Every finding on record at Friendship Rehab and Health

Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to promote a multidisciplinary approach with care conferences for of three out of 12 months (March, April, and May 2026).Findings include: Review of facility policy Interdisciplinary Care Conference Guidelines dated 101/25, indicated that a care conference will be held within 21 days of admission, and at least quarterly thereafter. Care conference may be held whenever the team feels it is necessary to review the plan of care for the resident. Documentation will be provided for the evaluation of effectiveness of the care plan. The following should have representation at the meeting: Social Services, Nursing, Recreation, and Dietary. Review of the clinical record indicated Resident R1 was admitted [DATE]. Review of Resident R1's MDS (minimum data set a periodic review of assessment needs) dated 3/31/26, indicated diagnosis of gastro esophageal reflux disease (GERD- a digestive condition when stomach acid repeatedly flows back into the throat area), age-related physical debility, and abnormal weight loss. Review of Resident R1's Multidisciplinary Care Conference sign in sheet dated 3/30/26, failed to indicate that a staff member from dietary was present. Review of Resident R1's Multidisciplinary Care Conference sign in sheet dated 4/7/26, failed to indicate that a staff member from dietary was present. Review of Resident R1's Multidisciplinary Care Conference sign in sheet dated 5/4/26, failed to indicate that a staff member from dietary was present. During an interview on 6/9/26 at 11:37 a.m. Director of Social Services Employee E4 confirmed that dietary was unavailable during care conference meetings dated 3/30/26, 4/7/26 and 5/4/26, as required. 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain a clean homelike environment in two of eight nursing units (3 Main North Hallway bathroom and 4 Main North Hallway bathroom).Findings include: Review of facility policy Resident Environment dated 10/1/25, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike, allowing the resident to use his or her personal belongings to the extent possible. During an observation on 6/9/26, at 10:29 a.m. of the 3 Main North Hallway bathroom revealed the following:The second toilet stall had a black trash bag covering the toiletThe third toilet stall has visible yellow urine and smeared feces in the bowl During an interview on 6/9/26, at 10:32 a.m. Assistant Director of Nursing Employee E2 confirmed the above observations and stated, I think the bag over the toilet means that it is out of order. During an observation on 6/9/26, at 10:47 a.m. of the 4 Main North Hallway bathroom revealed the following:The first toilet stall privacy curtain had a large dried brown stain on the bottom and the raised seat over the toilet had dried yellow and brown stains in numerous spots on the lidThe third toilet stall had plastic wrap over the toilet, and the bowl appeared to have brown discoloration throughout During an interview on 6/9/26, at 11:02 a.m. Housekeeper Employee E3 confirmed the above observations and stated, It looks like the toilet got clogged and overflowed. The toilet has been out of order for probably two days. I was off yesterday, but it was fine when I last worked. During an interview on 6/9/26, at 11:30 a.m. the Director of Nursing confirmed that the facility failed to maintain a clean homelike environment in two of eight nursing units (3 Main North Hallway bathroom and 4 Main North Hallway bathroom). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(2.1) Management.28 Pa. Code: 201.29(a) Resident rights.

Based on review of employee qualifications, employee file review, and staff interview it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for approximately 1 month out of 12 months (May 2026 through June 2026).Findings include: During an interview on 6/9/26, at 10:27 a.m., Food Service Director Employee E1 stated he was not certified, did not possess any higher education beyond high school, and that the Registered Dietitian only works two to three days a week. During an interview on 6/9/26, at 11:26 a.m., the Director of Nursing stated that the Registered Dietitian (RD) was not employed full time she comes two to three times a week, and The RD was not on-site full time to oversee the operation of the kitchen in the absence of a full time qualified dietary manager. Review of Food Service Director Employee E1's Employee file revealed that he was hired on 5/12/26, and did not possess any required qualifications for Food Service Director. During an interview on 6/9/26, at 2:50 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that Dietary Manager Employee E1 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect a resident from physical abuse that resulted in the actual harm of left comminuted displaced intertrochanteric fracture (a break in the upper thigh bone) that required surgery for one of three residents (Resident R1).Findings include: Review of the facility policy Abuse: Protection From last reviewed 10/1/25, indicated each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/31/26, indicated the diagnosis of traumatic brain injury (TBI), anxiety, and mild neurocognitive disorder due to know physiological condition with behavioral disturbance. Section C0500 Brief interview for mental status (BIMS- a screening test that aids in detecting cognitive impairment) score 13 indicated cognitively intact. Review of nursing progress note dated 4/23/26, at 10:51 p.m. indicated supervisors urgently called to unit 2 Main at 8:30 p.m. for a resident attacking staff. Upon exiting the elevator, resident was noted to be lying on his right side, screaming, complaining of pain to his left hip. When asked what happened, resident stated that big mother------ tackled me I was going to knock his ass out. Resident R1 reportedly with increasing agitation throughout the evening, and resident attempted to punch the nurse and nurse aides. Nurse reported that when the resident swung at him, the nurse grabbed the resident's arm/shoulder and took him down to the floor. Resident with 10/10 left hip pain, with left leg shortening and external rotation. Emotional support provided. Physician notified and received order to send resident to local emergency room. Review of facility provided statement dated 4/23/26, completed by Registered Nurse (RN) Employee E1 indicated this nurse heard Resident R1 yelling in his room in an aggressive manner. This nurse and all staff went to Resident R1's room to see what was going on. Resident was yelling at Nurse Aid (NA) because she wanted to move the roommate's wheelchair further away so roommate cannot attempt to self-transfer. Resident was agitated and was saying that he personally had moved the wheelchair to stay next to the roommate because it was obstructing his window view. Resident was cursing at the NA. Staff attempted to calm resident down but were unsuccessful, Resident continued to pace in his room while yelling and cursing. Resident walked out of room and went down the hall to the bathroom. After about 5 minutes the resident came down to the nursing station yelling. Resident had both fists folded and moved forward and was actively swinging. This nurse grabbed his arm and moved away to avoid being punched. Resident lost his balance and this nurse assisted him to the floor and was able to restrain him until the supervisors came up. Review of witness statement completed on 4/23/26, by RN Employee E17 indicated called urgently to 2 Main around 8:30 p.m., for Resident R1 attacking staff members, Resident was lying on his right side on the floor in front of the elevator, screaming and holding on to his left hip. RN Employee E1 was standing over the resident holding the residents left arm to the resident's body to prevent him from striking staff. When asked what had happened, RN Employee E1 stated that Resident R1 was attacking staff and he grabbed his arm/shoulder and took him down to the floor. Resident R1 was yelling that big mother ------ tackled me. I was gonna knock his ass out resident complained of 10/10 left hip pain and left leg externally rotated. Physician called orders to send resident to the local hospital. Review of witness statement completed on 4/23/26, by Nurse Aid (NA) Employee E18 indicated I was charting about 8:00 p.m. and heard a loud commotion on the North Hall. Resident R1 was chasing and yelling at the NA about a wheelchair being moved to the wrong place. He was uncontrollable, The RN tried to talk to him. Resident R1 kept getting in the nurses' face telling him to go get his boys and saying he would teach him how to fight. The nurse left the room, and the resident went to the bathroom. After about 10 minutes Resident R1 came to the nursing station and started swinging, the nurse moved to the other cart and said he wasn't going to fight with him. Resident R1 swung and the nurse caught his swing by the forearm and was put to the floor by the nurse. Review of witness statement dated 4/23/26, completed by NA Employee E19 indicated I walked into Resident R1's room and saw resident residing in bed 1 sitting at the edge of bed with the wheelchair close by him. I walked over to Resident R1 and asked Resident R1 not to put the chair on that side because the resident residing in bed one can fall out of bed. Resident R1 goes to curse saying the chair was in his way and for me and the other NA to get out. The nurse heard the chaos and came down and Resident R1 got in the nurses' face and was saying I'll push you down. The nurse asked him to calm down. Resident walked into the bathroom. The nurse went down the hall. Resident came up to the nurse cart telling the nurse he was going to knock him out and asked if the nurse had a problem with him and started swinging at the nurse, The nurse grabbed him by the shoulder and sat him down on the floor. Review of the facility investigative report dated 4/24/26, at 8:44 a.m. indicated on 4/23/26, resident R1 was sent to emergency department for evaluation following an altercation with a staff member. Resident R1 was admitted to the hospital with a diagnosis of comminuted left hip fracture. Investigation started immediately. At approximately 8:30 p.m. nursing supervisor responded to unit due to report that Resident R1 was attacking staff. Upon arrival to the unit, Resident R1 was noted to be lying on the floor complaining of left hip pain. Resident R1 stated to nursing supervisor that big mother------ tackled me, referring to staff member Registered Nurse (RN) Employee E1. Resident R1 was immediately assessed for injury with left lower leg external rotation and shortening noted. Provider was contacted and gave order to send to emergency room for evaluation. Emotional support was offered. Family was called; police and APS were notified. Staff interviews were conducted. RN Employee E1 was interviewed and sent home pending investigation. RN Employee E1 reported that Resident R1 had been acting aggressively toward staff, and that Resident R1 came toward him and was threatening to knock him out. RN Employee E1 stated that Resident R1 swung at him and lost his balance, and he grabbed Resident R1 to assist him to the floor and restrained him until the supervisor came. Review of hospital history and physical dated 4/24/26, indicated [AGE] year-old male with past medical history of TBI, alcohol abuse with history of hepatic encephalopathy, apparently went into at Rehab center presented with left hip pain. Patient wanted to view the sunset and move a wheelchair which was obstructing his view. Apparently, staff told him not to do this and there was an altercation that pursued and when he was tackled to the ground the patient started having sever left hip pain and was brought to the emergency room. For further evaluation. Patient has some mild cognitive impairment baseline per record. Further review of Resident R1's hospital record confirmed a left comminuted displaced intertrochanteric fracture and Orthopedics was consulted for surgical correction. Resident has surgical intervention on 4/24/26. During an interview completed on 4/30/26, upon asking Resident R1 what happened to his leg stated, I was in my room, and a big wheelchair was blocking my view, so I moved it. The staff were bitching about me moving it. I went to the front desk to have them move the chair. I can't put it by the other guy because he would try to get up. I told them I wanted to see the sunset. I have the right to look out the windows. He tackled me down to the floor. I broke my hip. It hurts it is swollen; they are giving me pain medication. This is my room. I can't remember, I couldn't move. I didn't need to be tackled. I don't have a weapon. He physically attacked me; he was over 200 pounds. I had to have surgery; I can't do anything. During an interview completed on 4/30/26, at 2:30 p.m. upon asking NA Employee E9 the process if a resident is exhibiting aggressive behavior stated, we are not allowed to restrain. I would just leave the room and call for help. During an interview completed on 4/30/26, at 2:36 p.m. upon asking RN Employee E10 the process if a resident is exhibiting aggressive behaviors stated, we are not allowed to restrain. I would ask for assistance, take the resident to a no-resident area, talk to the resident deescalate, see if someone else can help, find out what was triggering them and remove it If a resident fell, I would not restrain them to the ground. During an interview completed on 4/30/26, at 2:42 p.m. upon asking Licensed Practical Nurse (LPN) Employee E11 the process if a resident was exhibiting aggressive behaviors stated, back off, I'm not allowed to protect myself so I would back off and try to talk them down. I would expect to see interventions in the care plan. I would try to fix the trigger to calm down. During an interview completed 4/30/26, at 2:46 p.m. Upon asking RN Employee E12 the process if a resident is exhibiting aggressive behaviors stated, walk away, make sure they are safe, sometimes it's the approach, can call the physician. If I knew the cause I would remove it or the resident from it. If they wanted to fight, I would wait for them to calm down not allowed to restrain them for anything. During an interview completed on 4/30/26, at 2:50 pm upon asking LPN Employee E6 the process if a resident is exhibiting aggressive behaviors stated, I would look in the orders or care plans, call the supervisor to come down and help. Remove the trigger. During an interview completed on 4/30/26, at 2:56 p.m. upon asking LPN Employee E7 the process if a resident is exhibiting aggressive behaviors stated, I would try to redirect, give them time to cool off, let them walk around, remove other residents, call the physician the care plan should have interventions it depends on what is agitating them. Remove what is bothering, just give them time. During an interview completed on 4/30/26, at 3:00 p.m. upon asking LPN Employee E8 the process if a resident is exhibiting aggressive behaviors stated, I would see what was wrong, try to find the reason and remove what was agitating them. I would look in the care plan, progress notes, check the medication administration record (MAR). During an interview completed on 4/30/26, at 4:13 p.m. upon asking NA Employee E15 if she could recall an altercation that happened with Resident R1 replied that night we had a fall in the room, The roommate had a fall so we moved his wheelchair. I was in another room and heard him yelling, the NA was trying to explain to the resident that the chair can't be over by the resident explaining it really calmy, He was really mad about it, the nurse came in and tried to calm him down. The resident went to the bathroom, maybe it was like 5 minutes, and he ran out of the bathroom down to the nursing station. He attempted to hit the nurse. The nurse was trying to calm him down. There was a lot of commotion. I saw the nurse use a hand to try and stop him. He put him to the floor. When the resident was on the ground he was still punching. The nurse was holding his arms down. He calmed down when the supervisor came to the floor. During an interview completed on 4/30/26, at approximately 2:00 p.m. the Director of Nursing confirmed the investigation was not complete and stated I have been working on a plan of correction and have not completed the investigation. I am not going to substantiate, at what point do we protect our employees and confirmed that the facility failed to protect a resident from physical abuse that resulted in actual harm of left comminuted displaced intertrochanteric fracture that required surgery for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights28 Pa. Code 211.10(c)(d) Resident Care Policies.