Every finding on record at Forest Park Nursing and Rehabilitation

Based on facility policy review, facility document review, observations, and staff interview, it was determined that the facility failed to properly label medications in two of two medications carts reviewed (Laurel Lane and Evergreen) and in one of two medication rooms reviewed (Evergreen/Stepping Stones).Findings include: Review of facility policy, titled Administering Medications, dated April 2019, with a last review date of February 9, 2026, revealed, in part, 17. Insulin pens are clearly labeled with the resident's name or other identifying information. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of facility policy, titled Storage of Medications, dated November 2020, with a last review date of February 9, 2026, revealed, in part, 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. Review of facility policy, titled Labeling of Medication Containers, dated April 2019, with a last review date of February 9, 2026, revealed, in part, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Review of facility document, titled Medications with Shortened Expiration Dates, dated August 2022, revealed that Lantus insulin expires 28 days after opening and that tuberculin skin testing solution should be discarded 30 days after opening. Observation of the Laurel Lane medication cart with Employee 6 (Licensed Practical Nurse) on August 4, 2026, at 9:24 AM, revealed an opened, half-full bottle of liquid protein supplement with no open date noted on the bottle. The bottle indicated that it was to be discarded 60 days after opening. In addition, there was an albuterol inhaler stored in the cart without a manufacturer package noted and no label containing a resident's name. Observation of the Evergreen medication cart with Employee 7 (Licensed Practical Nurse) on August 4, 2026, at 9:30 AM, revealed three Lantus insulin pens were not dated with an open date (Residents 14, 85, and 87). Observation of the Evergreen/Stepping Stones medication room with Employee 8 (Licensed Practical Nurse) on August 4, 2026, at 9:39 AM, revealed an opened multi-dose vial of tuberculin testing solution with no opened date indicated on vial or box. During a staff interview with the Nursing Home Administrator on August 4, 2026, at 11:16 AM, she confirmed that she would expect medications to be labeled and stored properly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1)(j)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for four of five residents reviewed for nutrition (Residents 4, 10, 103 and 110). Findings include: Review of facility policy, titled Weight Assessment and Intervention, last reviewed February 9, 2026, read, in part, Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The dietitian will respond within 24 hours of receipt of written notification. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Care planning for weight loss or impaired nutrition is a multidisciplinary effort. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes, and those wishes will be respected. Review of the facility policy, titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol last reviewed February 9, 2026, read, in part, The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Review of Resident 4's clinical record revealed diagnoses that included anorexia (a general medical symptom meaning the complete loss of appetite or a refusal to eat) and depression (a common and serious medical mood disorder that causes sadness and a loss of interest in things you once liked). Review of Resident 4's clinical record revealed he was hospitalized from [DATE], to May 11, 2026. Review of Resident 4's weight measures revealed he had a significant weight loss of 25.4 pounds (-15.38%) from April 20, 2026, to May 12, 2026. Further review of his weights revealed a reweight was not obtained, and his next weight measure recorded was on June 4, 2026. Review of Resident 4's clinical record revealed a Nutrition/Dietary progress note on May 13, 2026, at 10:13 AM, acknowledging the weight change and requesting a further weight from nursing. Review of Resident 4's clinical record failed to reveal a reweight of the Resident until June 4, 2026, with a weight of 138.6 pounds. Review of Resident 4's clinical record for May 11, 2026, revealed an order for weekly weights for four weeks every seven days for admission weights for four administrations. Further review of Resident 4's TAR (Treatment Administration Record-record of treatments administered) for May 2026 and June 2026, revealed he was checked off as having weekly weights on May 19 and 26, 2026, and June 2, 2026. Review of Resident 4's clinical record failed to reveal weekly weight measures for May 19, 2026, through June 2, 2026. During an interview with the NHA (Nursing Home Administrator) and Director of Nursing (DON) on August 5, 2026, at 1:43 PM, the NHA revealed she would expect weekly weights to be restarted after a hospital stay with return and reweights competed as necessary for weight changes. During an interview with the Director of Nursing (DON) on August 6, 2026, at 11:30 AM, she revealed that the facility did not get a reweight for Resident 4 from May 12, 2026, and would have expected the Resident to be reweighed the next day per their policy for significant changes. Review of Resident 10's clinical record revealed diagnoses that included muscle weakness, dysphagia (difficulty chewing and/or swallowing), and depression. Review of Resident 10's physician orders revealed an order for Weights: Monthly Weights Day shift, every day shift every 30 days, with a start date of June 1, 2025. Further review of Resident 10's physician orders revealed an order for Boost Plus or Ensure Plus, two times a day supplement related to significant weight changes and varied intake, with a start date of May 4, 2026. Review of Resident 10's January 2026 MAR (Medication Administration Record- record of treatments/medications administered) revealed he was checked off as having a January 2026 monthly weight, obtained on January 27, 2026. Review of Resident 10's clinical record failed to reveal a weight measure for January 2026 and February 2026. Review of Resident 10's February 2026 MAR revealed it was noted to check the nurses notes for his weight order on February 26, 2026. The nurse's note for the weight order revealed not completed, without a rationale for lack of completion. Review of Resident 10's weight measures revealed he had a significant weight loss of 15 pounds (-10.2%) from April 14, 2026, to May 1, 2026. Review of Resident 10's clinical record revealed a note written by Employee 1 (Registered Dietitian) on May 1, 2026, at 1:20 PM, that stated Weight changes noted. Will reach out to nursing to obtain further weight to better assess resident. Review of Resident 10's clinical record revealed a reweight wasn't obtained until May 4, 2026. In response to the weight change, the dietitian ordered a supplement twice daily, no physician notification of the significant weight loss was noted. Review of Resident 10's weight measures revealed he had a continued weight loss of 6.4 pounds (-4.8%) from May 4, 2026, to June 8, 2026. Review of Resident 10's clinical record revealed a note written by Employee 1 on June 8, 2026, at 9:35 AM, Will increase supplement TID [three times daily] related to varied intake at meals, make nursing and provider aware of changes and continue to monitor. Review of Resident 10's clinical record failed to reveal his supplement had been increased in response to the note on June 8, 2026, and failed to reveal significant weight loss was noted on his care plan. Further review of his record revealed he was readmitted from the hospital on July 12, 2026, at his most recent weight was obtained on July 5, 2026. During an interview with the DON on August 6, 2026, at 11:40 AM, she revealed she was unable to locate a January 2026 or February 2026 weight for Resident 10, and she was unsure as to why the supplement didn't get increased per the dietitian recommendation on June 8, 2026. She further revealed she would expect weekly weights x4 upon admission/readmission, she would expect reweighs to be completed timely in response to significant weight changes, weights to be obtained per order, the doctor to be notified of significant weight changes, and care plans to be updated to reflect significant weight losses. Review of Resident 103's clinical record revealed diagnoses that included muscle weakness, need for assistance with personal care, and depression. Review of Resident 103's weight measures revealed he had a significant weight loss of 21 pounds (-11.5%) from December 5, 2025, to January 6, 2026. Further review of his weights revealed a reweigh was not obtained, and his next weight measure recorded was on February 6, 2026. Review of Resident 103's clinical record revealed a nutrition note written by Employee 3 (Registered Dietitian) on January 23, 2026, at 8:56 AM, in response to the weight loss that stated it was desired related to recent weight gain and overweight body mass index (height to weight ratio), and that the interdisciplinary team was notified and that a reweigh was requested. Review of Resident 103's weight measures revealed his next weight was not obtained until the following month on February 6, 2026. Resident 103's weight went from 159.8 pounds on February 6, 2026; 155.4 pounds on March 7, 2026; and 152 pounds on April 2, 2026. Review of Resident 103's clinical record revealed a summary for providers note on February 12, 2026, at 12:55 PM, that read, in part, Nursing observations, evaluation, and recommendations are: Mobile dentist visit today found abscess on bilateral lower teeth. New order for Amoxicillin 500mg three times daily x 7 days. Review of Resident 103's clinical record revealed a nutrition note written by Employee 3 on March 9, 2026, in response to the weight from February 6, 2026, that read, in part, Weight loss now undesired as resident is at a healthy weight for age and po (by mouth) intake has declined. PO intake decline may be due to recent tooth abscess noted per MD/nursing. Although, resident is prone to weight fluctuations due to daily diuretic use, with interventions to monitor for need for soft food and a daily nutritional supplement. Review of Resident 103's clinical record revealed a nutrition note written by Employee 3 on March 31, 2026, in response to the March 7, 2026, weight measure that read, in part, Resident with 17% loss x 90 days, trending down x 30 days, varied intake. Increased supplement to BID and will monitor. Resident 103's comprehensive care plan failed to reveal his care plan had been updated to reflect he has experienced significant weight loss and had a tooth abscess with reduced po intake. During an interview with the DON on August 6, 2026, at 11:40 AM, she revealed she would expect reweighs to be completed timely in response to significant weight changes, timely nutrition assessments in response to significant weight changes, and care plans to be updated to reflect significant weight losses. Review of Resident 110's clinical record revealed diagnoses that included hypertension and dementia. Review of Resident 110's clinical record revealed she weighed 132.9 pounds on June 9, 2026, and 124.9 pounds on July 2, 2026, indicating a -6.02% weight loss. Review of Resident 110's clinical record revealed a Nutrition/Dietary progress note on July 3, 2026, acknowledging the weight loss and requesting a reweight. Review of Resident 110's clinical record failed to reveal a reweight of the Resident in July 2026. Review of Resident 110's clinical record revealed they were not reweighed until August 4, 2026, with a weight of 124.9 pounds. Review of Resident 110's clinical record failed to reveal a physician notification of the Resident's significant weight loss. During an interview with the DON on August 6, 2026, at 11:30 AM, she revealed that the facility never did get a reweight for Resident 110 from July 2, 2026, and would have expected the Resident to have been reweighed the next day and the physician to have been notified of the significant weight loss. 28 Pa Code 201.18(b)(1) Management28 Pa Code 211.2(d)(3) Medical director28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of four residents reviewed for respiratory care (Resident 13).Findings include: Review of facility policy, titled Oxygen Administration, dated October 2010, with a last review date of February 9, 2026, revealed, in part, Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.; and Reporting: 1. Notify the supervisor if the resident refuses the procedure. Review of Resident 13's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations) and chronic respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood). Review of Resident 13's physician orders revealed an order for oxygen at 2 liters/minute via nasal cannula every shift, dated June 7, 2026. During a resident interview with Resident 13 on August 3, 2026, at 10:00 AM, Resident 13 was observed to have her oxygen concentrator running but she was not wearing her oxygen. During an immediate interview with Resident 13, she indicated that she took it off because she only wears her oxygen at night. Observation of Resident 13 on August 4, 2026, at 11:04 AM, revealed her oxygen concentrator was running and her nasal cannula was lying on her bed. Resident 13 indicated that she only wears it when she wants to, and that is usually at night. Observation of Resident 13's room on August 5, 2026, at 9:25 AM, revealed that she was not present in her room. Her oxygen concentrator was running, and her nasal cannula was lying on her bed. During a staff interview with Employee 6 (Licensed Practical Nurse) on August 5, 2026, at 9:29 AM, Employee 6 indicated that Resident 13 was out of the facility on a leave of absence. When asked if Resident 13 had taken oxygen with her on her leave of absence, Employee 6 said that Resident 13 did not take any portable oxygen with her because her oxygen was only ordered for nighttime. Review of Resident 13's August Medication Administration Record revealed that she had been documented as receiving her oxygen on every shift for August 1, 2, 3, 4, and 5, 2026. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on August 5, 2026, at 1:05 PM, the DON indicated that Resident 13 had been hospitalized recently and, prior to her hospitalization, her oxygen was ordered at night and as needed for an oxygen saturation level below 90%, but when she returned from the hospital the oxygen order was entered for continuous use. She said that she was clarifying the order. 28 Pa. Code 211.10(c) Resident care policies.28 Pa code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, review of facility diet extension sheets, review of select facility recipes, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for 6 of 34 resident's reviewed on a consistent carbohydrate diet (Resident's 1, 14, 40, 56, 77, and 92).Findings include: Review of facility policy, titled Therapeutic Diets last reviewed February 9, 2026, read, in part, A 'therapeutic diet' is considered a diet ordered by a physician, practitioner, or dietitian as part of a treatment for a disease or clinical condition, to modify specific nutrients in a diet, or to alter the texture of a diet, for example: diabetic/calorie controlled diet. Review of facility menu extension sheets for day 25 of the spring and summer menu, revealed residents on a carbohydrate controlled (diabetic) restriction should be served 4 ounces (unit of measure) of diet pudding with topping in place of the brownie for dessert. Review of select facility menus for brownies and diet pudding revealed the brownie contains 31.27 grams of carbohydrate (sugar, starch and dietary fiber occurring in foods) per serving, and the diet pudding contains 9.54 grams of carbohydrate per serving. Review of physician orders for Residents 1, 14, 40, 56, 77, and 92, revealed they were ordered a consistent carbohydrate diet for diabetes. Observations during tray line meal service on August 5, 2026, revealed residents were being served brownies as dessert. During an interview with Employee 4 (Cook) at the completion of tray line meal service on August 5, 2026, at 11:17 AM, she revealed everyone was served a brownie for dessert at lunch that day, and there was not an alternate dessert served. Observation of Residents 1, 14, 40, 56, 77, and 92 in their rooms on August 5, 2026, between 11:19 AM and 11:36 AM, revealed they had been served lunch, and a brownie was on their tray. Interview with the Nursing Home Administrator on August 5, 2026, at 1:23 PM, revealed she would expect therapeutic diets to be provided as ordered and extension sheets followed for therapeutic diet alterations. 28 Pa Code 201.18(b)(1) Management

