. During an interview with resident R36 on January 7, 2026, at 10:45 a.m., he revealed that he often saw roaches and other insects in his room and other areas of the building. He stated that he had made the administrator aware of the problem and that pest control services had been ineffective at managing the presence of insects in the facility. Review of clinical record for resident R36 revealed that he was alert and oriented. During an interview on January 7, 2026, at 2:30 p.m., employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, were informed by surveyors of the reports of pests made during the resident council meeting. On January 7, 2026, at 10:30 a.m., a resident council meeting was held with alert and oriented residents (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, and R146), who reported seeing roaches and mice and stated that they had reported these issues to staff. On January 9, 2026, at 9:39 a.m., an observation on the third floor near the activities office revealed a live roach. This observation was confirmed by the housekeeping aide, Employee E13.

Based on observations, resident and staff interviews, and facility policy it was determined that facility failed maintain a safe, clean comfortable and home like environment for residents of one of three nursing units. (First floor and 3rd floor shower room)Findings Include:Facility Policy titled Cleaning and disinfecting Resident's Rooms last revised on August 2013 stated the purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. Housekeeping surfaces will be disinfected on regular bases and when surfaces are visibly soiled. Under bulletin #6 it stated floor mopping solution will be replaced every three resident rooms or changed no less often than at 60 minutes intervals.Observation of first floor nursing unit on January 6, 2026, 11:34 a.m. revealed there was a strong odor of urine in the hallway of the 1st unit as you get on the unit. Observation of the first-floor nursing unit on January 6, 2026, at 12:09 p.m. revealed a strong odor of urine and feces in the hallway near room [ROOM NUMBER]. The Unit Manager, Employee E4, confirmed there was a significant fecal odor and urine spilled next to bed 129A. Approximately 10 minutes later, Resident R25 arrived in her wheelchair after taking a shower and reported that her Foley catheter had leaked during the night. She stated that her bed, floor, sheets, and surrounding area were soiled and had not yet been cleaned.Observation in room [ROOM NUMBER], Bed C, on January 6, 2026, at 12:27 p.m. revealed a large pile of dried brown bodily fluid consistent with vomit next to Bed C. Nursing Assistant Employee E5 reported that a resident in Bed C vomited earlier that morning and confirmed that the area had not yet been cleaned. The affected resident was not in the room at the time of the interview. Unit Manager Employee E4 confirmed the situation and contacted the Housekeeping Director, Employee E12, who stated that he had not been notified about Rooms 128 or 129. He further reported that nursing staff are responsible for cleaning up bodily fluids and notifying housekeeping to disinfect the area afterward.On January 6, 2026, at 1:30 p.m., observations were conducted with the Housekeeping Director, Employee E12, who confirmed that the first-floor shower room, first shower stall, had a significant amount of hair on the floor, reportedly from a recent haircut. Additionally, the third-floor shower room had dirty socks left behind and a dirty towel on the floor in the first shower stall.On January 7, 2026, at 9:26 a.m., observation of the first-floor nursing unit revealed a strong odor of urine upon entering the unit. The Unit Manager, Employee E4, confirmed the odor and reported that it was coming from room [ROOM NUMBER].On January 8, 2026, at 9:48 a.m., an observation was conducted with the Administrator, Employee E1, who confirmed the presence of a urine odor and stated that it appeared to be coming from room [ROOM NUMBER]. Upon observation of room [ROOM NUMBER], a urine odor was present.28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on interviews with residents and staff, and review grievance, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns for 1 of 1 resident interviewed (Resident R145) and facility did not share the results of the grievances resolution to 15 of 15 residents reviewed during the resident council (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, R146).Findings include:On January 6, 2026, at 2:36 p.m., Resident R145 reported that his cell phone was damaged while it was lying on the heating unit in his room. He stated that he notified the Administrator a few months ago and provided an invoice for a replacement cell phone he purchased; however, his grievance had not been resolved. He further reported that he notified the Administrator again on this date and provided a second copy of the invoice.On January 7, 2026, at 10:12 a.m., grievance records dated November 10, 2025, were reviewed. The grievance stated: Resident R145 let admin know cellphone was damaged; wanted reimbursed. Cell phone cost $130 to resident. The grievance was assigned to the Administrator for investigation.On January 7, 2026, at 10:30 a.m., a resident council meeting was held with alert and oriented residents (Residents R3, R4, R12, R16, R26, R28, R59, R65, R72, R88, R112, R119, R136, R145, and R146). The residents reported that they file grievances but do not receive resolution to their grievances.On January 8, 2026, at 9:42 a.m., an interview with the Administrator confirmed that the grievance for Resident R145 had not been resolved and that the receipt had just been sent to the corporate office to request payment for the resident's cell phone. The Administrator also confirmed that residents are not notified at the conclusion of grievance investigations. This was further confirmed through review of the grievance binder, which showed that residents were not marked as having been notified of the resolution of their grievances.28 Pa. Code 201.29(a) Resident rights

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to ensure that residents were free of misappropriation of resident property related to diversion of narcotic medication for four of four residents reviewed who were prescribed narcotic medications. (Resident R36, R53, R83, R165).Findings include: Review of facility policy Controlled Substances, revised 2022, revealed controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up. The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following:Records of personal access and usageMedication administration recordsDeclining inventory recordsDestruction, waste and return to pharmacy records.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. Review of Resident R83's clinical record revealed Resident R83 was admitted to the facility on [DATE] with a diagnosis of acute kidney failure (kidneys suddenly stop functioning), candidal balanitis (infection or inflammation of the penis head caused by yeast or bacteria), and muscle wasting and atrophy. Review of Resident R83's physician's orders, dated September 28, 2025, revealed an order for Oxycodone HCL 20 mg give 1 tablet by mouth every 6 hours as needed for pain- severe. Review of facility investigation revealed on October 23, 2025 a narcotic audit was completed on P-1 unit. Resident R83's Oxycodone 20 mg medication was noted with tampering to back of blister pack. Three tablets of Oxycodone were removed and replaced with Metoprolol. This was discovered prior to administration of medication. Further audit was completed on all narcotics in the facility and there were two other narcotic diversions noted. Resident R36 Oxycodone 5 mg tabs (20 tabs) were replaced with Namenda. Resident R53 Percocet 5/325 mg (8 tabs) tampered on back of blister pack with Tylenol replacing medication. Review of Employee E14, Registered Nurse, witness statement revealed while performing random narcotic audit Employee E14 noticed a piece of tape on the blister card of oxycodone 5 mg tablet. The pill was noted to be small, round, white, and had U171 imprinted on the pill. Per google it was noted those findings were specific to the medication Namenda. The facility investigation concluded no harm was done to Resident R83, R36, and R53 and no perpetrator was identified. Review of Resident R165's clinical record revealed Resident R165 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm (cancer- abnormal growth of cells) and neoplasm related to pain (pain can arise from tumor itself or as side effects of cancer treatments). Review of Resident R165's physician's orders, dated May 21, 2025, revealed an order for Oxycodone HCL 10 mg give 1 tablet by mouth every 6 hours as needed for severe pain. Review of facility investigation revealed on May 28, 2025 a narcotic discrepancy was identified for Resident R165's Oxycodone 10 mg PO q6h PRN for severe pain x 3 days; 12 pills in total. Narcotic book was found with page struck out with verbiage, to cart P1, transferred room [ROOM NUMBER]B. Resident did not move rooms. Unit Manager performed cart audit for both front and back medication carts. Missing narcotic was not found. Review of Employee E15, Licensed Practical Nurse, witness statement revealed on May 27, 2025 I counted out the cart with the 11-7 nurse. Count was correct and all blister packs were in the narcotic box. The resident had 12 pills in the blister pack yesterday morning. This morning the whole blister pack was missing and the page in the narcotic book now reads that the medication was transferred to a different cart. Staff unable to locate the medication. Further review of facility investigation revealed the medication was discontinued on May 25, 2025, no harm was done to the resident, and perpetrator was identified. Interview on January 9, 2025 at 9:45 a.m. with Administrator, Employee E1, confirmed the above incidents were substantiated. 