Every finding on record at Forest City Nursing and Rehab Center

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Storage Areas last reviewed by the facility on June 25, 2026, indicated leftover food is stored in covered containers or wrapped carefully and securely. Each item is to be clearly labeled and dated before being refrigerated. Leftover food is to be used within 3 days or discarded. During the initial tour of the dietary department on August 25, 2026, at 9:30 AM, accompanied by the facility's Corporate Dietary Manager, the following observation was made: The produce refrigerator contained two open bowls of pudding, one bowl of patient specific potato salad, eight bowls of oranges, and nine premade salads. All these items were undated to indicate when the items were made and put into use so staff would be aware when to discard the items. During an interview on August 25, 2026, at 2:00 PM, the Nursing Home Administrator acknowledged the facility's failure to maintain the dietary food storage areas in a sanitary manner consistent with facility policy. 28 Pa. Code 201.18 (e) (2.1) Management28 Pa. Code 211.6 (f) Dietary services

Based on select facility policy, a review of clinical records, and staff interview, it was determined the facility failed to document the use of non-pharmacological interventions prior to the administration of an as needed psychotropic medication one of 23 residents reviewed (Resident 89).Findings include: Federal requirements for the use of psychoactive medications expect that psychoactive medications (medications that affect how a person thinks, feels, behaves, or sleeps; the medications can change mood, calm someone down, help with anxiety, or affect alertness) are used only when necessary to treat a specific, documented condition. Non-pharmacological interventions are approaches that do not involve medications, such as reassurance, redirection, environmental modifications, distraction techniques, or comfort measures. When clinically appropriate, these interventions should be attempted and documented prior to administering a PRN (as needed) psychoactive medication. The American Geriatrics Society Beers Criteria (AGS) (2023) supports the use of non-drug measures prior to the use of psychoactive medications. Psychoactive medications increased the risk of cognitive impairment, falls, fractures, and delirium when administered to older adults. Because of this high risk profile, facilities and clinicians are expected to try safer, non pharmacologic approaches before using psychoactive medications such as sedatives. A review of the facility's policy titled Psychoactive Medication Use reviewed June 25, 2026, indicated psychotropic medications are not prescribed or administered on a PRN basis unless the medication is necessary to treat a diagnosed specific condition that is documented in the medical record. The policy further reveals that behavioral and other non-drug approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support efforts at gradual dose reduction. A clinical record review revealed Resident 89 was admitted to the facility on [DATE], with diagnoses that included depression and anxiety disorders (the resident experiences both the heaviness of depression and the constant tension of anxiety). A review of Resident 89's significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 3, 2026, revealed that Resident 89 experiences severe cognitive impairment with a BIMS score of 2 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 signifies significant challenges with memory and orientation). Review of a physician order initially dated May 24, 2026 and renewed on June 11, 2026, revealed the resident was to receive Diazepam (a psychotropic anti-anxiety medication) 2 milligrams (mg) every eight hours as needed for anxiety. Review of the Medication Administration Record (MAR) revealed Diazepam 2 mg was administered on the following dates and times:June 2, 2026, at 9:18 PMJune 16, 2026, at 6:32 PMJune 17, 2026, at 12:44 PMJune 21, 2026, at 2:15 PMJune 28, 2026, at 6:16 PMJune 29, 2026, at 7:58 PM Review of the clinical record failed to identify documentation that non-pharmacological interventions were attempted or ineffective prior to administration of the PRN Diazepam medication on all six occasions. As a result, the facility could not demonstrate that less restrictive interventions were considered before the medication was administered. During an interview on August 27, 2026, at 12:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the clinical record did not contain documentation of non-pharmacologic interventions prior to the administration of the psychotropic medication. 28 Pa. Code 211.2(3) Medical director.28 Pa. Code 211.5(ii)(xi) Clinical records.28 Pa. Code 211.8(e) Use of restraints.28 Pa. Code 211.9(1) Pharmacy services.28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(1)(2)(5) Nursing services.

Based on a review clinical record review, personnel records, and staff interviews, it was determined the facility failed to ensure nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to verify Licensed Practical Nurses possessed the required education, training, and competencies for the administration of an intravenous (IV) medication via peripheral inserted central venous catheter (PICC) for one of 23 residents reviewed (Resident 73).Findings include: A review of Pennsylvania Code Title 49, Professional and Vocational Standards, Department of State, State Board of Nursing, S21.145 Functions of the Licensed Practical Nurse (LPN) indicate the LPN functions as a member of the health care team and administers medications and therapeutic treatments in accordance with established standards of safe nursing practice. Section 21.145(b) IV therapy curriculum requirements indicate an LPN may perform IV therapy functions only when the LPN has completed the required education and training and possesses the knowledge, skill, and ability to perform the procedure safely, and only under appropriate direction and supervision of a licensed professional nurse or other authorized health care provider. Permitted IV therapy functions include administration of IV medications and fluids, monitoring of the IV site, maintenance of IV access devices, and recognition and reporting of adverse reactions. Clinical record review revealed Resident 73 was admitted to the facility on [DATE], with diagnoses that included urinary tract infection (an infection in any part of your urinary system) A review of physician orders revealed an order dated August 20, 2026, for Meropenem (an antibiotic medication used to treat serious bacterial infections) 1 gram intravenously every eight hours via PICC line (a thin, flexible tube put into a vein in your arm and guided to a large vein near your heart) for treatment of the urinary tract infection for 7 days. Review of the resident's August 2026 Medication Administration Record revealed Employee 11, Licensed Practical Nurse (LPN), documented administration of Meropenem IV on August 20, 2026, August 25, 2026, and August 26, 2026. Employee 12, Licensed Practical Nurse (LPN), documented administration of Meropenem IV on August 21, 2026, and August 24, 2026. Employee 13, LPN documented administration of Meropenem Iv on August 22, 2026, August 23, 2026, and August 24, 2026. Employee 14, LPN documented administration of Meropenem IV on August 22, 2026, and August 23, 2026. The facility failed to produce evidence that Employees 11, 12, 13, and 14 completed IV therapy education and training consistent with the requirements of Pennsylvania Code Title 49 S21.145(b). The facility was unable to provide documentation of competency validation (process used to confirm staff have demonstrated the ability to safely perform a clinical skill), supervision documentation, or evidence of training specific to administration of IV medications through a PICC line. During an interview conducted on August 28, 2026, at 11:50 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of the above findings of the facility's failure to provide documentation demonstrating Employees 11, 12, 13, and 14 completed the required IV therapy education or competency validation necessary to administer IV medications through a PICC line. 28 Pa. Code 201.20(a) Staff Development.28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on select facility policy, clinical record review, and staff and resident interviews, it was determined the facility failed to monitor and manage hydration status in accordance with a physician-ordered fluid restriction to ensure proper fluid balance for one of 23 residents reviewed (Resident 8).Findings include: A review of the facility policy titled Encouraging and Restricting Fluids last reviewed June 25, 2026, indicated the facility will provide an appropriate amount of fluid to residents to maintain one's health. The policy further stated that when a fluid restriction (a medical order that limits the total amount of liquids a resident may consume) is ordered by the physician, the water cup should be removed from the resident room unless the resident refuses. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included end state renal disease (permanent kidney failure where the kidneys stop working). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 16, 2026, revealed that Resident 8 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 means no significant issues in memory recall or knowing the date/day). A clinical record review identified a physician order dated June 13, 2026, for a 1500 milliliter (ml) daily fluid restriction including 1080 ml with meals and 420 ml during nursing care, including medication administration. A review of a nutrition evaluation completed by the clinical nutritionist dated June 16, 2026, documented the presence of the 1500 ml fluid restriction. A review of a care plan revised on February 14, 2026 revealed a concerns addressing nutritional risk and identified the need for fluid restriction due to fluid excess. The goal indicated the resident was to be free from complications related to end stage renal disease (final, irreversible stage of chronic kidney failure, where kidney function has declined to the point that life-sustaining treatment becomes essential). The care plan failed to accurately address the prescribed fluid restriction. A clinical record review, including documentation of fluid intake during meals and medication administration, showed that Resident 8 exceeded the prescribed 1500 ml daily fluid restriction on multiple occasions, including:August 1, 2026: 2120 mLAugust 2, 2026: 1760 mLAugust 4, 2026: 2640 mLAugust 19, 2026: 3000 mLAugust 25, 2026: 2030 mL An interview was conducted on August 27, 2026, at 11:57 AM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) to review the above information. The NHA and DON acknowledged the facility failed to monitor Resident 8's hydration status and adherence to the prescribed fluid restriction. 28 Pa Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on select facility policy, review of clinical records, and staff interviews, it was determined the facility staff failed to follow physician orders when administering pain medication for one resident out of 23 reviewed (Resident 15).Findings include: According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following:An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician.Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions.A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes. A review of a facility policy entitled Pain Clinical Protocol last reviewed by the facility on June 25, 2026, revealed the facility staff will implement the medication regimen as ordered. The policy revealed it is the staff responsibility to administer the medication as ordered, monitor, and document the resident's response to the medication. The provider will order appropriate non-pharmacological interventions and medications to address an individual's pain. A review of Resident 15's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included generalized muscle weakness, and pain of the left hip and right knee. A review of a physician order initially dated May 21, 2026, revealed an order for Tramadol 50mg tablets (controlled pain medication) one tablet every 12 hours as needed for moderate pain on a scale of 4-6. The order directed staff to administer nonpharmacological interventions including relaxation/massage, reposition, food/fluid, diversional activity, toileting, adjust room temperature/adjust lighting, or other prior to the administration of the as needed pain medication. A review of Resident 15's June 2026 Medication Administration Record (MAR) revealed staff administered the as needed Tramadol nine times. Of the nine doses given, two doses were administered without attempting non-pharmacological interventions prior to the administered of the as needed medication, despite the physician's order. On one occasion, staff administered the as needed Tramadol outside of the physician's specified pain scale.June 4, 2026, at 10:47PM the as needed medication was administered but the area to document nonpharmacological interventions was documented as NA (non applicable).June 10, 2026, at 8:06PM, the as needed medication was administered but the area to document nonpharmacological intervention was documented as NAJune 10, 2026, at 08:00AM, the as needed medication was administered for a pain scale of 3, despite the physician's order to administer the medication for a pain scale of 4-6. A review of Resident 15's July 2026 MAR revealed staff administered the as needed Tramadol 22 times. Of the 22 doses given, three doses were administered without attempting non-pharmacological interventions prior to the administration of the as needed medication, despite the physician's order. On six occasions staff administered the as needed Tramadol outside of the physician's specified pain scale.July 10, 2026, at 08:51, the as needed medication was administered for a pain scale of 2.July 11, 2026, at 05:42, the as needed medication was administered but the area to document nonpharmacological interventions was documented as NA.July 14, 2026, at 08:53, the as needed medication was administered for a pain scale of 10, and the area to document nonpharmacological interventions was documented as NA.July 17, 2026, at 9:28PM, the as needed medication was administered for a pain scale of 10, and the area to documented nonpharmacological interventions was documented as NA.July 23, 2026, at 08:19AM, the as needed medication was administered for a pain scale of 3.July 25, 2026, at 7:14PM, the as needed medication was administered for a pain scale of 3.July 26, 2026, at 7:15PM, the as needed medication was administered for a pain scale of 3. During an interview with the Director of Nursing on August 28, 2026, at 11:10AM the above findings were reviewed and the DON acknowledged the facility's failure to ensure staff were administering the narcotic pain medication as specified in the physician order for Resident 15. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.9 (f)(2) Pharmacy services.