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of clinical records, facility investigations, and staff interview it was determined the facility failed to timely complete an investigative report for an allegation of physical abuse resulting in serious bodily injury for one resident of 3 residents (Resident R1).Findings include: Review of the facility policy Reporting Unusual Occurrences last reviewed 10/1/25, indicated unusual occurrences are reported by the facility to regulatory authorities as required by federal, state laws and local agencies. Appropriate agencies will be notified if the following events occur that include but not inclusive to:suspected, alleged or actual abuse, neglect, misappropriation of resident propertyfracturesincidents that necessitate a resident being transferred for medical evaluation regardless of admission to hospitalstaff to resident altercationA written report will be forward to all appropriate agencies within 5 working days or per regulation describing the event, circumstances, effects on residents, and actions taken by the facility.Review of the facility policy Abuse: Protection From last reviewed 10/1/25, indicated each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the Code of Federal Regulations (CFR) S483.12(c)(4). At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation and if the alleged violation is verified, take corrective action. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/31/26, indicated the diagnosis of traumatic brain injury (TBI), anxiety, and mild neurocognitive disorder due to know physiological condition with behavioral disturbance. Review of Resident R1's nursing progress note dated 4/23/26, indicated Supervisors urgently called to unit 2 Main at 8:30 p.m. for a resident attacking staff. Upon exiting the elevator, resident was noted to be lying on his right side, screaming, complaining of pain to his left hip. When asked what happened, resident stated that big mother------ tackled me. I was going to knock his ass out. Resident reportedly with increasing agitation throughout the evening, and per witness attempted to punch the nurse and nurse aids. Nurse reported that when the resident swung at him, the nurse grabbed the resident's arm/shoulder and took him down to the floor. Resident with 10/10 left hip pain, with L leg shortening and external rotation. Emotional support provided. Physician notified received order to send resident to local emergency room. Review of the Event Reporting System revealed a report was submitted to State Agency on 4/23/26, at 8:44 a.m. Review of facility provided investigation report on 4/30/26, at 10:00 a.m. did not include a PB-22, or outcome of investigation. During an interview completed on 4/30/26, at approximately 2:00 p.m. the Director of Nursing confirmed the investigation was not complete and stated I have been working on a plan of correction and have not completed the investigation. I am not going to substantiate, at what point do we protect our employees and confirmed that the facility failed to timely complete an investigative report for an allegation of physical abuse resulting in serious bodily injury for one resident of 3 residents (Resident R1). 28 Pa. Code 201.14(a)(c) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights 28 Pa. Code 211.10 (c) Resident care policies

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to develop a care plan that included instructions to provide person centered care for one of three residents (Resident R1).Findings include: Review of the facility policy Care Planning Implementation Guide: last reviewed 10/1/25, indicated Each resident will have an individualized interdisciplinary care plan developed that addresses the resident's needs as they are discovered through the assessment process. The overall care plan will be oriented towards but not inclusive to:Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence.Managing risk factors to the extent possible or indicating the limits of such interventionsAddressing ways to try to preserve and build upon resident strengths.Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities.Involving the direct care staff with the care planning process relating to the resident's expected outcomes.Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting.The care plan is initiated upon admission to the facility by the admitting nurse. From that point forward the care plan is updated as new information becomes available that needs to be addressed for the interdisciplinary team to provide care. Every significant event should be reviewed for the need to make a care plan or to update an existing care plan. Some examples include but not inclusive to:Negative resident interactionsResident fearsDangersAll Care plan items must be specific to the resident and consider their unique risks and strengths. All actual and potential issues should be addressed with the goal to promote the resident's highest practical level of functioning and well-being. This may be with the goal of improvement, maintaining, preventing avoidable decline, or managing symptoms. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/31/26, indicated the diagnosis of traumatic brain injury (TBI), anxiety, and mild neurocognitive disorder due to know physiological condition with behavioral disturbance. Review of Resident R1's current care plan indicated:Focus: Resident has a behavior problem of refusal of care and aggression; voiding in inappropriate areas related to TBI and alcohol abuse history, refusal to bathe/shower, refusal to change clothes, refusal for linen changes, disturbing other resident's televisions, remotes, and physical aggression.Goal: Resident will have fewer episodes of refusal of care and no aggression by review date.Interventions/Task: Anticipate and meet needs. Assist resident to develop more appropriate methods of coping and interacting by encouraging to express feelings appropriately, emotional support and psychology consult as needed. The care plan failed to include interventions for Residents R1's physical aggression, The care plan failed to include any interventions to apply when resident is experiencing physical aggression. During an interview completed on 4/30/26, at 12:26 p.m. upon asking Registered Nurse (RN) Employee E16, what the interventions are for a resident experiencing physical aggression stated, all of that should be in the care plan Upon looking at Residents R1's care plan RN Employee E16 stated that Resident R1's care plan failed to include interventions for physical aggression. During an interview completed on 4/30/26, at 12:54 p.m. Upon asking Licensed Practical Nurse (LPN) Employee E3 what she would do if a resident was experiencing physical aggression stated, I would look in the care plan for interventions. During an interview completed on 4/30/26, at 12:57 p.m. upon asking LPN Employee E4 what she would do if a resident was experiencing physical aggression stated, I would check the orders and care plan. We also have some residents that come in with a behavioral care plan that have interventions to use. During an interview completed on 4/30/26, at 1:00 p.m. upon asking RN Employee E5 what she would do if a resident was experiencing physical aggression stated, I would check the care plans they should have interventions, also look in the medication administration record sometimes they have it listed there. During an interview completed on 4/30/26, at approximately 2:00 p.m. the Director of Nursing confirmed that interventions were not included in Resident R1's current care plan and confirmed that the facility failed to develop a care plan that included instructions to provide person centered care for one of three residents (Resident R1). 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to properly store, label and date food items, and failed to properly perform handwashing in the Main kitchen, and also failed to maintain sanitary conditions on the second floor kitchenette which created the potential for cross contamination in one of six kitchenettes (second floor). Findings include: Review of the facility policy Food Storage dated 10/1/25, indicated that un-served leftovers shall be labeled, dated, and stored for a period not to exceed seven days. Review of the facility policy Personnel Standards dated 10/1/25, indicated that hands must be washed after each trip to the restroom, after leaving storage rooms, dumpster areas, washrooms, after touching hair, mouth, or nose, and at any other time it is necessary. During an observation, and interview on 3/9/26, at 9:45 a.m. the Dietary Manager (DM) Employee E19 confirmed that in walk-in refrigerator Number One of the Main Kitchen an opened package of sliced turkey was noted to be unsealed, with no label or date During an observation on 3/10/26, at 1:21 p.m. in the Dish Room, Dietary Aide Employee E20 was observed loading dirty dishes into the dish machine, and then remove clean dishes from the dish machine without washing her hands. During an interview on 3/10/26, at 1:21 p.m. DM Employee E20 confirmed that the facility failed to properly perform handwashing which created the potential for foodborne illness. During an observation 3/10/26 at 10:00 a.m. of the second floor kitchenette the following was observed: -Ice machine, scoop stored in machine, no separate scoop holder -mayonnaise, no label or date - (2) nonfat peach yogurts, no label or date - starbucks creamer, no label or date - pizza, individual, no laebl or date - frozen hot wings, no label or date - (2) crispy rice cereal, no label or date During an interview on 3/10/26 at 10:30 a.m., Registered Nurse Employee E18 confirmed that the facility failed to maintain sanitary conditions which created the potential for cross contamination in one of six unit kitchenette. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of seven residents sampled with facility-initiated transfers (Residents R9, R55, R79, R178), failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R9), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for seven of seven resident hospital transfers (Resident R9, R10, R55, R79, R178, R273, R300).Findings include: Review of facility policy Emergency Transfer and Discharge reviewed 10/1/25, indicated the facility shall make an emergency transfer or discharge when it is in the best interest of the resident. When a resident is transferred, a copy of the clinical summary shall be sent to the facility that will continue the care of the resident. Information that must be communicated to the receiving provider must include a minimum of the following: contact information of facility provider, contact information for the resident's representative, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan, and a copy of discharge summary. Information sent must be documented in the medical record. Discharge information will be reported to the state ombudsman via email. Review bed hold policy with residents or their representative and provide a copy. Resident R9's clinical record revealed an admission date of 11/18/25, with diagnoses including open wound of the scrotum and testes, muscular dystrophy (group of genetic diseases that cause progressive muscle weakness and degeneration), paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), and neuromuscular dysfunction of the bladder (injury or disease interrupts the electrical signals between your nervous system and bladder function). Departmental progress notes dated 10/14/25, and 12/04/25, indicated that Resident R9 was transferred to the acute care hospital, lacked evidence that the facility had communicated specific information to the receiving health care provider for the resident's transfer and expected to return, which included the resident's care plan goals, advanced directive instructions for ongoing care, resident representative information and, all information necessary to meet the resident's specific needs at the receiving facility. Further review of Resident R9's clinical record lacked evidence that the facility's bed hold policy was made available to the resident and/or the resident's representative at the time of the transfer, and documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 12/20/25. During an interview on 3/11/26, at 10:25 a.m. the Director of Nursing confirmed there was no evidence of the bed hold policy and evidence that the facility communicated specific information to the receiving health care provider at the time of transfer on 10/14/25, and 12/04/25. Resident R10's clinical record revealed an admission date of 8/04/25, with diagnoses including Human Immunodeficiency Virus Disease (HIV- virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), extradural and subdural abscess (bacterial infection in the brain and/or spinal cord), and paraplegia. Departmental progress notes dated 1/19/26, indicated that Resident R10 was transferred to the acute care hospital for evaluation and treatment. Review of Resident R10's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 1/19/26. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/26, indicated diagnoses of high blood pressure, depression, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of the clinical record indicated Resident R55 was transferred to the hospital on 3/2/26, and returned to the facility on 3/3/26. Review of Resident R55's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record revealed Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's MDS dated [DATE], indicated diagnoses of high blood pressure, End Stage Renal Disease (ESRD - an inability of the kidneys to filter the blood), and anxiety. Review of the clinical record indicated Resident R79 was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of Resident R79's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals. Review of Resident R79's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 12/16/25. Review of the clinical record revealed Resident R178 was admitted to the facility on [DATE]. Review of Resident R178's MDS dated [DATE], indicated diagnoses of anemia (too little healthy red blood cells in the blood), anxiety, and constipation. Review of the clinical record indicated Resident R178 was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of Resident R178's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 12/20/25. Review of the clinical record indicated Resident R273 was admitted to the facility on [DATE]. Review of Resident R273's MDS dated [DATE], indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and dysphagia (difficult swallowing). Review of the clinical record indicated Resident R273 was transferred to the hospital on 9/23/25, and returned to the facility on [DATE]. Review of the clinical record revealed Resident R300 was admitted to the facility on [DATE]. Review of Resident R300's MDS dated [DATE], indicated diagnoses of dementia (decline in cognitive function, affecting memory, thinking, behaviors and the ability to perform everyday activities), anemia and cardiomyopathy (progressive heart disease characterized by the abnormal enlargement of the heart muscle). Review of the clinical record indicated Resident R300 was transferred to the hospital on 3/4/26. Review of Resident R300's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/4/26. During an interview on 3/11/26, at 10:44 a.m. Social Worker Employee E5 confirmed that there was no evidence that the State Ombudsman office was notified for Residents R9, R10, R55, R79, R178, R273, R300's transfer to the hospital. During an interview on 3/12/26, at 9:03 a.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of seven residents sampled with facility-initiated transfers (Residents R9, R55, R79, R178), failed to notify the resident or resident's representative of the facility bed-hold policy for one of seven resident hospital transfers (Resident R9), and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for seven of seven resident hospital transfers (Resident R9, R10, R55, R79, R178, R273, R300). 28 Pa. Code: 201.14.(a) Responsibility of licensee. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for four of 50 residents (Residents R2, R55, R273, and R280).Findings include: Review of facility policy Care Planning and Implementation dated 10/1/25, indicated each resident will have an individualized interdisciplinary care plan developed that addresses the residents' needs as they are discovered through the assessment process. Applying current standards of practice in the care planning process. Assessing and planning for care to meet the residents medical, nursing, mental, and psychosocial needs. Evaluating treatment of measurable objectives, timetables, and outcomes of care. Respect the resident's right to decline treatment. Offering alternative treatments, as applicable. Using an appropriate interdisciplinary approach to care plan development. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R2's physician orders dated 8/16/24, indicated that Resident R2 was to be transferred with a Hoyer lift, assist of two. Review of Resident R2's care plan dated 5/19/25, indicated transfers Hoyer lift, assist of two. Resident R2's care plan failed to indicate the kind of Hoyer pad and the Hoyer size to use when transferring resident. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's MDS dated [DATE], indicated high blood pressure, depression, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Resident R55's physician orders dated 2/3/26, indicated that Resident R55 was to be transferred with a Hoyer lift, assist of two, no ambulation. Review of Resident R55's care plan dated 3/9/26, indicated to assist with transfers and ambulation as ordered. Resident R55's care plan failed to indicate the use of Hoyer Lift for transfers, the kind of Hoyer pad, and the Hoyer size to use when transferring resident. Review of the clinical record indicated Resident R273 was admitted to the facility on [DATE]. Review of Resident R273's MDS dated [DATE], indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), heart failure. and dysphagia (difficult swallowing). Review of Resident R273's physician orders dated 9/8/25, indicated that Resident R273 was to be transferred with a Hoyer lift, assist of two. No ambulation. Review of Resident R273's physician orders dated 9/2/25, indicated that Resident R273 receives Jevity 1.5 (a type of feeding that goes through a tube into stomach) at 65 milliliters(ml)/hour with 60 ml of water flush every hour for 24 hours. Review of Resident R273's physician orders dated 7/18/24, indicated that Resident R273's G-Tube ( a tube that goes from the outside of the body to the stomach to provide nutrition) size is 20 French. Review of Resident R273's physician orders dated 9/4/24, indicated that Resident R273's trach (an opening in the neck and into the windpipe to provide an alternative airway for breathing) size is 60 xlt, shiley (kind of trach tube). Review of Resident R273's current care plan failed to be individualized, person-centered and failed to identify the kind of Hoyer pad, the correct size of Hoyer pad to use, the type of tube feeding, the size of G-Tube, and the size of trach tube. Resident R280's clinical record revealed an admission date of 1/21/25, with diagnoses including frostbite with necrosis (freezing of the tissue cells causing death to the tissue) of the left foot and right toes, morbid obesity (excess body fat significantly impacts daily functions and overall health), and psychoactive substance abuse, in remission (harmful or compulsive use of substances that alter brain function, affecting mood, perception, cognition, or behavior). Review of Resident R280's care plan entitled, Pain related to frostbite wounds included the following interventions initiated 1/22/25. Monitor/record/report any signs or symptoms of non-verbal pain such as changes in breathing, vocalizations (grunting, moans, yelling), mood/behavior changes, eyes and facial expression, body posture. Administer pain medications as per MD orders and note the effectiveness. Give as needed medications for breakthrough pain as per MD orders and note the effectiveness. There was no evidence that Resident R280's care plan for pain management included. Individualized, person-centered interventions (pharmacological and non-pharmacological). Included measurable objectives, interventions, and timeframes for how staff will meet Resident R280's needs. Resident R280's goals and desired outcomes. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specialized services to be provided as a result of the comprehensive assessment. Resident R280's referral to the local contact agency. Any services that would otherwise be required but not provided due to the residents' right to refuse treatment, During an interview on 3/13/26, at 11:25 a.m. Director of Nursing confirmed that the facility failed to develop comprehensive care plans to meet resident care needs for Residents R2, R55, and R273. During an interview on 3/13/26, at 11:55 a.m. the Director of Nursing confirmed that Resident R280's care plan for pain management was not individualized and lacked the necessary interventions to provide person-centered care. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility provided documents, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of three residents (R55), and failed to ensure that residents were free from potential accidents during a transfer for two of 46 residents (R2 and R273).Findings include: Review of the facility Accidents and Incidents policy dated 10/1/25, indicated that all accidents or incidents occurring on our premises must be investigated and reported to the administrator. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/6/26, indicated high blood pressure, depression, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Resident R55's physician orders dated 2/3/26, indicated that Resident R55 was to be transferred with a Hoyer lift, assist of two, no ambulation. Review of documentation provided by the facility identified as Nurse Aide (NA) Assignment Sheets on 3/10/26, indicated that resident R55 was transferred with Hoyer lift. Review of a written witness statement dated 3/2/26, from NA Employee E26 stated, At approximately 8:15 p.m., NA Employee E27 and I were preparing to transfer resident from her wheelchair to her bed via the Hoyer lift. As we were completing the transfer, resident slid out of the Hoyer and landed on her head. Nursing was immediately notified and resident was assessed and sent out to hospital for evaluation. No injuries occured. Review of an interview conducted by facility dated 3/3/26, at 11:40 a.m. with NA Employee E27 stated, NA Employee E26 were transferring Resident R55, and I checked the Hoyer pad, there were no tears or anything. The Hoyer seemed to be working fine. I noticed the resident was starting to slide and I told NA Employee E27 to hurry so we could get her to the bed before she fell out but didn't make it in time. Review of an interview conducted by the facility dated 3/3/26, at 12:00 p.m. with NA Employee E26 stated, Transferring resident with NA Employee E27. I set up her room and hooked her up to the blue straps. We lifted her out of her chair and moved her toward her bed when she slid out bottom first. I did not notice her sliding before it happened. They Hoyer pad was still attached to the hoyer after she fell. During an interview on 3/10/26, at 10:05 a.m. the Director of Nursing stated, The NA's used the Hoyer pad that had the legs cut out on and not the one-piece Hoyer pad that looks like a square during the Hoyer transfer and we replayed the scenario and did drawings and cannot figure out what went wrong. During a review of facility provided documentation labeled Hoyer on 3/10/26, at 1:10 p.m. indicated that 46 residents utilize a Hoyer Lift and Hoyer pad for transfers. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R2's physician orders dated 8/16/24, indicated that Resident R2 was to be transferred with a Hoyer lift, assist of two. Resident R2's physician orders failed to indicate what kind of Hoyer pad and what size of Hoyer pad to use that properly fit Resident R2. Review of Resident R2's care plan dated 5/19/25, indicated transfers Hoyer lift, assist of two. The care plan failed to have what kind of Hoyer pad and Hoyer size to use that are resident specific per resident's weight and height. Review of the clinical record indicated Resident R273 was admitted to the facility on [DATE]. Review of Resident R273's MDS dated [DATE], indicated diagnoses of cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), heart failure. and dysphagia (difficult swallowing). Review of Resident R273's physician orders dated 9/8/25, indicated that Resident R273 was to be transferred with a Hoyer lift, assist of two. No ambulation. Resident R273's physician orders failed to indicate what kind of Hoyer pad and what size of Hoyer pad to use. Review of Resident R273's care plan dated 4/16/24, indicated transfers Hoyer lift, assist of two. Non-ambulatory. The care plan failed to have what kind of Hoyer pad and Hoyer size to use that are resident specific per resident's weight and height. During an interview on 3/10/26, at 10:30 a.m. NA Employee E29 stated, Takes two people to use a Hoyer lift. There are different kinds of Hoyer pads. I eyeball which color to use. I gauge the size. The sizes range from small to bariatric During an interview on 3/10/26, at 10:37 a.m. NA Employee E30 stated, We just kind of know the size of the Hoyer pad. When State Agency (SA) asked, Who designates what pad and size goes with a resident?, the NA Employee E30 responded That's a good question. I don't know. There are no care plans for the kind of Hoyer pad and its not on the Kardex. During an interview on 3/10/26, at 11:52 a.m. Rehab Director Employee E31 stated, Physical Therapy determines if a resident needs a Hoyer lift for transfers and they put the order in the residents medical record but we do not determine the kind and size of a Hoyer pad to use. During an interview on 3/11/26, at 10:05 a.m. the SA asked the Director of Nursing, How does staff know what kind of Hoyer pad or what size of Hoyer pad to use on a resident? The Director of Nursing stated, We don't have a process that determines this. During an interview on 3/13/26, at 9:32 p.m. Director of Nursing confirmed that the facility failed to ensure that a resident was free from a preventable accident during a transfer for one of three residents (R55), and failed to ensure that residents were free from potential accidents during a transfer for two of 46 residents (R2 and R273). 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a) Resident rights. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for four of seven residents (Resident R7, R82, R87, and R108), and failed individualize care plans to address the resident specific nutritional concerns for five of seven residents (Resident R3, R4, R79, R82, and R87).Findings include: Review of the facility policy Nutrition Management dated 10/1/25, indicated that residents will be weighed within 24 hours of admission. Residents will then be weighed weekly for four weeks, then monthly unless otherwise noted. Review of the facility policy MDS (minimum data set- periodic assessment of resident care needs) / RAI (resident assessment instrument- a standardized interdisciplinary system used to evaluate clinical status, functional ability, and care needs of residents) / Care Planning, dated 10/1/25, indicated that the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems, and needs. Review of the facility policy Care Planning and Implementation: dated 10/1/25, indicated that it is the responsibility of the Dietary Director to update the care plan when changes relative to the dietary needs of the resident occur. During morning meeting the Dietary Director will verify that all necessary care plan updates were completed during review of the 24-hour report. Any updates that were not previously completed will be completed during this review without delay. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident 3's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/8/25, indicated diagnoses of high blood pressure, hyperkalemia (high levels of potassium in the blood), and chronic pain. Review of Resident R3's clinical record revealed a physician's order dated 1/19/26, that stated to provide a Consistent Carb (diet for treatment of diabetes) Mechanical Soft texture (food is ground for ease in chewing), nectar liquids (liquids are thickened for ease in swallowing). Review of Resident R3's care plan last revised on 1/7/26, indicated that resident is at nutrition/hydration risk and interventions include the following: Provide diet/supplements per orders and honor food preferences as able. Monitor: weights, intakes, labs, skin signs and symptoms of dehydration. Notify the doctor with any significant changes. Review of Resident R3's care plan failed to include resident specific interventions for the physician ordered diet listed above. Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Review of Resident 4's MDS dated [DATE], indicated diagnoses of high blood pressure, chronic pain, and kidney failure. Review of Resident R4's clinical record revealed a physician's order dated 9/5/25, to provide a Consistent Carb diet, regular texture, thin consistency, Renal (kidney) Control Shake daily. Review of Resident R4's care plan last revised on 10/3/25, indicated that resident is at nutrition/hydration risk and interventions include the following: Provide diet/supplements per orders and honor food preferences as able. Monitor: weights, intakes, labs, skin signs and symptoms of dehydration. Notify the doctor with any significant changes. Review of Resident R4's care plan failed to include resident specific interventions for the physician ordered diet listed above. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and Bipolar disorder (a mental condition marked by alternating periods of elation and depression). Review of Resident R7's weight record failed to reveal any documented weights for June 2025, July 2025, September 2025, and December 2025. Review of the clinical record revealed Resident R79 was admitted to the facility on [DATE]. Review of Resident R79's MDS dated [DATE], indicated diagnoses of high blood pressure, End Stage Renal Disease (ESRD - an inability of the kidneys to filter the blood), and anxiety. Review of a physician order dated 12/23/25, indicated Renal diet, regular texture, thin consistency, Potassium restrictions to 75 mEq (milliequivalent), Protein 90 grams, 2 gram NA (sodium), no seeds, nuts, hulls. Review of Resident R79's comprehensive care plan indicated the resident is a nutrition/hydration risk related to: hyperkalemia (high levels of potassium in the blood), ESRD on HD (hemodialysis), T2DM (type 2 diabetes mellitus), FTT (failure to thrive), and edema. Interventions included provide diets/supplements per orders and honor food preferences as able. No seeds, nuts, hulls. 1500 mL (milliliter) fluid restriction. Fluid restriction as directed nursing 780 mL, dietary 720 mL. Review of Resident R79's care plan failed to include resident specific interventions for the physician ordered diet listed above. Review of Resident R79's active physician orders failed to include an order for a fluid restriction. During an interview on 3/12/26, at 11:25 a.m. Assistant Director of Nursing (ADON) Employee E8 confirmed Resident R79 is not currently ordered a fluid restriction and that the facility failed to revise the resident's care plan to address the resident specific nutritional concerns. Review of the clinical record revealed that Resident R82 was admitted to the facility on [DATE]. Review of Resident 82's MDS dated [DATE], indicated diagnoses of high blood pressure, stroke (disruption of blood supply to the brain), and reduced mobility. Review of Resident R82's clinical record revealed a physician's order dated 9/2/25, to provide enteral feed (liquid feeding administered through a tube in the stomach) of Jevity 1.2 at 70 milliliters (ml) per hour with 35 ml water flush every hour. Review of Resident 82's care plan last revised on 12/25/25, indicated that resident is at nutrition/hydration risk and interventions include the following: Provide TF (tube feeding) per orders Monitor: weights, TF tolerance labs, skin signs and symptoms of dehydration. Notify the doctor with any significant changes. Review of Resident 82's care plan failed to include resident specific interventions for the physician ordered diet/enteral tube feed listed above. Review of Resident R82's clinical record revealed the last weight recorded was on 12/1/25 at 169.8 pounds Review of clinical record revealed no monthly weight was obtained in January or February of 2026. Review of clinical record revealed that Resident R87 was admitted to the facility on [DATE]. Review of Resident 87's MDS dated [DATE], indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing), and stroke. Review of Resident R87's clinical record revealed a physician's order dated 9/2/25, to provide enteral feed of Osmolite 1.2 at 55 ml per hour with 35 ml water flush every hour. Review of Resident 87's care plan last revised on 2/26/26, indicated that resident is at nutrition/hydration risk and interventions include the following: Provide TF (tube feeding) per orders Monitor: weights, TF tolerance labs, skin signs and symptoms of dehydration. Notify the doctor with any significant changes. Review of Resident 87's care plan failed to include resident specific interventions for the physician ordered diet/enteral tube feed listed above. Review of Resident R87's clinical record revealed that resident was not weighed in January 2026. Review of the clinical record revealed Resident R108 was admitted to the facility on [DATE]. Review of Resident R108's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Bipolar disorder (a mental condition marked by alternating periods of elation and depression), and anxiety. Review of Resident R108's weight record failed to reveal any documented weights for December 2025 and January 2026. Review of a physician order dated 2/18/26, indicated weekly weights x 4 weeks one time a day every Wednesday for health maintenance. Review of Resident R108's clinical record failed to reveal documentation that the resident was weighed on 2/18/26, and 2/25/26. During an interview on 3/12/27, at 12:17 p.m. the Director of Nursing confirmed that the facility failed to monitor weights for Resident R7, R82, R87, and R108 by not obtaining monthly weights as required. During an interview on 3/12/27, at 2:05 p.m. the DON confirmed that the facility failed to individualize care plans to address the resident specific nutritional concerns for Resident R3, R4, R79, R82, and R87. 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)(5) Nursing services.

Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for seven of seven residents (Residents R5, R6, R17, R87, R108, R124, and R190). Findings include: Review of the facility policy Enabler Bars last reviewed 10/1/25, indicated the use of enabler bars or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of enabler bars have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/21/25, indicated diagnoses of diabetes (high sugar in the blood), hyperlipidemia (high fat in the blood) and anxiety. Review of Resident R5's physician orders dated 8/30/24, indicated bilateral (both sides) bed enablers to aid in independence with bed positioning. During an observation on 3/12/26, at 10:58 a.m. bilateral side rails were observed on the top of Resident R5's bed. Review of Resident R5's clinical record revealed enabler bar assessments were completed for 2/9/26, and 3/11/26, no prior assessments were completed. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and schizophrenia (a serious mental health condition that affects thinking, feeling and behavior). Review of Resident R6's physician orders dated 1/22/25, indicated bilateral bed enablers to increase independence with bed positioning, absence of left leg below knee. During an observation on 3/12/26, at 11:01 a.m. bilateral side rails were observed on the top of Resident R6's bed. Review of Resident R6's clinical record revealed enabler bar assessments were completed for 1/8/23, 2/9/26, and 3/11/26, no other assessments were completed. During an interview completed on 3/12/26, at 11:03 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed that Resident R5 and Resident R6 did not have bedrail assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage and stated I was not aware that the side rail assessments were needed, I just started to do them. Review of the clinical record revealed Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's MDS dated [DATE], indicated diagnoses of high blood pressure, obstructive uropathy (condition in which urine flow is blocked), and hemiparesis (one-sided muscle weakness, often caused by stroke or brain injury). Review of a physician order dated 11/2/23, indicated bilateral (both sides) bed enabler bar to aid in bed mobility with diagnosis of left hemiparesis.During an observation on 3/9/26, at 11:10 a.m. bilateral enabler bars were observed on the top of Resident R17's bed. Review of Resident R17's clinical record failed to reveal an ongoing accurate assessment for the resident's enabler bar usage. Review of clinical record revealed that Resident R87 was admitted to the facility on [DATE]. Review of Resident 87's MDS dated [DATE], indicated diagnoses of high blood pressure, dysphagia (difficulty swallowing), and stroke (disruption of blood supply to the brain). During an observation on 3/11/26, at 12:34 p.m. Resident R87 had enabler bars to both sides of her bed. Review of clinical record failed to reveal a physician's order to apply enabler bars to the bed, or any assessment to ensure that Resident R87 was safe to utilize enabler bars. During an interview on 3/11/26, at 12:38 p.m. LPN Employee E32 stated that Resident R87 is not physically or mentally able to utilize the enabler bars. During an interview on 3/12/26, at 9:50 a.m. Assistant Director of Nursing (ADON) Employee E8 stated that the enabler bars were applied to Resident R87's bed without an order or assessment and would be removed for safety. Review of the clinical record revealed Resident R108 was admitted to the facility on [DATE]. Review of Resident R108's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), bipolar disorder (a mental condition marked by alternating periods of elation and depression), and anxiety. Review of a physician order dated 9/23/25, indicated patient to have bilateral enabler bars to increase independence with bed mobility. During an observation on 3/9/26, at 10:07 a.m. bilateral enabler bars were observed on the top of Resident R108's bed. Review of Resident R108's clinical record failed to reveal an ongoing accurate assessment for the resident's enabler bar usage. Review of the clinical record revealed Resident R124 was admitted to the facility on [DATE]. Review of Resident R124's MDS dated [DATE], indicated diagnoses of aphasia (language disorder that affects communication), epilepsy (disorder of the brain characterized by repeated seizures), and anoxic brain injury (occurs when the brain is deprived of oxygen, leading to damage or deal of brain cells).During an observation on 3/9/26, at 10:17 a.m. bilateral padded enabler bars were observed on the top of Resident R124's bed. Review of Resident R124's active physician orders failed to include an order for bilateral padded enabler bars. Review of Resident R124's clinical record on 3/11/26, failed to include an ongoing assessment for the resident's padded enabler bar usage, and failed to include the development of goals and interventions related to the resident's padded enable bar usage in the comprehensive care plan. Review of the clinical record revealed Resident R190 was admitted to the facility on [DATE]. Review of Resident R190's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and dementia. Review of a physician order dated 9/19/25, indicated patient to have bilateral enabler bars on bed to increase independence with bed mobility. During an observation on 3/9/26, at 11:04 a.m. bilateral enabler bars were observed on the top of Resident R190's bed. Review of Resident R190's clinical record failed to reveal an ongoing accurate assessment for the resident's enabler bar usage. During an interview on 3/12/26, at 9:53 a.m. ADON Employee E8 confirmed that the facility failed maintain accurate resident care plans for Resident R124 and failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for Residents R17, R108, R124, and R190. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRRs) were completed by the facility for five of seven residents (Resident R3, R6, R97, R133 and R137), and failed to ensure MRRs were reviewed by the resident's attending physician monthly for one of seven residents (Resident R7).Findings include: The Pharmacy Service policy last reviewed 10/1/25, indicated the nursing home shall have pharmaceutical services that meet the needs of the residents. A licensed pharmacist will review the drug regimen reviews of each resident at least monthly. The pharmacist will report any irregularities to the attending physician and the Director of Nursing (DON) they will sign off and/or address the report in their progress note. Review of the clinical record indicated Resident R97 was admitted to the facility on [DATE]. Review of Resident R97's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/22/26, indicated diagnoses of multiple sclerosis (autoimmune disease that affects the central nervous system), dementia (decline in cognitive function, affecting memory, thinking, behaviors and the ability to perform everyday activities) and anxiety. Review of Resident R97's MRR indicated the following: November 2025 - facility failed to provide the completed MRR by attending physician December 2025 - facility failed to provide the completed MRR by attending physician Review of the clinical record indicated Resident R133 was admitted to the facility on [DATE]. Review of Resident R133's MDS dated [DATE], indicated diagnoses of anoxic brain damage, adult failure to thrive and dementia (decline in cognitive function, affecting memory, thinking, behaviors and the ability to perform everyday activities). Review of Resident R133's MRR indicated the following: October 2025- facility failed to provide the completed MRR by attending physicianNovember 2025 - facility failed to provide the completed MRR by attending physician Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/8/25, indicated diagnoses of high blood pressure, hyperkalemia (high levels of potassium in the blood), and chronic pain. Review of Resident R3's care plan indicated that the resident requires use of psychotropic medication and is at risk for adverse side effects. Review of Resident R3's clinical progress notes did not include a pharmacy notation or review by a licensed pharmacist for August 2025, and November 2025. Review of the clinical record indicated Resident R6's was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 2/2/26, indicated diagnoses of high blood pressure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and schizophrenia ( a serious mental health condition that affects thinking, feeling and behavior). Section N045 A. Antipsychotic: coded yes, indicated resident is taking an antipsychotic medication. Review of Resident R6's physician order dated 11/13/24, indicated monitor resident for side effects of psychotropic usage: dystonia, dry mouth, tardive dyskinesia, increase in gait disturbance, somnolence. If side effects are present document assessment in progress note and notify physician every shift. Review of Resident R6's clinical record failed to include any documentation that pharmacy medication regimen reviews were completed by a licensed pharmacist. During a clinical record review and interview completed on 3/13/26, at 9:42 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed that Resident R6's clinical record failed to include any MRR's completed by a licensed pharmacist and stated, I know there was an issue with them. Review of the clinical record indicated Resident R137 was admitted to the facility on [DATE]. Review of Resident R137's' Minimum Data Set (MDS -a periodic assessment of resident care needs) dated 2/16/26, indicated diagnoses of high blood pressure, anxiety disorder and depression. Section N0415 A. Antipsychotic coded yes indicated resident is taking an antipsychotic. B. Antianxiety coded yes indicated resident is taking an antianxiety medication. C. Antidepressant medication coded yes indicated resident is taking an antidepressant medication. Review of Resident R137's physician orders dated 11/13/24, indicated monitor resident for side effects of psychotropic usage: dystonia, dry mouth, tardive dyskinesia, increase in gait disturbance, somnolence. If side effects are present, document assessment in progress note and notify physician. Review of Resident R137's clinical record failed to include any documentation that pharmacy medication regimen reviews were completed by a licensed pharmacist. During a clinical record review and interview completed on 3/13/26, at 9:42 a.m. Registered Nurse (RN) Employee E15 confirmed that Resident R137's clinical record failed to include any MRR's completed by a licensed pharmacist and stated, we were having an issue with them they just started back within a month or two. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, depression, and Bipolar disorder (a mental condition marked by alternating periods of elation and depression). Review of Resident R7's MRR dated 1/23/26, indicated the following recommendation from the pharmacist to the physician: Recommend discontinuation/re-evaluation of the following PRN (as needed) psychotropic agent(s) per following Federal Guideline: PRN Lorazepam (a medication used to treat anxiety). Review of Resident R7's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/23/26. On 2/24/26, a Certified Registered Nurse Practitioner (CRNP) addressed the MRR, stating, continue medication, will enter new order, put focus on comfort/quality of life.Review of a follow up progress note dated 2/27/26, completed by CRNP Employee E25 stated, Continue PRN Ativan (Lorazepam) 0.5 mg (milligrams) q6 (every 6 hours) prn x 120 days - med effective for anxiety, with pt (patient) current focus of comfort and quality of life psychology and mind care. During an interview on 3/12/26, at 12:26 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure medication regimen reviews were reviewed by the resident's attending physician monthly for Resident R7 and that the facility failed to ensure that MRR were completed monthly for Resident R3, R6, R97, R133, R137. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.5(f) Medical records. 28 Pa. Code: 211.9(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in three of four medication rooms (2 East Medication Room, 3 East Medication Room, and 5 Main Medication Room), and one of eight medication carts (3 East units [NAME] Hall Medication Cart) and failed to properly secure one of eight medication carts (3 East units [NAME] Hall Medication Cart) while not in use.Findings include: Review of facility policy Storage of Medications dated 10/1/25, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. No discontinued, outdated or deteriorated medications are available for use in the facility. All such medications are destroyed. Compartments containing medications are locked when not in use. During an observation on 3/9/26, at 12:32 p.m. of the 5 Main Medication Room, an opened bottle of tuberculin solution (a medication administered to test for tuberculosis) was observed in the medication room refrigerator with no open date. During an interview on 3/9/26, at 12:32 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above observation and that the facility failed to properly store medications in the 5 Main Medication Room. During an observation completed on 3/10/26, at 9:08 a.m. the 2 East medication rooms refrigerator contained the following: 1 opened bottle of Fluphenazine Deconate (long-acting antipsychotic) opened and without a date. 1 box Afluria Influenza Vaccine containing 12 syringes with the expiration date of 5/25. 1 white unlabeled ice pack in freezer During an interview completed on 3/10/26, at 9:16 a.m. Licensed Practical Nurse (LPN) Employee E 16 Confirmed the above observations and that the facility failed to properly store medications in the 2 East medication room. During an observation completed on 3/10/26, at 9:52 a.m. the 3 East Medication rooms bottom cupboard to right of the sink contained: An opened package of Oreo cookies An opened box of moon pies An opened package of iced oatmeal cookies An opened package of animal crackers An opened bag of pretzels The upper cupboard on the left wall contained: An opened perfume bottle 2 cups of instant noodles The medication room refrigerator had a brown substance on the inside bottom and a black substance around the seal. During an interview completed on 3/10/26, at 9:54 a.m. Registered Nurse RN Employee E15 confirmed the above observations and stated, the snacks are from the staff they bring things in, I have no idea whose perfume or noodles those are and that the facility failed to properly store medications in the 3 East Medication room. During an observation completed on 3/11/26, at 9:10 a.m. the 3 East unit's [NAME] side medication cart contained the following: One Lantus insulin pen opened and not labeled with a date as required. During an interview completed on 9/11/26, at 9:12 a.m. Licensed Practical Nurse (LPN) Employee E21confirmed the Lantus insulin was opened and not labeled with a date as required and that the facility failed to properly store medications in the 3 East unit's [NAME] side medication cart. During an observation completed on 3/10/26, at 9:56 a.m. the 3 East unit's [NAME] side medication cart was left unattended and unlocked outside of room [ROOM NUMBER]. During an interview completed on 3/10/26, at 9:57 a.m. LPN Employee E21 confirmed the medication cart was left unattended and unlocked and that the facility failed to properly secure the 3 East units [NAME] Hall Medication Cart. 