28 Pa. Code 201.14(a)(b) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based upon interviews with facility staff, review of clinical records, facility documentation and policy it was determined that the facility failed to ensure a complete and thorough investigation was completed to rule out neglect when one resident slipped on a wet floor and sustained a fracture for one of 32 resident records reviewed (Resident R90). Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022, states that all allegations are thoroughly investigated and at a minimum, interviews are conducted to any witnesses to the incident and/or staff members (on all shifts) who had contact with the resident during the alleged incident, and documents the investigation completely and thoroughly. Resident R90 was admitted to the facility February 2025, diagnosed with dementia. Facility documentation/investigation revealed on April 19, 2025, the resident suffered a fall that fractured the resident's humerus from a wet floor recently mopped by housekeeping. The documentation stated the Wet floor Sign was present and the resident fall occurred when ambulating to bed. Surveyor interviewed Third floor Unit Manager on January 8, 2026, at 2:30 p.m. and could not answer what the resident was doing or where he was coming from prior to the fall but did state, The resident is very spontaneous We can go into his room, and he will be taken something apart or doing something in his room. He is so spontaneous that if he was coming back from one of his walks, he may not have realized the floor was even wet or noticed that floor sign. Throughout the survey, Resident R90 was observed almost always walking throughout the third-floor unit. Attempting to interview Resident R90 found him pleasantly confused. Resident R90 said he did not remember the wet floor, the fall or healing from the fracture. The resident showed no safety awareness and appeared confused when asked what his response would be if he saw a wet floor or a wet floor sign. Interview with the Assistant Director of Nursing (ADON) a former third floor nurse of Resident R90 who said he knew the resident well stated, Even if the sign was up who is to say he would acknowledge it. The ADON who was part of the investigation and gathered witness statements was asked was the resident entering his room when he fell. ADON agreed he could not answer that question gathered from the investigation. Further review of the investigation revealed the whereabouts of the resident prior to the fall; the placement of the floor sign was not determined and the witness statement from the maintenance staff was not obtained. The investigation to rule out neglect was incomplete. 28 Pa Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility did not ensure that that professional standards of quality were met related to blood pressure management for one of 32 residents (Resident R36).Based on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility did not ensure that that professional standards of quality were met related to blood pressure management for one of 32 residents (Resident R36). Findings include: Review of facility policy Blood Pressure, Measuring, dated September 2010, revealed that Hypertension is usually defined as blood pressure over 140/90 mm/Hg . Hypotension is defined as blood pressure less than 100/60 mm/Hg . Continued review revealed that Hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day, and Hypotension should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnosis including, but not limited to, malignant neoplasm (cancer) of the rectum and colon, and hypertension. The record revealed that at the time of his admission the resident was receiving the following medications for his blood pressure: Amlodipine Besylate Oral Tablet 10 MG.Give 1 tablet by mouth one time a day for High Blood Pressure and Lisinopril oral tablet 40 MG . Give 1 tablet by mouth one time a day for High Blood Pressure. Review of blood pressure measurements for the resident revealed that on September 19th, 2025, at 9:51 a.m. the resident had a blood pressure reading of 86/53, meeting the facility definition of hypotension. No further blood pressure readings are recorded until October 7, 2025. Review of a physician progress notes for resident R36 revealed a note written by the employee E17 on September 20, 2025, at 11:30 a.m. which read BP (blood pressure) running low, d/c ed (discontinued) amlodipine, lisinopril. Review of physician orders revealed that the amlodipine and lisinopril orders were discontinued on September 19, 2025. Continued review of the resident's blood pressure record revealed the following blood pressure measurements which met the definition of either hyper- or hypotensive, and which according to facility policy, required follow-up measurements and communication with the physician: October 7, 2025, at 9:54 a.m., 142/90; on October 14 at 9:30 a.m., 141/97; on December 15 at 9:00 a.m. 166/129; on December 18, at 1:32 p.m. 143/97; on January 4, 2026, at 12:53 p.m., 95/57; on January 6, at 12:40 p.m., 142 / 100. No follow up measurements noted. Review of progress notes Revealed no indication that the physician was informed of these blood pressure readings, or that facility policy to follow up with additional measurements was followed. Interview with employee E16, the Medical Director, on January 9, 2026, at 11:45 a.m., confirmed that the staff had not complied with facility policy related to obtaining additional measurements following abnormal blood pressure reading, and reporting the results to the physician. 28 Pa. Code 211.10 (a)(c) Resident care policies28 Pa. Code 211.12. Nursing services (d)(1)(2)(3)

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that included the minimum information necessary to properly care for one of four resident care plans reviewed (Resident R162). Review of facility policy Care Plans-Baseline, revised 2022, revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:a. Initial goals based on admission orders and discussion with the resident/representative;b. Physician orders;c. Dietary orders;d. Therapy services;e. Social services; andf. PASARR recommendation, if applicable.Review of Resident 162's clinical record revealed Resident R162 was admitted to the facility on [DATE] with a diagnosis of surgical aftercare following surgery on the circulatory system, hypertension, and pain. Review of Resident R162's care plan revealed Resident R162's baseline care plan was not developed until January 06, 2025 and only addressed Resident R162's nutritional status. Interview on January 9, 2025 at 10:00 a.m. with Employee E3, Assistant Director of Nursing, confirmed Resident R162 did not have a baseline care plan completed within 48 hours of admission. 28 Pa. Code 211.10(d) Resident care policies

Based on review of clinical records, interviews with staff and review of facility documentation revealed the facility failed to give one resident diagnosed with Alzheimer Disease and a history of wandering adequate supervision when found in a restricted area for one of 32 residents (Resident R129).Findings include:Review of Resident R129 clinical records revealed the resident was admitted to the facility diagnosed with Alzheimer disease (a form of dementia with cognitive decline) and a history of wandering in the facility.Nursing note dated September 8, 2025, indicated Resident R129 was witnessed to have retrieved a urine specimen from the specimen fridge and sipped it.Nursing was reeducated on the facility's policy related to Hazardous Areas, Device and Equipment revied in July 2017. Policy defines a hazard as Anything in the environment that has the potential to cause injury or illness .and Open areas or items that should be locked when not in use. Furthermore, the same policy indicates assessment and analysis of hazardous area and equipment will include resident-specific information including identification of vulnerable residents.Interview with the Third floor Unit Manager on January 8, 2026, at 2:00 p.m. explained an aide used the biohazard room where we keep the dirty linen and the refrigerator that stores all the urine samples in the facility. The door locks automatically when you shut it, but it was not shut all the way and left open. The resident was able to get into the room, open the unlocked refrigerator to find the urine samples and drank from one. We now have a lock on the fridge.