Based on select facility policy, clinical record review, observations, and staff interviews, it was determined the facility failed to to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 23 sampled residents (Resident 8). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis, (a life-sustaining treatment for individuals with kidney failure that removes waste and excess fluids from the blood) and utilize central venous hemodialysis catheters, (tubes placed into large veins to allow blood to flow to and from a dialysis machine), are associated with serious complications including infection and bleeding. The Centers for Disease Control and Prevention further identifies central lines as devices that can result in significant complications such as bloodstream infection and hemorrhage (severe bleeding). Standard dialysis emergency guidance indicates that if a dialysis catheter becomes dislodged (moves out of place) or begins to bleed, immediate firm pressure must be applied to the site and emergency medical care must be obtained to prevent life-threatening blood loss. Therefore, residents who receive hemodialysis through a central venous catheter require immediate access to appropriate emergency supplies, such as clamps and pressure dressings, to ensure prompt intervention in the event of catheter-related complications. A review of the policy Hemodialysis Catheters - Access and Care of last reviewed June 25, 2026, indicated that staff caring for residents with ESRD (End Stage Renal Disease) including residents receiving dialysis care outside of the facility shall be trained in the care and special needs of these residents. The policy also indicated that the resident's comprehensive care plan will reflect the resident's needs related to dialysis care and ESRD. A clinical record review revealed Resident 8 was admitted to the facility on [DATE], with diagnoses that included end state renal disease (also referred to as kidney failure, when the kidneys have lost nearly all the ability to keep an individual healthy). A review of Resident 8's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 16, 2026, revealed that Resident 8 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 means no significant issues in memory recall or knowing the date/day). An observation on August 25, 2026, at 11:45 AM, revealed Resident 8 had a dialysis access site on the upper right part of the chest. No emergency dialysis supply kit, clamps, pressure dressings, or other catheter-related emergency equipment were present at the bedside, mounted on the wall, or otherwise visible and readily accessible in Resident 8's room. During the observation Resident 8 revealed emergency supplies were kept in an unlabeled green shopping bag mixed with many other items. The bag was not easy to see and was placed on top of a dresser at the far end of the resident's bed, along with several other bags and personal items. During an interview on August 25, 2026, at 11:50 AM, Employee 1, Licensed Practical Nurse (LPN) stated that an emergency kit with appropriate supplies should have been easily visible and accessible in the resident's room. On August 26, 2026, at 12:30 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) regarding the absence of required emergency supplies for residents receiving hemodialysis. 28Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on select facility policy a review of clinical records, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of prescribed medications for one resident (Resident 104) and failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for two of 23 sampled residents (Resident 2 and Resident 11).Findings include: A review of a facility policy labeled Medication Ordering and Receiving from Pharmacy last reviewed by the facility on June 25, 2026, revealed medications are to be received from the dispensing pharmacy on a timely basis. The facility is to maintain accurate records of medication order and receipt. The policy details that timely delivery of new orders is required so that medication administration is not delayed. A review of facility policy labeled Medication Administration-General Guidelines last reviewed June 25, 2026, revealed medication is administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so. A review of Resident 104's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of psoriasis (a chronic, non-contagious immune-mediated disease that speeds up the growth cycle of skin cells, leading to thick, scaly, and itchy patches) and muscle weakness. A review of Resident 104's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 17, 2026, revealed that Resident 104 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). A review of the progress note dated August 6, 2026, at 9:29 AM, revealed that communication was received from the outside dermatology provider instructing the facility to begin Skyrizi (a prescription biologic injection used to reduce chronic inflammation and treat immune mediated inflammatory diseases, like psoriasis). It was noted that the outside pharmacy was unable to fill the prescription while Resident 104 remained in the facility. Further review indicated that staff requested the outside pharmacy to fax the prescription to the facility so it could be forwarded to the in-house pharmacy, ensuring the resident would receive the medication. There was no documented evidence of any additional updates regarding the receipt of the medication, any attempts that had been made to obtain it, or any further communication between the facility and the outside pharmacy concerning the medication. Interview with Resident 104 on August 25, 2026, at 12:15PM, revealed the resident still did not receive his medication. The resident stated he was suffering from itching related to his psoriasis, and that he was unaware why the facility had not received the medication yet. Resident 104 stated the constant itching causes him frustration. An interview was conducted with the Director of Nursing (DON) on Monday August 28,2026 at 10:00 AM to review the above findings. The DON acknowledged the facility failed to ensure the timely acquisition and administration of the prescribed medications for Resident 104. A facility policy titled Controlled Medication Storage last reviewed by the facility on June 25, 2026, revealed medications included in the Drug Enforcement Administration (DEA) classification as a controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. A review of facility documentation revealed the facility utilizes a Controlled Substance Record to track, monitor, and reconcile each controlled medication. The facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period) and Atrial Fibrillation (an irregular heart rhythm). A review of a physician order dated June 30, 2026, revealed Resident 2 was to receive Oxycodone HCL oral tablet 5 mg (narcotic pain medication) administer one tablet every eight hours as needed for moderate pain 4-6. A comparison of Resident 2's Controlled Substance Record with the Medication Administration Record (MAR) from June 30, 2026, through August 21, 2026, revealed 11 entries which indicated Oxycodone HCL was utilized according to Resident 2's Controlled Substance Record. However, there was no documented evidence in Resident 2's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 2's Controlled Substance Record and MAR: July 1, 2026, at 1:00 PMJuly 4, 2026, at 10:40 PMJuly 12, 2026, at 8:00 AMJuly 17, 2026, at 7:30 PMJuly 19, 2026, at 6:30 PMJuly 20, 2026, at 8:00 PMAugust 2, 2026, 8:00 AMAugust 3, 2026, at 9:00 PMAugust 7, 2026, at 8:00 PMAugust 20, 2026, at 10:00PMAugust 21, 2026, at1:45 PM A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that included Unspecified Severe Protein Calorie Malnutrition (where the body lacks adequate calories and protein to maintain essential physiological functions) and Infrarenal Abdominal Aortic Aneurysm (a bulging and weaking of the abdominal aorta the largest artery in the abdomen). A review of a physician order dated March 29,2026 indicated the resident was to receive Morphine Sulfate Oral Solution (narcotic medication) 20 mg/ml administer 0.25 ml. (5 mg) every four hours as needed for pain A comparison of Resident 11's Controlled Substance Record with Resident 11's MAR from March 30, 2026, through August 26, 2026, revealed 14 entries indicating the Morphine Sulfate was utilized according to Resident 11's Controlled Substance Record. However, there was no documented evidence in Resident 11's MAR indicating that the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 11's Controlled Substance Record and MAR: April 8, 2026, at 5:25 PMApril 8, 2026, at 12:00 AMApril 11, 2026, at 9:20 AMApril 23, 2026, at 8:30 PMApril 24, 2026, at 5:00 PMJune 21, 2026, at 6:00 AMJune 25, 2026, at 10:00 AMJuly 3, 2026, at 8:00 AMJuly 4, 2026, at 2:00 PMJuly 4, 2026, at 9:30 PMJuly 5, 2026, at 10:30 AMJuly 9, 2026, at 3:15 AMAugust 3, 2026, at 6:00 AMAugust 10, 2026, at 6:00 AM A comparison of Resident 11's Controlled Substance Record with the MAR for March 30, 2026, through August 26, 2026, revealed four entries indicating Morphine Sulfate was documented as administered on the MAR. However, there was no corresponding documentation in the Controlled Substance Record indicating the medication was removed from inventory on the following dates: April 9, 2026, at 12:00AMMay 6, 2026, at 11:26 PMJuly 10, 2026, at 3:17 AMJuly 23, 2026, at 6:13 AM An interview was conducted on August 28, 2026, at 10:15AM, with the Director of Nursing to review the above findings related to the facility's failure to implement effective procedures to reconcile controlled substance medications. 28 Pa Code 211.5(f)(xi) Medical records28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on select facility policy, observations, and staff interviews, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. (Second floor Medication Storage Room)Findings include: A review of facility policy titled Storage of Medications last reviewed by the facility in [DATE], revealed medications that are outdated, contaminated, or deteriorated, and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reorder from pharmacy, if a current order. Observation of the Second-floor medication storage room on [DATE], at 8:50 AM revealed one box of Acetylcysteine Inhalation Solution (a medication used to thin and loosen mucous in the lungs) containing one open 30 ML vial dated [DATE], and two sealed vials. A review of manufacturer instructions revealed the printed expiration date on the sealed vial is for the unopened product. Once a vial is opened, the label sets a shorter beyond use date to ensure the safety and efficacy of the medication, the remaining medication should be refrigerated and is usable for 96 hours (four days). Interview with Employee 2, a licensed practical nurse (LPN), during the time of the observation, confirmed the open vial of medication Acetylcysteine should have been discarded or destroyed. An interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 12:15 PM confirmed the expectation was that expired resident medications would be removed from the medication room by a licensed nurse and destroyed per facility policy. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services28 Pa. Code 211.12 (d)(3)(5) Nursing services28 Pa Code 211.10 Resident care policies.