Based on review of facility meal tray test form, review of resident council meeting minutes, a resident group interview, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and beverages at appetizing temperatures. Findings include: Review of form titled Culinary and Nutrition Test Tray not dated, revealed standard temperatures for hot foods and beverages at point of service are greater than 135 degrees Fahrenheit (F- unit of measure); and the standard temperature for cold beverages at point of service is below 41 degrees F. Interview with Resident 47 on August 3, 2026, at 11:25 AM, revealed the food is often served cold and the trays sit in the meal carts on the units for extended periods of time before they are passed to the residents. He stated the cold items just sit on the trays for extended periods, and the coffee is usually not hot. During a group interview with residents on August 4, 2026, at 10:30 AM, they revealed the food tastes poor and the temperatures are not appetizing. Review of Resident Council Minutes from February 27, 2026, under dietary concerns it was revealed that residents complained of food served cold. Review of Resident Council Minutes from July 31, 2026, under dietary concerns it was revealed that residents complained of food served cold. Review of facility menu on August 5, 2026, revealed the main lunch meal consisted of Ham, [NAME] beans & Potatoes (Entree), Dinner Roll, and a Brownie. A test tray was completed on August 5, 2026, at 12:06 PM, with Employee 4 (Cook) that included the Ham, [NAME] beans & Potatoes, Dinner Roll, Brownie, Milk, and Coffee. The test tray was placed on a meal cart and delivered to the Chapel [NAME] unit with other trays being delivered at that time; approximately 35 minutes had elapsed between leaving the kitchen and when the test tray was served for evaluation, as it was the last tray served on that unit after all others had been passed. Employee 4 took temperatures of the food items at the time the test tray was served for evaluation. At that time, the entree had a highest recorded temperature of 120.4 degrees F; the coffee had a highest recorded temperature of 125 degrees F; and the milk had a lowest recorded temperature of 59 degrees F. The aforementioned entree, coffee, and milk were not served at appetizing temperatures. During an interview with Employee 2 (Certified Dietary Manager) on August 5, 2025, at 12:12 PM, she confirmed that the aforementioned food and beverage temperatures were not within acceptable ranges. During an interview with the Nursing Home Administrator (NHA) on August 5, 2026, at 1:24 PM, the surveyor revealed the concern with food palatability and the test tray results. The NHA revealed her expectation that food and beverages would be served at appetizing temperatures. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three out of 23 residents reviewed (Residents 56, 84, and 97).Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, with a last review date of February 9, 2026, revealed, in part, 14. The interdisciplinary team must review and update the care plan a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs). Review of Resident 56's clinical record revealed diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves which disrupts communication between the brain and the body) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart). Further review of Resident 56's clinical record revealed that she was diagnosed with an urinary tract infection (UTI) on July 30, 2026, and was ordered Cipro oral tablet 250 MG (antibiotic--ciprofloxacin hydrochloride) give one tablet by mouth two times a day for UTI for seven days (July 30, 2026-August 6, 2026). Review of Resident 56's care plan failed to reveal that she had a UTI. During a staff interview with the Nursing Home Administrator (NHA) on August 6, 2026, at 10:30 AM, she confirmed that Resident 56's care plan should have been revised to include her UTI. Review of Resident 84's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (loss of cognitive functioning that interferes with daily life and activities). Review of Resident 84's clinical record revealed the Resident was admitted to hospice on June 30, 2026. Review of Resident 84's clinical record revealed the Resident had a significant change MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) completed on June 30, 2026, in relation to starting hospice. Review of Resident 84's comprehensive care plan revealed a focus area and interventions for hospice were created and initiated on July 28, 2026. During an interview with the NHA on August 6, 2026, at 10:24 AM, revealed she would have expected Resident 84's hospice care plan to have been implemented prior to July 28, 2026. Review of Resident 97's clinical record revealed diagnoses that included dementia, muscle weakness, and need for assistance with personal care. Review of Resident 97's physician orders revealed an order for a treatment for a skin tear to her top right shoulder until resolved. This order was noted to be discontinued on July 8, 2026, with a discontinued reason of area healed. Review of Resident 97's comprehensive care plan revealed an active care plan for Actual skin breakdown related to skin tear R[ight] shoulder with an intervention for Administer treatment per physician orders. Review of Resident 97's Quarterly MDS assessment with ARD (Assessment Reference Date- last day of the assessment period) of July 24, 2026, revealed it was marked no for the presence of a skin tear. During an interview with Employee 5 (Registered Nurse Assessment Coordinator) on August 5, 2026, she revealed the care plan for her skin tear should have been revised when it was resolved. Interview with the NHA on August 6, 2026, at 11:41 AM, revealed she would expect care plans to be revised as needed and at least quarterly to reflect the resident's current status. 42 CFR 483.21(b) Comprehensive Care Plans.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure staff implemented appropriate infection control guidelines during medication preparation and administration for one of three residents observed (Resident 3).Findings include: Review of facility policy, titled Storage of Medications, dated November 2020, with a last review date of February 9, 2026, revealed, in part, 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Review of facility policy, titled Administering Medications, dated April 2019, with a last review date of February 9, 2026, revealed, in part, 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. During a medication administration observation of Employee 6 (Licensed Practical Nurse) on August 4, 2026, at 8:57, revealed that while preparing medications for Resident 3, Employee 6 dropped an albuterol inhaler onto the floor. Prior to Employee 6 dropping the inhaler, the inhaler was noted to be lying in the drawer of the medication cart with no box and no label containing a resident's name. Employee 6 picked the inhaler up off the floor and placed it back inside the medication cart. Employee 6 said that the inhaler was not for Resident 3 and confirmed that the inhaler had no resident name on it. He indicated that he would have to investigate it further when he was done with the medication pass. In addition, Employee 6 was observed to take a cup of oral medications, a nasal inhaler, and an oral inhaler into Resident 3's room to administer. After entering Resident 3's room, Employee 6 sat the nasal inhaler and oral inhaler onto Resident 3's overbed table. The overbed table was noted to be soiled with a clear sticky looking substance and a white colored powdery-like substance. After Employee 6 finished administering the medications, he took the nasal and oral inhaler and placed them back into their boxes inside the medication cart. During an immediate interview with Employee 6, he confirmed that Resident 3's overbed table was soiled and that he should not have sat the inhalers on the dirty table or cleaned them before returning to the cart. Employee 6 also acknowledged that he should not have placed the inhaler that he dropped on the floor back into the cart without cleaning it first. During a staff interview with the Nursing Home Administrator on August 4, 2026, at 11:20 AM, she confirmed that she would expect appropriate infection control measures to be followed by nurses during medication preparation and administration. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and failed to provide adequate supervision and assistance devices to prevent accidents for one of four residents reviewed for falls (Resident 3).Findings include: Review of facility policy, titled Falls - Clinical Protocol last reviewed February 9, 2026, read, in part, While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Review of Resident 3's clinical record revealed diagnoses that included need for assistance with personal care, muscle weakness, and difficulty in walking. Review of Resident 3's clinical record revealed that he sustained a fall on July 28, 2026, and that he has had a history of falls due to impaired mobility and non-compliance with transfers. Review of Resident 3's comprehensive care plan revealed he had active fall interventions including bilateral fall mats with a start date of August 14, 2025, and signage to remind resident to ring the call bell for assistance, with a start date of October 27, 2025. Observations in Resident 3's room on August 3, 2026, 11:37 AM; August 4, 2026, 12:58 PM; and August 5, 2026, 9:37 AM, failed to reveal a sign to remind the Resident to ring the call bell for assistance. Observation in Resident 3's room on August 4, 2026, 12:58 PM, revealed he was lying in bed, and he only had one fall mat on the right side of his bed. There was no fall mat on the left side of his bed, which was the side he transfers in and out of bed. Multiple staff were observed to be passing by the room at that time and looking into the room. Observation in Resident 3's room on August 5, 2026, 1:49 PM, revealed he was lying in bed, and he only had one fall mat on the right side of his bed. There was no fall mat on the left side of his bed. Interview with Resident 3 on August 5, 2026, 1:49 PM, revealed staff had helped him into bed that afternoon. Review of Resident 3's nurse aide task for turning and repositioning revealed staff had recently turned and repositioned him in bed on August 5, 2026, at 1:21 PM. During an interview with the Director of Nursing on August 6, 2026, at 11:39 AM, she revealed she spoke with staff who stated the sign used to be on his closet door, but months ago his closet door was removed and converted to a curtain, and that must have been when the sign got removed from his room. She further revealed would expect fall interventions to be in place as applicable, and she would expect that the resident environment remains as free of accident hazards as is possible to prevent accidents. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy reviews, clinical record reviews, facility documentation review, hospital records review, and staff interviews, it was determined that the facility failed to ensure wound care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of four residents reviewed (Resident 1), which resulted in actual harm as evidenced by the need for surgical intervention for exposed hardware from a surgically repaired fracture for Resident 1.Findings include: Review of facility policy, titled Surgery-Related (Pre- and Postoperative) Management- Clinical Protocol, revealed, in part, The staff and physician will monitor for, and address, postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal, urosepsis from indwelling catheters inserted in the hospital, delirium, depression, etc. Review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included a surgically repaired displaced malleolar (ankle) fracture of right lower leg, muscle weakness, and unspecified abnormalities of gait and mobility. Review of Resident 1's clinical record revealed that at the time of her admission, she had a surgical dressing to her right ankle that was not to be removed until her follow-up appointment with her orthopedic surgeon on March 12, 2026. Review of Resident 1's orthopedic consultation report dated March 12, 2026, revealed that her staples were removed and steri-strips (thin adhesive bandages that help seal minor wounds by pulling skin edges together without touching the wound itself) were applied. The report further indicated that she was placed in a tall hard cam boot (boot that allows a fractured ankle to heal which lessens the amount of force placed on the ankle) that she should wear all the time, but it could be removed daily for skin checks by the nurses and in physical therapy for range of motion of the ankle. Additional recommendations included physical therapy and occupational therapy, she could shower with the boot off while sitting, and that gauze kerlix and an ace wrap were to be placed around the ankle inside the boot to protect the incisions. It also indicated that the steri-strips could be removed when they start to fall off. A follow-up was scheduled for four weeks with repeat x-rays of the ankle. Review of Resident 1's physician orders revealed an order for Resident ankle to be wrapped q [every] 2 days, with ABD pads, kerlix and ace wraps to protect skin under the cam boot and to monitor skin closely while healing. Cam boot can be removed gently while in bed and put back on immediately after dressing change. Document skin check every day shift, dated March 13, 2025, with a start date of March 15, 2026. Review of Resident 1's Treatment Administration Record (TAR) for March 2026 revealed that the treatment as ordered above was not documented as being completed on March 26 and 27, 2026. March 26 was coded as 9 see progress note and March 27, 2026, was blank. Review of Resident 1's progress notes revealed that the corresponding note for her March 26, 2026, wound care failed to indicate why the treatment was not completed. This review also failed to reveal any documentation as to why the treatment was not completed on March 27, 2026. Review of Resident 1's TAR for April 2026 revealed that the ordered treatment was not documented as being completed on April 8, 2026, which was blank. Review of Resident 1's progress notes failed to reveal any documentation as to why the treatment was not completed on April 8, 2026. Further review of Resident 1's clinical record failed to reveal any documentation by nursing staff of the presence of a surgical wound/incision or an assessment of her surgical wound to her right ankle from the time the dressing was removed on March 12, 2026. Review of the daily skilled progress notes documented that her skin was intact. Review of Resident 1's physician's progress notes after her dressing was removed at her orthopedic appointment on March 12, 2026, revealed that she was seen by her physician on March 20, 2026, and April 6, 10, and 12, 2026. All these notes failed to include any acknowledgement of a surgical wound on her right ankle or any assessment of the surgical wound. Review of Resident 1's weekly body audit (skin check) forms revealed that they were completed on March 12, 16, 19, 26, 2026, and April 2, 2026. Review of these forms failed to include any documentation of Resident 1's surgical wound or the presence of a dressing, even though Section A2 indicated to note any areas of alteration in skin integrity and Section B1 indicated to note any additional comments on skin integrity. In, addition, her April 9, 2026, body audit was not completed. Review of Resident 1's clinical record progress note dated April 9, 2026, indicated that the Resident refused her shower and, therefore, the body audit was not completed. Review of Resident 1's clinical record progress note dated April 12, 2026, at 10:24 AM, revealed that Resident 1 was transferred to the hospital after a change in condition. Resident 1 was complaining of increased weakness and tremors/shakes and staff had observed Resident 1 shaking during her transfer out of bed. Review of Resident 1's hospital emergency room records dated April 12, 2026, indicated Postoperative incision noted on the right ankle. Medial appears fine without any surrounding cellulitis or discharge. Right lateral incision actually has an exposed screw. Family believes this is new. Pictures were included in the hospital records that showed a circular opening in the surgical wound between two steri-strips and the top of the exposed screw. The screw was not protruding from the skin but rather was slightly below the skin level and the skin was curled down around the edges of the screw. Review of Resident 1's initial hospital orthopedic consultation at the hospital dated April 12, 2026, revealed Upon inspection the ED provider noticed the pts surgical incision on her right lower ankle had dehisced with exposed hardware. A consult was made to orthopedics. Pt and family state they are unsure when the wound became dehisced. They state the pt resides at a nursing facility where her dressings have been managed regularly. Their last discussion with the staff about her wound was a few days ago and they were told it looks ok. Pt is 25% partial weight bearing of the RLE in her cam boot. She denies any drainage from the wound or significant pain around it. Further review of Resident 1's hospital records revealed that she had surgery on April 18, 2026, to replace the hardware from her right ankle after her medical conditions were stabilized. The note also indicated that Resident 1 had been discharged from the hospital to another facility on April 19, 2026. Further review of Resident 1's clinical record progress notes revealed a late entry nurse's note dated April 12, 2026, at 1:58 PM, with a created date of April 15, 2026 (three days after Resident 1 was transferred to the hospital and the facility was made aware of the screw being exposed in the ankle in the emergency room), which indicated Late note following wound care on this resident to the RLE on 04/12/2026. At the time this nurse completed wound care, there was nothing protruding, hurting, or leaking. This nurse palpated the entire space of the extremity with the only finding being dry flaky skin before I replaced and secured the ACE wrap and boot to the residents comfort. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 30, 2026, at 1:34 PM, the DON confirmed that nurses should still complete a weekly body audit (skin check) even if the residents refuse bath/shower. In discussion about Resident 1's surgical wound not being documented as being present or any actual assessment of the wound anywhere in the clinical record after her surgical dressing removed until the late note dated April 12, 2026, with a created date of April 15, 2026, the DON indicated that the nurse who performed the wound care on the morning of April 12, 2026, was adamant that there was no opening in the skin and no screw protruding when she completed the wound care prior to the Resident being sent out to the hospital. The DON indicated that the nurse said that the skin was dry and flaky. The DON confirmed that she had the nurse make a late entry to describe the Resident's surgical wound. During a staff interview with the NHA and DON on April 30, 2026, at 2:15 PM, the DON indicated that if a resident has any complications with surgical wounds or other non-pressure wounds, they are referred to the facility's wound consultant. The DON confirmed that Resident 1 was not seen by the wound consultant other than for a baseline admission evaluation. She said that since Resident 1 had no complications with her surgical wound and, therefore, a referral was not made to the wound consultant. The DON confirmed that there were no wound assessments documented in Resident 1's clinical record of her surgical wound. She said that if staff had noted any changes, they would have documented the changes and referred her to the wound consultant. The DON further indicated that since the order did not trigger staff to do a skin sheet when assessing the wound, she would have expected staff to have documented a note describing the wound daily as indicated in the physician's order. During a staff interview with the NHA and DON on April 30, 2025, at 3:00 PM, the DON indicated that she had spoken to Employee 2 and that she had said that she thought Resident 1's wound was healed since steri-strips were placed. During a staff interview with Employee 1 (Licensed Practical Nurse) on May 1, 2026, at 11:52 AM, he indicated that Resident 1 had a boot on her right leg and that there was a treatment ordered for the surgical wound. Employee 1 said that he remembered asking for clarification about Resident 1's wound treatment orders because it was confusing since part of the order said every two days and then another part said every day. Employee 1 said that when he asked for clarification of the order, he was told to do the dressing every day. Employee 1 said that he last observed Resident 1's wound on April 10, 2026, and that he did not note that the wound was opened with a screw exposed. Employee 1 further indicated that if he had seen that he would have reported it. When asked where he documented the daily skin check of the wound, Employee 1 indicated that he saw the wound, but he had not documented anything about the wound appearance or condition. During a staff interview with Employee 2 (Licensed Practical Nurse), the NHA, and the DON on May 1, 2026, at 12:30 PM, Employee 2 indicated that Resident 1's surgical wound care was completed on day shift and that she had never actually observed Resident 1's surgical wound. Employee 2 confirmed that she was the nurse who had completed all Resident 1's skin checks. Employee 2 said that since the treatment was being documented elsewhere, she did not document the presence of the dressing on the skin check forms that she completed and that she never removed Resident 1's dressing since it was done on day shift. Employee 2 said she was told to only indicate on the skin check form any new skin issues. During a staff interview with the NHA and DON on May 1, 2026, at 1:45 PM, they both confirmed that there was no documentation of any assessment of Resident 1's surgical wound by nursing staff or her physician from the time the surgical dressing was removed on March 12, 2026, by her orthopedic surgeon, and when she was transferred to the hospital on April 12, 2026. They also confirmed that the only note regarding the surgical wound was the late note that the nurse created on April 15, 2026, with an effective date of April 12, 2026. They both confirmed that they had no additional information to provide regarding Resident 1's surgical wound. During a final staff interview with the NHA on May 1, 2026, at 3:17 PM, she confirmed that she would expect nursing staff to have documented a daily assessment of Resident 1's surgical wound as per the physician's order. She also confirmed that she would have expected Resident 1's physician to have assessed the incision on his visits and documented his assessment of the wound as well. The facility failed to properly assess, monitor, and document the status of Resident 1's surgical wound. The wound re-opened and the orthopedic hardware was exposed, which resulted in Resident 1 requiring surgical intervention to repair. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on clinical record reviews, facility documentation review, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for three of four residents reviewed (Residents 1, 2, and 3).Findings include: Review of Resident 1's clinical record revealed diagnoses that included displaced malleolar fracture of right lower leg with healing, muscle weakness, and unspecified abnormalities of gait and mobility. Review of Resident 1's care plan focus for ADL (activities of daily living) self-care deficit related to physical limitations dated March 3, 2026. Interventions included, but were not limited to, toileting with assistance of two, dated March 3, 2026; squat pivot transfer with no weightbearing on right lower extremity with two assist, dated March 3, 2026, which was revised to transfer with one assist and slide board with no weightbearing on right lower extremity on March 11, 2026. Review of Resident 1's clinical record revealed a progress note dated March 11, 2026, at 3:27 PM, which indicated that she was found to have a bruise on the right side of her body measuring 10 centimeters (cm) x 10 cm; and two small bruises under her left arm, both measuring 0.5 cm x 0.5 cm. The note further indicated that Resident 1 said that they were from being transferred. She said that some people wrap their arms around her and others go under her arms. Review of Resident 1's nurse aide task documentation for March 3-11, 2026, revealed that on March 10, 2026, (the day before the bruises were noted) she was not documented as having assistance of two with chair/ bed to chair transfers for both the day and evening shift. Further review of Resident 1's aide task documentation for March 3-31, 2026, revealed that on 11 occasions she was not documented as having assistance of two with toileting (March 8-evening and night shift; March 14-day shift; March 15-day and evening shift; March 16-evening shift; March 19-evening shift; March 24-night shift; March 26-evening shift; March 28-day shift; and March 30-evening shift). Review of the facility provided incident report dated March 11, 2026, at 11:45 AM, indicated the same findings as the March 11, 2026, 3:27 PM, nurse's note. The incident report further indicated the immediate intervention was that nurse aides were educated that Resident 1 was to always be a two-assist transfer. It further indicated that therapy had been asked to evaluate Resident 1's transfer status and changed her to a slide board transfer with one assist. Review of Resident 1's nurse aide task documentation for April 1-11, 2026, revealed that on seven occasions she was not documented as having assistance of two with toileting (April 1-evening shift; April 2-night shift; April 7-day and evening shift; April 8-evening shift; April 9-evening shift; and April 11-day shift). Review of Resident 2's clinical record revealed diagnoses that included obesity, muscle weakness, unsteadiness on feet, and difficulty walking. Review of Resident 2's care plan revealed a care plan focus for ADL self-care deficit related to impaired mobility, dated December 3, 2024. Interventions included, but were not limited to, transfer with a mechanical lift and two person assist, with an initiated date of April 11, 2025. Review of Resident 2's nurse aide task documentation for March 2026 revealed that on six occasions she was not documented as having assistance of two with bed to chair transfers (March 10-evening shift; March 15-evening shift; March 19-night shift; March 20-day shift; March 24-day shift; and March 29-night shift). Review of Resident 2's nurse aide task documentation for April 2026 revealed that on four occasions she was not documented as having assistance of two with chair/ bed to chair transfers (April 2-evening shift; April 12-day and evening shift; and April 19-evening shift). Review of Resident 3's clinical record revealed diagnoses that included dementia (a chronic disorder of mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), muscle weakness, and unspecified abnormalities of gait and mobility. Review of Resident 3's care plan revealed a care plan focus for ADL self-care deficit related to physical limitations, dated October 5, 2025. Interventions included, but were not limited to, transfer with assist of one, ambulation with assistance of one, and toileting with assistance of one, all dated March 12, 2026. Review of Resident 3's nurse aide task documentation for March 12-31, 2026, revealed the following:1) on 20 occasions she was documented as being independent with chair/ bed to chair transfers (March 14-day shift; March 15-evening and night shift; March 16-evening and night shift; March 17-evening shift; March 18-night shift; March 20-day shift; March 22-night shift; March 23-all three shifts; March 24-evening and night shift; March 25-night shift; March 29-day and evening shift; March 30-evening and night shift; and March 31-evening shift); and2) on 21 occasions she was documented as being independent with toileting (March 14-day shift; March 15-all three shifts; March 16-evening and night shift; March 17-evening and night shift; March 18-night shift; March 20-day shift; March 22-night shift; March 23-night shift; March 24-evening and night shift; March 25-night shift; March 28-day shift; March 29 day and evening shift; March 30-evening and night shift; and March 31-evening shift). Review of Resident 3's nurse aide task documentation for April 2026, revealed the following the following:1) on 31 occasions she was documented as being independent with chair/ bed to chair transfers (April 1-night shift; April 6-day and night shift; April 7-evening and night shift; April 8-night shift; April 9-evening shift; April 10-night shift; April 12-evening and night shift; April 13-evening shift; April 14-evening and night shift; April 15-night shift; April 16-evening and night shift; April 18-day shift; April 19-day and evening shift; April 20-all three shifts; April 21-evening and night shift; April 22-night shift; April 26-night shift; April 27-evening and night shift; April 28-evening and night shift; and April 29-evening shift); and2) on 32 occasions she was documented as being independent with toileting (April 6-day and night shift; April 7-evening and night shift; April 8-night shift; April 9-evening shift; April 10 day and night shift; April 12-all three shifts; April 13-evening and night shift; April 14-evening and night shift; April 15-night shift; April 16-evening and night shift; April 18-day shift; April 19-day and evening shift; April 20-evening and night shift; April 21-evening and night shift; April 22-night shift; April 26-night shift; April 27-evening and night shift; April 28-evening and night shift; and April 29-night shift). During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 30, 2026, at 11:45 AM, the DON indicated that for Resident 1 no staff member admitted to transferring her with only one assist. She said that they had therapy evaluate Resident 1 and they changed her transfer status to a slide board with one assist. During a staff interview with the NHA and DON on April 30, 2026, at 1:34 PM, the DON acknowledged that nurse aide documentation was not in accordance with Residents 1, 2, and 3's care plans. The DON further indicated that the facility has hired several nurse aides recently and that she believes it is documentation errors and that staff are following the Residents' care plans or they would have more incidents occurring. During a final interview with the NHA on May 1, 2026, at 3:17 PM, the NHA confirmed that she would expect staff to follow a resident's comprehensive care plan. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of select facility documentation, and staff interviews, it was determined that the facility failed to implement interventions to ensure resident safety, which resulted in actual harm as evidenced by a frontal scalp laceration requiring sutures to repair for one of five residents reviewed (Resident 1).Findings include: Review of Resident 1's clinical record revealed diagnoses that included hemiplegia (a severe form of paralysis affecting one side of the body) and hypertension (high blood pressure). Review of Resident 1's current physician orders revealed an order for a scoop mattress, effective February 4, 2025. Review of Resident 1's current care plan revealed a focus area related to Resident's self-care performance deficit due to physical limitations, hemiplegia, muscle weakness, abnormal posture, history of CVA (cerebrovascular accident or stroke), dementia, and malformation of the spine. Further review revealed an active intervention that the Resident is to transfer with a Hoyer lift and two-person assist; as well as an intervention that the Resident requires a regular scoop mattress with extensive assist of two. Further review of Resident 1's current care plan revealed a focus area related to Resident being at risk for falls with an active intervention to maintain bed in low position. Review of Resident 1's clinical record revealed that for the bed mobility task the Resident is documented as being dependent on staff doing all of the effort, and the Resident does none of the effort to complete activity; or the assistance of two or more helpers is required for the Resident to complete the activity. Review of Resident 1's Annual MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes), dated December 7, 2025, revealed that Section GG - Functional Abilities; GG0170. Mobility, A. Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed was marked 1. Dependent, indicating the helper does all of the effort and the Resident does none of the effort to complete the activity. Review of Resident 1's clinical record revealed a task for a body pillow to be placed on the right side at all times when in bed. Further review of the task revealed on February 9, 2026, at 11:08 AM, it was documented that the Resident's body pillow was not placed on the right side of the bed. Review of a facility provided fall incident report revealed that Resident 1 had an un-witnessed fall on February 9, 2026, at 7:40 PM. Further review of the incident report revealed that the Resident was observed laying prone on the floor between the bed and out wall, and sustained a laceration to frontal region at hairline, measuring approximately 4.0 centimeters (cm) by 4.0 cm by 0.1 cm. The incident report confirmed that the Resident required a mechanical lift with two-person assist. Further review revealed that Resident 1 was a two-person assist with cares, and the Resident only moves their right hand up and down occasionally, does not assist of movement with transfers, and has no bed movement per nurse aids for care. Further review of the incident report revealed Resident 1's bed was medium height. Resident 1 was sent to the Emergency Department for treatment, which resulted in the Resident needing 8 sutures for the laceration. Review of staff witness statement, revealed Employee 1 (Nurse Aid) saw Resident 1 before the fall, laying in the middle of her bed, and minutes later she was bleeding on the ground. Further review of Employee 1's statement revealed that Resident 1 was a total dependent and does not roll, lean, or move without maximal assistance. Employee 1 stated that they witnessed a clean brief on Resident 1's bed as if she was being changed. Review of Employee 2's (Nurse Aid) witness statement on February 9, 2026, revealed Employee 2 saw the Resident at 7:40 PM flip over on the floor and tried to pull her back and she kept leaning on that side of the bed. Review of Employee 3's (Nurse Aid) witness statement on February 9, 2026, revealed that they last saw Resident 1 at 7:40 PM, with her bed at waist level, wearing no brief, although there was a clean brief unfolded on the bed. Further review of the witness statement revealed Resident 1 does not turn on her own and was a two-person assist. Employee 3 revealed Employee 2 had gloves on when they came out of Resident 1's room during the time of the fall. During an interview with Employee 2 on February 18, 2026, at approximately 1:30 PM, revealed that Resident 1 was leaning off the bed, with the bed being in a tilted position, and had no body pillow to the right side of the bed. Employee 2 denied performing care to Resident 1 during the time of the fall. During an interview with the Nursing Home Administrator (NHA) on February 18, 2026, at approximately 1:45 PM, she revealed that it is her understanding that when Employee 2 went by Resident 1's room, Resident 1 was leaning over the bed with the bed tilted up and went to grab the Resident but could not get there in time. NHA was not able to identify how Resident 1 was leaning to the side if she is not able to move in bed without assistance. The facility failed to implement interventions to assure Resident safety, resulting in actual harm as evidenced by a laceration to a Resident's scalp, requiring sutures. 28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room in the facility is changed for one of one resident reviewed (Resident 6).Findings include: Review of Resident 6's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and Gastroesophageal reflux disease (GERD - a chronic condition where stomach acid frequently flows back into the esophagus). Observation conducted of Resident 6 on February 18, 2026, revealed the Resident was residing in the locked dementia unit. Interview conducted with Resident 6 on February 18, 2026, at approximately 1:00 PM, revealed the Resident did not give consent to move rooms and was not provided with a written notice of the room change. Interview conducted with Employee 4 (Social Worker) on February18, 2026, at 1:25 PM, revealed that staff reported to him Resident 6 was going to get his money and car, and was going to leave the facility, so Employee 4 met with Resident 6, and Resident 6's POA (Power of Attorney) and decided to have Resident 6 move to the locked unit due to being an elopement risk. Employee 4 confirmed that Resident 6 had a wander guard on, however, the facility had issues in the past where residents walked out of the facility wearing a wander guard and, at the end of the day, did not want to put anything to chance. Employee 4 revealed that prior to the room change, Resident 6 was not having any issues in the room he was previously in. Review of Resident 6's admission MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes), revealed that Resident 6 has a BIMS (Brief interview of Mental Status) of 15, indicating normal thinking and memory. Review of Resident 6's clinical record revealed a progress note written on February 13, 2026, at 4:03 PM, that the Resident changed rooms. Review of Resident 6's clinical record revealed a progress note written on February 14, 2026, at 8:26 AM, that Resident 6 was upset and did not agree with the room change. During an interview conducted with the Nursing Home Administrator (NHA) on February 18, 2026, at approximately 1:45 PM, it was revealed that it was a late Friday afternoon and Resident 6 was upset and wanted to leave, so they decided to put Resident 6 in a locked unit, so he was not able to do so. NHA confirmed Resident 6 was wearing a wander guard. The facility was unable to provide a room change notification document that was provided to Resident 6 prior to changing rooms on February 13, 2026. Pa. code 211.12(d)(1) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of three resident reviewed for pressure ulcers (Resident 2).Findings include: Review of facility policy, titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, with a last revised date of April 2018, revealed, in part, The nurse shall describe and document/report the following full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of Resident 2's clinical record revealed diagnoses that included pressure induced deep tissue injury (DTI-pressure-related injury to subcutaneous tissues under intact skin) to left heel, stage 4 pressure ulcer (a pressure injury that is deep, reaching into muscle and bone and causing extensive damage) to sacrum, and paraplegia (paralysis of the lower body/legs). Review of Resident 2's current physician orders revealed the following orders: Follow-up with Wound center in 2 weeks, dated December 10, 2025; Cleanse sacral region pressure ulcer and peri wound (skin located around the perimeter of the wound) with normal saline solution; apply skin prep to peri wound skin; apply 1/4 strength Dakin's solution moistened gauze roll to wound beds/tunnel creases, cover with absorbent pads and secure with tape. Change daily on night shift and as needed for drainage saturation. May change outer absorbent pads if drainage strike through occurs, dated December 12, 2025; and weekly body audit every Monday on day shift. Complete form in electronic health record, dated January 5, 2026. Review of Resident 2's clinical record revealed that she had a Weekly Body Audit form completed on December 17, 18, and 22, 2025. These forms all failed to include any documentation of her existing pressure ulcers in Section A2. Note any areas of alterations in skin integrity. Further review of Resident 2's clinical record, including progress notes, failed to reveal any documented assessment of her wounds to include description and measurements between December 11 and 28, 2025. Review of Resident 2's clinical record revealed that she was transferred to the hospital on December 28, 2025, and remained hospitalized until January 1, 2026, when she returned to the facility. Review of Resident 2's readmission Evaluation dated January 1, 2026, indicated in Section H. Skin Evaluation that she had a pressure ulcer on her coccyx, right heel, and left heel. The sections for length, width, depth, stage, and additional observations/comments were blank. Further review of Resident 2's clinical record to include progress notes failed to reveal any documented assessments of her pressure ulcers to include description and measurements between January 1 and 13, 2026. Resident 2 was transferred to the hospital on January 13, 2026, and remained hospitalized at time of survey.During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 14, 2026, at 3:13 PM, the DON confirmed that Resident 2 had refused services from the in-house wound consultant. She also acknowledged that Resident 2 had allowed facility nursing staff to perform her ordered routine wound care. The DON confirmed that nursing staff probably should have completed and documented a full wound assessment to include measurements on at least a weekly basis to determine if any treatment changes were needed. The DON indicated that it had been difficult to get Resident 2 to an outside wound clinic for a thorough evaluation and treatment management because of Resident 2's frequent hospitalizations. Email communication received from the NHA on January 15, 2025, at 9:48 AM, indicated that Resident 2 had a scheduled appointment on January 20 and 16, 2026; and February 5, 2026, with an outside wound clinic.During a final staff interview with the NHA on January 15, 2026, at 2:03 PM, she confirmed that she would expect nursing staff to complete a full wound assessment to include measurements at least weekly on residents with pressure ulcers. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for one of five residents reviewed (Resident 6).Findings include: Review of facility policy, titled Catheter Care, Urinary, with a last revision date of September 2014, revealed, in part, the step-by-step procedural instructions on how to perform catheter care, which included the following: Wash resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry; using a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. In addition, the policy indicated that the following information should be documented in the resident's medical record: date and time catheter care was given; name and title of individual giving the catheter care, and all assessment data obtained when giving catheter care. Review of Resident 6's clinical record revealed diagnoses that included neuromuscular dysfunction of the bladder, urinary retention (incomplete emptying of the bladder or inability to urinate), and cognitive communication deficit (a group of disorders that affect a person's ability to communicate which can cause difficulty with understanding or producing language and nonverbal communication skills such as gestures and facial expressions). Review of Resident 6's current physician orders revealed an order for an indwelling Foley Catheter (a flexible tube placed through the urethra to the bladder to drain urine) 16 French Coude with 10 cc (cubic centimeter) balloon to straight bag gravity drainage for urinary retention, dated December 11, 2025. Further review of Resident 6's clinical record revealed that his catheter was originally ordered on November 13, 2025. Resident 6's clinical record, including physician orders and treatment administration records from December 1, 2025, through January 14, 2026, failed to reveal any order or documentation of the provision of catheter care or emptying of his catheter drainage bag. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on January 14, 2026, at 3:15 PM, the above concern was shared and the NHA indicated that she would investigate. During a final staff interview with the NHA on January 15, 2026, at 2:02 PM, she confirmed that Resident 6 did not have orders for catheter care and that he should have had them in place since the catheter was ordered. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the needs of the residents for three of three residents reviewed for the use of hipsters (Residents 1, 2, and 3).Findings include: Review of the clinical record for Resident 1 revealed clinical diagnoses that included depressive disorder (mood disorder causing persistent sadness and loss of interest affecting daily activities) and adjustment disorder (extreme emotional or behavioral reaction to a specific, identifiable stressor impacting daily functioning) and a history of falls. Review of Resident 1's Quarterly Minimum Data Set (periodic assessment and care screening) dated December 18, 2025, revealed a BIMS (brief interview of mental status) score of 11, indicating moderate cognitive impairment. Review of Resident 1's current physician orders revealed the order to encourage to wear hipsters every shift, document refusals with an effective date of November 3, 2025, and reentry of same order on January 5, 2026, because initial order was missed when reviewed by Administration. Resident 1 was care planned for risk of falls and encouraged to wear hipsters every shift, effective November 3, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 1 not wearing any hipsters while in the resident lounge/dining area. Review of the clinical record for Resident 2 revealed clinical diagnoses that included dementia (cognitive decline of memory, thinking, and behavior interfering with daily life), atrial fibrillation (fast, irregular heartbeat), and a history of falls. Review of Resident 2's Quarterly Minimum Data Set, dated [DATE], reveals a BIMS score of 99, indicating the Resident was unable to complete interview for cognitive status. Review of Resident 2's current physician orders revealed an order to encourage to wear hipsters, document refusals with an effective date of December 5, 2025. Resident 2 was care planned for risk of falls and encouraged to wear hipsters every shift effective, August 13, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 2 not wearing any hipsters while in the resident lounge/dining area. Review of the clinical record for Resident 3 revealed clinical diagnoses that included dementia, depressive disorder (mood disorder causing persistent sadness and loss of interest affecting daily activities), and a history of falls. Review of Resident 3's Quarterly Minimum Data Set, dated [DATE], reveals a BIMS score of 2, indicating severe cognitive impairment. Review of Resident 3's current physician orders revealed an order to encourage to wear hipsters at all times with an effective date of February 17, 2025. On January 5, 2026, a second order was written stating encourage resident to wear hipsters. Resident 3 was care planned for risk of falls and encourage to wear hipsters at all times, effective February 17, 2025. Observation on January 5, 2026, at approximately 11:00 AM, revealed Resident 3 not wearing any hipsters while in the resident lounge/dining area. During an interview with Employee 1 (Nursing Assistant) on January 5, 2026, she stated that residents do not have any hipsters in their rooms to apply. Employee 1 was asked if any of the residents refused hipsters and she replied no. Employee 1 added that she didn't get Resident 3 out of bed this morning, he was already up and groomed when she arrived. During an interview with Employee 2 (Laundry) on January 5, 2026, when asked if there were any hipsters available for Residents 1, 2, and 3, Employee 2 replied, we do not have any hipsters, and later added there could be some in a washer. An interview with Employee 3 (Central Supply) on January 5, 2026, revealed multiple pairs (all sizes) of new hipsters locked in a cabinet in her office. During an interview and observations with the Director of Nursing (DON) on January 5, 2026, the DON confirmed with the surveyor that no hipsters were present in Resident 1's, 2's, or 3's rooms and stated that each resident should have two pairs each. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to provide residents with private closet space for all 46 semi-private rooms within the facility.Findings include:Observation of semi-private room closets on January 5, 2026, revealed one closet in the room with roommates' clothing touching, and personal items on the shelf and floor were intermingled because there was no partition. A tour of the semi-private rooms revealed no partition in any of the closets.During an interview with the Director of Nursing (DON) on December 5, 2026, at 2:30 PM, the DON confirmed that none of the closets have a partition to provide private closet space for residents. 28 Pa. Code 201.18(b)(2) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for three of nine residents reviewed (Residents 7, 8 and 9). Findings Include:Review of Resident 7's clinical record revealed diagnoses that included hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident 7's TAR (Treatment Administration Record), dated November 2025, revealed the following orders: weekly body audit, every evening shift every Friday; cleanse left heel pressure wound with normal saline solution, apply betadine and leave open to air, every day and evening shift; catheter care every shift; enhanced barrier precautions due to Foley catheter every shift; monitor for signs and symptoms of a UTI (urinary tract infection) and notify physician of changes, every shift; and offloading heel boots at all times, every shift. Further review of Resident 7's TAR revealed that on November 21, 2025, there was no signature on the TAR, indicating that the following treatments were performed on day shift: weekly body audit; left heel pressure wound dressing change; catheter care; enhanced barrier precautions; and offloading heel boots.On November 21, 2025, during evening shift, there was no signature on the TAR indicating that the following treatments were performed: left heel pressure wound dressing change; catheter care; enhanced barrier precautions; and offloading heel boots. On November 24, 2025, on night shift, there is no evidence that the following treatments were performed for Resident 7, as there was no signature on the TAR, indicating that they were completed: catheter care; and monitoring for signs and symptoms of a UTI. On November 27, 2025, on day shift, there is no evidence that the following treatments were performed for Resident 7, as there was no signature on the TAR, indicating that they were completed: left heel pressure wound dressing change; catheter care; enhanced barrier precautions; monitor for signs and symptoms of a UTI; and offloading heel boots. Review of Resident 8's clinical record revealed diagnoses that included Alzheimer's Disease and hyperlipidemia. Review of Resident 8's November 2025 TAR revealed the following orders: alarming security bracelet, check placement every shift, and if Resident avoids laying flat due to shortness of breath, answer yes or no, every shift. Further review of Resident 8's TAR revealed that on November 21, 2025, on day and evening shift, and on November 27, 2025, on day shift, there was no signature indicating that the placement of the security bracelet was checked and no yes or no answer if Resident avoided laying flat. Review of Resident 9's clinical record revealed diagnoses that included hypertension and bipolar disorder (a mental health condition that causes extreme mood swings). Review of Resident 9's November 2025 TAR revealed the following orders: alarming security bracelet, check placement every shift, and if Resident avoids laying flat due to shortness of breath, answer yes or no, every shift.Further review of Resident 9's TAR revealed that on November 21, 2025, on day and evening shift, and on November 27, 2025, on day shift, there was no signature indicating that the placement of the security bracelet was checked and no yes or no answer if resident avoided laying flat.During an interview with the Nursing Home Administrator on December 17, 2025, at 2:51 PM, she stated that she would expect treatments be completed as ordered and signed off on the Resident's TAR. She further stated that she contacted the nurse assigned on those days and shifts to see if the treatments were completed, but she received no response back. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, employee record reviews, and staff interview, it was determined that the facility failed to ensure that nursing staff possessed an active nurse aid certification for one of eight employee files reviewed (Employee 8). Findings include:Review of the employee file for Employee 8 revealed a signed position description for a certified nursing assistant (CNA) with a date of hire listed as [DATE]. Further review of Employee 8's file revealed a document from Pennsylvania Department of Health Nurse Aide registry verification website, indicating the facility verified Employee 8's nurse aid certification on [DATE]. Review of the aforementioned document revealed Employee 8's Nurse Aide certification had an expiration date of February 23, 2025. Additional review of Employee 8's filed failed to reveal an updated nurse aide registry verification. The Surveyor's review of the Pennsylvania Department of Health Nurse Aide registry verification website revealed Employee 8's Nurse Aide certification was renewed on [DATE]. Review of Employee 8's work schedule from February 24, 2025 to [DATE] revealed she worked 98 shifts with an expired Nurse Aide certification. An interview on [DATE] at approximately 3:15 PM, with the Nursing Home Administrator, revealed the facility recently discovered Employee 8‘s CNA certification had expired. She was suspended and an audit was completed of all licensed and certified staff. No other staff licenses or certifications were found to be expired. The NHA stated she would expect staff to have current license/certifications and for verifications to be completed.28 Pa Code 201.18(e)(1)(2) Management28 Pa. Code 211.12(d)(5) Nursing services

Based on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, comfortable, and home-like interior in two of three unit spas (Evergreen and Laurel Lane). Findings include: Interview with Resident 3 on June 25, 2025, at 12:30 PM, she stated the temperature in the bathroom in her room and the spa are is hot. Observation with Employee 1 on June 25, 2025, in the Laurel spa at 2:23 PM, revealed the ambient temperature registered 85.8 degrees Fahrenheit. Audible fan noise noted. Spa shower noted to be dry. Observation in the Evergreen spa at 2:38 PM, revealed the ambient temperature registered 85 degrees Fahrenheit. Audible fan noise noted. Spa shower noted to be dry. The surveyor discussed the concern of the temperature in the Laurel and Evergreen spa with the Nursing Home Administrator on June 25, 2025, a 2:45 PM. No further information was provided. 28 Pa. Code 201.18 (b)(1)(3)(e)(2.1) Management

Based on facility policy review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure all alleged violations involving abuse were reported in a timely manner for two of three residents reviewed (Residents 1 and 2). Findings include: Review of facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated April 2021, revealed If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of facility policy, titled Resident-to-Resident Altercations, dated December 2016, revealed All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. Review of facility reported incident dated June 9, 2025, revealed that the Nursing Home Administrator (NHA) was made aware on June 9, 2025, at 8:45 AM, of possible resident-to-resident sexual abuse that occurred on June 7, 2025. Review of facility's investigation revealed an interview with Employee 4 (Housekeeper) on June 9, 2025, stating that over the weekend, she observed a female resident, possibly Resident 1, in Resident 2's room and it looked like they were kissing. Employee 4 denied seeing anything else occur and stated she could not recall where the female Resident's hands were placed. Employee 4 stated she told Employee 1 (Nurse Aide) who arrived in the room and told the Residents to stop. Review of Employee 1's witness statement, undated, revealed that on Saturday June 7, 2025, at approximately 2:30 PM, Employee 4 called Employee 1 to Resident 2's room. Employee 1 wrote in her statement that she observed Resident 1 in Resident 2's room, bent over Resident 2 with her hand on his penis. Employee 1 stated she walked Resident 1 back to her room and then told the nurse what she had just witnessed. Review of facility's interview with Employee 2 (RN-Registered Nurse) on June 9, 2025, revealed that on June 7, 2025, Employee 1 came out of the resident's room openly stating what she saw between the two residents .I told her I am not the Supervisor on duty, please go tell them. Further review of the interview revealed no details regarding what exactly Employee 1 witnessed occuring between the two residents. Review of facility's interview with Employee 6 (Nurse Aide) dated June 9, 2025, revealed The housekeepers called our attention to the room. [Employee 1] went in and immediately asked [Resident 1] to leave the room. She came out to the nurses' station telling [Employee 2] that she saw them making out, [Resident 1] was kissing [Resident 2], and she reached down towards his crotch. I did not hear her say she was touching any part of his body. At no time did I hear him [Employee 2] tell her to go tell the Supervisor. Review of facility's interview with Employee 3 (RN Supervisor) dated June 9, 2025, revealed that nobody informed her of any incident or inappropriate sexual encounters between Residents 1 and 2. Review of facility's interview with Employee 5 (Manager on duty) dated June 10, 2025, revealed Employee 1 had called her on June 7, 2025, and told her that she saw Resident 1's hands down Resident 2's pants. Employee 5 asked Employee 1 if she notified the supervisor and Employee 1 stated yes. Employee 5 stated I thought the supervisor was going to take the steps that needed to be done. Review of facility's follow up interview with Employee 1 dated June 10, 2025, revealed I told [Employee 2], I thought he was the supervisor, that [Residents 1 and 2] were making out. I told dayshift and second shift aides to keep the residents separated. I called [Employee 5] told her that [I] had just seen them making out and that [Employee 2] the supervisor had been notified. During an interview with the NHA on June 10, 2025, at 10:18 AM, she stated that she was not made aware of the resident-to-resident interaction that occurred on June 7, 2025, until June 9, 2025. She stated that she was informed of the incident at this time by Employee 5, who was the manager on duty on June 7, 2025. She further stated that Employee 1 reported the incident to Employee 2, but he was not the supervisor and the nursing supervisor denied any knowledge of the incident occuring. In a follow up interview with the NHA on June 10, 2025, at 12:41 PM, she stated that abuse allegations are to be reported immediately. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to protect the residents' right to be free from neglect by failing to provide orientation and/or training to agency staff and failed to ensure agency staff responded to a medical emergency, which resulted in a delay in emergency services to a resident who went unresponsive (Resident 1). This failure placed a total of 48 residents in an immediate jeopardy situation who would require emergency intervention if found unresponsive (Residents ,d+[DATE]). Findings Include: Review of facility policy, titled Identifying Neglect, dated [DATE], revealed, 'Neglect' is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Any situation in which te resident's care needs are known (or should be known) by staff (based on assessment and care planning), and those needs are not met due to other circumstances, can be defined as neglect. Circumstances that can lead to neglect include: a. failure to monitor or supervise residents; b. lack of training on a specific care interventions or use and care of needed equipment. Review of facility policy, titled Emergency Procedure - Cardiopulmonary Resuscitation, with a revision date of February 2018, revealed, If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). Review of Resident 1's clinical record revealed diagnoses that included alcoholic cirrhosis of the liver with ascites (a condition where chronic alcohol abuse damages the liver, leading to the accumulation of fluid in the abdominal cavity), congestive heart failure (CHF - a chronic condition where the heart muscle is weakened and cannot pump blood effectively, leading to a buildup of fluid in the lungs, legs, and other parts of the body), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar/glucose as a fuel), and pneumonia (lung infection). Review of Resident 1's physician orders revealed an order, dated February 4, 2025, for Full Code, meaning if Resident 1 is found unresponsive and without a pulse, CPR (cardiopulmonary resuscitation) is to be performed. Review of Resident 1's POLST form (Pennsylvania Orders for Life-Sustaining Treatment), revealed that if Resident 1 was found without a pulse and not breathing, Resident 1's wishes were for CPR/attempt resuscitation. Resident 1 signed the POLST form on February 4, 2025. The POLST form was also signed by Resident 1's physician. Review of Resident 1's progress notes revealed a note, written by Resident 1's nurse, Employee 1 (Licensed Practical Nurse), dated February 7, 2025, stated that at approximately 8:40 PM, Employee 1 was informed by a nurse aide that Resident 1 did not appear to be himself. Employee 1's note stated that upon assessment, Resident 1 appeared pale and with tachypnea (rapid breathing). The note further stated that Resident 1's blood glucose was 64 (normal is ,d+[DATE]), blood pressure ,d+[DATE] (normal ,d+[DATE]), temperature 97.1, respiratory rate 38 (normal ,d+[DATE]). No pulse was documented and Employee 1 stated she was unable to obtain an oxygen saturation. The note further stated that Employee 1 immediately notified the nursing supervisor and supplied oxygen to the Resident at 2 L (liters). Review of Resident 1's progress notes revealed a note, written by the RN (registered nurse) supervisor, Employee 3, dated February 7, 2025. The note stated that at approximately 8:45 PM, Resident 1's nurse asked Employee 3 to check on Resident 1. Upon assessment, Resident 1 was noted to be pale, sweaty, short of breath and his respiratory rate was 30. The note stated Resident 1 was talking but with labored breathing and he denied pain. Vital signs at this time were documented as temperature 97.1, heart rate 101 (normal ,d+[DATE]), blood pressure ,d+[DATE], unable to obtain an oxygen saturation and oxygen was applied at 4 L via nasal cannula. Employee 3 notified Resident 1's physician and an order was received to transfer Resident 1 to the hospital and 911 was called. Further review of Employee 3's progress note stated that she was then called to the room by a nurse aide who stated that Resident 1 was unresponsive. The note further stated that Resident 1 was found unresponsive and without a pulse. EMS (emergency medical services) arrived and CPR was initiated. Resuscitation efforts continued without success and Resident was pronounced deceased at 9:21 PM. During a telephone interview with Resident 1's nurse, Employee 1 (Agency LPN), on February 12, 2025, at 10:11 AM, Employee 1 stated that she was at the nursing station and was told that Resident 1 wasn't looking good. She stated she immediately went to assess the Resident and stated that he didn't look good. Employee 1 stated that she assessed the Resident, took his vital signs and informed the RN supervisor (Employee 3). Employee 1 stated that Employee 3 assessed Resident 1 and at this time, he was responsive. Employee 1 stated that Employee 3 notified the physician and called 911 and that Employee 1 put oxygen on Resident 1. Employee 1 stated she was unable to recall anything else that happened after that. Employee 1 stated she did not know who started chest compressions. Employee 1 was asked if she was in the room when EMS arrived or went into the room after EMS was already there, and she replied I can't recall at this very moment. Employee 1 was unable to provide any additional information at that time, stating I can't remember everything that happened and I'm trying to remember everything accurately. Review of Employee 1's CPR certification revealed she was issued her CPR certification in [DATE], with an expiration date of [DATE]. During a telephone interview with Employee 2 (Nurse Aide) on February 12, 2025, at 11:50 AM, she stated that Resident 1 was having trouble breathing so she notified Resident 1's nurse, Employee 1. She stated that Employee 1 came into the room to assess Resident 1. She stated Employee 1 then notified Employee 3, who also assessed Resident 1, who was still responsive at this time. Employee 2 stated that Employee 3 made the comment Let me call his family and see what they want done with him. Employee 2 stated there was confusion, as Resident 1 was wearing a bracelet on his arm that said DNR but his POLST said to perform CPR. Employee 2 stated that Resident 1 may have come back from the hospital with the DNR band in place, as she wasn't aware of the facility using those bands. Employee 2 stated she then left Resident 1's room to tend to her other residents and she thinks that Employee 1 was still in Resident 1's room at that time. Employee 2 stated she was not present when EMS arrived and was not present when CPR was started. During a telephone interview with Employee 3 (Agency RN) on February 12, 2025, at 1:33 PM, she stated that she assessed Resident 1 upon the request of Employee 1. Employee 3's assessment revealed that Resident 1 was having difficulty breathing, but he was responsive, talking and had a pulse. Employee 3 instructed Employee 1 to put Resident 1 on oxygen while she went out to call the physician. Employee 3 stated that Employee 1 was then asking where all of the supplies were for the oxygen and that another employee had to get the oxygen tank for Employee 1. Employee 3 stated the physician ordered Resident 1 to be sent to the hospital. Employee 3 stated she was then questioning Resident 1's code status. She stated that Resident 1's physician order said full code and the POLST said to perform CPR but Resident 1 was wearing a DNR bracelet and in his electronic clinical record, it said full code but had special instructions underneath the full code that said DNR with limited interventions. Employee 3 stated that Resident 1 had a recent hospital stay, being readmitted to the facility on [DATE], and, at that time, changed his POLST, indicating he wanted CPR. She stated although the POLST said CPR, the bracelet and the special instructions in the chart were misleading. Employee 3 stated she then called the Director of Nursing (DON) to apprise her of Resident 1's change in condition and to question the code status. Employee 3 stated the DON instructed her to follow the POLST. Employee 3 then stated that as she was on the phone with the DON, she observed EMS had arrived in the building and were down at the end of the hallway. At this same time, she stated a nurse aide called out to her to come to Resident 1's room. Employee 3 stated she immediately entered Resident 1's room and found that he was unresponsive, warm, not breathing and had no pulse. Employee 3 stated that at that time, EMS arrived and they started chest compressions. She stated CPR was performed but was unsuccessful and Resident was pronounced deceased . During this interview, Employee 3 was asked where Employee 1 was during this time and what her role was. Employee 3 stated she didn't know where Employee 1 was and stated that she was not in Resident 1's room when Employee 3 went back in his room and found him unresponsive. Employee 3 stated she did not feel there was a delay in Resident 1's care but she did have a concern that it was mostly agency staff present. Review of facility's staffing deployment sheet, dated February 7, 2025, for evening shift, revealed that one of one RNs was agency and two of four LPNs were agency staff. During a telephone interview with Emergency Response Personnel 1 (ERP) on February 12, 2025, at 2:02 PM, she stated that EMS was dispatched to a call at the facility for someone who was having trouble breathing. She stated that upon arrival, there was nobody at the door to meet them and let them in. She stated they had to ring the door bell and wait, and it was a painter who was in the building who let them in. She stated that upon arrival to the nursing unit, she observed the charge nurse (Employee 3), on the phone and looking through a chart. She stated that upon entering the Resident's room, no staff were present in the room. ERP 1 stated that Resident 1 felt warm and they placed him on the monitor, which said PEA (pulseless electrical activity- a life-threatening condition where the heart's electrical activity is present but there is no pulse). ERP 1 stated that she initiated chest compressions. EPR 1 then stated that an unidentified staff member was standing in the Resident's doorway. EPR 1 asked her if she could help do chest compressions. She stated the employee looked away shyly and left the room. EPR 1 stated she continued with compressions until a nurse from a different unit came to assist and relieve her. EPR 1 stated she was then able to assist her partner to place an intraosseous line (IO-a hollow needle inserted into the bone marrow to deliver fluids, medications, and blood products), start an airway, and give medications. She stated they continued resuscitation for approximately 25 minutes before terminating efforts and pronouncing the Resident deceased . Email correspondence received on February 12, 2025 at 3:06 PM, ERP 2 stated no one was in the room when they arrived to Resident 1's room. During a telephone interview with Employee 4 (Nurse Aide) on February 12, 2025, at 3:34 PM, she stated that when EMS arrived, there were no staff members present in Resident 1's room. She stated that she thought the RN and LPN were confused about what to do, because Resident 1 was wearing a DNR bracelet. Employee 4 stated that after EMS arrived, nurses from other units came to assist with compressions. In a follow-up telephone interview with Employee 3, on February 13, 2025, at 8:40 AM, she stated that after she found Resident 1 to be not breathing and without a pulse, she ran out of the room to get the code cart. When Employee 3 was asked why she didn't immediately start chest compressions, she stated because EMS was right there, she didn't know if any of the nurse aides, or any of the agency staff, would know where the crash cart was, and she did not know where Resident 1's nurse, Employee 1, was. Employee 3 stated that Employee 1 was not involved in Resident 1's resuscitation efforts. The facility failed to ensure that Resident 1 was free from neglect and provided the necessary emergency services. Employee 1 was assigned to work on the unit that Resident 1 resided on. She was aware of the Resident's decline during her assessment and that EMS was called for transport to the hospital. There was no evidence that Employee 1 followed up with Resident 1 to check his status. When Resident 1 was found without a [NAME] or respirations and CPR was initiated, Employee 1 did not assist and staff on the unit did not know where she was. Additionally, when Employee 3 found Resident 1 without a pulse, she did not immediately start CPR, instead she left the room to obtain the Crash cart. During the onsite survey on February 13, 2025, at 1:16 PM, in an interview with Employee 5 (LPN, agency) stated that she did not know where the crash cart or emergency equipment is located, and she would ask a RN where they are located. She also revealed she would look for a resident's code status on the POLST form. During an interview with Employee 6 (LPN, agency) on February 13, 2025, at 1:20 PM, she stated her first time at the facility was a couple of months ago and she had been working at the facility this week and last week. She further revealed she did not know where the oxygen room was and knew where the crash cart was on the other unit she usually works on, but not on the unit she was currently working. She revealed that in the event of an emergency, she would run to the other unit to get the crash cart and notify to Registered Nurse on duty. She stated she would look for code status in physician orders and in the hard chart. She stated she had not received any orientation to the facility, such as a facility tour or orientation to facility policies. During an interview with the Nursing Home Administrator (NHA) and DON, on February 13, 2025, at 2:55 PM, the NHA stated that when the receptionist is not present, visitors need to ring the doorbell, which is only heard in the lobby area, not at the nursing stations. She stated that visitors would then have to call the facility's main number and when someone picked up the phone, that person would then need to walk to the front door to let them in. The NHA stated that if someone is calling 911, someone should be at the door waiting for EMS to arrive. She stated that she is not sure if agency staff would know to send someone to the door to wait for EMS. At that time, the DON stated that staff are supposed to look at a resident's orders and POLST, to determine their code status. The DON stated that if there is a discrepancy, staff are instructed to go by the POLST. The NHA stated that when agency comes to the building for the first time, they are not given any orientation or tour of the facility. The facility failed to provide orientation and/or training to agency staff. They failed to ensure agency staff responded correctly to a medical emergency. This resulted in a delay in emergency services to a resident who went unresponsive, placing 48 other residents in an immediate jeopardy situation, who requested CPR be administered in the event that they were to suddenly become unresponsive and pulseless. Review of facility provided provided documentation revealed that Residents ,d+[DATE] were a full code and wanted CPR. The NHA and DON were notified of the immediate jeopardy situation on February 13, 2025, at 3:00 PM, and were provided the immediate jeopardy template. An immediate action plan was requested. On February 13, 2025, at 5:12 PM, the facility's immediate action plan was accepted, which included: DON/Designee will provide immediate orientation/education to licensed agency and facility staff currently working in the facility to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well as how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. DON/Designee will provide orientation/education to any additional licensed agency and facility staff prior to the start of their shift to include facility policies on resident code status, copy of floor plan including location of crash carts, oxygen, and other emergency supplies as well a how to meet EMS at the front door after calling 911 if receptionist is not on duty. Education will include the following information: if a resident has change in condition, the nurse refers to the order and the POLST. If there is no order and no POLST, resident is automatic full code. If resident is a full code and CPR is to be initiated, code is called immediately, All available licensed staff are to be present and CPR initiated and not stopped until EMS arrives and instructed to do so. Do not freely type a special instruction in PCC regarding code status. When a resident is admitted or readmitted to facility from the hospital, all hospital bracelets are to be removed. Human Resources Director/Designee will review schedule daily to ensure licensed agency and staff scheduled have completed the orientation or will complete prior to start of shift for new agency staff. This education/orientation will be forwarded to agencies for signatures prior to start of shift. DON/Designee will audit current resident code status to ensure the order and POLST match, there are no residents with hospital wrist bands and no special instructions in PCC regarding code status. DON/Designee will audit 10 resident charts weekly for 2 months, then monthly for 3 months to ensure resident have code status in order and if there is a POLST that it matches the order. NHA/Designee will audit licensed agency staff for completed orientation weekly for 2 months, then monthly for 2 months. Results of audit will be reviewed by QAPI committee for any recommendations. Date of compliance will be February 14, 2025. On February 14, 2025, at 10:53 AM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. Staff interviews on February 14, 2025, revealed the facility had re-educated staff on facility policy regarding resident code status, the locations of crash carts, oxygen and other emergency supplies, the process for removal of hospital wrist band upon admission, the process for meeting emergency services at the door when the receptionist is not on duty, and abuse and neglect policies. Interviews were conducted with three RNs and three LPNs. All were able to verbalize understanding of the education points. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, facility document review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for two of 11 residents reviewed (Residents 4 and 5). This failure resulted in continued decline of one resident (Resident 4), which required an emergency transfer to the hospital for low blood oxygen levels and difficulty breathing which contributed to cardiac arrest and resulted in death. This failure placed the residents residing on one of four units (Laurel Lane) in an immediate jeopardy situation. Findings include: Review of the current facility policy, titled Change in a Resident's Condition or Status, revealed the policy statement was, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The Policy Interpretation and Implementation, section revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has ben a(an) .