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Findings Include: A review of the Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows Beginning on ., the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay.Review of facility documentation revealed Resident R1 was provided with a notice of Medicare non-coverage that indicated Medicare coverage for facility services would end on September 16, 2025. Resident R1 remained in the facility status post termination of Medicare coverage. Review of facility documentation revealed Resident R2 was provided with a notice of Medicare non-coverage that indicated Medicare coverage for facility services would end on October 17, 2025. Resident R2 remained in the facility status post termination of Medicare coverage. Review of facility documentation revealed Resident R3 was provided with a notice of Medicare non-coverage that indicated Medicare coverage for facility services would end on October 21, 2025. Resident R3 remained in the facility status post termination of Medicare coverage.Continued review of documents provided by the facility revealed no documented evidence Resident R1, R2, and R3 were provided with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN; Form CMS-10055) to notify the residents and/or Representative of the cost of the facility's items and services no longer covered under Medicare. Interview on October 29, 2025, at 12:30 p.m. with the Nursing Home Administrator, Employee E1, confirmed Resident R1, R2, and R3 were not provided with the SNF-ABN Form CMS-10055. 29 PA. Code 201.14(a) Responsibility of licensee

Based on interview with staff, it was determined that the facility failed to provide a copy of a resident's medical and financial records upon request by the resident one of one clinical record reviewed. (Resident R1)Findings include:A review of the clinical record revealed that Resident R1 had a care conference on June 2, 2025. During an interview with Resident R1 on August 28, 2025, at 10:38 a.m., it was confirmed that a request had been made for the full medical and financial records.On August 28, 2025, at 12:30 p.m., an interview with the Administrator, Employee E1 revealed that a meeting had been held a few weeks ago with Resident R1 and their family, during which Resident R1 requested a copy of their medical and financial records. These records were never provided to Resident R1. The Administrator confirmed that a full set of medical and financial records had not been given. It was further revealed that the medical record department is in the process of making a copy of the records to provide to Resident R1 as of today.A further interview with Employee E1 on August 28, 2025, at 4:10 p.m. revealed that there was no written documentation in the clinical record indicating that the facility had provided any medical or financial records to Resident R1.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(2) Management

Based on clinical records reviewed and staff interview, it was determined that the facility failed to ensure that a resident's urinary catheter's bag was maintained in sanitary condition for one of one resident reviewed. (Resident R1) Findings include:A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of pressure ulcer of sacral stage 4 (ulcer involving full thickness of skin loss), urinary tract infection, klebsiella pneumoniae (gram-negative bacterium commonly found in the intestine of humans which causes unitary [NAME] infections, pneumonia, bloodstream infections).A review of the physician orders dated May 8, 2025, revealed an order for a supra pubic urinary catheter 20 fr (french) 30 ml (milliliters) for obstructive and reflux uropathy (blockage of the urinary track).During an interview with Resident R1 on August 28, 2025, at 10:38 a.m., it was noted that the resident's urinary catheter's leg bag was lying on top of the sink in the resident's room in an unsanitary condition.On August 28, 2025, at 11:42 a.m., an interview with Unit Manager, Employee E4, confirmed that the resident had an unsanitary urinary catheter's leg bag lying above the resident's sink.28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that the facility was adequately equipped resident call system for the second floor nursing unit, 7 out of 7 residents reviewed (Resident R1, R2, R3, R4, R5, R6 and R7).Findings include:Review of information submitted to the State Survey Agency on August 4, 2025 indicated that the resident call system at the facility was not working properly, and that some residents had to yell for help. The information submitted also indicated that the facility provided hand-held silver bells for residents to use to shake when they need help, and that such bells cannot be heard from a distance. During interview with Resident R1 and Resident R2's room on August 21, 2025 at 10:20 A.M. both residents reported that their call bells have not worked for quite some time. Resident R1 and Resident R2 reported that they have to yell for help because staff cannot hear them when they ring the silver handheld bells. Resident R1's call bell was not observed in her room during the above referenced observation. When asked where her silver hand held call bell was, she reported that it was gone and stated that someone took it. Resident R2's call bell was out of her reach on a dresser that was across from her bed. She stated, look where they put it. I can't reach over there.' When Resident R1 and Resident R2's call bell system was tested it was found to be non- functional. Observations and testing of resident call system with the maintenance staff, Employee E5 on August 21, 2025, at 11:25 a.m. confirmed that the call system in the resident room or bathroom for Resident R1 and Resident R2 was not working. Observation of Resident R3 on August 21, 2025 at 11:50 a.m. revealed that the resident had a wireless call bell system that was purchased by the facility due to the original facility installed wired call bell system in the resident's room not working. The call bell system transmitted was attached to a black lanyard where is hung on his bed. The wireless call bell system had a digital display screen that was observed at the nursing station. When the wireless call bell transmitter was pressed, the notification can only be heard if you are at the nursing station when the system calls out the room number requesting help. With the above referenced wireless system, facility nursing staff do not have functioning devices in their possession that will notify them of a resident's need for assistance if they are not at the nursing station. No working call light system in the bathroom for Resident R3 was also observed. Observation conducted of Resident R4 and Resident R5 on August 21, 2025 at 11:56 a.m. room also had the above referenced wireless system that worked in the same manner as noted above. No working call light system in the bathroom was observed for Residents R4 and R5. Observation of Resident R6's room on August 21, 2025 at 11:59 a.m. revealed a call bell indicator did not light up above his room when tested, and there was a faint volume at the nursing station. Observation of Resident R7' call bell on Augsut 21, 2025 at 12:05 p.m. revealed that the resident's call bell did not work and the resident was provided a silver hand held bell to ring for assistance. During an interview with Nursing Home Administrator (NHA) on August 21, 2025 at 1:00 p.m. the NHA reported that there have been problems with the facility call bell system on the facility's second floor and some of the first floor due to the system being old and the parts are not able to be replaced. 28 Pa. Code 205.28(c)(1) Nurses' station

Based on the review of clinical records and interviews with staff it was determined that the facility failed to ensure a complete and thorough investigation was conducted into a resident's allegation of a fall for 1 out of 2 residents reviewed (Resident R1)Findings include:Review of the August 2025 physician orders for the resident included diagnosis that included hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia ( a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality , disorganized thinking or behavior, and flat or inappropriate affect) and substance abuse. Review of a nursing note dated April 5, 2025 at 3:05 p.m. indicated Resident reports falling last week, she states she dose[sic] not remember the day but it was approximately Tuesday at 5am when she fell. She reports slipping on water at left bed side while attempting to walk to wheelchair, hitting her head when she fell. She stated that nursing supervisor and nurse transferred her back to bed. She complains of pain 5/10 to right side of head. [Physician] notified N/o (new order) to obtain x-ray of skull and c-spine. Resident is own responsible party. Review of the resident's clinical record did not show any documented evidence of falls of the entire month of March 2025. During an interview with the Assistant Director of Nursing (ADON) on August 22, 2025, at 11:15 a.m. it was confirmed with the ADON that there was no investigation into the resident's alleged reported fall as communicated by the resident to nursing staff.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights.