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in two of two outside dumpsters to prevent the potential for rodent and insect infestation (dumpster one, and dumpster two).Findings include: Review of the facility policy Garbage and Rubbish Disposal, dated 10/1/25, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area. During an observation and interview of the facility's outdoor trash receptacles on 3/10/26, at 1:30 p.m. Dietary Manager Employee E19 confirmed that the lid/cover was not closed on dumpster one, and dumpster two, and that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R293), failed to prevent cross contamination during a medication pass for one of three residents (Resident R248) and failed to implement appropriate transmission-based precautions for three of six residents (Residents R18, R111 and R276). Review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 10/1/25, indicated Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO). Enhanced barrier precautions are to be implemented for residents with an infection or colonization with a MDRO, wounds and or indwelling medical devices. An enhanced barrier precaution sign will be displayed near the entrance of the room. Review of the facility policy Wound Care dated 10/1/25, indicated the facility follows physician orders to maintain the highest level of comfort and promote healing of wounds. Discard old dressing and gloves in a plastic bag. Perform hand hygiene. Put on clean gloves to apply new dressing. Review of the facility policy Hand Hygiene/Handwashing dated 10/1/25, indicated effective hand hygiene reduces the incidence of healthcare-associated infections. Wash hands when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood, or other body fluids. Review of the admission record indicated Resident R248 was admitted to the facility on [DATE]. Review of Resident R248's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/22/26, indicated the diagnosis of high blood pressure, diabetes (high sugar in the blood) and seizure disorder (disrupts movement, awareness and sensation). Review of Resident R248's current physician orders indicated Depakote sprinkles oral capsules 125 milligram (mg) give two capsules by mouth two times a day related to seizures During an observation completed on 3/11/26, at 9:26 a.m. Licensed Practical Nurse (LPN) Employee E21 was preparing Resident R248's medications. LPN Employee E21 placed Resident R248's Depakote sprinkle capsules into a separate medication cup. LPN Employee E21 then placed a small amount of pudding into another medication cup, using bare hands plucked the capsules out of the other medication cup, opened the capsules and sprinkled the medication into the pudding. During an interview completed on 3/11/26, at 9:31 a.m. LPN Employee E21 confirmed touching and opening Resident R248's Depakote sprinkle capsules without completing hand hygiene or utilizing gloves. Review of the admission record indicated Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's MDS dated [DATE], indicated the diagnosis of high blood pressure, anemia (low iron in the blood) and depression. Section M0100 Pressure Ulcer/Injury risk: A. checked box that indicated resident has a pressure ulcer/injury. Review of Resident R111's physician order dated 12/19/25, indicated enhanced barrier precautions (EBP). Resident with presence of wound. Staff to wear gloves and gowns for high contact resident care: Dressing, bathing, transferring, changing linen, toileting/hygiene care, device/line care, wound care. Review of Resident R111's current care plan indicated enhanced barrier precautions. Resident with presence of wound. Staff to wear gloves and gown for high contact resident care: Dressing, bathing, transferring, changing linen, toileting/hygiene care, device/line care, wound care Observation completed on 3/9/26, at 10:30 a.m. Resident R111's room door had a bin hanging on it containing personal protective equipment (PPE). The door failed to include an enhanced barrier precaution sign near the entrance of the room. Review of the admission record indicated Resident R276 was admitted to the facility on [DATE]. Review of Resident R276's MDS dated [DATE], indicated the diagnosis of high blood pressure, diabetes (high sugar in the blood) and renal insufficiency (reduced kidney function). Section H0100 Bladder and bowel appliances: C checked box that indicated resident has an ostomy (including (urostomy, ileostomy, and colostomy). Review of Resident R276's physician orders dated 1/28/25, indicated Enhanced barrier precautions. Resident with presence of urostomy. Staff to wear gloves and gowns for high contact resident care: Dressing, bathing, transferring, changing linen, toileting/hygiene care, device/line care, wound care. Review of Resident R276's current care plan indicated resident with presence of urostomy requiring enhanced barrier precautions. Staff to wear gowns and gloves for high contact resident care activities: dressing, bathing, transferring, changing linen, providing hygiene, changing briefs/toileting, device or line care, wound care. Observation completed on 3/9/26, at 10:30 a.m. Resident R111's room door had a bin hanging on it containing personal protective equipment (PPE). The door failed to include an enhanced barrier precaution sign near the entrance of the room. During an interview completed on 3/9/26, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E16 confirmed that Resident R111 and Resident R276's rooms failed to include an enhanced barrier precaution sign near the entrance of the room. Resident R18's clinical record revealed an admission date of 7/16/25, with diagnoses including intellectual disabilities, urinary incontinence, physical debility, and progressive neuropathy (nerve disorder of an unknown cause that worsens over time, leading to sensory, motor, and sometimes autonomic dysfunction). Resident R18's physician's orders dated 10/20/25, for enhanced barrier precautions due to the presence of a foley catheter and that staff are to wear gloves, and gown for high contact resident care including device care. Observation on 3/10/26, at 10:15 a.m. of urinary catheter care for Resident R18 revealed Nurse Aid (NA) Employee E33 failed to don a protective gown while performing care. During an interview at that time NA Employee E33 confirmed that he/she does not wear a protective gown during catheter care unless the resident has an infectious organism in their urine. Interview on 3/10/26, at 10:40 a.m. the Director of Nursing confirmed that NA Employee E33 should have worn a protective gown while providing catheter care to Resident R18. Review of the clinical record indicated Resident R293 was admitted to the facility on [DATE]. Review of Resident R293's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/12/26, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). During a review of Residents R293's physician orders dated 1/6/26, indicate to cleanse wound to left buttocks with vashe (a type of wound cleanser), apply Santyl (a chemical agents for removing dead skin cells), nickel thick, then alginate (a highly absorptive dressing that creates a protective gel and maintains a moist wound environment), and cover with dressing every day shift. During a wound care dressing change observation on 3/12/26, at 11:40 a.m. Registered Nurse (RN) Employee E12 entered Resident R293's room to complete a dressing change. RN Employee E12 cleaned the bedside table, placed a clean barrier down, and placed the dressing supplies on the barrier. RN Employee E12 then removed the old dressing and placed it in dirty plastic bag. RN Employee E12 cleansed the wound with vashe and threw away the dirty supplies. RN Employee E12 failed to remove gloves and perform hand hygiene prior to applying clean wound care treatment to the left buttocks wound. During an interview on 3/12/26, at 11:50 a.m. RN Employee E12 confirmed the failure to perform hand hygiene during Resident R293's dressing change. During an interview on 3/12/26, at 11:54 a.m. Assistant Director of Nursing Employee E13 confirmed that the facility failed to prevent cross contamination during a dressing change for one of two residents (Resident R293). 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)(5) Nursing services.

Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for two of five residents (Residents R17 and R298).Findings include: Review of facility policy Resident Rights dated 10/1/25, indicated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Review of the clinical record revealed Resident R17 was admitted to the facility on [DATE]. Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/3/26, indicated diagnoses of high blood pressure, obstructive uropathy (condition in which urine flow is blocked), and hemiparesis (one-sided muscle weakness, often caused by stroke or brain injury). Review of a physician order dated 2/13/26, indicated 16 French (catheter size) foley catheter with 5 cc (cubic centimeter, unit of volume measurement) balloon for other obstructive and reflux uropathy.During an observation on 3/9/26, at 11:10 a.m. Resident R17's foley catheter collection bag was observed partially full of urine, hanging on the right side of the bed, facing the entrance of the room, without a privacy cover applied.During an interview on 3/9/26, at 11:23 a.m. Nurse Aide Employee E3 confirmed Resident R17's catheter collection bag did not have a privacy cover and that the facility failed to ensure that care was provided in a manner in which maintained Resident R17's dignity. Review of the clinical record revealed Resident R298 was admitted to the facility on [DATE]. Review of Resident R298's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), depression, and cachexia (metabolic disorder characterized by the severe, involuntary loss of skeletal muscle mass and fat). Review of a physician order dated 10/16/25, indicated upright or OOB (out of bed) for all meals and full feed (staff to feed) to ensure adequate nutrition and safety. During an observation on 3/9/26, at 12:36 p.m. Resident R298 was observed sitting in the 5 Main dining room at a table. A meal tray was observed sitting on the table next to the resident. Another resident was sitting across from Resident R298 eating their lunch. During an interview on 3/9/26, at 12:44 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R298 is a staff feed and was waiting in the dining room to be fed their lunch. During an interview on 3/9/25, at 12:44 p.m. LPN Employee E1 confirmed that the facility failed to provide a dignified dining experience for Resident R298. Pa. Code: 201.14(a) Responsibility of licensee.Pa. Code: 211.10(d) Resident care policies.Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain residents' confidential personal and medical records for one of five residents (Resident R3). Findings include: A review of the facility policy titled, Resident Rights dated 10/1/25, indicated that residents have the right to privacy in treatment and personal care. Review of the clinical record revealed that Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 12/8/25, indicated diagnoses of high blood pressure, hyperkalemia (high levels of potassium in the blood), and chronic pain. During an observation on 3/10/26, at 9:18 a.m. a sign was observed posted on Resident R3's wall above the bed that included the following information: Nectar thick liquids, no thin liquids. Review of Resident R3's clinical record failed to include any documentation that the above residents or their representatives approved the posting of private health information. During an interview on 3/12/26, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to maintain residents' confidential personal and medical records for one of five residents (Resident R3). 28 Pa. Code: 201.18(e)(1) Management

Based on review of Resident Assessment Instrument (RAI) User Manual, clinical records, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS- a periodic assessment of care needs) accurately reflected the resident's status for two of seven residents (Resident R15, R13). Findings include: Review of MDS instructions for Section N Medications N0415F, Antibiotics is to be checked if the resident is taking any medications by pharmacological classification during the last seven days or since admission/entry or reentry if less than 7 days. Resident R13's clinical record revealed an admission date of 12/30/24, with diagnoses including stroke, difficulty speaking, left-sided weakness, and human immunodeficiency virus. Resident R13's Annual MDS with an Assessment Reference Date (ARD) of 1/06/26, Section N0415F was coded yes receiving antibiotics admission/entry or reentry if less than 7 days. Residents R13's clinical record lacked evidence that he/she had received antibiotics admission/entry or reentry if less than 7 days. Interview on 3/12/26, at 9:45 a.m. the Director of Utilization Review confirmed that Resident R13's Annual MDS ARD of 1/06/26, Section N0514F was coding incorrectly for receiving antibiotics. Review of Resident R15's admission record indicated he was admitted [DATE]. Review of Resident R15's MDS assessment (Minimum Data Set MDS- a periodic assessment of care needs) dated 2/4/26, indicated that he had diagnoses included dementia (decline in cognitive function, affecting memory, thinking, behaviors and the ability to perform everyday activities), chronic kidney disease and hyperlipemia. Review of Resident R15's MDS assessment completed 2/4/26, Section E900-Wandering indicated a 2. resident has wandered in the last 4-6 days. Review of Resident R15's physician orders 1/9/26, did not include a wander guard. Review of Resident R15's progress notes dated 1/1/26- 2/4/26 indicated no wandering behavior. Review of Resident R15'2 Elopement Risk assessment dated [DATE] indicated a score of 0, no risk of elopement. During an interview on 3/12/26, at 10:20 a.m. Utilization Review Director Employee E24 confirmed that the facility failed to ensure Minimum Data Set assessment (MDS) accurately reflected Resident R15's status as required. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of three residents reviewed (Resident 65).Findings include: Review of the clinical record revealed that Resident R65 was admitted to the facility on [DATE]. Review of Resident 65's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/10/26, indicated diagnoses of bipolar disorder (a mental condition marked by alternating periods of elation and depression), anxiety, and depression. Further review of Resident 65's clinical record revealed a PASARR Level I (federally required assessment to help ensure that all individuals with serious mental disorders and/or intellectual disabilities are not inappropriately placed in nursing homes for long term care) dated 5/25/16 with the following outcome: Individual has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). A PASARR Level II determination letter dated 5/27/16, indicated that, the resident had been determined eligible for the level of services provided by a nursing facility and may be admitted or continue to reside in a nursing facility enrolled in the Department's Medicaid (MA) Program. The nursing facility must provide or arrange for provision of mental health services for any resident with mental illness who needs such services. Such services include: preparation of systematic plans which are designed to facilitate appropriate behavior, drug therapy and monitoring for effectiveness and side effects, structured social activities, the teaching of daily living skills to enhance self-determination and independence, Individual/group/family therapy, and/or personal support networks and formal behavior modification programs as determined by and provided by qualified personnel. During an interview on 3/11/26, at 11:01 a.m. Social Services Director (SSD) Employee E5 confirmed that the PA-PASARR II form completed had identified Resident 65 as a target resident, and that no more recent documentation existed to absolve resident from meeting the requirements. SSD Employee E5 confirmed that the facility failed to provide coordination of the provision of specialized services for Resident R65. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services28 Pa. Code 211.5(f) Clinical Records

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 66 residents (Resident R3) identified as having a high risk for wandering. This failure was determined to be past non-compliance. Findings include: Review of the facility policy Resident Elopement last reviewed 10/1/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Upon admission, residents will be assessed for elopement risk.1. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. In the event that a facility does not have an operational electronic monitoring system, the resident will be evaluated for transfer to a more appropriate facility that offers electronic monitoring. The resident and legally responsible person shall be notified of the facility recommendation. Interim safety monitoring measures shall be implemented pending transfer. 2. Elopement risk will be care-planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made.3. Residents at risk for elopements shall have their pictures maintained for identification purposes.4. Facility staff shall conduct a physical count of residents at least once every 24 hours.5. Electronic monitoring devices should be checked for function at least once every 24 hours. In the event of an electronic monitoring system failure, alternate security measures will be implemented to include temporary use of manual door alarms, visual monitoring of exit doors, increased staffing levels, and/or increased observation of at-risk residents.- A head count should be conducted on all units after a fire drill to ensure residents are accounted for.-Any exit doors failing to arm or magnetize following a fire alarm must be reported to the nursing supervisor immediately.6. Residents shall be reassessed at least quarterly related to elopement risk. Any resident assessed to have 3 or more yes answers on the elopement risk will be considered an elopement risk.7. Residents at high risk for elopement shall not be admitted to the facility unless appropriate interventions are identified prior to admission and the facility has the ability to appropriate supervise and monitor the resident.8. In the event that a resident is identified as missing, the following steps shall be taken:- The charge nurse will initiate a search on the unit to determine if the resident is in another location.-The charge nurse will notify the Nursing Supervisor or designee that they have been unable to locate a resident during a routine check. The Nursing Supervisor shall notify the other units. Each unit shall conduct a search for the resident. The Nursing Supervisor shall assign staff members to search non-resident areas and the facility perimeter. If the resident is not located within ten (10) minutes, the Director of Nursing and Administrator will be notified of a possible elopement.- The Director of Nursing or Administrator will assign staff members to conduct a search of the surrounding community to include a four-block radius of the facility based on the resident ' s physical ability. The resident ' s responsible party and physician will be notified of the potential elopement. This contact will also be utilized to assure that the resident is not with a family member and to obtain potential areas for an expanded search.