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .8. The nurse will record the resident's medical record information relative to changes in the resident's medical/mental condition or status . Review of Resident 4's clinical record revealed diagnoses that included hypertension (elevated/high blood pressure) and peripheral vascular disease (narrowing or blocking of blood vessels, which results in decreased blood flow to the body's extremities). Review of the facility's schedule and assignments for the night shift of November 26 into the 27, 2024, revealed that Employee 4 (Licensed Practical Nurse) was the only nurse assigned to Resident 4's unit during that shift. Review of Resident 4's progress notes revealed a note that was entered on November 27, 2024, at 5:50 AM, Employee 4 documented, resident [oxygen saturation] was 88% head of bed was up and resident voiced his struggle to breath [Registered Nurse] aware now on oxygen @2L [liters per minute]. At 5:59 AM, Employee 4 documented resident on 2L oxygen and o2 [saturation] now at 91%. Review of Resident 4's physician orders revealed that Resident 4 did not have an order for supplemental oxygen on November 27, 2024. Further review of the clinical record revealed no evidence that the Registered Nurse was made aware or assessed the Resident. Review of Resident 4's progress notes revealed that on November 27, 2024, at 7:14 AM, Employee 7 (Registered Nurse) who was the dayshift RN, documented a Situation, Background, Assessment, and Recommendation (SBAR) note which revealed assessment findings of blood pressure 88/49 (normally less than 120/80; however, considered low when below 90/60), pulse of 102 (normal range 60 to 100 beats per minute), respiration rate 46 (normal range between 12 to 20), and oxygen saturation while on supplemental oxygen via nasal cannula was 73% (normal range between 95 and 100%). Further review of the SBAR note completed by Employee 7 stated, At [6:45 AM], RN alerted by LPN [Licensed Practical Nurse] that resident was having [shortness of breath] with decrease in [oxygen] saturation at 77% on [room air], reported began at [3:30 AM]. Placed on 2L [nasal cannula] by LPN on duty, repeat [oxygen saturation] at [6:45 AM] 73%. [Oxygen] increased to 5L, [oxygen saturation] 78%. Color = pale and resident continued to report pain in abdomen. No [blood sugar] noted . As a result of the assessment findings, Employee 7 notified the attending physician and received an order to send Resident 4 to the hospital for further evaluation. Review of the clinical record for Resident 4 revealed no vital signs documented on November 26 or November 27, 2024, prior to 6:45 AM, entered by Employee 7. During a staff interview on December 5, 2024, at approximately 2:42 PM, Employee 5 (Licensed Practical Nurse) stated that between the hours of 5:00 AM and 6:00 AM, Employee 4 had called Employee 5's unit to speak with the night shift RN supervisor (Employee 6). During that call, Employee 4 stated that she needed to speak with Employee 6 regarding a Resident's complaints of difficulty breathing. Employee 5 stated that Employee 6 was not available at that time but would inform Employee 6. During a staff interview on December 5, 2024, at approximately 3:40 PM, Employee 6 stated that he did not recall being informed of Resident 4's change of condition on November 27, 2024. During a staff interview on December 5, 2024, at approximately 2:50 PM, Employee 7 (Registered Nurse) revealed that she had arrived at the building for the 7:00 AM to 3:00 PM shift on November 27, 2024. At which time she called the unit that Employee 4 was working on as the nurse. Employee 7 stated that she had called the unit to remind nursing staff to complete documentation. Employee 7 stated that at the time of that phone call, Employee 4 reported that Resident 4 was having difficulty breathing and needed oxygen via nasal cannula. It was at that time that Employee 7 went to Resident 4 to assess the Resident condition. During the interview, Employee 7 said that Employee 4 stated that Resident 4 initially had complaints of difficulty breathing and approximately 3:30 AM on November 27, 2024, and had low oxygen saturation that required the use of supplemental oxygen via nasal cannula. Employee 7 stated that Employee 4 reported notifying Employee 6. Review of hospital records revealed that upon arriving at the hospital, Resident 4's pulse was 114, respiratory rate was 38, blood pressure was 81/51, oxygen saturation was 100% and pain level was 10. Review of the laboratory blood studies performed on Resident 4 revealed the following values: hemoglobin (cellular component responsible for carrying oxygen) 6.0 (reference normal range 12.8 to 16.6); venous (blood returning to the heart) pH 7.14 (acidic range, normal reference range 7.32 to 7.42); venous PcO2 (measure of carbon dioxide levels in the blood returning to the heart) less than 15 (reference normal range 37 to 47); and troponin (protein in the heart muscle cells that is released when the heart sustains damage) 4,231 (reference normal range less than 20). Review of the hospital notes stated, .On examination patient is toxic appearing. He appears to be very ill and pale. He has diffuse abdominal pain .Patient was very pale and I was concerned that he was having hypovolemic shock secondary to bleeding. Patient hemoglobin came back at 6 .In the setting of the patient's poor function prior to the cardiac arrest including elevated troponin, severe lactic acidosis, low hemoglobin and patient's age and comorbidities I was concerned that the patient would not have a good neurological outcome. Cardiac arrest resuscitation efforts were stopped at [9:35 AM]. Time of death was [9:35 AM]. Employee 4 failed to notify the RN supervisor and/or the attending/on-call physician of Resident 4's change in condition, which required medical intervention. Review of Resident 5's clinical record revealed diagnoses that included pneumonitis (inflammation of lung tissue), resistance to multiple antimicrobial drugs (condition where bacteria within the body develops resistance to a wide range of antibiotics causing the medications to be ineffective for treating infections), and COVID-19 (respiratory virus characterized by fever and cough and is capable of progressing to severe symptoms). Review of Resident 5's physician orders revealed that Resident 5 had an order for supplemental oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%, dated November 17, 2024 and Albuterol sulfate nebulization solution 3 milliliters via nebulizer every four hours as needed for shortness of breath/wheezing. Review of the facility's schedule and assignments for the night shift of November 26 into the 27, 2024, revealed that Employee 4 was the only nurse assigned to Resident 5's unit during that shift. Review of Resident 5's progress notes revealed a note dated November 18, 2024, at 5:38 PM, that stated Resident 5 tested positive for COVID-19 and was receiving Levaquin (antibiotic medication) for pneumonia. Further review of Resident 5's progress notes revealed a note dated November 27, 2024, 6:00 AM, Employee 4 documented, resident [complained of] not being able to breath checked oxygen he was on 3L [liters] stats [oxygen saturation] at 77%, increased oxygen to 5L now at 92%. Further review of Resident 5's clinical record revealed no evidence that the Registered Nurse was made aware and assessed the Resident. Review of Resident 5's medication administration record (MAR - document utilized to record when medications are administered) for November 2024, revealed no nebulizer treatments were documented as administered during the night shift hours for November 26 or 27, 2024. Further review of Resident 5's MAR revealed no documentation that supplemental oxygen had been administered during the month of November 2024. Review of Resident 5's progress notes revealed that on November 27, 2024, at 9:35 AM, Employee 7, documented a SBAR note which revealed assessment findings of blood pressure 127/65, pulse of 44, respiration rate 22, and oxygen saturation while on supplemental oxygen via nasal cannula was 92%. Further review of the SBAR note completed by Employee 7 (Dayshift RN) stated, During this nurse's review of 24hr report, it was noted that resident [4] c/o SOB [shortness of breath] at 0600 and was placed on 5L NC for O2 sat of 77%. With this nurses's assessment at 0920, resident sitting in w/c, no acute distress noted. Duoneb given .LS [lung sounds] with positive wheezing to right upper lobe. Employee 7 notified the physician. No new orders were received. A progress note dated November 27, 2024, at 11:37 AM, stated the physician was in and evaluated Resident 5. New orders were obtained for stat (medical term used when an order is to be completed immediately) blood work and a chest x-ray. A progress note dated November 27, 2024, at 8:55 PM, stated the physician review Resident 5's chest x-ray and blood work. The chest x-ray indicated bilateral lower lobe pneumonia, worsening. New orders received for Lasix (medication used to treat fluid retention) and Zithromax (antibiotic medication) and repeat blood work in two weeks. Review of the electronic health record revealed the vitals section did not contain any vital signs documented on November 26 or 27, 2024, prior to 9:36 AM entered by Employee 7. Review of the facility's schedule and assignments for the night shift of December 1 into the 2, 2024, revealed that Employee 4 was the only nurse assigned to Resident 5's unit during that shift. Review of Resident 5's progress notes revealed a note dated December 2, 2024, at 4:15 AM, Employee 4 documented, resident constantly screaming for help when asked what he needs he state he doesn't know [nurse aides] and nurse did multiple attempts in trying to make him comfortable resident continue to just scream but denies pain. Further review of Resident 5's clinical record revealed no evidence that Employee 4 notified the RN Supervisor. An additional note dated December 2, 2024, at 6:19 AM, revealed Employee 4 documented, oxygen [saturation] at 92 now with increase in O2 from 3L to 4.5L. A progress note entered December 2, 2024, at 6:33 AM, revealed Employee 8 (RN) documented, .O2 sat was checked at 78% during the night, given the [as-needed] albuterol breathing treatment and O2 increased to 4.5 L via NC [nasal canula]. Increasingly coughing wet cough but no sputum. Further review of Resident 5's clinical record revealed no evidence that Employee 8 notified the attending/on-call physician of Resident 5's change of condition. Review of Resident 5's progress notes revealed that on December 2, 2024, at 1:01 PM, Employee 7 (Registered Nurse) who was the dayshift RN, documented a SBAR note which revealed assessment findings of blood pressure 104/60, pulse of 52, respiration rate 24, and oxygen saturation while on supplemental oxygen via nasal cannula was 90%. Further review of the SBAR note completed by Employee 7 stated, Resident yelling out throughout shift and previous shift per hand off of care report. When asking resident what is wrong and why yelling he states, 'I don't know' . Employee 7 notified the attending physician and received orders for a urinalysis and culture and to initiate IV (intravenous) fluid, one liter of normal sterile saline at 60 cubic centimeters (metric unit of measure) per hour. Review of the electronic health record revealed the vitals section did not contain any vital signs documented on December 2, 2024, prior to 10:40 AM. Review of Resident 5's MAR for December 2024, revealed Employee 4 documented a nebulizer treatment was administered at 3:08 AM on December 2, 2024. Further review of Resident 5's MAR revealed no documentation that supplemental oxygen had been administered as of December 2, 2024. Employee 4 failed to notify the RN supervisor of Resident 5's change in condition on November 27, 2024, and December 2, 2024, which required medical interventions and Employee 8 failed to notify the attending/on-call physician of Resident 4's change in condition on December 2, 2024, which required medical intervention. The failure to notify the RN supervisor and/or the attending/on-call physician of a change in condition placed the other residents who resided on the unit, under the care of Employee 4, in an Immediate Jeopardy situation. The Nursing Home Administrator (NHA) was provided the immediate jeopardy template on December 6, 2024, at 12:40 PM, and an immediate action plan was requested. On December 6, 2024, at 4:43 PM, the facility's immediate action plan was accepted, which included: 1. Education was provided to Employee 4 verbally on November 27, 2024, and in written form on December 2, 2024. 2. Education has been given to licensed nursing staff on change in condition protocol including the need for LPNs and RN's as charge nurses to notify the RN Supervisor immediately, including Physician notification and orders. Any New/Agency Staff will be educated on the same protocol on arrival December 5 and 6, 2024. 3. Facility wide audit will be completed of current residents by review of the facility's 24 hour shift report to ensure that any resident with a change in condition has had an RN assessment with notification of the physician on completed on December 6, 2024. 4. Every shift the Director of Nursing or designee will review the 24 hour shift report for any changes in condition and will ensure that an RN assessment and physician notification was completed for four weeks. On December 6, 2024, at 5:27 PM, the Immediate Jeopardy was lifted during the onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found lying in the parking lot of the facility and was medically compromised as evidenced by a low body temperature and abrasions. This failure placed a total of five residents in an Immediate Jeopardy situation who were identified as at risk for elopement and not on a locked unit (Residents 1, 6, 7, 9, and 10). Findings include: Review of facility policy, titled Wandering and Elopements, undated, read, in part; The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of Resident 1's clinical record revealed diagnoses that included encephalopathy (a disturbance in brain function causing confusion, memory loss, and a decline in the ability to reason), mild cognitive impairment, and alcohol abuse. Review of Resident 1's physician orders revealed orders dated March 19, 2024, for an alarming security bracelet (Wander guard, SecureCare, Accutech), with placement checks every shift and function checks every night shift. Further review of Resident 1's physician orders revealed an order dated August 30, 2024, for frequent monitoring, every 15-minute checks for behaviors/safety. Review of documentation in Resident 1's clinical record for the past 30 days indicated Resident 1 was independent with ambulation. Further review of Resident 1's clinical record revealed an assessment titled wandering risk scale, dated April 1, 2024. The assessment indicated Resident 1 was at high risk for wandering and to continue use of wander guard. An additional assessment titled elopement/wandering risk, dated May 22, 2024, indicated Resident 1 was at risk for elopement and to implement plan of care for unsafe wandering/exit seeking behavior. Review of Resident 1's nursing progress notes revealed a note dated November 16, 2024, at 7:40 PM, that indicated Resident 1 was wanting to go home, asking a nurse aide for a beer, exhibiting increased behaviors, exit seeking, and setting off door alarms. Further review of Resident 1's progress notes revealed a note dated November 30, 2024, at 6:42 PM, that Resident 1 was found lying on the ground in front of the building by a visitor. An additional progress note dated November 30, 2024, at 6:45 PM, indicated Resident 1 was brought in through the front lobby entrance by two staff and placed in a wheelchair. A Registered nurse assessment was completed, and Resident 1 was noted to have abrasions to the tip of his left middle finger, the top of his left hand, left eyebrow, left cheek, and left knee. The areas were cleaned with normal sterile saline. Resident 1's left middle finger was wrapped with gauze and the other abrasions were left open to air. Resident 1's initial vital signs were temperature 92.9 degrees Fahrenheit (F), blood pressure 180/110, pulse 50, and oxygen saturation 82% on room air (Normal vital signs are as follows: temperature 97.8 - 99.1 degrees F, blood pressure 90/60 - 120/80, pulse 60 - 100 beats per minute, oxygen saturation 95 - 100%). Resident 1 was noted to have appeared shaky and cool to touch. Resident 1 was changed into warm clothes and covered in blankets. Vital signs were reassessed: temperature 96.8 degrees, blood pressure 175/102, pulse 90, and oxygen saturation 95% on room air. Resident 1 denied pain, but wincing was noted with right arm movement when applying a sweater. The physician was notified and no new orders were received. A progress note dated December 1, 2024, at 9:51 AM, indicated Resident 1 was incontinent of urine and needed extensive assistance to sit up in bed, which was not Resident 1's baseline. According to the Cleveland Clinic, hypothermia is a condition that occurs when body temperature drops below 95 degrees F. The average normal body temperature is 98.6 F. Hypothermia symptoms include: shivering and chattering teeth, exhaustion, clumsiness/slow movements and reactions, sleepiness, week pulse, fast heart rate, rapid breathing, pale skin color, confusion and poor judgment/loss of awareness, excessive urination, and trouble speaking. Review of the facility provided incident report under section titled Immediate Action Taken revealed: RN assessment completed. Resident taken into shower room, hands cleaned and noted abrasion to tip of left middle finger 2 cm x 2 cm, top of left-hand abrasion 1.5 cm x 1.5 cm, left eyebrow abrasion 2 cm x 1 cm, left cheek abrasion 0.5 cm x 0.5 cm, left knee abrasion 1 cm x 1 cm. Areas cleansed with NSS (normal sterile saline) and left open to air, left middle finger wrapped with gauze and secured with tape. Review of witness statements provided by the facility indicated Resident 1 was last seen by a nursing assistant in his room eating around 5:10 PM and that no door alarms had sounded. The witness statements also revealed that Resident 1 was wearing a blue sweat suit with a blue zip-up hoody, tan slipper socks, and a hat at the time he was found outside. Review of facility provided document titled Safety Check, revealed on November 30, 2024, Resident 1 was on every 15 minutes safety checks and is documented as checked at 5:30 PM and 5:45 PM. Review of Resident 1's care plan revealed that Resident 1's care plan was not updated to reflect wandering and being at risk for elopement with additional interventions until December 2, 2024, which was two days after Resident 1 eloped from the facility. Resident 1's care plan included the following focus areas: 1) At risk for behavior symptoms related to alcoholism, encephalopathy, adjustment disorder, depression, initiated on October 2, 2022. 2) At risk for changes in mood related to anxiety, depression, alcohol abuse, and adjustment disorder, may feel down, initiated on October 2, 2022. 3) At risk for falls due to history of falls, impaired balance/poor coordination, initiated October 2, 2022. 4) At risk for substance abuse history of alcohol abuse, initiated October 14, 2022. 