Based on select facility policy, a review of clinical records, and staff interview, it was determined that the facility failed to timely notify the physician of a change in condition for one resident out of 23 sampled (Resident 58).Findings include: A review of facility policy entitled Change in a Resident's Condition or Status last reviewed June 25, 2026, revealed the facility will promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy indicated the nurse will notify the resident's attending physician or physician on call when there has been a accident or incident involving the resident, discovery of injuries of an unknown source, significant change in the resident's physical/emotional/mental condition, and when there is a need to transfer the resident to a hospital. The policy defines a significant change as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff, or if the situation impacts more than one area of the resident's health status. A review of the clinical record revealed that Resident 58 was admitted into the facility on September 27, 2025, with diagnoses of hypertension (high blood pressure) and hyperlipidemia (high levels of fats in your blood). A review of a progress note dated May 8, 2026, at 10:59 PM revealed during the shift Resident 58 experienced a seizure (a sudden rush of uncontrolled electrical activity in the brain that changes how a person moves, thinks, or feels) that lasted less than 1 minute. It was noted Resident 58 was lethargic immediately after the seizure and that nursing staff would continue to monitor. A progress note on May 9, 2026, at 3:16AM revealed Resident 58 was noted to have altered mental status (a person is not thinking, acting, or reacting the way they normally do) around 2:30 AM. The resident was weak and lethargic. Slight jerking movements were noted throughout the body. The resident was unable to answer any questions and had multiple large amounts of vomiting. It was indicated the resident was transferred to the hospital at 3:00AM. A review of Resident 58 hospital records documented Resident 58 was sent to the hospital for seizure like activity, with a last known well time of 11:00PM. The records indicated Resident 58 was lethargic, having tremors, and vomiting on arrival at the hospital. Resident 58 was evaluated by neurology in hospital and was diagnosed with seizures and aspiration pneumonia. A review of the resident's clinical record revealed no documented evidence the facility staff had promptly notified the residents physician of the new onset seizure activity after the incident initially occurred. The resident continued to decline and was documented as having jerking movements throughout the body hours after the new onset of seizure activity was identified. During an interview with the Director of Nursing (DON) on August 27, 2026, at 2:00 PM the above findings were reviewed and the DON acknowledged the facility's failure to timely notify the physician of Resident 58's change in condition. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, facility policy, documentation provided to residents regarding transfers from the facility, records obtained from the acute care hospital, facility census records, and staff interviews, it was determined the facility failed to ensure an appropriate discharge by failing to permit a resident to return to the facility following hospitalization in accordance with its policies for one of five residents reviewed (Resident 1).Findings include: A review of the facility policy titled Bed-Holds and Returns (no revision date identified) revealed the facility policy required that all residents and their representatives receive written information regarding the facility's bed-hold policy, which addresses the holding or reservation of a resident's bed during hospitalization or therapeutic leave (a temporary absence from the facility for therapeutic purposes). The policy required that residents, regardless of payer source (the source responsible for payment of a resident's care, such as Medicare, Medicaid, private insurance, or private pay), receive written notice of the facility's bed-hold and return policies and that all residents be permitted to return to the facility following hospitalization or therapeutic leave in accordance with applicable federal requirements. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE]. The clinical record revealed Resident 1 was transferred from the facility to an acute care hospital (a hospital that provides short-term medical or surgical treatment) on July 4, 2026, for evaluation and treatment of a displaced suprapubic catheter (SPC), a tube surgically inserted through the lower abdomen into the bladder to drain urine. A displaced suprapubic catheter occurs when the catheter becomes partially or completely dislodged from the bladder, which may result from a deflated or ruptured retention balloon, accidental traction on the catheter tubing, or inadequate securement of the catheter. A review of the acute care hospital case management notes revealed documentation that the hospital case manager contacted the facility to arrange Resident 1's return following hospitalization. Documentation dated July 9, 2026, at 3:26 PM, revealed the facility informed the hospital case manager that no bed was available for Resident 1's return to the facility. A review of the facility census dated July 9, 2026, revealed the facility had 30 available beds on the date it informed the hospital that no bed was available for Resident 1's return. During an interview conducted on July 29, 2026, at 10:50 AM, the Nursing Home Administrator stated the facility believed Resident 1 was dissatisfied with the care previously provided and indicated the resident's family had contacted the Area Agency on Aging (AAA), an organization that advocates for and provides services to older adults and individuals with disabilities, regarding concerns about the care provided by the facility. The Nursing Home Administrator stated the facility determined there was no appropriate bed available for Resident 1 to return despite the resident having been admitted to and cared for by the facility before the hospitalization. A review of the clinical record failed to identify documented evidence the facility conducted an interdisciplinary evaluation to determine whether it could continue to meet Resident 1's care needs following hospitalization. There was no documented evidence that the facility assessed the resident's post-hospital condition, identified specific clinical needs the facility could no longer meet, or documented the basis for concluding the resident could not safely return. In addition, there was no documented evidence that the facility coordinated discharge planning with the hospital or took steps to facilitate the resident's return. During an interview on July 29, 2026, the Nursing Home Administrator and Director of Nursing both acknowledged Resident 1 had a complex medical history and stated the facility determined it could not meet the resident's needs because the resident was dissatisfied with the care previously provided. However, they were unable to provide documented evidence demonstrating the facility conducted a formal clinical assessment supporting that determination or explaining why the facility could no longer meet the resident's needs despite previously providing care to the resident and having 30 available beds at the time the hospital requested the resident's return. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 201.29 (b)Resident rights

Based on a review of clinical records, resident interviews, staff interviews, facility documentation, and facility policy, it was determined the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living consistently received the care and services necessary to maintain personal hygiene and dignity for one of 10 residents reviewed (Resident 1).Findings include: A review of the facility policy titled Activities of Daily Living, (ADL's routine daily self-care activities such as bathing, dressing, grooming, and oral hygiene) last reviewed by the facility on June 26, 2026, revealed residents who are unable to perform activities of daily living independently will receive the services necessary to maintain good grooming and personal and oral hygiene. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a group of permanent disorders affecting movement and posture caused by abnormal development of or injury to the developing brain, most commonly occurring before or during birth) and quadriplegia (partial or complete paralysis of all four limbs, most commonly caused by injury or disease affecting the cervical spinal cord). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 26, 2026, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). The MDS further revealed Resident 1 was completely dependent on staff to provide oral hygiene, showering and bathing, upper and lower body dressing, and personal hygiene, including combing hair and washing the resident's face and hands. Resident 1 was transferred to the hospital on July 4, 2026, before the survey. Therefore, the surveyor was unable to directly observe the resident's grooming or hygiene status. The determination was based on the resident's clinical record and the facility's documentation of care provided. A review of the facility's Documentation Survey Report Version 2 for June 2026 and July 2026 revealed oral hygiene was scheduled to be completed each shift. Review of the documentation revealed incomplete documentation for the following oral hygiene tasks:June 22, 2026: Night shift documentation was left blank.June 25, 2026: Evening shift documented as Not Applicable; night shift documentation was left blank.June 26, 2026: Evening shift documented as Not Applicable.June 27, 2026: Evening and night shift documentation was left blank.June 28, 2026: Evening shift documentation was left blank; night shift documented as Not Applicable.June 29, 2026: Evening shift documentation was left blank; night shift documented as Not Applicable.June 30, 2026: Night shift documentation was left blank.July 1, 2026: Day shift documentation was left blank; night shift documented as Not Applicable.July 2, 2026: Night shift documented as Not Applicable.July 3, 2026: Night shift documentation was left blank.Review of the Documentation Survey Report Version 2 further revealed incomplete documentation for personal hygiene on the following dates and shifts:June 22, 2026: Night shift documentation was left blank.June 25, 2026: Night shift documentation was left blank.June 27, 2026: Evening and night shift documentation was left blank.June 28, 2026: Evening shift documentation was left blank.June 29, 2026: Evening shift documentation was left blank.June 30, 2026: Evening shift documentation was left blank.July 1, 2026: Day shift documentation was left blank.July 2, 2026: Night shift documented as Not Applicable.July 3, 2026: Evening shift documentation was left blank.A review of the Documentation Survey Report Version 2 further Resident 1 was scheduled to receive a shower or bath every Friday during the 3:00 PM to 11:00 PM shift. Review of the documentation revealed no documented evidence Resident 1 received a scheduled shower or bath during the resident's 12-day stay at the facility. Documentation for the scheduled shower on June 26, 2026, was recorded as Not Applicable. Documentation for the scheduled shower on July 3, 2026, was left blank. Resident 1 was completely dependent upon staff to provide oral hygiene, personal hygiene, and bathing. Despite the resident's identified need for total assistance and the facility's established schedule for providing these services, the facility failed to provide documented evidence that oral hygiene, personal hygiene, and scheduled bathing were consistently provided. As a result, the facility failed to ensure Resident 1 received the necessary services to maintain personal hygiene and dignity in accordance with the resident's assessed needs and the facility's policy. The findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 28, 2026, at 1:00 PM. The facility was unable to provide documentation demonstrating that Resident 1 received the scheduled showers or other hygiene services as assigned. 28 Pa. Code: 201.18(e)(6) Management.