Based on staff interviews, review of facility policy and the review of facility documentation, it was determined that the facility failed to ensure that one resident had a physician's order for a leave of absence from the facility for 1 out of 2 residents reviewed (Resident R1).Findings include: Review of the facility policy, Signing Resident' s Out-LOA (Leave of Absence), with a revision date for August 2006 indicated that each resident leaving the premises (excluding transfers and discharges) must be signed out. Review of Resident R1's August 2025 physician orders included the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia (a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality , disorganized thinking or behavior, and flat or inappropriate affect, and other psychoactive), and substance abuse. Review of nursing note dated March 6, 2025 at 9:30 a.m. indicated that the resident out of the facility on a leave of absence visit with her sister with plans to return to the facility in the afternoon. Review of a the physician's note dated March 12, 2025 at 5:41 p.m. stated that the resident had a LOA over the weekend and that the resident had returned to the facility. Review of the resident's August 2025 physician orders did not include a physician's order for the resident to leave the facility on a leave of absence. During an interview with the Nursing Home Administrator (NHA) on August 22, 2025 at 12:28 p.m. it was discussed that the resident had at least two LOA's in March 2025, but there was no physician's order approving the resident's absences from the facility.28 Pa. Code 211.12 (c) Nursing Services28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on the review of clinical records, it was determined that the facility failed to ensure that a person-centered plan of care was developed for a resident with a history of substance abuse for 1 out of 2 residents reviewed (Resident R1).Findings include:Review of Resident R1 August 2025 physician orders revealed the diagnoses of hypertension (high blood pressure); cerebral infarction (a stroke); arthritis; history of falling; diabetes (a group of common endocrine diseases characterized by sustained high blood sugar levels); schizophrenia ( a mental disorder characterized variously by hearing voices, having false beliefs that conflict with reality, disorganized thinking or behavior, and flat or inappropriate affect) and substance abuse. Review of the resident's person-centered plan of care included a plan of care dated July 18, 2023, stating that the resident admitted to smoking drugs in her room. Interventions included the use of a smoke detector in the resident's room, restricting the resident's leave of absence visits on a temporary basis, and supervised visitation. Review of a physician's note dated November 15, 2024, at 4:42 p.m. documented that a crack pipe (drug paraphernalia used to smoke crack cocaine) was found in the resident's room. During an interview with the nursing supervisor on August 22, 2025 at 11:53 a.m. revealed that she conducted a room search with the Nursing Home Administrator (NHA) on November 15, 2024 during her 3:00 p.m. through 11:00 p.m. nursing shift and that a crack pipe was found in bags that in the resident's room. The nurse supervisor reported that the resident was asked if she had ever used the crack pipe in the past and the resident reportedly responded, I guess I did now. The nurse supervisor continued the interview and stated that some time last week or the week before, she found what she described as crack cocaine that was stored in a lip balm tube that had been cleared of its original contents inside. Nurse supervisor reported that the resident pulled the lip balm tube from her bra, the resident opened it and said see to the nurse supervisor. The Nurse supervisor stated that she saw white rocks in the lip balm tube that she showed the nurse supervisor The nurse supervisor reported that she told the resident, that's crack in there, which then the resident closed the lip balm tube up and put it back in her bra. The nurse supervisor reported that she did not take what she thought was crack cocaine in the lip balm tube because another nurse on the shift that she was working told her that she would need a search warrant. During an interview with the NHA on August 22, 2025 at 12:38 p.m. the NHA confirmed the room search with the nursing supervisor was conducted with the resident's permission. The NHA reported that a crack pipe was found, taken out of the resident's room, and that he told the nurse supervisor to go back and resume her regular duties after the room search. Review of a physician's visit note dated October 24, 2024 documented the concern of cocaine and that cessation was strongly encouraged. The physician's note also indicated that the resident will require close monitoring for signs and symptoms of drug abuse, which places the resident at significant risk.#Concern cocaine abuse infacility - Strongly encourage cessation. Pt will require close monitoring for s/s drug abuse which places pt at significant risk. Review of the person-centered plan of care and clinical record did not show evidence of a detailed plan of care that included interventions to prevent the resident's possession of drugs and drug paraphernalia and a plan of care to address supervision of the resident who has a history of substance abuse, and recently suspected of having drug paraphernalia that was taken from her, and suspected drugs in her possession. During a discussion with the NHA and the Director of Nursing (DON) on August 22, 2025 at 2:30 p.m. it was discussed that the resident's care plan did not include detailed interviews for resident supervision and interventions to prevent the resident from obtaining drugs and drugs paraphernalia. 28 Pa Code 211.11(d) Resident care plan28 Pa. Code 211.12(c(1) )Nursing services28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews, the review of clinical records, and the review of facility documentation, it was determined that the facility failed to provide adequate staff supervision and monitoring to Resident R1 who was found to have a alcohol bottles in the resident's room. The facility's failure to provide adequate staff supervision and monitoring to Resident R1 with a history of storing and consuming alcohol resulted in Immediate Jeopardy to Resident R1 who sustained a fall, required transfer to the hospital and was diagnosed with a fracture hip for one of three residents reviewed. (Resident R1). Findings include: Review of the September 2024, physician orders for Resident R1 revealed the diagnoses of arthritis; hypertension (high blood pressure); bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy); depression (major loss of interest in pleasurable activities), and repeated falls. Review of the nursing notes from May 1, 2024, through September 5, 2024, revealed that the resident sustained five falls. The falls occurred on: May 4, 2024, August 3, 2024, September 3, 2024, September 4, 2024, and September 5, 2024. Review of a nursing note dated May 4, 2024, at 11:09 p.m. indicated that the resident's nurse aide notified nursing staff that the resident had an unwitnessed fall in her room on the above referenced date at approximately 8:14 p.m. The note documented that the resident initiated a transfer from her bed, slid to the floor instead, and was found lying on her side in her room by the nurse aide. Review of the nursing notes dated May 7, 2024, at 1:50 p.m. indicated that the resident was seen by a nurse practitioner for the fall that occurred on May 4, 2024. The nurse practitioner documented that nursing reported to the nurse practitioner that the resident had a fall over the weekend (May 4, 2024) due to possible alcohol intoxication. Continued review of the nurse practitioner's note indicated that the resident admitted to the nurse practitioner on May 7, 2024, that she consumed alcohol on the day of fall. Patient admits to intake of alcohol on the day of the fall. Nursing staff who worked during the shift on which the resident's fall occurred (3:00 p.m. through 11: 00 p.m.) and the nurse practitioner were no longer employed by the facility, and they could not be reached for an interview. Review of Resident R1's Psychological Services note dated May 31, 2024, indicated that the licensed clinical social worker (LCSW) documented the unit nurse manager met with the LCSW on May 31, 2024, regarding the concern of Resident R1 having an increase in falls and alcohol consumption. The unit nurse manager met with the clinician regarding concern with [Resident R1]. The manager expressed increase falls and alcohol consumption. Continued review of the resident's encounter notes with the LCSW indicated that the resident denied alcohol use and contributed her falls to her health conditions.clinician agreed to follow up . Review of a nursing note dated August 3, 2024, at 12:10 a.m. documented that the resident had a witnessed fall while transferring from her bed to the wheelchair next to her bed. The note indicated that the wheels were unlocked on her wheelchair and that the resident fell in view of staff, and before staff could get to the resident. No further information was documented about this fall. Review of a nursing noted dated September 3, 2024, at 7:24 p.m. written by Employee E3 (licensed nurse) stated that the resident was found on the floor next to her bed. Employee E3 (licensed nurse) documented that the resident told him that she was trying to get into her wheelchair and fell . Review of the incident report completed by the licensed nurse indicted that the resident was placed back in her bed, encouraged to use the call bell, and wear the proper shoes while transferring. Review of a nursing note from Employee E4 (licensed nurse) on September 4, 2024, at 1:27 a.m. indicated that she found a bottle of vodka (1.5 L) underneath the resident's bed. Licensed nurse documented that she removed the bottle from the resident's bed and gave