5) Inappropriate physical/social sexual behavior towards Resident by another female resident. History of attempting to enter a female resident's room needing redirection and reminders of inappropriate behaviors. May wander around the unit, initiated November 14, 2022. Intervention for wander guard to right arm, initiated May 31, 2023. Further review of Resident 1's clinical record revealed that an Elopement Risk assessment was completed on December 2, 2024, after the elopement occurred, which indicated that Resident 1 was assessed as High Risk. During an interview with the Director of Nursing (DON) on December 4, 2024, at 10:03 AM, the DON indicated that Resident 1 exited though a side door that is used by staff and family members. The door does not have a wander guard alarm but does have an alarm that sounds if opened without entering a code. After the code is entered there is an eight second delay before the alarm resets. It is believed the Resident followed a visitor out of the door. During the interview, the DON indicated that after Resident 1 was found outside on November 30, 2024, the maintenance department was called in and all exterior doors were inspected, all were found to be functioning properly. The facility also contacted the door company, and an inspection was completed on December 2, 2024. The door was found to be functioning properly. The DON reported she performed a full system check of the wander guard system on November 30, 2024, and the system was found to be functioning properly. During an additional interview with the DON on December 4, 2024, at 12:30 PM, the DON revealed Resident 1 had been found lying on the ground in the fire lane in front of the building. She also revealed that the side exit door on Laurel Lane is primarily used by staff because the time clock is located by the door. She stated that a few frequently visiting family members had obtained the code for the door and at least four different families used the door that day without staff assistance. The DON stated that it was the expectation of the facility that family members are not given the code to locked doors. She also indicated that the code had been changed on November 30, 2024, and only maintenance and administration have the new code. An interview with Employee 1 on December 4, 2024, at approximately 11:48 AM, revealed he had been called in the evening of November 30, 2024, and was to inspect all exit doors. Employee 1 indicated that his inspection revealed all doors and alarms were functioning properly. Employee 1 also indicated that the code for the exit door on Laurel Lane had been changed on November 30, 2024. Assessment of the side exit door located on the Laurel Lanes unit on December 4, 2024, at approximately 11:45 AM, revealed the door had been covered with clear plastic that was taped around the top and edges of the door, with a zipper down the center. The code box had been covered with caution tape and signage was present indicating the door was not to be used. Upon opening the door, by pushing on a metal bump bar (a type of door opening mechanism which allows a door to open by pushing a bar), a loud alarm sounded, and a code was required to be entered to silence the alarm. Information provided by the facility indicated that there are four additional residents identified as elopement risks that reside on the unlocked units (Residents 6, 7, 9, and 10). Review of the clinical records for Resident 6, 7, 9, and 10 revealed orders for a Wander guard and to check placement and function every shift. The facility is located on a main road with a one way half circle drive at the front of the building. There is a parking lot on the right side of the building, parking lots on each side of the lobby in front of the building, and a portico located at the main front entrance outside of the door that vehicles drive through. Outside temperatures on November 30, 2024, for the facility's location, per online historical data, was high of 37 degrees F and a low of 24 F. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement. The DON was provided the immediate jeopardy template on December 4, 2024 at 2:04 PM, and an immediate action plan was requested. The facility initiated immediate interventions on November 30, 2024, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included: The code to the side door was changed on November 30, 2024. The new code was only given to the maintenance department and administration. All staff and families were notified on November 30, 2024, that that door is no longer in use and that anyone seeking entryway or exit should go to the main entrance. The door was closed via signage to noticeably display its lack of service as an exit/entry and only to be used as an emergency exit as of November 30, 2024. All staff were educated on awareness of residents' whereabouts when entering or leaving an exit area. Staff were educated not to provide the code to doors to family members. A letter was sent to all family members that they are only to use the main entrance to enter or exit. All residents assessed as elopement risks were identified and their wander guards checked for functionality. Audits were initiated on November 30, 2024, and will be done weekly on the residents with wander guards for placement and function and also of the exit doors for function. Additionally, a QAA committee meeting was held on December 2, 2024, to review the investigation process and develop additional recommendations. The facility's plan was reviewed on December 4, 2024, during the onsite survey. On December 4, 2024, at 4:32 PM, the facility's immediate action plan was accepted, which included: 1) On November 30, 2024, the code to the side door was changed. The new code was not given to staff or visitors. 2) All staff and families have been notified that that door is no longer in use. The door has been closed via signage to noticeably display its lack of service as an exit/entry and only to be used as an emergency exit as of November 30, 2024. 3) All staff have been educated on awareness of residents' whereabouts when entering or leaving an exit area starting November 30, 2024, completed December 4, 2024. 4) Signs have been placed since the occurrence stating the door is presently not in use as an exit/entry and only to be used as an emergency exit and that anyone seeking entryway or exit should go to the main entrance as of November 30, 2024. 5) Education included that staff are not to provide the code to doors to family members. A letter has also been sent to all family members that they are only to use the main entrance to enter or exit the facility as of November 30, 2024. 6) All residents assessed as elopement risk have been identified and their wander guards checked for functionality December 2, 2024. 7) Audits will be done weekly on the resident with wander guards for placement and function and also of the exit doors for function started November 30, 2024. 8) The above ensure that any resident that is at risk is secured from exiting from the side door. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of education regarding using the main front door for entry and exit of the building, only using the side door for an emergency exit, not providing visitors with door codes, and being aware of their surroundings when entering and exiting the building. The Immediate Jeopardy was lifted on December 4, 2024, at 4:40 PM, after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure the resident environment remains free of accident hazards for one of seven residents reviewed (Resident 2) and failed to ensure that interventions were put into place to prevent falls, resulting in harm, as evidenced by transfer to the hospital for a laceration to the left eyebrow requiring four sutures and a laceration to the left cheek requiring three sutures for one of seven residents reviewed (Resident 2). Findings Include: Review of facility policy titled Assessing Falls and Their Causes, revised December 2007, revealed After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. Review of Resident 2's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation (Afib-an irregular, often rapid heart rate that commonly causes poor blood flow), depression, and muscle weakness. Review of Resident 2's current care plan revealed a fall intervention of nonskid shoes/slippers, initiated on April 16, 2023, and a fall intervention of a bed alarm, initiated on April 20, 2023. Review of Resident 2's clinical record revealed that on May 20, 2023, Resident 2 was found on the floor by the nurse aide. Review of Resident 2's fall report, dated May 20, 2023, revealed that Resident 2 stated he was getting up to do something unintelligible. Further review of the fall report revealed that the box for Alarm(s) sounding/functioning, was not checked and the box next to bare feet was checked. Review of Resident 2's fall care plan revealed that Resident 2 had an unwitnessed fall on May 20, 2023 and that Resident 2's alarm was not turned on and Resident 2 had bare feet. Further review of the care plan revealed no new interventions were initiated after the fall. Review of Resident 2's clinical record revealed a progress note dated June 2, 2023, stating that staff heard a loud thump and found Resident 2 on the bathroom floor. Resident 2 was unable to give specifics of the fall but stated he fell while trying to urinate. Further review of the progress note revealed After checking bed alarm, it was noted to be turned off. Review of Resident 2's fall report dated June 2, 2023, revealed that the box next to Alarm(s) NOT sounding/functioning was checked. Further review of the fall report revealed that the bed alarm was turned off and therefore, staff were unaware that Resident 2 got out of bed. Review of Resident 2's fall care plan revealed that on June 2, 2023, Resident 2 had an unwitnessed fall in the bathroom, the bed alarm was not turned on and staff were disciplined and educated. Further review of the care plan revealed no new interventions were initiated after the fall. Review of Resident 2's fall report dated June 8, 2023, revealed that Resident 2 was observed exiting another resident's room. Resident 2 reported to nursing staff that he fell in the bathroom. Further review of Resident 2's June 8 fall report revealed that the box next to Alarm(s) NOT sounding/functioning was checked. Review of Resident 2's fall care plan revealed that during the fall on June 8, 2023, Resident 2's bed alarms were not on and that staff were disciplined and educated. Further review of the care plan revealed no new interventions were initiated after the fall. During an interview with the Director of Nursing (DON) on June 20, 2023, at 3:00 PM, she confirmed that Resident 2's alarm was not on when Resident 2 fell on [DATE], June 2, and June 8, 2023. Review of Resident 2's clinical record revealed a progress note dated June 9, 2023, at 9:45 PM, stating that Resident 2 was found laying on the floor from an unwitnessed fall. It was observed that Resident 2 had a left head laceration (a deep cut or tear in the skin), large bruising around his jaw line and a laceration to the left arm. Resident 2 was then transferred to the Emergency Department. Review of Resident 2's hospital records, dated June 9, 2023, revealed Resident 2 had a laceration to his left cheek, measuring 2 cm (centimeters) in length and 5 mm (millimeters) in depth, requiring three sutures to repair it. Resident 2 also had a laceration to his left eyebrow, measuring 3 cm in length and 5 mm in depth, requiring four sutures to repair it. Review of Resident 2's fall report, dated June 9, 2023, revealed that the boxes next to Alarm(s) sounding/functioning, Fall alarm and Non-skid socks in place were not checked. Further review of the fall report revealed no evidence that Resident 2's fall interventions were in place at the time of Resident 2's fall. Review of Employee 1's (Licensed Practical Nurse) witness statement, dated June 9, 2023, revealed This nurse was doing med pass down resident side of the hall when I witnessed resident open door, resident was laying on floor and had a laceration to head near left eye. The witness statement further stated that a Registered Nurse was called to assess Resident 2 and he was transferred to the hospital. Review of Employee 2's (Licensed Practical Nurse) witness statement, obtained two days after the fall on June 11, 2023, revealed that Employee 2 was on a different nursing unit when Resident 2 fell and had no information to provide regarding the fall. Review of Resident 2's Treatment Administration Record (TAR), dated June 2023, revealed an order to verify placement and patency of bed alarm while in bed, every shift, with a start date of April 24, 2023. Further review of the TAR revealed that on evening shift on June 9, 2023, it is documented as a 9, meaning other/see progress note. Review of corresponding nursing progress note, dated June 9, 2023, at 10:28 PM, revealed the statement no alarm box attached. Review of Resident 2's nurse aide task documentation for the bed alarm being on and functioning, dated June 9, 2023, revealed that it was signed off as being completed on day shift at 9:26 AM and not signed off as being completed until after the fall on evening shift at 10:48 PM. During an interview with the Director of Nursing (DON) on June 20, 2023, at 3:00 PM, she stated that there are normally more witness statements to accompany a fall report but there are only two witness statements for Resident 2's fall on June 9, 2023. At this time she also stated that the alarm checks should be done at the beginning of the shift. During an interview with the Nursing Home Administrator (NHA) and DON on June 20, 2023, at 3:30 PM, they stated they could not say for certain if Resident 2's alarms were on or not at the time of the fall on June 9. On June 23, 2023, at 10:00 AM, the NHA was made aware of the concern with Resident 2's fall on June 9, 2023, and that the fall report and witness statements provided no evidence that Resident 2's fall interventions, to include the bed alarm, were on and functioning at the time of Resident 2's fall. She stated that she couldn't find a policy specific to alarms but stated that it is her expectation that alarms would be checked at the beginning of the shift, but would continue to look for a policy. On June 23, 2023, at 11:38 AM, the NHA stated she was unable to locate a facility policy in regards to bed or chair alarms. Resident 2 experienced repeated falls due to the facility staff's continued non-compliance with alarms not being in place per Resident 2's care plan, which resulted in harm after the fourth fall. The facility failed to thoroughly investigate Resident 2's fall on June 9, 2023, to determine the root cause analysis, and only obtained two witness statements, one of which was not working on the same nursing unit at the time of the fall. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review, observation, facility document review, staff interview, and facility policy review, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 7). This failure placed three additional residents at the facility in an Immediate Jeopardy situation who were identified as at risk for elopement (Residents 8, 10, and 11) out of 11 residents reviewed. Findings include: Review of facility policy, titled Section 10F- All Hazards Emergency- Elopement Policy, undated, revealed the following: It is the policy of the facility to institute measures to identify residents who may be at risk to leave the facility without knowledge of the staff. In order to protect all residents, especially those identified as 'at risk of elopement,' it is the policy of the facility to implement measures to reduce or eliminate the possibility of elopement. It further indicated the following: Function of the alarm monitoring system will be checked quarterly by the Director of Nursing or Maintenance Director. If a concern is identified at any point in time, the nursing supervisor or Maintenance Director will alert the Administrator and Director of Nursing and assign a staff member to the area in question. Review of Resident 7's clinical record revealed diagnoses that included hypertension, alcohol dependence, nicotine dependence, depression, and healing fracture of left tibia (larger bone in lower leg often referred to as the shin bone). Further review of Resident 7's clinical record revealed that the Resident had obtained the fracture to his left tibia as the result of being struck by an automobile when crossing the street prior to admission to the facility on [DATE]. Review of Resident 7's physician orders revealed an order for an Alarming Security Bracelet (such brands include Wanderguard, SecureCare, and Accutech), every shift Check Placement dated December 16, 2022. The order did not indicate to check the alarm for proper functioning. Review of Resident 7's Treatment Administration Record (TAR) revealed that placement had been checked on the evening shift of December 16, 2022, and night shift, day shift, and evening shift of December 17, 2022, and placement was continuing to be checked each shift. Review of Resident 7's care plan revealed the following focus areas: 1) at risk for falls, initiated on December 16, 2022; 2) verbal and/or physical agitation and/or aggression related to alcohol and/or drug withdrawal, initiated on December 16, 2022; 3) at risk for substance abuse with history of alcohol and nicotine dependence, initiated on December 16, 2022; Review of Resident 7's progress notes revealed a note dated December 16, 2022, at 10:45 PM, that indicated Resident 7 was up in the wheelchair, pushing himself through the hallways, stating he was going home. The note further indicated that a nurse aide walked with Resident 7 throughout the hallways to ensure there were no attempts to leave, Resident 7 decided to return to his room and that a Wanderguard (a bracelet that is equipped to alarm when it comes in contact with a sensor box at an exit door) was placed for safety. Further review of Resident 7's care plan revealed that the care plan was not updated to include at risk for elopement and no interventions were implemented other than the placement of the wanderguard bracelet at the time Resident 7 was noted to be wandering and exit seeking on December 16, 2022. Further review of the care plan revealed a care area for Elopement risk related to Cognitive impairment, initiated on December 19, 2022. Review of Resident 7's progress notes revealed a note dated December 17, 2022, at 9:42 PM, revealed that Resident 7 was found in the front parking lot of the facility at 6:45 PM by a nurse aide who reported it to the Licensed Practical Nurse (LPN). The LPN brought Resident 7 back into the facility. Resident 7 revealed he had let himself out the front the door. Resident 7 was then moved to the secured unit due to wandering and exit seeking. Review of facility provided incident report for Resident 7 indicated under section titled Incident Description that on December 17, 2022, a nurse aide came in from outside at [6:45] PM and asked the LPN Supervisor, if we have a resident with a brace on their leg. The LPN Supervisor went out front of the building and noted that resident was in his wheelchair in the parking lot. LPN Supervisor brought resident back into building. It further indicated that the Resident stated, he let himself out, so he could get some fresh air. Review of the facility provided incident report under section titled Immediate Action Taken revealed: the Resident had a Wanderguard in place at time of elopement, but alarm did not sound; Wanderguard was activated by LPN Supervisor; Director of Nursing (DON) and Nursing Home Administrator (NHA) were called and made aware; Resident was moved to the locked unit in a new room due to wandering and exit seeking; Emergency contact was made aware of the elopement and room move; and the physician was also made aware. Further review of the incident report revealed the following: the alarm was not sounding/functioning; resident had confusion, was non-compliant, and had depression ; and the resident was an active exit-seeker, was admitted within the last 72 hours, using wheelchair, and a wanderer. There were no investigative statements with the incident report that indicated the facility had attempted to determine when the Resident was last seen and why alarm did not sound. Further review of Resident 7's clinical record revealed that an Elopement Risk Assessment was completed on December 17, 2022, after the elopement occurred which indicated that Resident 7 was now assessed as At Risk for Elopement. Resident 7's care plan was not updated to reflect their assessed risk for elopement with additional interventions added until December 19, 2022, which was two days after Resident 7 eloped from the facility. On December 21, 2022, at approximately 2:15 PM, NHA stated she would see if there were any statements in the DON 's office, but indicated that there was a nurse's note documented at 6:15 PM, and that was when Resident 7 was most likely last seen. During an interview with NHA on December 21, 2022, at approximately 2:30 PM, NHA indicated that she had tried the current Wanderguard bracelets the facility was using which was Accu-tech and that this brand would not alarm at the front door because it was a [NAME] Wanderguard sensor box that is located at this door. Assessment of front