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on clinical record review, physician order review, nursing documentation review, wound care consultation notes, diagnostic testing, and staff interview, it was determined the facility failed to ensure care and treatment was provided in accordance with professional standards of practice and physician orders for one of five sampled residents (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include heart failure, diabetes and morbid obesity and a recent vascular surgery to the left groin (a surgical procedure performed in the upper thigh where the leg meets the body, involving the large blood vessels that carry blood to and from the leg, done to repair or improve blood flow that may have been narrowed, blocked, or damaged). A review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident to be cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. A score of 13-15 indicates the resident is cognitively intact, meaning able to understand and make decisions about care. The assessment documented that the resident was admitted with a surgical wound and required staff assistance with activities of daily living. A nursing admission assessment dated [DATE], documented a surgical wound in the left groin measuring 5 cm x 2 cm x 0.3 cm, with the area noted as red and irritated. No drainage was documented at that time. Physician's admission orders dated July 18, 2025, directed staff to cleanse the left groin surgical wound with normal saline (a sterile saltwater solution commonly used for wound cleansing), pat dry, apply a dry 4x4 gauze pad, and cover with an ABD dressing (a thick, absorbent wound dressing) twice daily, morning and evening. A review of the resident's July 2025 Treatment Administration Record (TAR) revealed the above physician-ordered wound treatment was not transcribed onto the TAR. Physician progress notes dated July 20, 2025, documented that the surgical wound site had a reddish discharge. Vascular surgery, who evaluated the wound during the resident's hospital stay prior to admission, had determined the wound was not infected and ordered a dry dressing. Nursing documentation dated July 19, 2025, at 11:20 a.m., revealed the left groin surgical wound measured 4 cm x 1.5 cm with a large amount of serosanguineous drainage (a mixture of blood and clear yellow fluid commonly seen in wounds). The nurses' note stated the wound treatment was completed, with a large amount of drainage noted on the old dressing. The next available nursing documentation regarding wound care was July 22, 2025, at 1:59 a.m., stating the dressing was applied with moderate serosanguineous drainage and no signs of infection. Another nurses' note dated July 24, 2025, at 1:09 p.m., indicated the dressing was changed as ordered and the resident tolerated it well. A contracted wound care nurse practitioner assessment dated [DATE], documented that the wound now measured 1.5 cm x 1.7 cm x 4 cm deep, classified as an open, full-thickness wound. The wound bed was described as containing 30% granulation tissue (healthy red tissue that promotes healing) and 60% slough (dead tissue appearing white or yellow). The wound was draining a moderate amount of seropurulent drainage (a mixture of clear and pus-like drainage, suggesting possible infection). The wound treatment plan was updated to include cleansing with normal saline, application of Santyl (an enzymatic debriding agent used to remove dead tissue), packing with iodoform gauze (a sterile medicated gauze used for deep wounds), and covering with a 4x4 gauze and ABD pad. An ultrasound study (noninvasive imaging test that shows structures inside the body using high-intensity sound waves) of the left groin completed on July 24, 2025, revealed a fluid collection measuring 5.2 cm x 2 cm x 1.5 cm, consistent with either an abscess (a localized collection of pus due to infection) or hematoma (a localized collection of blood). The physician was notified, and an order was obtained for immediate follow-up with vascular surgery. Resident 1 was sent to the vascular surgeon on July 24, 2025, and admitted to the hospital for further treatment of the surgical wound. An interview with the Director of Nursing (DON) on August 7, 2025, at approximately 11:00 a.m., confirmed that the admission physician order for the left groin wound treatment had been entered into the physician's order section of the chart but was never transcribed onto the electronic treatment administration record. The DON stated that because the order was not transcribed, it could not be verified that the physician-ordered wound treatments were completed twice daily as prescribed. 28 Pa. Code 211.12(d)(3)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to develop and implement a person-centered baseline care plan that incorporated individualized interventions for wound management for one resident out of five sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include heart failure, diabetes and morbid obesity. A review of an admission Minimum Data Set assessment (Minimum Data Set a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 23, 2025 revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates the resident to be cognitively intact) had a surgical wound upon admission to the facility and required staff assistance with activities of daily living. A review of an admission nursing assessment dated [DATE], revealed that the resident was admitted to the facility with a surgical wound to the resident's left groin measuring 5 cm (centimeters) by 2 cm by 0.3 cm. The area was described as red and irritated, with no drainage noted. Physician's orders dated July 18, 2025, directed staff to cleanse the surgical wound with normal saline solution (a sterile mixture of water and salt used to irrigate and cleanse wounds), pat dry, apply a dry 4 x 4 gauze pad over the site, and cover with an ABD dressing (a thick, highly absorbent wound dressing) twice daily, in the morning and evening. A review of the baseline care plan, dated July 17, 2025, addressed the resident's potential for pressure sore development related to a mobility deficit. However, there was no evidence that the baseline care plan included the resident's surgical wound or the corresponding wound care interventions as ordered by the physician. During an interview on August 7, 2025, at approximately 1:00 PM, the Director of Nursing confirmed the baseline care plan did not reflect person-centered approaches specific to the resident's left groin surgical wound and that the physician-ordered wound care was not incorporated into the care plan. cross refer F684 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation and staff interview, the facility failed to maintain proper storage and service practices for food in the dietary department and second-floor resident pantry/nourishment room. This failure created the potential for contamination, microbial growth, and an increased risk of foodborne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Storage Areas provided by the facility on November 27, 2024, indicated that sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is started in an area that is clean, dry, and free from contaminants. All foods should be covered, labeled, dated, and stored off the floor. When taking dietary supplements out of the freezer to defrost, they should be labeled with a use by date. Magic Cups (high calorie, high protein ice cream/pudding nutrition supplement) within five days, 4-ounce Health Shakes/Nutritious Juice (high calorie, high protein oral nutrition supplements) within 14-days. The initial tour of the dietary department was conducted with the facility's food service director (FSD) on February 4, 2025, at 9:02 AM, and revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, including: Upon entry to the dietary department/kitchen area observed an unlidded garbage can full of trash in the cook's prep area. Observations of a metal wire storage rack revealed three plastic white bulk food storage containers with sugar and flour left uncovered and stored less than six inches from the floor. Inside of the walk-in freezer two white bins containing Magic Cup frozen supplements in direct contact with the walk-in freezer floor. Inside of the walk-in produce cooler, a wet tray of 16 thawed Mighty Shakes in the walk-in produce cooler that were not labeled with a thaw date, contrary to manufacturer instructions requiring a use by date (manufacture notes a 14-day shelf life after thawing) A clear pitcher containing an unidentified tan-colored, gritty substance and an open gallon of whole milk, both unlabeled and undated, inside the walk-in produce cooler. The dry-storage area revealed seventeen cases of food and supplies in direct contact with the dry storage area floor post-delivery. Additional food safety concerns were noted in the food preparation area: A hole in the ceiling tile and reddish-brown splatters on multiple ceiling tiles. A drawer storing cooking equipment containing food particles and a reddish substance smeared inside. A soft, discolored (dark yellow) brick of butter with food particles adhered to the surface. Food debris and splatter on the wall behind the stove, oven, and griddle. Four uncovered knives stored on a magnetic strip in the cook's area. A red bucket with a rag left inside the prep sink. Ceiling tiles above the tray line and dish room area with visible food splatter and water staining. During an observation of the second-floor resident pantry/nourishment room on February 4, 2025, at 11:37 AM: A dirty breakfast tray was found on top of the ice machine next to an uncovered plastic bin with an ice scoop inside. Food splatter, chipping, and rust were observed inside the microwave. The pantry refrigerator/freezer contained multiple opened and unlabeled food items, including a 14-ounce bottle of ketchup, a 15-ounce container of butter, and a half gallon of ice cream and and a plastic gallon container of ice cream. A cabinet in the pantry area contained an unlabeled plastic storage container with peanut butter, a pre-portioned bag of cookies, and an opened loaf of bread, all without proper labeling. The inside of the cabinet had debris. An interview with the Nursing Home Administrator (NHA) on February 5, 2025, at 1:00 PM confirmed that the dietary department and pantry/nourishment areas should be maintained in a sanitary manner and all supplements should be labeled and stored according to manufacturer instructions. The facility's failure to adhere to proper food storage and sanitation practices increased the risk of food contamination and potential foodborne illness among residents 28 Pa. Code 201.18 (e) (2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents are free from unnecessary drugs to include duplicate pain medications for one of 19 sampled residents (Resident 28). Findings include: Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnosis to include dementia and polyneuropathy (a condition where peripheral nerves outside the brain and spinal cord are damaged). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2025 revealed a BIMS score (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information of 9, (a score of 8-12 indicate moderate impairment), required staff assistance for activities of daily living and frequently had severe pain and frequently experienced severe pain and was prescribed both daily pain medications and as-needed (PRN) pain medications A review of the clinical record revealed that Resident 28 had current physician orders for multiple opioid and non-opioid pain medications, including: Morphine Sulfate Solution 100 mg/5ml (a narcotic opioid pain medication) solution, take 0.25 ml 5 mg by mouth every 4 hours as needed for severe pain initiated July 11, 2023. Fentanyl transdermal patch (an opioid narcotic medication) 72 hour-12 mcg/hr., Applied every 72 hours for polyneuropathy-initiated May 21, 2024. Gabapentin (a seizure medication sometimes used for nerve pain) 200 mg by mouth three times daily for chronic polyneuropathy (initiated March 13, 2024. Oxycodone HCL (a narcotic opioid pain medication) 5 mg by mouth every 8 hours for chronic pain management initiated October 19, 2024. Clinical record review did not include documentation justifying the use of duplicate opioid pain medications (Morphine, Fentanyl, and Oxycodone) for this resident. During an interview on February 6, 2025, at approximately 11:00 AM, the Director of Nursing confirmed that there was no justification for the duplicate pain medication therapy for Resident 28. Cross refer F 697 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)Pharmacy services.