- The local Police Department will be notified of the elopement upon completion of facility search. Timeframe for notification may be altered based on weather conditions.- Local hospitals will be notified of the elopement.- Additional resources will be utilized as needed until such time as the resident is located.- The Pennsylvania Department of Health Field Office will be notified of the elopement.9. Any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. In the event that a facility does not operate a secured unit, transfer to an alternate facility may be necessary.Review of the facility policy Resident Elopement Follow-Up Procedure last reviewed 10/1/25, indicated it is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement.Review of the admission Record indicated Resident R3 was admitted to the facility on [DATE].Review of R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/3/25, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), anxiety (intense, excessive, and persistent worry and fear about everyday situations), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), alcoholism in remission, cocaine use in remission, altered mental status, and encephalitis (inflammation of the brain). Section C - Brief Interview for Mental Status (BIMS -is a screening test that aids in detecting cognitive impairment) indicated a score of twelve - moderately impaired. Section GG - walks 50 feet with two turns with staff supervision or touching assistance.Review of R3's progress note dated 11/23/25, at 9:00 a.m. indicated upon entering the unit for rounds, Nurse Assistant reports that individual is missing from the unit states we are searching the unit and can't find him. I think he was just sitting here with his breakfast, I don't know where he went. Unit locked down, all other residents accounted for. Staff reported the missing individual was wearing a blue shirt, black hoodie and jeans with belt, has a balding head with gray hair and gray beard. Building wide search initiated. House administrators notified for review of cameras and guidance. Front desk began notifying other units and requesting head counts to be done and to search for the missing individual. 911 notified at 9:04 a.m. Pictures of the individual left at front desk. Supervisors began searching outside around campus, staff searching inside in all departments. Individual returned to facility via police cruiser at 9:24 a.m. Individual returned to his unit and immediately assigned 1:1 supervision.Review of facility provided documents dated 11/24/25, indicated Resident R3 was last seen in the dining room (on 11/23/25), at approximately 7:30 a.m. the nurse on the unit was unable to located Resident R3 to administer medications. A sweep of the unit was conducted and Resident R3 was not found. Search of the facility and surrounding grounds were then done, and police were notified. Police located Resident R3 at the entrance to facility approximately 600 yards from the facility. Review of R3's Elopement Risk assessment dated [DATE], indicated the following:1. Is the resident cognitively impaired? Yes.2. Is the resident independently mobile (ambulatory or wheelchair)? Yes.3. Does the resident have poor decision-making skills? Yes.4. Has the resident demonstrated exit seeking behavior? Yes.5. Does the resident wander oblivious to safety needs? No.6. Does the resident have a history of elopement? No.Determination:1. Resident is determined at risk for elopement. Yes.2. Plan has been implemented to ensure resident safety. Yes.Review of Resident R3's physician order dated 6/4/25, indicated check wander guard (a bracelet that alerts staff by an alarm if they go beyond a specified area) for placement every shift. Check that irritation has not developed from wander guard placement.Review of Resident R3's physician order dated 8/26/25, indicate every (q) 15-minute checks every shift.Review of Resident R3's care plan initiated on 6/4/25, with revision on 11/23/25, indicated resident exhibits wandering or exit seeking behavior and requires placement on secure unit with wander guard at risk for elopement due to cognitively impaired, independently mobile, poor decision-making skills, and demonstrating exit seeking behavior and resident has a history of elopement Goal - resident will remain safely within the facility. Interventions included:- - One on one for elopement risk- -Assess skin daily for irritation related to wander guard.- -Check wander guard function every day -- -Evaluate elopement risk as needed with any change in condition and any increase wandering or exit seeking behavior.- -Report increase in exit seeking behaviors to provider- - Resident R3 may try to exit secured unit during fire alarm, verify location on unit during alarm Review of Resident R3's progress note dated 11/23/25, at 12:16 a.m. indicated continues on q 15-minute checks no issues noted. Review of NA Employee E8's statement dated 11/23/25, indicated the only time I saw Resident R3 was at 7:00 a.m. sitting in the dining room at table in the back by the window. Review of Nurse Aid (NA) Employee E6's statement dated 11/23/25, indicated I talked to Resident R3 at 7:25 a.m. when I placed my two residents at the table for breakfast. He was walking around on the unit that was the last time I seen him. Review of NA Employee E4's statement dated 11/23/25, indicated at 7:15 a.m. I saw Resident R3 sitting at the dining room table at 7:30 I went to get a patient up I walked into the dining room, and he was still sitting by the window. Review of NA Employee E5's statement dated 11/23/25, indicated the last time I saw Resident R3 was about 7:40 a.m. he was sitting in a chair in the dining room by the window. Review of Licensed Practical Nurse (LPN) Employee E3's statement dated 11/23/25, indicated about 7:30 a.m. Resident R3 was observed walking up and down hall, then into the dining room. I continued to pass meds when I got too Resident R3 I went to his room he was not there I checked the dining room did not see him only his hat was sitting on the table. Additional documentation of a facility completed telephonic interview completed with Employee E3 on 11/24/25, indicated at around 8:40 a.m. I went to give resident his meds and he was not in his room. Myself and the other staff checked the unit then notified the supervisor. Review of Licensed Practical Nurse (LPN) Employee E7's statement dated 11/23/25, indicated I was at the med cart passing meds when I was alerted to look for Resident R3 because he was no longer sitting in the dining room at the table by the window. This nurse help look and search every room and area on 2 East and did not find patient. Review of Resident R3's statement dated 11/23/25, when asked to describe how he got off the unit and why he wanted to leave Resident R3 stated I got on the elevator and went downstairs. I went out the door and the police picked me up. I was trying to go to my stepmothers house. It would be a long walk but whatever. I don't want to be here anymore. They keep me here against my will. I will do whatever it takes to get out of here. Even if you change the codes, I will find out how to leave here. Review of Resident R3's Patient Safety Assessment Every 15-minute checks on 12/3/25, at 1:00 p.m. indicated the November sheets were incomplete on 11/13/25, 11/14/25, 11/18/25 and 11/19/25, the 11/23/25, sheet only had documentation for 7:30 a.m. No sheets were able to be produced for 11/1/25, through 11/12/25. During an interview completed on 12/3/25, at 1:13 p.m. Resident R3 was sitting in the dining room a NA was sitting across from him. Upon asking Resident R3 if he could recall leaving the facility replied I was told by someone at the jail I could leave. Upon asking Resident R3 how he was able to get on the elevator Resident R3 responded people say the code out loud. I feel good I just don't like being here, just want to keep me here to make money. If I can get out of here I'm going again. Review of Resident R3's progress notes dated 11/23/25, at 12:06 a.m. indicated q 15 min checks were maintained, no further documentation was noted concerning resident until he was discovered not be accounted for on 11/23/25. Interview on 12/4/25, at 10:45 a.m. the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and the failure created an immediate jeopardy situation for one of 66 residents (Resident R3) identified as high risk for wandering. On 12/4/25, at 2:39 p.m. the Nursing Home Administrator and the Director of Nursing were provided with the Immediate Jeopardy (IJ) template, and an immediate corrective action plan was requested. Review of the facility's immediate action plan on 12/4/25, at 5:54 p.m. indicated the following:- -11/23/2025, facility implemented an immediate action plan following the successful elopement of R3 on 11/23/2025. Upon return to facility, R3 was assessed for injury (none noted). Physician orders were reviewed, and plan of care was updated. R3's care plan was reviewed and updated to include a change from Q 15-minute checks to 1:1 observation based on length of time needed to exit unit. Family and provider were notified. - -11/23/2025, a root cause analysis was conducted. Maintenance immediately changed elevator code. All stairwell doors and exterior doors were checked to ensure functionality with no issues identified. Immediate education on facility elopement policy, notifying maintenance in the event a resident learns the elevator code, and making sure stairwell doors are closed and locked after use was implemented. - -11/24/2025, ad-hoc QAPI meeting was held to review root cause analysis and elopement policy. No policy revisions were required. - -11/24/2025, Director of Nursing confirmed that R3 elopement risk assessment correctly identified him as an elopement risk and was up to date. Elopement risk assessments were then reviewed and confirmed up to date and accurate for 320 of 320 residents. Of the 61 residents assessed to be at risk for elopement, care plans were confirmed to include interventions to minimize risk of successful elopement. - - 12/1/2025, 260 of 260 staff were confirmed to have received elopement education. - -Director of Nursing will audit all admissions/readmissions for a period of 30 days to ensure elopement risk assessment is completed and residents at risk of elopement have interventions listed in their care plan to reduce the risk of successful elopement. - -Nursing Home Administrator requested past non-compliance. On 12/5/25, at 12:50 p.m. the following items have successfully been verified as met per the immediate action plan: The Immediate Jeopardy was lifted on 12/5/25, at 12:50 p.m. after ensuring that the immediate action plan had been implemented. The facility demonstrated past non-compliance by initiating immediate interventions starting 11/23/25, following the incident. Documents and actions provided by the facility to address Immediate Jeopardy were reviewed on 12/5/25, during the onsite survey and included: -It was verified that the root cause analysis of the elopement was determined to be that Resident R3 had seen the elevator code, entered the code and was able to exit unit. -It was verified that on 11/23/25, at 10:30 a.m. all facility staff education was initiated immediately by ADON regarding the facility elopement policy and ensuring residents are accounted for. -It was verified that on 11/23/25, at 11:30 a.m. the full facility head count was completed, and all residents were accounted for. -It was verified that on 11/23/24, at 11:30 a.m. the elevator code was changed on the East Wing and was functioning appropriately the stairwell doors were also checked and functioned appropriately. -It was verified that on 11/24/25, ad-hoc QAPI meeting was held to review root cause analysis and elopement policy -It was verified that on 11/24/25, the root cause analysis was presented to QAPI Committee. -It was verified that on 11/24/25, all elopement assessments were up to date. -It was verified that on 11/24/25, 236 of 260 staff received education. -It was verified that on 12/4/25, all residents were reassessed for elopement risk. -It was verified on 12/4/25, 66 residents were identified as being at risk for elopement and 66 have appropriate interventions in place in the plan of care to minimize risk of successful elopement. -It was verified on 12/4/25 that a total of 316 employees received education which include agency staff. -It was verified on 12/5/25, via 21 in person interviews that education was provided and understood regarding elopement and notifying maintenance in the event a resident learns the elevator code and making sure stairwell doors are closed and locked after use. -It was verified on 12/5/25, via 7 telephonic interviews that education was provided and regarding elopement and notifying maintenance in the event a resident learns the elevator code and making sure stairwell doors are closed and locked after use. Review of immediate action plan was verified on 12/5/25, at 12:50 p.m. that the past non-compliance Immediate Jeopardy situation was in effect until 11/24/25, when the facility completed their plan as stated. Exit interview on 12/5/25, at 3:00 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision that resulted in an elopement. This failure created an immediate jeopardy situation for one of 66 residents (Resident R3) identified as high risk for wandering and that the Immediate Jeopardy situation has successfully met the task of Past Non-compliance effective on 11/24/25, when the action plan was achieved by the facility. 28 Pa. Code 201.14 Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29 Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for one resident resulting in elopement (resident exits to an unsupervised and unauthorized location without staff's knowledge). This failure created an immediate jeopardy situation for one of 78 residents (Resident R2) identified as having a high risk for wandering. This failure was determined to be past non-compliance.Findings include: Review of the facility policy Resident Elopement dated 10/1/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Upon admission, residents will be assessed for elopement risk.1. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. In the event that a facility does not have an operational electronic monitoring system, the resident will be evaluated for transfer to a more appropriate facility that offers electronic monitoring. The resident and legally responsible person shall be notified of the facility recommendation. Interim safety monitoring measures shall be implemented pending transfer. 2. Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made.3. Residents at risk for elopements shall have their pictures maintained for identification purposes.4. Facility staff shall conduct a physical count of residents at least once every 24 hours.5. Electronic monitoring devices should be checked for function at least once every 24 hours. In the event of an electronic monitoring system failure, alternate security measures will be implemented to include temporary use of manual door alarms, visual monitoring of exit doors, increased staffing levels, and/or increased observation of at-risk residents.6. Residents shall be reassessed at least quarterly related to elopement risk.7. Residents at high risk for elopement shall not be admitted to the facility unless appropriate interventions are identified prior to admission and the facility has the ability to appropriate supervise and monitor the resident.8. In the event that a resident is identified as missing, the following steps shall be taken: The charge nurse will initiate a search on the unit to determine if the resident is in another location. The charge nurse will notify the Nursing Supervisor or designee that they have been unable to locate a resident during a routine check. The Nursing Supervisor shall notify the other units. Each unit shall conduct a search for the resident. The Nursing Supervisor shall assign staff members to search non-resident areas and the facility perimeter. If the resident is not located within ten (10) minutes, the Director of Nursing and Administrator will be notified of a possible elopement. The Director of Nursing or Administrator will assign staff members to conduct a search of the surrounding community to include a four-block radius of the facility based on the resident's physical ability. The resident's responsible party and physician will be notified of the potential elopement. This contact will also be utilized to assure that the resident is not with a family member and to obtain potential areas for an expanded search. The local Police Department will be notified of the elopement upon completion of facility search. Timeframe for notification may be altered based on weather conditions. Local hospitals will be notified of the elopement. Additional resources will be utilized as needed until such time as the resident is located. The Pennsylvania Department of Health Field Office will be notified of the elopement.9. Any resident with a successful elopement will be reassessed and additional interventions will be identified and included with the Plan of Care. In the event that a facility does not operate a secured unit, transfer to an alternate facility may be necessary. Review of the admission Record indicated Resident R2 was admitted to