it to the nursing supervisor (Employee E5). During an interview with Employee E4 on September 14, 2024, at 11:27 p.m. licensed nurse reported that she relieved Employee E3 and started her shift on September 3, 2024, at 7:00 p.m. and it ended on September 4, 2024, at 7:00 a.m. Licensed nurse, Employee E4 reported that she was alerted by Resident R1's roommate that Resident R1 had a fall and was lying on the side of her bed. Licensed nurse, Employee E4 reported that she went in the room with the resident's nurse aide, asked the resident if she was in pain, obtained her vitals, which the licensed nurse reported were within normal limits. Licensed nurse, Employee E4 reported that both she and the nurse aide assisted the resident off the floor and back into her bed. Licensed nurse, Employee E4 reported that the nursing supervisor (Employee E5) told her to write a note and that he would follow-up with the Director of Nursing (DON) and the Nurse Practitioner in the morning. Licensed nurse Employee E4, reported that the bottle that she retrieved from underneath the resident's bed was a 1.5-liter bottle of vodka that was half empty. The licensed nurse, Employee E4 stated during the above interview, I knew something was not right with her because she was not herself, and she was laughing, and she did not recognize me. During an interview with the nursing supervisor, Employee E5 on September 14, 2024, at 11:50 p.m. the nursing supervisor reported that he worked from 11:00 p.m. starting on September 3, 2024 through 7:00 a.m. on September 4, 2024. Nurse supervisor was asked about the fall that the resident sustained on September 4, 2024. The nurse supervisor reported that he was only aware of the one fall. Continued interview with nursing supervisor indicated that nursing supervisor reported during the interview that Employee E4 (licensed nurse) did give him a bottle of vodka that was half empty close to the end of his shift (7:00 a.m.) as he was giving report to the Nursing Supervisor (Employee E6) for the 7:00 a.m. shift. Nursing supervisor reported that Employee E4 (licensed nurse) told him that she found the bottle in Resident R1's room. Nursing supervisor reported that he took that bottle to the Director of Nursing (DON) as he was leaving out and told the DON that it was found in Resident R1's room during his shift. Employee E4 (licensed nurse) reported that the Nursing Supervisor (Employee E6) for the 7:00 a.m. shift also accompanied him when he gave the bottle to the Director of Nursing (DON) in her office. Review of a note written on September 5, 2024, at 11:24 a.m. by Employee E7 (licensed nurse) indicated that the resident's nurse aide came to licensed nurse at 7:10 a.m. and informed the licensed nurse that the resident was sitting on the floor next to her bed. The note indicated that the licensed nurse went to the resident's room and the resident reported that her bed, was broken and that she fell twice the day before. The corresponding incident report indicated that the resident reported that she slid out of bed. The incident report documented that the resident was assessed and was subsequently sent out to the hospital on September 5, 2024, after complaining about hip pain. During an interview with Employee E7 (licensed nurse) on September 14, 2024, at 12:00 p.m. the licensed nurse reported that 2 nurses found 3-6 bottles of alcohol in the resident's room after she was transported to the hospital. There was no information in the above referenced incident report that was reviewed indicating that any bottle of alcohol were removed by nursing staff after the resident's fall. During an interview with Employee E7 on September 14, 2024, at 12:00 p.m. Licensed nurse reported that she was the charge nurse on the unit when the resident had a fall on September 5, 2024, and was sent out to the hospital. Licensed nurse reported that she entered the resident's room and the resident reported that the sides of her bed were broken, and that she was trying to get up to got to the bathroom, or something like that, as the licensed nurse stated. Licensed nurse also reported that the resident told her that she also had two falls the day before. Licensed nurse reported that she assessed the resident once she entered the room, and that afterwards, both she and the nurse aide assisted the resident from the floor and into a chair. Licensed nurse reported that the nurse aide for the resident reported that this happened yesterday and the nurse aide explained that nursing staff found alcohol in the resident's room the day prior. Licensed nurse reported that 2-3-unit managers came to the unit to assist with the fall that the resident had in her room. Licensed nurse reported that the resident was assessed by the nurse practitioner (Employee E8) and was subsequently sent out to the hospital due to resident complaining about hip pain during the nurse practitioner medical assessment. Review of a nursing note dated September 5, 2024, at 6:18 p.m. documented that the resident returned from the hospital with a diagnosis of Greater Trochanter fracture due to fall (Greater Trochanter part of the hip and the upper femur/thigh bone). During an interview with the facility's Medical Director (Employee E9) on September 12, 2024, at 2:42 p.m. it was reported that he was called by a nurse at the facility on September 5, 2024 who informed that someone found 5-6 empty bottles of alcohol in the resident's room. The Medical Director reported that he told the nurse that he will speak with the resident regarding the alcohol when he comes into the facility this week. The Medical Director reported that when he came into the facility on [DATE], he spoke with the resident regarding the empty bottles of alcohol in her room and asked her who gave her the bottles. The Medical Director reported that when he asked her the question regarding how she is obtaining the alcohol, the resident told him that a friend brings in a box of food supplies to her. The Medical Director reported that the resident did not directly state that the alcohol was in the box of food supplies that she stated that she received from her friend, but the Medical Director reported that although she did not state this, it was implied that the friend is supplying her with the alcohol. During an interview with Employee E10 (Unit Manager on 1st floor) on September 14, 2024, at 1:54 p.m. Unit Manager reported that on September 5, 2024, both she and the nurse practitioner, Employee E11 (Unit Manager from the 3rd floor) and the nursing supervisor (Employee E6) were on the 2nd floor when someone call the DON to notify her that Resident R1 fell . Employee E10 reported that they, the nurse practitioner, the unit manager for the 3rd floor and the nursing supervisor all went on the unit to the resident's room. Employee E10 reported that the resident told them that she fell in the bathroom. Employee E10 reported that the nurse practioner sent her out to the hospital after she assessed the resident, and she screamed in pain when she asked the resident if she could flex a foot. Employee E10 reported that she then went back to her own unit. During an interview with Employee E11 (Unit Manager for 3rd floor) on September 14, 2024, at 1:54 p.m. the unit manager reported that both she and the nursing supervisor (Employee E6) were the 2 nurses who found the 3 empty alcohol bottles in the resident's room after the resident left for the hospital on September 5, 2024. Unit Manager reported that both she and the nursing supervisor took the 3 empty bottles of alcohol to the Director of Nursing (DON) office and gave them to her. Review of the Psychiatric Evaluation and Consultation dated September 11, 2024, documented the nurse practitioner's visit with the resident on the above referenced date. The note documented that nurse practitioner's notification by nursing staff of the resident's fall and nursing staff's report that the alcohol was found in the resident's possession and staff concern that the resident's falls are related to her alcohol consumption. Continued review of the notes documented that during this session the resident told the nurse practitioner that she drank 2 shot glasses as needed and would not tell the nurse practitioner how she obtained the alcohol: .Pt reported drinking only 2 shot glasses as needed but won't tell how she obtained the alcohol. There has been a few other instances where alcohol was found, and staff believe the falls are related to her being drunk. During an interview with the Director of Nursing (DON) on September 14, 2024, at 4:12 p.m. the DON reported that she was unaware of the falls that the resident had in May 2024, or concerns that the staff had that the resident's falls could be attributed to alcohol use. During the above interview, the DON reported that she was aware of the falls that the resident had on September 3, 2024, and on September 5, 2024. The DON reported that she not aware of the documented fall that the resident had on August 3, 2024 or the documented fall that the resident had on September 4, 2024 with charge nurse (Employee E4). During an interview with the DON on September 15, 2024, at 4:20 p.m. the DON reported that she was provided with 1 bottle of alcohol on September 4, 2024 (prior to the resident's fall with injury on September 5, 2024), that was given to her by the night nursing supervisor (Employee E5) and the day nursing supervisor (Employee E6). The DON reported that she disposed of the bottle down the drain in the laundry room. The DON was asked during the interview what did she do to address the issues of the bottle of alcohol that was found in the resident's room by nursing staff after they brought it to her attention, and she responded nothing. The facility failed to provide adequate staff supervision and monitoring to Resident R1 who was found to have alcohol bottles in the resident's room. The facility's failure to provide adequate staff supervision and monitoring to Resident R1 with a history of