Based on review of controlled drug records and select facility policy and staff interview, it was determined the facility failed to implement procedures to promote accurate controlled medication records and failed to ensure medication availability for one of 19 residents sampled (Resident 28). Finding include: Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnosis to include dementia and polyneuropathy (a condition where peripheral nerves outside the brain and spinal cord are damaged). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2025 revealed a BIMS score (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information of 9, (a score of 8-12 indicate moderate impairment), required staff assistance for activities of daily living and frequently had severe pain and frequently experienced severe pain and was prescribed both daily pain medications and as-needed (PRN) pain medications A review of the clinical record revealed that Resident 28 had a current physician's order dated May 22, 2023, for Morphine Sulfate Solution 100 mg/5 ml (a narcotic opioid pain medication) to be administered 0.25 mls (5 mg) by mouth every four hours as needed for severe pain. A review of the controlled substance record for the above medication revealed that nursing staff signed out doses of 0.25 mls on the following dates and times: December 31, 2024, at 5:30 P.M. January 3, 2025, at 6:30 P.M. January 6, 2025, at 12:00 P.M. January 7, 2025, at 8:00 A.M. January 11, 2025, at 2:30 P.M. January 13, 2025, at 8:00 P.M. January 27, 2025, at 4:00 P.M. January 29, 2025, at 5:00 P.M. February 1, 2025, at 9:40 A.M. February 3, 2025, at 11:00 P.M. However, there was no corresponding documentation on the resident's Medication Administration Record (MAR) indicating that the medication was administered on those dates and times. During an interview conducted on February 6, 2025, at 1:00 P.M., Resident 28 was unable to provide information regarding her pain or medication regimen due to cognitive impairment. During an interview on February 6, 2025, at approximately 11:00 A.M., the Director of Nursing (DON) confirmed that there were inconsistencies in the controlled medication records, specifically that doses were signed out but not documented on the MAR to confirm administration. The facility failed to ensure that appropriate procedures were followed for controlled medication documentation and administration. Cross refer F 761 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)Pharmacy services. 28 Pa Code 211.5(f)(x) Clinical records

Based on clinical record review, select facility review and staff and resident interview, it was determined the failed to reassess a resident's pain status and the repeated daily use of opioid pain medication prescribed on an as-needed (PRN) basis to ensure the development and implementation of an effective, individualized pain management plan for one of 19 residents sampled. (Resident 28). Findings include: A review of the facility's policy for pain assessment and management, last reviewed in January 2025, revealed that the purpose of the pain management procedure is to assist staff in identifying pain in residents and developing interventions that align with the resident's goals and needs while addressing the underlying causes of pain. The policy requires a comprehensive pain assessment upon admission, at quarterly reviews, when there is a significant change in condition, or when there is a new onset or worsening of pain. Clinical record review revealed that Resident 28 was admitted on [DATE], with diagnoses including dementia and polyneuropathy (a condition involving damage to peripheral nerves outside of the brain and spinal cord). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2025, revealed a BIMS score (Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment) of 9, a score of 8-13 indicate moderate impairment, required staff assistance for activities of daily living and frequently had severe pain and was receiving both daily pain medications as well as needed (PRN) pain medications. Physician orders for pain management included: Morphine Sulfate Solution 100 mg/5ml (opioid narcotic medication)- 5 mg (0.25 mL) by mouth every 4 hours as needed (PRN) for severe pain, initiated July 11, 2023. Fentanyl transdermal patch (opioid narcotic medication) (12 mcg/hr.) - Applied every 72 hours for polyneuropathy, initiated May 21, 2024. Gabapentin 200 mg (a seizure medication used for nerve pain) - By mouth three times daily for chronic polyneuropathy, initiated March 13, 2024. Oxycodone HCL 5 mg (opioid narcotic medication) - Every 8 hours for chronic pain management, initiated October 19, 2024. A review of the resident's pain management care plan, initiated May 3, 2023, included interventions such as: Administer pain medications as ordered. Monitor for pain each shift and attempt nonpharmacological interventions (e.g., relaxation, repositioning, music therapy). Encourage the resident to communicate pain levels and try different pain relief methods. Evaluate the effectiveness of pain interventions, including compliance, symptom alleviation, and impact on function and cognition. A review of narcotic medication reconciliation records and medication administration records (MARs) from June 2024 through February 2025 indicated the following PRN Morphine administration: 1 dose in June 2024 1 dose in August 2024 1 dose in October 2024 4 doses in November 2024 2 doses in December 2024 37 doses in January 2025 7 doses from February 1-3, 2025 The MARs also confirmed that the resident received the Fentanyl patch, Oxycodone, and Gabapentin daily as ordered. A review of a resident evaluation dated August 21, 2024, revealed Resident 28 reported chronic, continuous, bilateral knee pain, rated 6/10 worst (on a scale of 0-10 with 0 being no pain and 10 being the most severe), but the assessment did not document factors exacerbating or relieving the pain. September 10, 2024 - Resident 28 denied pain. October 22, 2024 - Resident 28 denied pain. No additional documented pain assessments were found in the clinical record at the time of the survey. During an interview on February 6, 2025, at 1:00 PM, the Director of Nursing (DON) confirmed that no additional pain assessments had been conducted to justify the significant increase in daily PRN opioid use. The DON acknowledged that there was no evidence of a comprehensive pain reassessment to determine whether the resident's pain management regimen was effective, appropriate, or in need of adjustment. At the time of the survey, there was no documentation indicating that the facility had evaluated the causes of the resident's increased PRN opioid use or modified the pain management plan accordingly. The failure to reassess pain and adjust treatment as needed does not align with professional standards of practice, current clinical guidelines, or the facility's own pain management policy. This deficient practice resulted in the potential for unmanaged pain, unnecessary opioid exposure, or adverse medication effects, failing to ensure that Resident 28's pain management was individualized, effective, and consistent with their needs, goals, and preferences. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of 3 out of 19 sampled (Residents 7, 42, and 17). Findings included: A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia and muscle weakness. A review of Resident 7's quarterly MDS assessment dated [DATE], indicated in Section K0200 - A height was coded as 62 inches, and Section K0200 - B weight was coded as 103 pounds (MDS instructions indicate to enter the weight taken within 30 days of this assessment and if the last recorded weight was taken more than 30 days prior to the assessment reference date (ARD) of the assessment or previous weight is not available, weigh the resident again). Record review revealed the weight used for coding was obtained on December 21, 2024, more than 30 days before the ARD. No weight had been obtained within the required timeframe. According to MDS coding instructions, when no weight is available within 30 days, a dash (-) should be used to indicate missing data. In an interview on February 4, 2025, at 1:15 AM, the Registered Dietitian (RD) stated she was unaware of the requirement to code a dash (-) and mistakenly used the outdated weight A review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included pulmonary edema and spinal stenosis. A review of Resident 42's quarterly MDS assessment dated [DATE], indicated in Section K0200 that the resident's height was 62 inches, and the weight was 117 pounds. Review of Section K0300 indicated that Resident 42 experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The quarterly MDS dated [DATE], coded height as 62 inches and weight as 117 pounds. Section K0300 indicated the resident had a weight loss of 5% or more in one month or 10% or more in six months. Review of the clinical record found no evidence supporting this weight loss, as the resident had been admitted on ly two days prior to the assessment. The MDS inaccurately reflected the resident's weight status. A review of Resident 17's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia. A review of Resident 17's admission MDS assessment dated [DATE], indicated in Section K0200 that the resident's height was 62 inches, and the weight was 139 pounds. Review of Section K0300 indicated that Resident 17 experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The clinical record review revealed no documented evidence that Resident 17 experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months since the resident had been newly admitted to the facility 4 days prior to the MDS submission. On February 4, 2025, at approximately 1:20 PM, the RD confirmed the MDS assessments contained errors. The RD stated she had been using self-reported weights or hospital data rather than documented facility weight records to evaluate weight loss. 28 Pa Code 201.5(f)(i)Medical records. 28 Pa Code 211.12(d)(3)Nursing services.

Based on clinical record review, staff interviews, and observations, the facility failed to ensure medications were labeled in accordance with currently acceptable principles of medication storage and administration, including appropriate resident identification, medication information, and expiration/open dates for one of 19 sampled residents (Resident 28). Findings include: According to the FDA (federal drug administration) current as of January 21, 2025, and best practice, Expiration Dating of Multi-dose Vials indicated the date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date. Medication vials should always be discarded whenever sterility is compromised or cannot be confirmed. For example: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated with the last date that the product should be used (expiration date) and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Labeling the vial with the 'date opened' does not meet the intent of this requirement. If a multi-dose vial has not been opened or accessed (e.g., tab removed, needle-punctured), it should be discarded according to the manufacturer's expiration date which is generally printed on the label by the manufacturer. For expiration dates that only include the month/year, the unopened product is considered usable until the end of the month unless otherwise stated by the manufacturer. Clinical record review revealed that Resident 28 was admitted to the facility on [DATE], with diagnosis to include dementia and polyneuropathy (a condition where peripheral nerves outside the brain and spinal cord are damaged). A quarterly Minimum Data Set assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 22, 2025 revealed a BIMS score (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information of 9, (a score of 8-12 indicate moderate impairment), required staff assistance for activities of daily living and frequently had severe pain and frequently experienced severe pain and was prescribed both daily pain medications and as-needed (PRN) pain medications. Physician orders dated May 22, 2023, included an order for Morphine Sulfate Solution 100 mg/5 ml, with a dosage of 0.25 mL (5 mg) by mouth every four hours as needed for severe pain. A review of narcotic sign out sheets for Resident 28 revealed a 30 mL bottle of Morphine Sulfate dispensed from the pharmacy on May 22, 2023, was still in use as of January 1, 2025, despite multi-dose liquid medications requiring disposal within 28 days of opening unless otherwise specified by the manufacturer. This bottle was in use for approximately 20 months beyond recommended guidelines. Further review of the record revealed the medication was removed from the bottle and administered to Resident 28 on the following dates and times: December 8, 2023, at 2:30 A.M., May 6, 2024, at 5:00 P.M. May 6, 2024, at 8:00 P.M. May 7, 2024, at 8:00 A.M. May 7, 2024, at 4:00 P.M. May 8, 2024, at 9:00 A.M. May 8, 2024, at 4:00 P.M. May 10, 2024, at 4:00 A.M. May 10, 2024, at 2:00 P.M. June 26, 2024, at 4:00 P.M. August 22, 2024, at 9:30 A.M. October 31, 2024, at 12:00 P.M. November 1, 2024, at 2:00 P.M. November 1, 2024, at 8:00 P.M. November 1, 2024, at 12:25 P.M. December 13, 2024, at 2:00 P.M. December 29, 2024, at 4:45 A.M. December 31, 2024, at 5:30 P.M. January 1, 2025, at 8:00 A.M. January 1, 2025, at 12:29 P.M. The narcotic