door with Employee 7, a maintenance employee, and Nursing Home Administrator (NHA) on December 21, 2022, at approximately 3:30 PM, revealed that the front door can only be locked by turning off the breaker to the door. Employee 7 indicated that this should be done when the receptionist leaves for the day. The NHA indicated that Monday through Friday the receptionist leaves at 7:00 PM and on Saturday and Sunday, the receptionist leaves at 5:00 PM. The breaker box is approximately four feet from the main door and is covered with the same wallpaper as the lobby, making the breaker box concealed. Employee 7 also confirmed that the Wanderguard system on this door does not work and has not worked since this new door was installed. Employee 7 indicated that this door had been installed recently and he would obtain the exact date. Employee 7 further indicated that, in the event of an emergency, even if this door was locked by shutting off the breaker, this door can be pushed against and it will open. The NHA indicated that she was not aware that the door had to be locked and that she was not aware that the wanderguard system on this door did not work. It was also noted that directly (approximately 12 inches) to the left hand side of the front door when exiting there was a push button with a framed sign that said Press square button to open door and there was an arrow pointing directly to said button. The button is located at wheelchair level and has the handicapped logo. The button can be easily pushed. The facility is located on a main road with a one way half circle drive at the front of the building. There are parking lots on each side of the lobby and a portico located at the main front entrance outside of the door that vehicles drive through. Email communication received from NHA on December 21, 2022, at 3:53 PM, indicated the new door was installed on October 13, 2022. During an interview with Employee 8 (Receptionist) on December 21, 2022, at approximately 3:55 PM, Employee 8 indicated that, prior to today, she was not aware that there was a way to lock the front door and that she was not aware that she was to turn the breaker off when she would leave for the day. She indicated that she had been employed at the facility in this position since May 2022. Email communication received from NHA December 21, 2022, at 5:12 PM, indicated that there were three additional residents identified as elopement risks: Residents 8, 10, and 11. Review of the clinical records for Resident 8, 10, and 11 revealed orders for a Wanderguard and to check placement and function every shift. During an interview with NHA on December 22, 2022, at 3:30 PM, NHA confirmed that she that she had no investigative statements to provide that would identify when the Resident was last seen or why the alarm was not sounding at the time of Resident 7's exit from the building. NHA also confirmed that she would expect the Wanderguard system to have been in place and proper door locking procedures to be followed to protect the safety and welfare of the residents and prevent elopements. This failure placed residents at the facility who are at risk for elopment, with an intervention of a wanderguard in place, in an Immediate Jeopardy situation. The NHA was provided the immediate jeopardy template on December 21, 2022, at 4:00 PM, and an immediate action plan was requested. On December 21, 2022, at 6:33 PM, the facility's immediate action plan was accepted which included: 1) Staff educated as to how to turn off the breaker at front door to prevent it from opening. When the evening receptionist leaves for the day, he/she will turn off the breaker for the evening. There is signage indicating to staff and visitors the need to go to the side door and ring the doorbell. 2) All other doors have functioning alarms that sound when door is opened. 3) Vendor has been contacted to install a new Wanderguard system. 4) Until new Wanderguard system is installed, a staff person will be positioned in the lobby after receptionist leaves for the day and will remain until the morning receptionist arrives. 5) Evening and night shift supervisors will audit the door two times nightly to ensure that it remains off. 6) When the new system is installed on the front door, residents deemed at risk will receive new bracelets compatible with system. Orders will be obtained to check for placement and function every shift. 7) When the new alarm system is installed, a designated staff person will check the front door daily utilizing a compatible bracelet. On December 22, 2022, at 3:28 PM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of facility policy, facility documents, clinical records and staff interviews, it was determined that the facility failed to ensure that an assessment was completed and care was documented by a licensed nurse when a resident experienced chest pain, resulting in death from a presumed [CONDITION(S)], for one out of 12 residents reviewed (Resident 8). This deficiency is cited as past noncompliance. Findings include: Review of facility policy titled, Charting and Documentation dated July 2017, states All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of a facility reported Incident Report, dated December 4, 2021, stated Resident 8 was found without respirations this morning 12/4/2021 at 7:40. Resident 8's family expressed concern that the facility staff did not provide timely follow up care when the family called in during the previous night. Resident 8's daughter stated that her mother told her she was having chest pain and she reported this to agency LPN 1 (licensed practical nurse). Review of the facility investigation, including statements from Licensed Practical Nurse 1 (LPN 1) and Registered Nurse 2 (RN 2) revealed a timeline of events from the evening of December 3, 2021. The timeline noted that at 7:19 PM, Resident 8's daughter received a call from Resident 8 stating she had leg and arm pain. While on the phone with her daughter the resident saw a nurse walk by and called for her. LPN 1 then administered [MEDICATION(S)] (medication used to treat muscle spasms) , [MEDICATION(S)] (medication used to treat chest pain , heart failure, and high blood pressure), and her inhaler. Between 7:50 PM and 8:00 PM, the daughter received a call from Resident 8, where she complained of chest pain. LPN 1 heard the resident calling out and came to the room, LPN 1 spoke with the daughter and said a Registered Nurse (RN) would be in to do an assessment. At an unknown time that evening the timeline reports that the power of attorney (POA) for Resident 8 called into the facility to speak with LPN 1. The POA reported to LPN 1 that Resident 8 was having chest pain. LPN 1 stated that an RN would be doing an assessment, and someone would contact the family back per request. Between 8:00 PM and 9:00 PM, Resident 8 waved RN 2 into her room, RN 2 provided 15 minutes of emotional support as the resident expressed sadness and loneliness and missing her family. Resident 8 at that time did not report any concerns of chest pain, RN 2 stated the resident expressed she felt better, and RN 2 left the room. After 9:00 PM, RN 2 checked with the resident and the resident said she was okay, LPN 1 notified the RN that she has anxiety about being alone and she has [MEDICATION(S)] for anxiety. LPN 1 administered Resident 8 [MEDICATION(S)] at 10:35 PM. Review of statement from RN 3, revealed she received a call from Resident 8's daughter at 2:30 AM who notified RN 3 that her mother was having chest pain earlier and the prior nurse was to assess her. RN 3 notified her that an assessment was not noted. There was no documentation showing that RN 3 assessed the patient after the call. The Nursing Home Administrator interviewed LPN 1 on December 4, 2021, at 5:00 PM. LPN 1 confirmed that the resident's daughter had notified her that her mother was having chest pain and she told her she would have an RN assess her. LPN 1 stated that the Resident's Power of Attorney then called her to report Resident 8's chest pain. LPN 1 reported she notified the RN of the resident's chest pain. LPN 1 stated that she saw RN 2 come out of Resident 8's room so she assumed the assessment was completed. LPN 1 reported that she did not document any of the aformentioned information in Resident 8's medical record because she was busy and didn't get around to it. Review of the statement from RN 2 revealed Resident 8 had called her into her room to talk. The resident stated that she was tired of being alone and missed her family, RN 2 stated she talked with her for 15 minutes and the resident stated she felt better. When RN 2 exited the resident's room she reported that she asked LPN 1 if the anxiety the resident had about being alone was her baseline, and the LPN stated yes. RN 2 reported she was never notified or called to resident room for chest pain or any other acute issue. RN 2 did not document any of the aformentioned information in Resident 8's medical record. Review of Resident 8's electronic medical record revealed no documentation relating to the pain she reported, or an assessment completed by the registered nurse. There were also no nursing notes regarding follow up after the medications were administered. A progress note dated December 4, 2021, at 2:30 PM, stated that Resident 8 was found unresponsive when staff were passing breakfast trays. Resident 8 was pronounced dead at 7:40 AM. Review of Resident 8's Death Certificate dated December 7, 2021, lists the immediate cause of death as presumed [CONDITION(S)] ([CONDITION(S)]) (damage to the heart muscle caused by a loss of blood supply). The centers for disease control (CDC) lists common symptoms of a [CONDITION(S)] as chest pain or discomfort and pain in one or both arms. Interview with the Nursing Home Administrator (NHA) on February 22, 2022, at approximately 12:30 PM revealed both LPN 1 and RN 2 were agency staff. The NHA reports LPN 1 is now on the do not return to the facility list. Information submitted by the facility to the Department included the following corrective actions in response to the harm of Resident 8. The facility's investigation and implementation of the corrective measures was January 13, 2022. -An Internal investigation was immediately initiated. The event was reported to the Department of Health through the Event Reporting System, followed by a PB-22. -A 48 hour look back was completed of residents on the identified unit for a change in condition and the lack of appropriate follow up. No affected residents identified -Interviews were conducted with residents on the identified unit related to Quality of Care and Service concerns by the Regional Director of Clinical Operations. No affected residents identified completed 12/13/2021 -Education provided to staff related to abuse/neglect - completed on 12/22/2021 -Education provided to licensed staff related to Change in Condition and Charting completed on 12/22/2021. -To monitor and maintain the ongoing compliance with the regulatory requirements, the facility completed audits of residents change in condition and appropriate follow up. Audits were completed by the Director of Nursing 3 times a week for 4 weeks. -Audits were completed in their entirety on 1/14/2022. -An AdHoc QAPI was completed with the Interdisciplinary Team on 12/13/2022. 28 Pa. Code 211.12(d)(5) Nursing services. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records

Based on observations, review of clinical records, staff interviews, review of selected facility documentation and policy and procedure, it was determined that the facility failed to maintain infection control practices for contact isolation precautions for skin infection and Methicillin-resistant Staphylococcus Aureus (MRSA- a bacterium responsible for difficult-to-treat infections) resulting in the use of non-fluid/contact resistant gowns being used to provide care for three residents reviewed (Residents 2, 3 and 5) and placing 42 other residents residing on one of three units at risk for the spread of infections (the Evergreen Unit) in a past non-compliance Immediate Jeopardy situation. Findings include: Review of the facility policy, Infection Control Practices Policy (Isolation - Categories of Transmission - Based Precautions), last revised January 2012, revealed that in addition to Standard Precautions (the wearing of gloves for resident care and hand washing) the staff were to implement Contact Precautions (disposable fluid resistant isolation gowns) upon entering the contact precaution room for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Review of the documentation provided by the facility revealed that 45 residents resided on the Evergreen Unit on February 20, 2017. Review of Resident 2's clinical record revealed a most recent admitted [DATE], and [DIAGNOSES REDACTED]. Review of Resident 2's physician's orders dated February 19, 2017, revealed an order to resume Contact Precautions every shift. Review of Resident 3's clinical record revealed an admitted [DATE], and [DIAGNOSES REDACTED]. The facility provided documentation that revealed the resident was tested for scabies (a contagious skin disease) on February 20, 2017, and tested positive. Contact precautions are defined by the Centers for Disease Control as procedures that reduce the risk of spread of infections through direct or indirect contact. Transmission occurs with physical contact of the infected patient or handling of a contaminated object in the infected patient's room. Masks, gowns, and gloves as well as standard precautions must be used by health care providers when in the infected patient's room to prevent the spread of infections to patients. Review of Resident 3's physician's order summary dated February 1, 2017 to February 28, 2017, revealed an order dated February 20, 2017, that indicated Contact Precautions until treatment on February 21, 2017. Observations of the door to Resident 3's room during the entire length of the survey, revealed a sign that instructed visitors to see nursing before entering the room. Review of Resident 5's clinical record revealed an admitted [DATE], and [DIAGNOSES REDACTED]. Review of facility provided documentation revealed that Resident 5's roommate, Resident 3, was placed on Contact Precautions on February 20, 2017, and Resident 5 was also placed on Contact Precautions due to sharing the room. During an interview with the Assistant Director of Nursing on February 20, 2017, at 2:40 p.m. it was revealed that Resident 5 was placed on Contact Precautions because the residents shared the same room and if one resident was on Contact Precautions, all residents in the room were on Contact Precautions. She also stated that they did not remove Resident 5 from the room to prevent spreading the condition. During an interview on February 21, 2017, at 1:00 p.m. with Nurse Aide 1 it was revealed that the facility ran out of disposable fluid resistant isolation gowns for Contact Precautions before the end of the second shift (3:00 p.m. thru 11:00 p.m.) on February 20, 2017. This employee was working that shift and observed the situation. During an interview with Licensed Practical Nurse 1 on February 21, 2017, at 12:54 p.m. it was revealed she had to use cloth resident gowns (similar to hospital gowns) when she entered the contact isolation resident rooms on February 21, 2017, during the first shift from 7:00 a.m. thru 3:00 p.m., until the new gowns arrived on the afternoon of February 21, 2017. During an interview and a facility tour with the Nursing Home Administrator (NHA) on February 21, 2017, at 12:39 p.m. in Resident 2's room, the NHA showed the surveyor a bag of cloth resident gowns and revealed that these gowns are what the facility had been using as isolation gowns until the appropriate gowns had arrived. The correct disposable fluid resistant isolation gowns were available at the time of the room observation. During an interview with Staff Person 1 on February 21, 2017, at 12:45 p.m. it was revealed that she was the person responsible for obtaining and stocking the disposable fluid resistant isolation gowns. It was also revealed that she had received a text message from the facility at approximately 10:30 p.m. on February 20, 2017, informing her that the facility was running out of disposable fluid resistant isolation gowns. When asked what she did about the situation, she responded, it was 10:30 at night what could I do. The facility ran out of disposable fluid resistant isolation gowns for Contact Precautions before the end of second shift, at approximately 10:30 p.m. on February 20, 2017, and the facility did not receive additional disposable fluid resistant isolation gowns until February 21, 2017, at 12:19 p.m. During this time the nursing staff were using cloth resident gowns, which are not fluid resistant and do not cover the caregivers' entire arm, to provide care to Resident 2, Resident 3, and Resident 5, thus increasing the risk of spreading an infection from resident to resident via the caregivers. Review of a staffing sheet obtained from the Assistant Director of Nursing revealed that 17 different staff members used cloth resident gowns to provide care from February 20, 2017, at 10:30 p.m. to February 21, 2017, at 12:19 p.m. to Residents 2, 3, and 5 as well as being assigned to care for the other residents on the Evergreen unit placing the residents in an Immediate Jeopardy situation related to the potential for the spread of infection during the time that the appropriate gowns were unavailable. The disposable fluid resistant isolation gowns arrived on February 21, 2017, at 12:19 p.m. and 9 more boxes were ordered. On February 21, 2017, at 3:45 p.m. the Nursing Home Administrator was notified that they were placed in past non-compliance Immediate Jeopardy status for Infection Control related to Contact Precautions and must provide a corrective action plan for review and approval. On February 21, 2017, at 6:45 p.m. the corrective action plan by the facility was received and included that the residents were monitored for signs and symptoms of infection, skin checks were done on all residents and staff were educated on Contact Precautions. The Par (the amount kept in the facility) for disposable fluid resistant isolation gowns was increased from 4 to 5 boxes on hand at all times. The facility had arranged with their supplier for overnight delivery of disposable fluid resistant isolation gowns when necessary. On February 22, 2017, at 10:45 a.m. the corrective action plan was reviewed and implementation was verified. On February 22, 2017, at 12:00 p.m. the Immediate Jeopardy was lifted. During an interview on February 22, 2017, at 12:45 p.m. the Nursing Home Administrator stated the expectation was that enough protective equipment should be available at all times. The facility failed to maintain infection control practices for contact isolation precautions for skin infection and Methicillin-resistant Staphylococcus Aureus for three residents reviewed (Residents 2, 3 and 5) resulting in the use of non-fluid/contact resistant gowns being used to provided care for these three residents and placing the residents on the Evergreen Unit in a past non-compliance Immediate Jeopardy situation for the transmission of infection by nursing staff. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 1/19/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/19/17, 8/19/16, 3/9/16, 9/10/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/19/16, 3/9/16, 9/10/15.