storing alcohol in her room and consuming alcohol resulted in Immediate Jeopardy to Resident R1 who sustained a fall and was diagnosed with a hip fracture. Based on the above findings, an Immediate Jeopardy was identified to the Nursing Home Administrator on September 13, 2024 at 11:25 p.m. The immediate jeopardy template was provided to the Administrator and an immediate action plan was requested. On September 13, 2024, at 4:14 p.m. the facility provided the following corrective action plan: -A facility sweep was completed on 9/12/24 on the 3-11 shift to ensure no residents have any illegal substances or alcohol was in their possession at that time. Permission was granted for all room searches. No other illegal substances or alcohol were found within the resident rooms. -ROBO call was made to all families on 9/13/24 to remind them, not to bring in any illegal substances or alcohol into the facility. -New admissions to the facility will be reviewed by Social Services to identify any history of or active use of illegal substances or alcohol to identify interventions to ensure the safety of the resident. -If current residents are identified to be in possession of an illegal substance or alcohol, the physician and family will be notified and interventions will be implemented to ensure their safety and supervision. -All staff are being educated on steps to address when alcohol is found in a resident room and what steps to take to ensure the safety of the resident at that time. Education was completed for staff working in the building on 9/13/24. -Education will continue until all staff have been in serviced on the safety of residents. -Residents attending a facility outing will be educated on not purchasing any illegal substance or alcohol on a facility outing prior to the outing. Resident purchases will be closely monitored by the supervising staff to ensure that no illegal substances or alcohol has been purchased during the outing. -The policy regarding supervision to prevent accidents with the use of illegal substances and alcohol was updated. All staff in the building will be educated today 9/13/24, or prior to encountering any residents. -A random audit will be conducted to ensure staff understand the above education. These audits will continue weekly x 3 and monthly x 3 months. -The facility will continue to conduct random audits of resident rooms per resident permission to ensure that there are no illegal substances or alcohol in the resident rooms. These audits will continue daily x 5 days, weekly x 3 and monthly x 3. -The facility activities staff will conduct an audit during the facility outing to ensure residents have not purchased illegal substances or alcohol during the facility outing, weekly x3 and monthly x3. -Audit results will be reviewed at QAPI (Quality Assurance Performance Inprovement Plan) X 3 months. Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on September 15, 2024, at 4:33 p.m. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plans

Based on clinical record reviews, observations, interviews with staff, review of policies and review of hospital records, it was determined that the facility failed to adequately supervise one of three residents reviewed who exhibited wandering behaviors (Resident R1). The lack of supervision resulted in actual harm to Resident R1 who was found by the police wandering outdoors, transported to the local hospital, and diagnosed with [REDACTED]. This was identified as a past non-compliance Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Wandering and Elopements, dated March 2019, indicated that it was the responsibility of the facility staff to identify residents who were at risk for wandering and possible elopement, and develop a care plan with strategies and interventions to maintain a safe environment for each resident. Review of a physician's progress note dated December 7, 2020, indicated that Resident R1 had a [DIAGNOSES REDACTED]. The physician documented that the resident had chronic psychiatric illness with [DIAGNOSES REDACTED]. The disorder affects a person's ability to think, feel and behave clearly). Review of Resident R1's wandering risk scale dated December 31, 2020, completed by licensed nursing staff, Employee E29 determined that Resident R1 was at high risk for exhibiting wandering behavior. Employee E29 documented that this resident was ambulatory, had a history of [REDACTED]. Review of nurses' progress notes, dated January 3, 2021, at 9:40 p.m. revealed that Resident R1 did not receive his evening medications and treatments as scheduled because he was not in the building. Nurse's note, dated January 4, 2021, at 12:19 a.m. indicated that the resident was last seen at approximately 10:00 a.m. on January 3, 2021, and that when the nurse went into his room at approximately 1:00 p.m. to administer a nutritional supplement the resident was not in his room. The note continued that the nursing supervisor reported that the resident was found at the hospital. The note further indicated that the resident did not receive any afternoon medications and that no Wanderguard was in place for the resident. Review of the next available nursing note dated January 4, 2021, at 7:07 a.m. revealed that the resident was placed on 15 minutes checks for elopement. During an interview on February 10, 2021, at 1:06 p.m. Employee E16, licensed practical nurse, confirmed that she was the nurse assigned to Resident R1 on January 3, 2021. Employee E16 stated that when she went to give the resident his afternoon supplement that he was not in his room. Employee E16 stated that this was nothing unusual and continued with her afternoon medication pass. Employee E16 stated that she did not think to look for the resident at that time and that she was not aware that he had eloped from the facility until she was notified by the nursing supervisor. Review of Resident R1's hospital records revealed that on January 3, 2021, at 1:30 p.m. Resident R1 was brought to the hospital emergency room by the fire rescue after being found by the police wandering outdoors. The resident was confused, and the skin was cool. Review of the physician's notes revealed that the resident demonstrated evidence of hypothermia (the condition of having an abnormally low body temperature, typically one that is dangerously low). Further review of hospital records revealed that the hospital staff contacted the facility to inform them that the resident was at the hospital and was being treated with warm blankets. Further review of the hospital report noted that hospital staff spoke with the facility's nursing supervisor who indicated at the time not being aware that the resident had eloped from the facility. Transportation was then arranged for Resident R1 to return to the facility. Continued review of Resident R1's hospital records revealed an, Emergency Flow Sheet Record dated January 3, 2021, at 1:22 p.m. which confirmed that the resident body temperature was 95.4 degrees Fahrenheit (normal body temperature range is typically 97.7-99.5 °F). Interview with the Nursing Home Administrator (NHA) on January 29, 2021, at 10:00 a.m. revealed that the facility staff were unaware that Resident R1 had exited the facility and was wandering outdoors. The Nursing Home Administrator confirmed that Resident R1 was not observed by staff responsible for his care during the noon meal service. Facility staff were unaware of Resident R1's whereabouts until a call was received from the hospital emergency room at 1:30 p.m. on January 3, 2021. The NHA communicated that the facility staff had last observed Resident R1 at 10:30 a.m., on January 3, 2021. This was three hours and 15 minutes before the resident was brought to the local hospital which was located twelve miles from the facility. Review of a written statement by the NHA revealed that in reviewing the facility's security cameras it was confirmed that Resident R1 exited the facility through the 1st floor at approximately 11:30 a.m. on January 3, 2021. Review of Resident R1's care plan revealed that on November 20, 2020, a care plan was developed related to the resident's impaired thought processes related to Dementia. Interventions included for staff to cue, reorient and supervise as needed as well as maintain a consistent routine to decrease confusion. Further review of Resident R1's care plan revealed that no care plan was developed related to the resident's wandering or risk for elopement until January 3, 2021. The resident's care plan was updated on January 4, 2021, to include a Wanderguard device and again on February 1, 2021, for 1:1 staff supervision. Observation of Resident R1 at 10:30 a.m. on January 28, 2021, revealed that the resident was in his bedroom and was on one to one monitoring by nursing staff, Employee E29. Observations were made of Employee E29 demonstrating the use/functioning of the personal alarm that had been placed on the resident's right ankle. Employee E29 reported that Resident R1 was on one to one observation, at all times, because Resident R1 was at high risk for wandering. Employee E29 also reported that Resident R1 had eloped from the facility on January 3, 2021. Interview with the NHA on January 29, 2021, at 11:00 a.m. revealed that the facility uses a personal alarm system as an assistive device for residents who were identified at risk for wandering behavior. Follow-up interview on February 20, 2021, at 10:30 a.m. the NHA and the Director of Nursing (DON) stated that Resident R1 did not have any previous attempts to leave the nursing unit and did not have a Wanderguard because they did not think he would try to leave. The NHA and the DON could not explain why the resident had been assessed as being at high risk for wandering but had no interventions in place to prevent elopement. An Immediate Jeopardy situation was identified to the NHA on February 10, 2021, at 4:40 p.m., and the IJ template was provided to the NHA, related to Resident R1's elopement from the facility that occurred on January 3, 2021. The Immediate Jeopardy was identified as a past non-compliance for the elopement incident of January 3, 2021. The NHA and the DON stated that they immediately initiated corrective actions as soon as they became aware of Resident R1's elopement on January 3, 2021, including reassessing every resident for wandering risk, adding Wanderguard devices and other interventions for residents identified as at risk, ensuring that all security systems were properly functioning and educating staff on elopement procedures. A corrective action plan was requested from the NHA to address the risk for elopement to residents identified at risk for elopement since January 3, 2021. The corrective action plan submitted by the facility included: 1. Entrances and exits of the facility were checked immediately by maintenance, as well as previous and ongoing daily checks to ensure proper closure and security features were functioning. No issues were found. Completed January 3, 2021. 