sign out record noted that 25 mls of the Morphine Sulfate Solution were destroyed by two facility licensed nurses on January 14, 2025, noting the reason for the medication destruction as, medication expired. A second 30 mL bottle dispensed on July 11, 2023, was administered to the resident through January 10, 2025, despite being open for 18 months. Further review of the record revealed the medication was removed from the bottle and administered to Resident 28 on the following dates and times: January 1, 2025, at 8:00 P.M. January 1, 2025, at 8:00 P.M. (The same licensed nurse documented that she spilled 15 mL on the floor-wasted medication.) January 3, 2025, at 6:30 P.M. January 4, 2025, at 8:31 A.M. January 4, 2025, at 1:52 P.M. January 5, 2025, at 9:26 A.M. January 5, 2025, at 5:56 P.M. January 6, 2025, at 8:00 A.M. January 6, 2025, at 12:00 P.M. January 6, 2025, at 4:00 P.M. January 6, 2025, at 8:00 P.M. January 8, 2025, at 7:15 A.M. January 9, 2025, at 3:30 P.M. January 10, 2025, at 7:00 A.M. January 10, 2025, at 3:00 P.M. The narcotic sign out record noted that 10.75 ml of the Morphine Sulfate Solution was destroyed by two facility licensed nurses on January 14, 2025, noting the reason for the medication destruction as, expired medication. An interview February 5, 2025, at 11:00 A.M. Employee 2 (agency LPN) indicated she was administering medications to residents on January 11, 2025, and noted Resident 28's bottle of Morphine Sulfate concentrate was faded in color. She stated that it should be a vibrant blue color and was a very faded shade of blue, almost clear. She stated she then checked the additional bottle in the locked narcotic box. The color was noted as the same. She confirmed both bottles were opened with approximately one half the medication remaining in the bottles. She indicated she had administered the Morphine Sulfate solution to Resident 28 on several previous occasions and did not check the label for expiration or open dates on either bottle. She stated that on January 11, 2025, when the discolored medication was discovered, a new bottle was retrieved from the emergency supply; however: an observation on February 5, 2025, at 8:00 A.M., in the presence of Employee 1 (LPN), of the locked narcotic drawer in the medication cart was a 30 ml plastic bottle of Morphine Sulfate Solution, 100 mg/5 cc (concentration) No label was affixed to the bottle. The resident's last name was handwritten on the cap with a marker. There was no pharmacy label or identifying information, including the medication name, concentration, dosing instructions, prescribing provider, or date of removal from the emergency supply. The controlled drug count sheet lacked essential details, including proper medication identification and tracking information. During an interview February 5, 2025, at 11:00 A.M., the Director of Nursing confirmed that both bottles the bottles of Morphine Sulfate solution had been opened and available for resident use since May 2023 (20 months) and July 2023 (18 months) and staff had not been monitoring open or expiration dates. The facility's expectation was to discard liquid medications 30 days after opening and staff failed to label the emergency supply medication and did not contact the pharmacy for proper labeling. This resulted in the administration of an unlabeled narcotic medication to Resident 28 from January 11, 2025, through February 3, 2025. During an interview on February 5, 2025, at 11:15 A.M., the DON confirmed that staff failed to label the emergency supply medication and did not contact the pharmacy for proper labeling. This resulted in the administration of an unlabeled narcotic medication to Resident 28 from January 11, 2025, through February 3, 2025. The facility failed to implement proper oversight and adherence to medication labeling protocols 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.9(a)(1)Pharmacy services. 28 Pa Code 211.5(f)(x) Clinical records

Based on review of clinical records and staff interview it was determined the facility failed to provide care and services in accordance with accepted professional standards of practice by inaccurately identifying a diagnosis of delusional disorder for one (1) of 19 residents (Resident 44) sampled without documented clinical evidence to support the diagnosis. Findings include: According to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition, Delusional Disorder, Diagnostic Criteria includes, but is not limited to: Delusional Disorder A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. A review of the Resident 44's clinical record revealed the resident was admitted to the facility on [DATE], with Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of the consultant pharmacist's initial medication review on September 23, 2024, indicated the resident had an order for Olanzapine 7.5 mg daily, with a recommendation that a diagnosis be provided to justify its use. A review of the Medication Administration Record (MAR) during the survey ending February 7, 2024, revealed that the resident had an order for: Olanzapine 2.5 mg by mouth once daily for delusional disorder. Olanzapine 5 mg by mouth once daily for delusional disorder. A review of the resident's progress notes lacked documented clinical evidence that the resident was experiencing delusions or hallucinations to support the diagnosis of delusional disorder. A review of an initial consult from the facility's Psychological Service provider dated December 12, 2024, indicated that the resident had a psychiatric history of Alzheimer's disease with behavioral disturbances but did not mention delusional disorder. The consultant further documented the resident was not experiencing delusions or hallucinations at that time. A comprehensive review of the resident's clinical record from admission (September 11, 2024) through the survey period ending February 7, 2024, revealed no documented evidence that a practitioner had diagnosed the resident with delusional disorder, nor were there supporting clinical findings to justify this diagnosis. In an interview with the Director of Nursing (DON) on February 5, 2025, at 2:00 PM, the DON confirmed that the facility did not have documented evidence of a practitioner diagnosing the resident with delusional disorder, and that the resident's medical record should reflect accurate clinical findings. The facility failed to ensure that services were provided in accordance with accepted professional standards of practice by assigning a diagnosis of delusional disorder to Resident 44 without documented clinical evidence or practitioner verification. 28 Pa. Code 211.2(d)(3) Medical director. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective fall prevention interventions including timely and necessary staff supervision of resident with a history of falls and known unsafe behaviors that increased the resident's risk for falls, to prevent a fall with serious injury, a fractured wrist, for one resident out of 18 sampled (Resident 49). Findings include: Clinical record review revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses to include dementia, chronic kidney disease, and history of urinary tract infections. A Quarterly Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 24, 2023, indicated that Resident 49 was severely cognitively impaired with a BIMS score of 0 and required extensive assistance from two staff members for toileting and transfers and limited assistance of one staff member for ambulation in the resident's room and corridors. The resident was noted to be unsteady while walking and only able to stabilize with staff assistance according to the MDS. The resident's care plan, initially dated February 3, 2020, indicated that the resident had the potential for falls, with history of falls, related to wandering without purpose, not knowing physical limitations, impulsivity and/or poor safety awareness. Planned interventions, to reduce potential for falls, included the resident's bed in lowest position, call bell within reach, ensure resident is wearing proper footwear, monitor toileting needs, motion sensor alarm while in bed, non-skid strips to floor in front of dresser, offer bedrest in the evening after dinner, offer diversional activities when restless (music, snack, walk), place belongings within reach, pull tab alarm to bed and chair. A facility investigative report dated July 20, 2023, revealed that at 8:20 PM, Employee 2, registered nurse, was called to the first floor to evaluate Resident 49 after a witnessed fall. According to the incident description, staff observed the resident to be restless and nursing was unable to redirect the resident from the start of the 3 PM to 11 PM. The resident was in chair at nursing station for staff observation when the resident's chair alarm sounded as the resident refused to sit and wanted to ambulate. The resident fell to the floor and hit the back of head. The resident was transported to the emergency room for an evaluation after she began to vomit at the facility. The resident returned to the facility without evidence of fracture or injury. Interventions planned for implementation was to encourage the resident to take rest periods after supper, although the resident fell during a period of restless behavior, refusing to sit and displaying a desire to ambulate. A review of witness statement dated July 20, 2023, revealed that Employee 3, a nurse aide, heard an alarm while exiting another resident's room and observed Resident 49 standing at the end of the hallway. The resident turned around while holding onto the railing and when staff asked the resident to sit down, the resident lost her balance and fell backwards hitting her head on the floor. A facility investigation report dated August 10, 2023, at 8:40 PM revealed that Resident 49 had another fall while at the nurses station, which on this occasion was noted as unwitnessed. According to the incident description, the resident was in her wheelchair at the nurse's station prior to the fall. The resident was assessed with apparent injury to right wrist and was sent to the emergency room for evaluation and was diagnosed with a fractured wrist. The resident returned to the facility with a splint and sling in place, and orders to follow-up with orthopedics in one week. The planned intervention implemented after this fall was to change the resident's chair alarm, from a clip alarm to pressure sensor alarm. Additionally, the resident's seating was evaluated with a change from standard wheelchair to a Broda chair. Prior to each fall, the witnessed fall on July 20, 2023, and the unwitnessed fall on August 10, 2023, the resident had been placed at the nurse's station for staff observation. Review of witness statement dated August 10, 2023, completed by Employee 4, nurse aide, revealed that when she came down to the first floor at 8:40 PM, came off the elevator and found the resident on the floor. Employee 4 further added on August 11, 2023, at 10 AM, indicated that it appeared that the resident had removed the clip alarm prior to attempting to stand. Review of witness statement dated August 10, 2023, completed by Employee 5, licensed practical nurse, revealed that the resident was last seen by Employee 3 sitting peacefully in the hall conversing with a peer at approximately 8:30 PM with alarm in place. Review of witness statement dated August 10, 2023, completed by Employee 3, nurse aide, revealed that at 6 PM {after dinner} she took the resident to the bathroom and got her ready for bed. At 7 PM and 8 PM Employee 3 offered the resident toileting and the resident refused. Employee 3 indicated that the employee last saw the resident seated in her chair in the hall talking to another resident, her alarm was in place and working. Review of resident's clinical record completed during survey ending March 22, 2024, revealed no documented evidence that the nursing staff had offered the resident to take a rest after dinner, which was the intervention planned after the resident's fall on July 20, 2023. Employee 3 noted the resident's activities that evening from 6 PM after dinner through the time of the fall in her statement, which did not include offering bedrest. There was also no evidence that the facility had maintained necessary supervision of the resident, who was known to display unsafe behaviors, including unassisted transfers and ambulation. Review of Resident 49's Kardex on March 21, 2024, revealed that safety interventions included in this resident's plan of care included all interventions identified on the resident's care plan, including to offer bedrest in the evening after dinner Interview with the Nursing Home Administrator on March 21, 2024, at approximately 1PM confirmed that there was no specific documentation that the nursing staff had offered the resident rest period after dinner prior to the resident's fall on August 10, 2023. According to the NHA, the nursing staff acknowledge completion of the planned interventions by clicking yes in the electronic record that care was provided according to Kardex including skin prevention and safety measures. This documentation is completed on each shift. During an interview on March 22, 2024, at approximately 1 PM the Nursing Home Administrator was unable to provide evidence that the facility provided effective safety and fall prevention measures, including sufficient staff supervision, to prevent this resident's fall with fracture. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff and police interviews, it was determined the facility failed to provide adequate staff supervision of a resident identified at risk for elopement to prevent the resident's elopement from the facility and failed to monitor the activities and whereabouts of a resident with known exit seeking behaviors to timely identify the resident's absence from the facility, which placed the resident in immediate jeopardy to his health and safety for one resident out of six residents identified at risk for elopement (Resident CR1). Findings include: A review of the facility policy dated January 2019 entitled Elopement revealed that It is the policy of the facility to provide a safe and secure environment for residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premise of the facility without the knowledge of facility staff. Staff should investigate and report all cases of missing residents. The facility elopement policy also indicated that electronic monitoring systems (Code Alert System) may be implemented as possible interventions as appropriate. If an electronic monitoring device is utilized as an intervention, they shall be checked according to manufacturer's recommendations for function and placement. Additionally, the policy indicated that residents at high risk for elopement may not be admitted to the facility unless appropriate interventions are identified prior to admission in the facility has the ability to appropriate least supervise and monitor the resident. The facility utilized the Code Alert electronic surveillance system, which is a bracelet with a monitor placed on a resident or resident's ambulation device. The code alert system is connected to the facility's main doors. The second-floor main entrance doors will be unlocked during specific hours (7:00 AM to 4:30 PM) and free access is possible. However, free access may be hindered when a resident wearing a transmitter is within sensor range of the door as the door will automatically lock. The magnetic code lock at the top of the door will lock when a resident wearing a transmitter is near the door. Once the monitored resident is moved away from the door it will unlock. A range of approximately 4 feet or less will activate the locks on the doors. These doors are equipped with an anti-tailgate feature, when a door is opened and monitored resident approaches, an alarm will sound. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE]. The resident's diagnoses included cerebral infarction due to occlusion (disrupted blood supply and restricted oxygen to the brain) or stenosis (narrowing) of a small artery, urinary tract infection, type II diabetes mellitus (referred to as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period) with [CONDITION(S)] (high blood sugar levels), weakness and difficulty walking. A review of Resident CR1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 11, 2022, revealed that the resident's cognition was moderately impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 12 (a score of 08-12 indicates moderately impaired cognition) and utilized a walker or wheelchair for mobility. Nursing progress notes dated April 27, 2022, indicated that Resident CR1 ambulates with a wheeled walker. A resident elopement assessment was conducted on April 27, 2022, which indicated that the resident was at moderate risk for wandering. An interdisciplinary note written by the nursing home administrator (NHA) dated April 28, 2022, indicated that the resident was pleasantly confused and always on the move and a wanderguard (code alert) was applied due to his wandering. Nursing documentation dated June 25, 2022, indicated that the resident wheeled his wheelchair to the front lobby. He was found standing by the double doors to exit the building. He stated that he knew the code to exit the door. It was noted that the code alert bracelets were on his wheelchair. He was standing by the door because he knew that the code alert system would not trigger if he didn't bring the wheelchair close to the system. Nursing indicated that they spoke with the resident and he was agreeable to having a code alert bracelet applied to his right ankle. Nursing documentation dated June 29, 2022 at 4:50 PM noted continue to monitor resident to ensure no knives, scissors, etc. that can be used to cut off Code Alert from person and wheelchair. Monitor resident frequently to ensure that Code Alerts are still in place. Interview with the NHA on September 6, 2022, revealed that the facility reportedly did not allow Resident CR1 to have any knives because he was able to cut off his code alert bracelet. Nursing documentation dated August 20, 2022, indicated that the resident's code alert was missing from his wheelchair at 1 PM and later at 7 PM the code alert had to be reapplied to his wheelchair. A social service note dated August 23, 2022, indicated that she visited the resident on a regular basis. Social services noted that he comes to her office to use the telephone to contact his family. His granddaughter does not answer the phone when he calls nor does his grandson. The resident verbalized that he wants to get back to his camper so he can get in his truck and drive back to Florida. The social worker indicated that the resident has no understanding of his physical limitations or impaired cognition. Progress notes dated August 31, 2022 at 3:11 PM indicated that the resident was assessed by a nurse from an alternate skilled nursing facility. According to the entry, the resident will be placed in a more secured facility. The entry noted that as soon as his paperwork was completed the resident could be transferred to another skilled nursing facility for his security. Nursing noted at 4:00 PM on August 31, 2022, that Resident CR1's code alert bracelet was on his person and it was intact. However, at 6 PM on this same date, nursing noted that Resident CR1's code alert bracelet was no longer in place and another code alert bracelet was placed on him. A review of a facility incident and accident report dated August 31, 2022, written by Employee 1, Registered Nurse Supervisor, revealed that the facility received a call at approximately 9:40 PM informing them that a resident had been found outside a community residence without apparent injury. The police were on the scene requesting that the facility staff come to transport the resident back to facility. According to the facility's report, at approximately 9:50 PM Employee 1 responded to the scene in the community. It was noted that resident was wearing a black sweatshirt, tan pants, ball cap, and socks and shoes. The approximate outdoor temperature was 70 degrees and it was not raining. The resident had left his wheelchair and walker at the facility. The resident denied any discomfort and stated that he was trying to get to his camper so that he could go to Florida. A decision at the scene was made that the resident could be returned in Employee 1's car. As the resident was being guided to the car by the police officer, he stumbled and fell on to his buttocks, scratching his left cheek on a mailbox post as he went down. He denied any pain. He had full range of motion to his extremities. The resident was offered an ambulance for a hospital assessment, but he adamantly refused to go to the emergency department. A decision was made that it would be best to get the resident back to the nursing home quickly where he could be fully assessed to ensure there was no underlying issues and for care to his cheek. The resident stood up with minimal assistance. The police seated and belted the resident into the vehicle. He had slight bleeding from his left cheek scratch, it was blotted clean to ensure bleeding was controlled. The facility's report further noted that at 10:00 PM, on August 31, 2022, upon arrival back at the facility he was transferred into a wheelchair from the car and brought onto the unit. He was placed on 1:1 observation, neurological checks were normal, his blood sugar was within normal limits and the scratch on his left cheek was cleansed and steri strips were applied to deter scarring. A skin assessment was unremarkable. The physician was notified. The resident was assisted into bed at 10:30 PM. The incident report indicated that the resident was last seen by Employee 1, at 7:30 PM self-propelling himself to his room. The nurse aide, Employee 3, assigned to the resident that shift stated in her witness statement that she provided care to him at 6:40 PM and his code alert was in place on his ankle. An interview was conducted at 2:55 PM on September 7, 2022, with Employee 3, nurse aide, who was assigned to Resident CR1 on the night of his elopement August 31, 2022. She stated that she saw him approximately 6:30 PM going into the dining room to do a puzzle She stated that she was unaware that he had removed his alert bracelet earlier that day. She stated that she usually checks the residents on her assignment every two to three hours. When asked about checking Resident CR1 after 6:30 PM that night she stated well I guess I didn't. She stated she was unaware he had exited the facility. She also stated I didn't think he would get out, he usually gets out on day shift, not on my shift. She stated that he got out on day shift, he only got to the parking lot. Employee 3 stated that she was not sure when it was, but she stated he was not out there too long. She could not remember if he exited the building at any other time. Interview conducted with the local police officer who had responded to the resident's elopement on August 31, 2022, conducted on September 6, 2022, revealed that the police officer responded to a report from a community member that a suspicious male was on the porch of a residence on August 31, 2022, at 9:15 PM. The location of the porch was determined to be approximately 0.4 miles away from the facility. The police officer was unaware who this male was or where he came from. According to the police officer, witnesses stated that he was walking back and forth for what the witnesses say was a few hours. When found by the police, the male had a paper in his wallet with emergency contact numbers, which the police contacted, but were unable to reach. The male did not know his current home address. However, there was a piece of paper with the facility's name listed on it in his possession. The officer contacted the facility, and it was determined that the unknown male was in fact Resident CR1. The evening shift registered nurse supervisor (RNS) Employee 1 arrived at the residence and picked up Resident CR1. When assisting the resident into the vehicle his legs gave out and he stumbled causing him to fall into a mailbox. The resident sustained a scratch on the side of his face, but he refused medical attention and assistance. The resident was returned to the facility by Employee 1. On September 6, 2022, Employee 1 was interviewed via telephone at 3:15 PM. Employee 1 stated that she picked up Resident CR1 in response to the police report on the night of August 31, 2022. She stated that the last time she saw him that evening was at 7:30 PM. He was in his wheelchair, wheeling back to his bedroom. She stated she was aware that he was able to remove his code alert bracelet, but unaware that he had done so earlier that day. An interview with Employee 2, the night shift registered nurse supervisor, on September 6, 2022, at 1:30 PM revealed that she was aware that this resident was known to cut off his Code Alert bracelet in the past. During interviews with the NHA, Employee 1 and Employee 2 on September 6, 2022, they all denied that Resident CR1 had ever exited the facility prior to this elopement. There was no documentation that Resident CR1 exited the building as Employee 3 stated during interview on September 6, 2022. According to interview with the police officer on September 6, 2022, Employee 1 had reportedly informed her, when she arrived at the location Resident CR1 was found on August 31, 2022, that he has Alzheimer's/Dementia and took off several times in the past 3 days, he is a flight risk. When Employee 1 was interviewed on September 6, 2022, she denied stating this to the officer. Continued interview conducted on September 6, 2022, with the police officer who arrived at the scene where the resident was found, revealed that when she found the resident, she contacted the facility and asked the facility if they had any residents that were missing. She was unsure of who she had spoken to, but the person on the other end of the phone stated, let me check. They then replied, after having determined that a resident was missing, that it turned out to be Resident CR1. It was determined by review of the facility incident accident report and interviews with facility staff and the police, that the resident was last seen between 7:10 PM when his medications were provided and 7:30 PM when the nursing supervisor saw him headed to his room in the wheelchair. There was no documented evidence regarding the resident's whereabouts until the police contacted the facility at 9:40 PM informing them that Resident CR1 was found 0.4 miles away from the facility. The facility's conclusion was that the resident had removed his code alert bracelet, wheeled himself to the second-floor main exit, and left his wheelchair at the door and exited the building. It could not be determined exact path the resident took to finally arrive at his destination when found by police. Surveyor observation of the path that leads out of the facility revealed a steep hill that leads to the main road, which the resident would have been required to cross to arrive at the location he was found. He was found at the corner of the street, near the woods. The witnesses reported to police that they saw this resident walking up and down the street. There was no video footage available at the time of the survey as the NHA stated during interview on September 6, 2022, that the facility's camera footage was unavailable to review to determine the specific time he had exited the facility. The resident was absent from the facility for greater than 2 hours and 10 minutes according to the documentation that was provided at the time of the survey and interviews with staff and the police. Staff were unaware that the resident had eloped from the building until notified by the police. Staff failed to monitor the resident's whereabouts although the resident was at risk for elopement and had removed his code alert approximately one hour before he exited the building. The facility relied on its electronic monitoring system to prevent resident elopements, which was ineffective in preventing Resident CR1's elopement. As a result of these failures to adequately supervise and monitor a resident at risk for elopement, which allowed Resident CR1 to successfully exit from the facility without staff knowledge, the resident's individualized needs for supervision of exit seeking behaviors were not met and Immediate Jeopardy to the health and safety of the resident was identified. The Nursing Home Administrator was notified of the immediate jeopardy and provided the IJ Template on September 6, 2022, at 4:15 PM The facility's immediate action plan provided to the survey team at 6:00 PM on September 6, 2022, was as follows: 1. Resident CR1 was discharged to a secured unit at another facility on September 2, 2022. 2. Current residents will be reassessed for elopement risk. 3. Residents identified as elopement risks will be re assessed for exit seeking behaviors and individual plans will be developed for supervision and monitoring. 4. Residents with code alerts will be audited to verify the placement of the code alert as per policy. Completed September 6, 2022 5. If a resident has been found to have self-removed their code alert, their code alert will be reapplied, the resident will be placed on one-to-one supervision until an alternate, appropriate plan can be implemented. Current nursing staff will be educated regarding this plan starting with the present 3:00 PM to 11:00 PM staff on September 6, 2022 and moving forward with each oncoming shift. Employees not scheduled within the next 24 hours will be educated by telephone. Anyone not educated will be removed from the schedule until education is completed. During the onsite visit to the facility on [DATE], verification of the implementation of the facility's removal plan was completed and the Immediate Jeopardy was lifted on September 6, 2022, at 6:15 PM. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices 28 Pa Code 201.18(e)(1)(3) Management 28 Pa Code 207.2(a) Administrators Responsibility 28 Pa Code 211.12(a)(c)(d)(3)(5) Nursing Services

Based on a review of clinical records and staff interview the facility failed to provide timely and necessary care and services for treatment of [REDACTED]. Findings include: A review of the clinical record of Resident 39 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. Idiopathic means the cause of the constipation is unknown) 145 mcg by mouth daily for constipation, beginning April 16, 2013. Resident 39 was also prescribed a high fiber diet and received stewed prunes daily. The resident's prescribed bowel management protocol included Milk of Magnesia suspension (a laxative, medication used to promote bowel movement) 30 cc's (one ounce) by mouth the evening of the third day (3 PM to 11 PM shift) as needed if no bowel movement (BM), Bisac-Evac 10 mg suppository (a stimulant laxative), insert one rectally, early in the morning of the fourth day (11 PM to 7 PM), as needed if no bowel movement and fleet enema (is a lubricant laxative that works by slowing the absorption of water from the bowel, which softens the stool) insert rectally on the fourth day (7 AM to 3 PM shift) as needed if no bowel movement, notify Physician if ineffective. A review of nursing documentation dated September 29, 2015 at 5:15 PM revealed that resident (39) not eating, abdomen very distended, firm, nontender, bowel sounds very hypoactive. Resident stated he had no discomfort or pain, but is just not hungry. Had two medium sized bowel movements today. The Physician was notified and the resident was sent to the hospital for evaluation. A review of a CT scan (A computed tomography (CT) scan uses X-rays to make detailed pictures of structures inside of the body) was completed at the hospital. The findings noted a 3.6 cm aortic, abdominal aneurysm (a weakening of the wall of the aorta, the main artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen) and the colon is very distended with air and stool. Large amounts of stool in the distal rectosigmoid colon. Constipation or fecal impaction (Fecal impaction is a mass of dry, hard stool that will not pass out of the colon or rectum) possible. The emergency department documentation dated September 29, 2015, at 8:18 PM noted a physical assessment to include a rectal exam revealing soft stool in the rectum. Emergency Department documentation also reflected, per the emergency department nurse, that the resident had a large bowel movement at the hospital ED department, his abdomen was noted to be less distended and non-tender. Nursing documentation upon the resident's return to the facility September 30, 2015, at 3 :45 a.m. revealed that the resident returned to the facility with a [DIAGNOSES REDACTED]. The entry continued to note that Resident 39 had an extra large bowel movement when he came back to the facility. However, there was no documented evidence that the facility had developed and implemented specific approaches to monitor the consistency and adequacy of the resident's bowel activity, following the [DIAGNOSES REDACTED]. The resident's physician was notified of the resident's return to the facility and ordered fiber juice (juice with added fiber) with meals and a repeat CT scan for abdominal aneurysm on October 2, 2015. Nursing documentation revealed that on October 1, 2015, the resident displayed slight abdominal distention and hypoactive bowel sounds (bowel sounds are made by the intestines while pushing food through them, a lack of bowel sounds indicate the intestines are not pushing out feces and can be a sign of constipation) were noted. A CT scan of the resident's abdomen was completed (10/2/15) and the results dated October 2, 2015, revealed that the resident had an increase in presumed fecal impaction with massive distention of the rectum and stool-filled colon diffusely identified. Nursing documentation on the CT report indicated that the facility notified the resident's attending physician on October 8, 2015, and the physician ordered prune juice with the resident's breakfast and changed the medication administration times of the Linzess and the [MEDICATION NAME]. Nursing documentation revealed that between October 2, 2015, and October 12, 2015, the resident's abdomen remained slightly distended on most days. There was no evidence that the facility had timely acted upon the resident's signs and symptoms of increased fecal impaction during this timeframe. A review of the resident's bowel movement records dated from September 30, 2015 through October 8, 2015, revealed that staff documented that the resident had bowel movements almost daily, but the documentation failed to describe/identify the consistency of the resident's bowel movements to determine if the resident was adequately evacuating his bowels or if the stool was liquid or seeping (as stool moves around the impaction). The resident's physician was not timely notified of the results of the October 2, 2015, CT scan to initiate prompt treatment desired and there was no documented evidence of any further evaluation or treatment the facility had provided for this resident's fecal impaction. An interview with the Director of Nursing on January 8, 2016, at 10:30 a.m., confirmed that facility nursing staff does not document the consistency of bowel movements and was unable to explain why there was no follow-up to the CT reports, which revealed a fecal impaction. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 2/12/15

Based on review of clinical records, select facility policy, resident incident/accident reports and a facility abuse/neglect investigation (PB#22) and resident and staff interview, it was determined that the facility failed to ensure that nursing staff provided the necessary services to avoid physical harm incurred by one resident out of 20 sampled (Resident 15). Findings include: Review of a facility policy entitled "Abuse/Neglect" reviewed by the facility December 14, 2010, revealed that neglect occurs when a resident receives a lack of care through inattentiveness, carelessness, or omission to provide timely, consistent, safe and adequate services and treatments. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident required staff assistance with activities of daily living including assistance of two staff when toileting. Review of the resident's care plan revised on February 28, 2010, revealed that the resident was at risk for falls due to a decrease in strength and endurance and a fall on the same date. Planned interventions at the time called for staff to transfer the resident by way of stand and pivot with extensive assistance of two staff. Review of an incident report dated February 28, 2010, at 9:05 p.m., revealed that while transferring the resident from the wheelchair to the bed, the resident lost her balance and began to fall backwards. The report further indicated that the nurse aide (CNA) was with the resident and was able to catch the resident and ease her to the floor. After being screened by physical therapy, additional interventions at the time called for the resident to be a two person assist for transfers and standing. Review of an incident report dated May 13, 2010, at 9:20 p.m., revealed that the nurse was called to the room by the CNA (Employee 5) as the CNA stated "I need help." The nurse indicated that the resident was observed on the floor with the nurse aide stating "I was attempting to pull her slacks up and her knees buckled and I had to eased her to the floor". The report also indicated that the resident complained of left ankle pain and that the physician and family was notified. The report further indicated that the nurse aide toileted the resident by herself; however, the plan of care for the resident calls for an extensive assist of two (for transfer). According to Employee 5's statement, she placed a wheelchair in front of the resident, who was in the bathroom, and had the resident stand up so as to wash her bottom. The resident said she needed to sit so she sat down on the edge of the high rise seat and started to fall off it. The nurse aide tried to hold her up and get her back on the seat, but "I (the CNA) couldn't hold her." She landed on her knees with her left lower leg outward to the side. Review of the facility's abuse/neglect investigation report (PB#22) dated May 13, 2010, revealed, that when interviewed, Resident 15 stated she told the nurse aide as she was being transferred out of bed, that she has two (2) aides at other times and that the nurse aide did not say anything or check any papers, just took her to bathroom by herself. Resident 15 stated she couldn't stand anymore as she was being transferred and fell to the floor. The PB#22 indicated that the nurse aide, Employee 5, did not follow the resident's plan of care, which instructs staff to transfer the resident with an extensive assist of two (2) staff. The facility investigation determined that the aide's actions were neglectful and Employee 5 was subsequently terminated. Review of a physician-ordered x-ray dated May 13, 2010, revealed that the resident suffered a non-displaced fracture in the medial and distal aspect of the left tibia as the result of the fall. Interview with Resident 15 on February 15, 2011, at 12:15 p.m., revealed that the resident told the nurse aide, Employee 5, on the day of the fall resulting in the injury, that "I'm always transferred with two nurse aides when getting in/out of bed, going to the bathroom and showering." The resident stated "I don't know why she only helped me by herself, I told her, and now,my hip and spine aren't strong." The results of the facility's investigation into this incident determined that Employee 5 neglected to read the resident's plan of care and listen to the resident and failed to provide the necessary planned safety measures that included the assist of two staff for transfers resulting in the resident's fall with serious injury. 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12 (a)(c)(d)(5)(e) Nursing services. Previously cited 1/13/10