2. Head count performed immediately by staff on duty to ensure other residents present and accounted. Completed January 3, 2021. 3. Resident R1 was returned to the facility on [DATE], at 11:05 p.m. and assessed by a licensed nurse. A Wanderguard was applied to Resident R1's right ankle. The resident was also placed on every fifteen-minute checks. On January 4, 2021, the resident was placed on one-to-one supervision and continues to remain on one-to-one supervision. The one-to-one will be re-evaluated weekly for continued support as needed. 4. Current residents' wander risk scores were checked initially on January 3, 2021, along with care plans, physician orders and cross referenced to the elopement book. Residents were re-evaluated for wandering risk and additional audits were completed on January 29, 2021, and February 6, 2021, by the nursing management team. Resident R2 refuses to wear a Wanderguard; alternate interventions were developed and initiated to include every fifteen-minute checks. Residents at risk of wandering were checked to ensure Wanderguard transmitters were in place and functioning. 5. Wanderguard controllers were checked to ensure proper functioning and on-going daily checks by licensed nurses. Initial check completed January 3, 2021, and ongoing. 6. Wanderguard controller and door security codes were changed and provided to key staff only by maintenance. Completed January 3, 2021. 7. Security codes will be changed monthly by maintenance, by end of each month and with any suspected breach. 8. An audit was developed to ensure residents who present with an elopement risk are provided a plan of care and safe environment. Anyone who was at risk intervention was determined, care plan was updated. Audits will be completed twice per month for three months then monthly for three months. Audits already completed on January 3, 2021, January 29, 2021, and February 6, 2021. Results of audits will be reviewed monthly at QAPI meeting. 9. New wander risk assessments will be reviewed by the IDT team in daily clinical meeting to ensure residents identified at risk for new admits and changes have appropriate plan of care in place. Initial review completed January 3, 2021, and ongoing daily. 10. The NHA updated the elopement policy to include no use of stair tower doors and elopement procedure and in-serviced active facility staff and is included in new hire/agency orientation, all departments, not to use stair tower doors or stairs. Started January 3, 2021, completed January 4, 2021. 11. New evidence-based practice assessments for elopement evaluation, creates a structured progress note and includes suggestions for interventions, and compares to prior assessments and indicates changes. This upgrade was purchased on July 16, 2020, facility go-live date is February 16, 2021, to replace the current wander risk assessment. Licensed nurses will be inserviced on February 11, 2021, February 12, 2021, and February 15, 2021, by interim Assistant Director of Nursing, Regional Clinical Services and the DON from sister facility. The implementation of the above stated action plan was confirmed on February 11, 2021, at 2:30 p.m. verifying the Immediate Jeopardy situation was corrected on January 4, 2021. 28 Pa. Code: 201.18(a) Management 28 Pa. Code: 201.18(b)(1)(3)(d) Management 28 Pa. Code 201.18 (b)(3)(d) Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan

APPEALED FILED Based on review of facility policy, clinical records and facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to Resident R1 which resulted in actual harm to Resident R1 sustaining two fall incidents, requiring transfer to the hospital and [DIAGNOSES REDACTED]. Findings include: Review of facility policy Falls-Clinical Protocol, dated revised (MONTH) (YEAR), stated that the staff and physician would identify pertinent interventions to try to prevent subsequent falls, and to address the risks of clinically significant consequences of falling. Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. fear and worry), [MEDICAL CONDITION] (a mental disorder characterized by disconnection from reality which results in strange behavior often accompanied by perception of stimuli, such as voices, images, sensations, and other hallucinations); dementia (a group of symptoms that together affect the memory, normal thinking, communicating and reasoning ability of a person), unspecified lack of coordination and muscle weakness. Resident R1's nursing documentation revealed that since the time of her admission into the facility, the resident had sustained a total of nine falls. Six of Resident R1's falls were unwitnessed by staff (November 7, (YEAR); (MONTH) 15, (YEAR); (MONTH) 21, 2019; (MONTH) 23, 2019; (MONTH) 13, 2019 and (MONTH) 2, 2019). Three of Resident R1's falls were witnessed by staff members (February 5, 2019; (MONTH) 4, 2019 and (MONTH) 27, 2019). Review of the clinical record revealed that Resident R1 had an unwitnessed fall on (MONTH) 13, 2019, when left unsupervised in the third-floor dining room by an activity staff member. Review of an investigation regarding the resident's fall on (MONTH) 13, 2019, revealed that Resident R1 was found on the dining room floor after the resident was left unsupervised in the dining room by an activity aide (Employee E3). Review of the witness statement for Employee E3 stated that when the employee returned, Resident R1 was on the floor lying on her right side next to her chair. Employee E3 notified nursing staff, and upon assessment by the nursing staff, the resident was noted with having a hematoma to the right temple (hematoma to the right temple- a localized swelling on the right side of the forehead that is filled with blood and caused by a break in the wall of a blood vessel) with a reddened area to the right shoulder. An x-ray was ordered by the physician and evidence of the right clavicular fracture (clavicular fracture-[MEDICAL CONDITION] collarbone, which is a long bone that lies between the shoulder blade and the breastbone) was identified. The resident was subsequently transported to the hospital on (MONTH) 13, 2019 and returned to the facility on (MONTH) 14, 2019 with a [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS- assessment of resident care needs) assessment completed (MONTH) 21, 2019 identified the resident with cognitive impairment. The resident required extensive assistance of two staff for transfer with no ambulation capabilities. The resident balance during transition from a seated to standing position was not steady and only able to stabilize with staff assistance. The resident was identified with limitation of range of motion to upper and lower extremities. Review of Resident R1's care plan revealed that the resident's care plan was updated upon readmission to the facility for care and treatment of [REDACTED]. Close supervision, Re-education with staff. was documented under the section Identify measures taken to prevent recurrence. During an interview with Employee E4, Unit Manager, on (MONTH) 21, 2019 at approximately 3:10 p.m. regarding Resident R1's fall on (MONTH) 13, 2019, Employee E4 was asked what the expectation was for activity staff when they were conducting activities with residents who may be a fall risk and they had to leave the room. Employee E4 reported that the expectation for staff was to not leave the residents in the room alone. Review of facility documentation related to Resident R1's unwitnessed fall on (MONTH) 2, 2019 revealed that the resident was found on the floor in the dining room at approximately 4:00 p.m. The resident was noted with a 0.5 x 0.5 cm abrasion on the right side of her face. Review of Resident R1's nursing documentation revealed that on (MONTH) 7, 2019, the resident complained of leg pain and when assessed made facial grimaces whenever the resident was touched. Further review of the resident's clinical record revealed that an x-ray was completed at the facility on (MONTH) 8, 2019, and the resident was transferred and admitted to the hospital with [REDACTED]. During a discussion with the Director of Nursing (DON) on (MONTH) 21, 2019, the DON reported that the facility also had a Safety Program, which was discussed during an interview on (MONTH) 21, 2019, at approximately 3:10 p.m. with Licensed Practical Nurse (LPN) who was the Unit Manager (Employee E4) for Resident R1. During the above interview, with Employee E4, reported that the Safety Program was a program that closely monitors residents who are fall risk between the hours of 11:00 a.m. through 9:00 p.m. seven days a week. Employee E4 reported that the program occurred in the dining room on the floor that Resident R1 resided on, and that each nursing assistant on the floor are assigned times in the dining room in half-hour intervals to ensure that someone is always in the dining room with the residents. Employee E4 stated that during the Safety Program, residents watch television and/or are engaged in activities such as trivia, in addition to other games. Employee E4 also stated that a task is created in the resident's electronic medical record where nursing staff can document a resident's participation in the facility's Safety Program, including the dates and times. It was confirmed during this interview that no documentation could be produced to show evidence of Resident R1's participation in the Safety Program. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing on (MONTH) 21, 2019 at approximately 2:25 p.m. it was confirmed that Resident R1 was left unsupervised in the dining room on the third floor on (MONTH) 2, 2019 after the activity staff member left the room to take another resident back to the unit at approximately 3:38 p.m. The facility failed to ensure adequate supervision to Resident R1 while in the dining area which resulted in actual harm to Resident R1 sustaining a fall on (MONTH) 13, 2019 requiring transfer to the hospital and [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/31/19, 12/04/18, 01/22/18, 03/05/2019 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 01/31/19, 12/04/18, 01/22/18, 03/5/2019 28. Pa. Code 211.10 (a) Resident care policies 28 Pa. Code 211.10(c) Resident care policies Previously cited 01/31/19, 12/04/18, 03/27/18, 01/22/18, 03/05/2019 28 Pa. Code 211.12(c) Nursing services Previously cited 01/31/19, 01/22/18, 03/05/2019 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/04/18, 12/11/18, 01/22/18, 03/05/2019 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/05/2019 28 Pa. Code 211.12 (d)(2)

Based on clinical record review, interviews with residents and staff, it was determined that the facility failed to ensure that the highest practicable level of pain management was maintained for one of nine residents reviewed which resulted in actual harm to the resident who experienced increased pain and emotional distress (Resident R1). Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. across most situations) and anxiety disorder (group of mental illnesses that cause constant fear and worry). Observations on (MONTH) 2, (YEAR), at 11:25 a.m. at the first-floor nursing station revealed a resident could be heard calling out from room [ROOM NUMBER], which was three rooms away from the nurse's station. Further observations from the doorway of room [ROOM NUMBER] revealed Resident R1 complaining loudly about her pain. Interview with Resident R1, at the time of the observation, revealed that she was really upset and said she needed her [MEDICATION NAME] to help calm her down and that she had not had it since 9 p.m. the night before. She said she had terrible pain in her legs with teary eyes kept saying she need her pain meds too, and why don't I have my meds, I should have had them at 9 a.m., and I usually get them by 9:30 a.m. I don't understand why I can't have my meds. Pulling her clothing aside she was trying to expose her pain patch on her chest saying I need a new pain patch too. Further observation at 11:40 a.m. revealed that the nurse, Employee E3, came into room [ROOM NUMBER] and attempted to give Resident R1 her 9 a.m. meds which included [MEDICATION NAME] (used to treat nerve pain), [MEDICATION NAME] (used to treat [MEDICAL CONDITIONS]), Multivitamin and [MEDICATION NAME] (an opioid - narcotic - pain medication used to treat moderate to severe pain). The resident asked if her [MEDICATION NAME] (an antidepressant medicine) was in the cup and the nurse said no, and at that point she refused to take anything unless her [MEDICATION NAME] was also given. She again was crying in pain saying she had not had her [MEDICATION NAME] since 9 p.m. the night before and she needed it to calm herself down. A few minutes later the nurse returned with the [MEDICATION NAME] and all the other meds in a cup. The resident looked in the cup and said that she did not want to take the iron pill because it upset her stomach and she was already upset and did not want to further upset her stomach, As the resident was trying to dig out the iron pill she dropped the [MEDICATION NAME] pill on the floor. At this point, the resident was almost hysterical and did not understand why the nurse would not let her have the pill that fell on the floor. At 11:50 a.m. the nurse returned with a new [MEDICATION NAME] pill and the resident finally took all her medication except the iron pill. Interview on (MONTH) 2, (YEAR), at 11:55 a.m. with Employee E3, floor nurse, confirmed that the medications that he had just given Resident R1 were in fact her 9 a.m. dose of medication and he understood that it was late being administered. A review of Resident R1's medical record revealed physician orders [REDACTED]. 9 a.m. and 9 p.m.; Multivitamin at 9 a.m.; [MEDICATION NAME] 9 a.m., 1 p.m. and 9 p.m.; and [MEDICATION NAME] at 1 a.m., 5 a.m., 9 a.m., 1 p.m., 5 p.m. and 9 p.m. The facility failed to ensure that the highest practicable level of pain management was maintained for one resident which resulted in actual harm to one resident who experienced increased pain and emotional distress. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/31/19, 12/04/18, 01/22/18 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 01/31/19, 12/04/18, 01/22/18 28 Pa. Code 201.29(j) Resident rights Previously cited 01/22/18 28 Pa. Code 211.12(c) Nursing services Previously cited 01/31/19, 01/22/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 01/31/19, 12/11/18, 12/04/18, 03/27/18, 01/22/18

Based on observations, review of clinical records, facility documentation, and policy and procedures, and interviews with staff, it was determined that the facility failed to promote a safe environment for one resident (Resident R132) and failed to provide adequate supervision, training, and safety devices to prevent an accident which resulted in an injury for one resident. (Resident CL1). Findings include: Review of the facility's policy and procedure titled, Vehicle Safety, dated February 2012 and reviewed July 2015, stated that a seat belt is mandatory in all company vehicles and that the operator of the vehicle must be an authorized driver who has been provided education on vehicle safety, operations of the vehicle lifts, and use of the wheelchair tie downs. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the documentation submitted by the facility dated January 30, 2016, revealed that Resident CL1 was in the facility's mini bus on the way to a dialysis appointment (a process of removing waste products and excess water from the body, that is usually done by healthy kidneys) at 12:30 p.m. Review of the facility documentation revealed that the bottom of the resident's wheelchair was secured to the floor of the mini bus, but the resident was not secured in the wheelchair, and the seatbelt was not secured around the resident. Continued review of facility documentation revealed that when the mini bus went down a hill, the resident fell out of the wheelchair onto the floor of the mini bus and hit both knees. Review of the progress notes dated the same day, January 30, 2016 revealed that the resident returned from the dialysis treatment approximately 5:00 p.m. with complaints of pain to both knees. Continued review revealed that the resident was medicated for pain with Tylenol at approximately 7:00 p.m., which after one hour, the resident stated gave no pain relief and stated the pain to both knees was a 10 out of a scale of one to 10, with 10 being the worst pain. The resident was noted to have swelling of the right knee and the resident had the shivers. An X-Ray was done at approximately 11:00 p.m., with the results reported at 1:20 a.m. January 31, 2016, of acute (new) fractures of both femurs (long bone from knee to hip). The resident was transferred to the hospital via an ambulance with an admitting [DIAGNOSES REDACTED]. An interview with Employee E1, Nursing Home Administrator, on October 31, 2016, at 1:00 p.m. revealed that the driver of the facility's mini bus was not an authorized driver and was actually a recreation (activities) worker and had never been trained to drive the mini bus. The facility failed to follow their policy for vehicle safety, failed to provide an adequately trained authorized driver, and failed to provide safety precautions, a seat belt, for one resident which resulted in harm. An observation of a nursing unit on the third floor and in the presence of Employee E4, a Registered Nurse, October 28, 2016, at 9:00 a.m. revealed that adjacent to the nursing station, was a small area which had a refrigerator with a microwave. Resident R132 was observed propelling herself in a wheelchair toward the microwave with a plate of food and a cup of coffee, which was her roommates meal. She stated, I can't stand it. This food is cold all the time! Resident R132 proceeded to propel her wheelchair to the microwave, open the microwave, and place the plate of food and the coffee cup inside. She pushed the timer for approximately 15 seconds and turned the microwave on. Employee E4 then intervened and took the plate and the cup of coffee out of the microwave and took it back to room 326A. Resident R132 was interviewed on October 31, 2016, at 11:30 am. and she revealed that the staff will not heat any meals served that are cold. She also stated that the residents are not permitted to use the microwave due to safety issues. The staff does offer to replace any food items which are cold but Resident R132 stated that it takes too long to receive another tray and she does not like the food at the facility. An interview conducted with Employee E4 on October 31, 2016, at 11:00 am after Resident R132 used the microwave, revealed only the staff members could utilize the microwave to heat up their own food. She concluded that the staff was not permitted to uses the microwave to heat up food for the residents. The facility failed to provide a safe environment in regards to use of a microwave on the third floor nursing unit for one resident, which had the potential for injury. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 12/14/15