the facility on [DATE]. Review of R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/3/25, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), anxiety (intense, excessive, and persistent worry and fear about everyday situations), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), alcoholism in remission, cocaine use in remission, altered mental status, and encephalitis (inflammation of the brain). Section C - Brief Interview for Mental Status (BIMS -is a screening test that aids in detecting cognitive impairment) indicated a score of eleven - moderately impaired. Section GG - walks 50 feet with two turns with staff supervision or touching assistance. Review of R2's Elopement Risk assessment dated [DATE], indicated the following:1. Is the resident cognitively impaired? Yes.2. Is the resident independently mobile (ambulatory or wheelchair)? Yes.3. Does the resident have poor decision-making skills? Yes.4. Has the resident demonstrated exit seeking behavior? No.5. Does the resident wander oblivious to safety needs? No.6. Does the resident have a history of elopement? No.Determination:1. Resident is determined at risk for elopement. Yes.2. Plan has been implemented to ensure resident safety. Yes. Review of R2's progress note dated 6/3/25, at 12:17 p.m. indicated staff noted resident on service elevator at 11:45 a.m. and was met by writer on the main floor with no injury noted. Resident stated that he was lost. Placed call to Assistant Director of Nursing (ADON) to inform. Call to supervisor on East unit (secure memory care unit) needing a room change for resident's safety. Placed call to Resident R2's sister notifying of the floor change and was given room number along with floor phone number. Resident R2 was moved from 5 Main (regular entry unit) to 2 East unit. All personal belongings, along with medication and chart. Review of R2's physician order dated 6/4/25, indicated check wander guard (a bracelet that alerts staff by an alarm if they go beyond a specified area) for placement every shift. Check that irritation has not developed from wander guard placement. Notify nurse if not place. Check for the function of wander guard every night shift. Review of Resident R2's care plan dated 6/4/25, indicated resident exhibits wandering or exit seeking behavior and requires placement on secure unit with wander guard at risk for elopement due to cognitively impaired, independently mobile, poor decision-making skills, and demonstrating exit seeking behavior. Goal - resident will remain safely within the facility. Interventions included: Assess skin daily for irritation related to wander guard. Check wander guard function every day. Review of Resident R2's progress notes indicated the following:-6/11/25, at 5:00 p.m. indicated resident noted to have increased behaviors at this time. Noted to try to throw feces on Nursing assistant (NA). Also had picked up nursing station computer and tried to throw it at NA. Redirected by this nurse at this time, will continue to monitor.-6/14/25 3:05 p.m. indicated resident noted to throw stool on NA. Continues getting stool out of brief and trying to throw stool at staff. Resident noted to pull the fire alarm at this time.-6/22/25, at 4:57 p.m. indicated resident pulled fire alarm this shift. Stated the psychiatrist told him to do so. Fire Department arrived; Township Police arrived to assess the situation and spoke with resident. Police requested resident to be seen by psych as soon as possible since resident has been known to pull the fire alarm. Supervisor aware and currently on unit.-6/25/25, at 8:04 p.m. psychiatric evaluation indicated the patient states feeling Not good and Mood is not good. Resident reports ongoing signs and symptoms of depression and anxiety related to feeling lonely. Resident reports worsening auditory (hearing) and visual (sight) hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there). Resident reports worsening paranoia (unjustified suspicion or mistrust) and irritability (a state of being easily annoyed, frustrated, or impatient).-7/22/25 7:49 p.m. indicated Nurse called down to office at 6:55 p.m. and informed Supervisor that staff were unable to locate Resident R2 on unit. At that time search began for resident inside building and perimeter. Resident unable to be located. Director of nursing (DON) notified of elopement. Camera checked and resident seen exiting rear auditorium exit at 4:37 p.m. Police Department contacted at 7:28 p.m. to report resident elopement, last time seen, and description given. Attempted to call the family at 7:30 p.m. but there was no answer. Message left requesting call back. The call was received at 7:40 p.m. stating police had located the resident and was returning resident to the facility. Resident returned with no signs of distress, no injury noted. Returned to unit without issue. Vital signs obtained and within normal limits. Skin check unremarkable. Fluids encouraged. Resident placed on every 15-minute checks (on the secure unit). Wander guard in place and working appropriately. Review of facility provided documentation dated 7/22/25, at 6:25 p.m. indicated Resident R2 was noted to be missing from the unit. Investigation started immediately. Resident R2 was last seen shortly after 4:40 p.m. on the unit during a fire alarm. When meal trays arrived on the unit at approximately 6:25 p.m. Resident R2 was noted to be absent from the unit. A search of the building and the immediate grounds was done and resident was not located. Local police were notified and located resident approximately a half of a mile from the facility. Upon return resident was assessed for injury (none noted) and offered fluids. The resident was dressed in pants, a t-shirt, sneakers, and was carrying a jacket. Outside, the environment was 82 degrees and dry. The provider and family were called. Review of NA Employee E11's signed statement dated 7/22/25, indicated about 4:30 p.m. the fire alarm went off. They went to take another resident into their room and then watch the door on the East Hall. They saw Resident R2 at that time standing in the [NAME] Hall past the nursing station. Meal trays came out at 6:25 p.m. Staff started passing trays and an unidentified NA said where is Resident R2? They checked the assigned room and Resident R2 wasn't there. They checked both hallways and Resident R2 wasn't there. The house supervisor was called and made aware. Review of NA Employee E12's signed statement dated 7/23/25, indicated on 7/22/25, they saw Resident R2 around 4:30 p.m. when fire alarm went off. The resident was in the hallway by the nurses' station inside the double doors. Then staff member went to the dining room to see what residents were in there and watched the door to steps. Staff passed trays and then noticed Resident R2 was not on the floor. Staff searched all the rooms and bathrooms. Resident R2 was behaving normally all day. Review of NA Employee E13's signed statement dated 7/22/25, indicated Resident R2 was last seen before the fire alarm went off around 4:10 p.m. in front of the doubled doors in solarium. Review of NA Employee E14's signed statement dated 7/22/25, indicated they were alerted to Resident R2 being missing when we were passing meal trays for supper. On the lead up to that, the last time they remember seeing resident was about five o'clock when they asked the resident to move so they could use the chair he was sitting in. Review of Licensed Practical Nurse (LPN) Employee E15's signed statement dated 7/22/25, indicated Resident R2 was last seen around 4:00 p.m. Unidentified NA realized resident was missing after fire alarms went off. Review of LPN Manager Employee E16's signed statement dated 7/23/25, indicated when resident was not located in the immediate area, units were called to conduct head counts. All the other residents were accounted for. Police were called to inform of the missing resident, Resident R2. Interview on 8/5/25, at 9:35 a.m. LPN Employee E17 indicated a code is needed to get on the elevator. If a wander guard is near, it beeps and won't leave the floor. The stairwells are alarmed with a keycode. If the fire alarm goes off the stairwell doors automatically unlock for safety escape down the stairs. There are double doors after the keypad door which would be opened during a fire drill as well. During a fire alarm we watch each door to make sure nobody can get out. Observation on 8/5/25, at 9:45 a.m. Resident R2 was lying in bed, fully dressed with a wander guard bracelet on the right wrist. Interview on 8/5/25, at 9:45 a.m. Resident R2 indicated The ambulance brought me here. I wasn't taking my medications, so I thought I'd better get in the ambulance. When asked if resident recalled going for a walk outside recently, the resident indicated Oh, I don't remember too much about that. I have succumbed to talking with my family, my next of kin. My house was bankrupt, and I learned I lost my house. Resident could not expound any further on the subject. Interview on 8/5/25, at 10:00 a.m. LPN Manager Employee 16 indicated Resident R2 went out the unit exit doors to another set of stairwell doors into the auditorium on the first floor and that's where resident got out of the facility during a fire alarm that disengages the doors to each doorway. Interview on 8/6/25, at 11:00 a.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision for one resident resulting in elopement and the failure created an immediate jeopardy situation for one of 78 residents (Resident R2) identified as high risk for wandering. On 8/6/25, at 11:00 a.m. the Nursing Home Administrator and the Director of Nursing were provided the Immediate Jeopardy (IJ) template and an immediate corrective action plan was requested. Review of the facility's immediate action plan on 8/6/25, at 11:00 a.m. indicated the following:-On 7/22/2025, facility implemented an immediate corrective action plan following the elopement of R2 on 7/22/2025.- A root cause analysis of incident determined that the verbiage in the existing elopement policy did not specifically state that a head count should be done following any fire alarm, including drills or non-emergent alarms. This verbiage was clarified in the policy. Staff in all departments were educated on the facility elopement policy and ensuring residents are accounted for following a fire drill.-On 7/23/2025, the Maintenance Director reviewed the door alarms/locks and fire alarm on East Wing, and they were functioning appropriately. -On 7/24/2025, 379 of 379 residents were confirmed by the Director of Nursing to have been reassessed for elopement risk. All residents who were identified as being at risk for elopement were confirmed to have appropriate interventions in place in the plan of care to minimize risk of successful elopement. -On 7/24/2025, revised policy and details of root cause analysis were presented to QAPI (Quality Assurance and Performance Improvement) Committee.-As of 7/26/2025, greater than 90 percent of staff had received education on elopement and monitoring the doors during and after fire drills.-The Director of nursing will continue to audit new admissions for 30 days to ensure all residents are assessed for elopement risk on admission and have a care plan initiated for elopement risk if appropriate.-As of 7/26/2025, immediate action plan was complete and moving to auditing phase. On 8/6/25, at 1:32 p.m. the following items have successfully been verified as met per the immediate action plan:- It was verified that the root cause analysis of the elopement was determined to be that the existing elopement policy did not specifically state that a head count should be done following any fire alarm, including drills or non-emergent alarms.-It was verified that the verbiage of the policy was updated to include the above.-It was verified that all facility staff education was initiated immediately by the ADON on 7/22/25, at 7:45 p.m. regarding the facility elopement policy and ensuring residents are accounted for following a fire drill. Review of education signatures indicated 366 of 366 total staff received education.-It was verified the Maintenance Director's evaluation of the door alarms/locks and fire alarm on East Wing were functioning appropriately.-It was verified that 379 of 379 residents were reassessed for elopement risk.-it was verified that 78 residents were identified as being at risk for elopement and 78 have appropriate interventions in place in the plan of care to minimize risk of successful elopement.-It was verified that on 7/24/25, the revised policy and details of root cause analysis were presented to QAPI Committee.-It was verified via 40 in person interviews that education was provided and understood regarding elopement and accounting for residents after a fire drill.-It was verified via eleven telephonic interviews that education was provided and understood regarding elopement and accounting for residents after a fire drill.-It was verified that ongoing audits for new admissions for 30 days to ensure all residents are assessed for elopement risk on admission and have a care plan initiated for elopement risk if appropriate. Twenty-four new admissions with six identified at risk for elopement. Review of immediate action plan was verified on 8/6/25, at 1:32 p.m. that the past non-compliance Immediate Jeopardy situation was in effect until 7/26/25, when the facility completed their plan as stated. Exit interview on 8/7/25, at 3:30 p.m. information was provided to the Nursing Home Administrator and the Director of Nursing that the facility failed to make certain each resident received adequate supervision that resulted in an elopement. This failure created an immediate jeopardy situation for one of 78 residents (Resident R2) identified as high risk for wandering and that the Immediate Jeopardy situation has successfully met the task of Past Non-compliance effective on 7/26/25, when the action plan was achieved by the facility. 28 Pa. Code 201.14 Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29 Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of two residents (Resident R456). This failure created an immediate jeopardy situation for one of two residents (Resident R456). Findings include: Review of the facility Resident Elopement policy last reviewed 10/1/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of facility staff. Upon admission, residents will be assessed for elopement risk. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. In the event that a facility does not have an operational electronic monitoring system, the resident will be evaluated for transfer to a more appropriate facility that offers electronic monitoring. The resident and legally responsible person shall be notified of the facility recommendation. Interim safety monitoring measures shall be implemented pending transfer. Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R456's admission record indicated he was admitted on [DATE]. It was indicated the resident was admitted to the locked unit. Review of Resident R456's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 2/1/25, included diagnoses of malignant neoplasm of brain (growth of cancerous cells in the brain), metabolic encephalopathy (change in how your brain works due to an underlying condition), and mood disorder due to physiological condition. Review of Section C0500-BIMS screening indicated a score of 10, which indicated Resident R456 was moderately impaired. Review of Resident R456's admission Elopement Risk assessment dated [DATE], revealed the assessment was left blank and not completed, however it indicated the resident was not at risk for elopement. The facility failed to complete and accurately identify Resident R456 as an elopement risk. Review of a progress note dated 1/27/25, at 10:25 a.m. stated the resident was irate, requested to be discharged and refused to sign the admission packet. The facility failed to complete an elopement risk assessment for Resident R456. Review of a progress note dated 1/27/25, at 11:58 a.m. entered by Social Worker, Employee E23 indicated the resident was in jail when he had a change in condition which led to hospitalization . It was indicated he was in jail for drug related charges. The resident had brain surgery. It was indicated the resident's discharge plan was to a facility that specialized in cognitive therapy. Review of a progress note dated 1/27/25, at 10:56 p.m. indicated Resident R456 stated it's wrong what you all are doing to me, I should be home. Resident began to ask when he was going to be discharged . The facility failed to complete an elopement risk assessment for Resident R456 after he displayed exit seeking behaviors. Review of Resident R456's psychiatric evaluation dated 1/28/25, indicated the resident was memory impaired and had difficulty with short term recall. His insight, judgement, and impulse control was poor. The resident was displaying severe agitation placing him at risk for harming himself and others. It was stated patients with brain injuries are periodically unable to restrain impulses that result in verbal or physical aggression. Review of Resident R456's smoking assessment dated [DATE], indicated the resident does not have cognitive loss. The facility failed to accurately assess Resident R456 for safe smoking. It was indicated the resident was safe to smoke with direct supervision. Review of Resident R456's physician order dated 2/2/25, indicated the resident may go on a leave of absence with a responsible party or escort. Review of information submitted to the Department of Health on 2/3/25, indicated Resident R456 was unable to be located. A search of the facility was conducted and police were notified. During an interview with his roommate it was indicated Resident R456 was talking about leaving to get his check. The facility was notified Resident R456 was back in Pittsburgh at a friend's house. Resident R456 returned to the facility on [DATE], and discharged against medical advice. Review of a progress note dated 2/3/25, at 8:35 p.m. entered by the Director of Nursing (DON) indicated the police were on site, a preliminary search of immediate area was done, and the resident was not located. Review of progress note dated 2/3/25, entered by Unit Manager, Licensed Practical Nurse, Employee E13 indicated a nurse notified her at 7:30 p.m. that Resident R456 was not able to be located. It was indicated the DON and police were notified. The facility contacted the resident's family member around 9:00 p.m. and the resident's family member informed staff Resident R456 was seen in Pittsburgh. During an interview on 2/10/25, at 9:52 a.m. Unit Manager LPN, Employee E27 stated elopement risk assessments are completed upon admission, and residents are reassessed if the resident displays exit seeking behaviors. It was indicated typically wander guards are applied, and if the resident refuses, then the doctor is notified, and it is documented in the clinical record. Staff are to monitor the resident. During an interview on 2/10/25, at 11:04 a.m. LPN Employee E26 stated Resident R456 was pretty defiant, difficult to redirect, anxious and wanted to leave. It was indicated Resident R456 had an order for a leave of absence to go smoke. LPN, Employee E26 stated someone was always with him when he left the unit, or he could go to the outdoor pavilion located on 2 West. Review of the facility's investigation for Resident R456's elopement on 2/10/25, at 12:30 p.m., revealed Resident R456 signed himself out on 2/3/25, sometime between 1:41 p.m. and 1:47 p.m. The section for who the resident was escorted by was left blank. No witness statements were obtained. During an interview on 2/10/25, at 12:54 p.m., the DON indicated video surveillance revealed Resident R456 getting on a bus at 2:08 p.m. on 2/3/25. It was indicated the resident's roommate said Resident R456 stated he was going to smoke after lunch, and he never returned. The DON confirmed Resident R456 was not escorted to supervised smoking on 2/3/25. The DON stated he was allowed off the unit. The DON confirmed the facility failed to complete an elopement assessment upon admission and failed to reassess Resident R456 when he displayed exit-seeking behaviors. The DON confirmed the facility failed to accurately complete Resident R456's smoking assessment. During an interview on 2/10/25, at 1:50 p.m. Nurse Aide, Employee E30 stated on 2/3/25, she worked 7 a.m. until 11 p.m. It was indicated when Resident R456 was admitted he was very confused, very agitated, and aggressive. His whole demeanor was not wanting to be here. NA, Employee E30 stated the unit Resident R456 was on, is a completely locked down unit. NA, Employee E30 stated she has been working on that unit for five years and just in her opinion she doesn't think residents should be allowed off the unit unattended to smoke. It was indicated Resident R456's family member was the first to take him off the unit to smoke and NA, Employee E30 stated staff on the unit are not responsible to take residents to smoke. NA, Employee E30 stated it was questioned what staff should do when the resident's brother isn't available to take the resident to smoke. It was indicated he was let off the unit by the supervisor and he returned to the unit the first time, however the second time he did not. During an interview on 2/10/25, at 2:02 p.m. LPN, Employee E26 stated she worked 7 a.m. until 3 p.m. on 2/3/25. It was indicated the last time she seen Resident R456 was on 2/3/25, sometime after lunch and he wanted a cigarette. LPN, Employee E26 stated she did not see him get on the elevator and didn't know he left. It was indicated Resident R456 recently received an order for an LOA (leave of absence) and he signed a smoking contract with RN, Employee E27. During an interview on 2/10/25, at 2:22 p.m. Unit Manager, LPN Employee E13 indicated she worked 3 p.m. until 11 p.m. on 2/3/25. It was indicated she only became familiar with Resident R456 after he eloped. She indicated his short-term memory was not so good and it was her understanding staff were letting him off the unit to smoke. Unit Manager, LPN E13 stated she never seen Resident R456 on 2/3/25, and was notified by staff around 7 p.m. that he was not on the unit and missing. It was indicated dinner was served around 5 p.m. and staff failed to realize Resident R456 was missing then. Unit Manager, LPN, Employee E13 stated Resident R456 was not identified as an elopement risk, so no interventions were in place. During an interview on 2/10/25, at 2:32 PM, NA Employee E33 stated she worked 7 a.m. until 7 p.m. on 2/3/25, and was not assigned Resident R456. It was indicated the few interactions she had with Resident R456, he was aggressive and combative. It was indicated he verbally expressed that he did not want to be at the facility. She indicated she heard him talking about smoking, but she did not know residents on the locked unit had privileges to go smoke. It was indicated the last time she seen him was after lunch and he was getting irate about wanting to smoke a cigarette. NA, Employee E33 stated I would never let a resident off the locked unit unattended, first of all it's a locked down unit, I don't know much about him, but he's on the locked unit for a reason. On 2/11/25, at 10:13 a.m. the NHA and DON were notified that Immediate Jeopardy was called due to the elopement of Resident R456 on 2/3/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 2/11/25, at 3:07 p.m. an immediate action plan was received and accepted which included the following interventions: 1. The facility made contact with R456 and family who returned to the facility and signed out of the facility Against Medical Advice. Facility will reassess all residents for elopement risk by 2/11/25. Assessments will be confirmed completed on 2/11/25. 2. All residents assessed to be at risk of elopement will have care plan and interventions implemented to reduce the risk of successful elopement by 2/11/25. Residents being housed on east side locked units who are not identified as needing a locked unit will have a physician order permitting them to leave unit unsupervised. 3. Administrator and Director of Nursing will review facility elopement policy and revise as necessary by 2/11/25. 4. All facility staff will be re-in serviced on elopement policy and identifying exit seeking behaviors upon arrival for next scheduled shift. Any staff not scheduled to work prior to 2/12/25, will be contacted by telephone by 2/12/25, to receive education. 5. Director of nursing will audit all new admissions for 30 days to ensure elopement risk assessment is complete and newly admitted residents who are at risk for elopement have care plan interventions in place to reduce the risk of successful elopement. 6. Policy revision, staff education and ongoing audits will be shared QAPI committee. Elopement policy was reviewed and revised on 2/11/25. During a phone interview on 2/12/25, at 9:54 a.m. RN, Employee E32 stated she was assigned Resident R456 on 2/3/35. It was indicated she was told the Unit Manager allowed Resident R456 to go off the unit to smoke, and was unsure when he left that day. She indicated she was unsure what interventions were in place for him and that he's new so it depended on whatever the Unit Manager allowed. During in-person interviews completed from 2/12/25, at 12:20 p.m. until 2/12/25, at 2:16 p.m. 58/58 staff confirmed they were educated. Staff were educated on how and when to complete an elopement assessment, and what to do for residents that are displaying exit seeking behaviors. Staff were educated on the updated elopement policy. During phone interviews completed on 2/13/25, at 10:19 a.m. 9 of 9 staff members confirmed they were educated on elopement risks. All staff must confirm they were educated prior to the start of their next shift and sign the education sheet in-person. 430 of 430 staff were educated. On 2/13/25 at 10:17 a.m., all residents' assessments for elopement risk were reviewed and found to be completed, and care plans were reviewed and updated if needed for 461 of 461 residents. Review of 8/130 Residents who resided on the locked unit had a physician order permitting them to leave the unit unsupervised. Staff education was verified with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated. On 2/13/25, the facility completed an audit of residents who were newly admitted as of 2/11/25. Daily audits will be completed by DON or designee for next 30 days to ensure an elopement risk assessment was completed. The facility's next QAPI meeting is scheduled for 2/27/25. Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 2/13/25, at 11:13 a.m. During an interview on 2/14/25, at 2:45 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision resulting in Resident R456's elopement. This failure created an immediate jeopardy situation for Resident R456 and potentially put him at risk of harm or injury. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on manufacturer's guidelines, facility policy, clinical record review, and staff interview it was determined that the facility failed to ensure that nursing staff have the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed one resident (Resident R811) in immediate jeopardy in which health and safety were impacted. Findings include: Review of the manufacturer's guidelines Life Vest Pocket Card indicated the following: -The Life Vest is a wearable cardiac defibrillator (a device that applies an electric charge to the heart to restore a normal heart beat). -The Respond message means: before delivering a treatment shock, Life Vest test to see if a patient is conscious (aware of their environment) by providing the patient an opportunity to press the response button to prevent a treatment shock. It is important that only the patient press the response button. -Life Vest therapy pads release a blue gel prior to a treatment shock to both improve shock conduction (the process by which heat or electricity is directly transmitted through a substance) and mitigate burning. The gel should remain on the patient as long as the patient is wearing the Life Vest in case additional treatment shocks are required. -Life Vest treats a ventricular (ventricles - the two lower chambers of the heart) arrhythmia (improper beating of the heart, irregular, too fast, or too slow). The time to treatment will be between 25 and 60 seconds depending on the type and rate of the arrhythmia and whether the patient presses the response buttons. -Nobody should touch the patient while a treatment shock is delivered. The device will warn bystanders with both a siren alert and a voice command stating Bystanders, do not interfere. before a shock is delivered. -Vibrations, along with the siren alerts and voice prompts are part of the device's consciousness test, which requires the patient to press the response button to avoid a shock. It is important that only the patient press the response button. -When possible the patient should bring the Life Vest charger, hotspot and extra battery to the hospital which allows the patient to download any stored data from the monitor and change the battery as required. Review of the facility policy Life Vest dated 10/1/24, indicated the facility is to establish procedures for the safe use of wearable defibrillators. The residents' wearable defibrillator will be in accordance with physician orders, and the medical record will include the following: -Name and contact information of the manufacturer. -Name and contact information of the ordering cardiologist or specialist. -Product pamphlet or web address to access product pamphlet for operating instructions and/or trouble shooting information. Staff responsible for the care of the resident with orders for a wearable defibrillator shall receive education on the use of the device, which is includes but is not limited to: -Purpose of the device and how it works. -Application and care of the garment. -Application of and operating instructions of the monitor. -How to respond to alarms. -When to notify attending or ordering physician. -When to notify manufacturer for replacement. Review of the clinical record revealed that Resident R811 was admitted to the facility on [DATE]. Review of Resident R811's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/5/25, indicated diagnoses of alcoholic cardiomyopathy (the heart is unable to pump blood efficiently, leading to heart failure from prolonged alcohol consumption), sarcoidosis of lung (autoimmune disease where the immune system starts attacking the body, forming small inflammatory lumps called granulomas), and depression. Review of Resident R811's Nursing admission evaluation dated 1/29/25, indicated Section H Cardiac/circulation - irregular rate. Section L Skin indicated chest - Life Vest. Review of Resident R811's physician order dated 1/30/25, indicated check Life Vest placement and battery daily. Change Battery daily for Life Vest one time a day. Review of Resident R811's care plan on 2/10/25, failed to include a problem, goal, or interventions for care and management of Life Vest. Observation of Resident R811 on 2/10/25, at 9:29 a.m. in bed under blanket with a device stored inside a black bag attached to his person on top of the blanket. Interview with Resident R811 on 2/10/25, at 9:30 a.m. indicated Yes, I have a Life Vest, and no, the staff don't know how to use it. I change my own battery every night around 10:00 p.m. The hospital only sent me with one garment. Interview on 2/11/25, at 9:01 a.m. Nurse Aide (NA) Employee E1 indicated I don't know what a Life Vest is. I've never been trained at this facility. Interview on 2/11/25, at 9:08 a.m. NA Employee E2 indicated A Life Vest is something they get at the hospital, it monitors their heart. I've never been trained by this facility, but we have a resident with Life Vest in room [ROOM NUMBER]-1 Resident R811. Survey Agency (SA) asked Is he allowed to take that off for showers? NA Employee E2 indicated I don't think so, because I don't think he's allowed to ever take it off. Interview on 2/11/25, at 9:20 a.m. Registered Nurse (RN) Wound Care Employee E3 indicated I've never had Life Vest training at this facility. Interview on 2/11/25, at 9:25 a.m. RN Employee E4 indicated A Life Vest is like a defibrillator, you can take off in the shower, I'm not sure for how long. I have not been trained at this facility on Life Vest. Interview on 2/11/25, at 9:30 a.m. Unit Director RN Employee E5 indicated she was in training and that they had Resident 811 with a Life Vest at the current time. I have not received training at this facility on Life Vest. Interview on 2/11/25, at 9:31 a.m. Unit Director RN Employee E6 indicated I've never been trained on Life Vest at this facility. On 2/11/25, at 10:35 a.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, that placed one resident (Resident R811) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. On 2/11/25, at 3:07 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -Facility will implement immediate education for nursing staff for care and operation of the Life Vest, on 2/11/25, to include what alerts mean, first responder instructions, emergency patient management, showering and laundering of vest. All additional staff will be in-serviced on care and operation of the Life Vest prior to the next shift worked. Any staff not scheduled prior to 2/12/25 will be contacted via telephone and educated prior to the next scheduled shift. Residents: -Resident R811's care plan will be revised to include use of the Life Vest on 2/11/25. Physician orders for R811 will be reviewed to ensure orders for care and operation of the Life Vest are present and being followed on 2/11/25. System Correction: -The NHA and DON will review the policy and procedure for use of the Life Vest to be revised as necessary on 2/11/25. Policy for ensuring equipment needs on new admissions will be reviewed and revised to include communication of equipment needs by admissions staff to nursing staff prior to admission. Admissions director will be re-inserviced on communicating equipment needs to nursing department. Education needs regarding use of equipment will be assessed and provided prior to use. Monitoring: -The NHA will audit all new admissions for 30 days to ensure all equipment needs for new admissions are being met and staff are educated on equipment prior to use. Education, policy revision, and ongoing audits will be shared with Quality Assurance and Performance Improvement (QAPI) committee. During an interview on 2/12/25, at 11:00 a.m. NA Employee E2 indicated, Yes, I was trained on the Life Vest. They said he could take a shower, and I went in with him when he removed the vest. I'm glad I know now. During an interview on 2/12/25, at 11:05 a.m. NA Employee E1 indicated I was trained on the Life Vest. It's pretty amazing what that thing can do. I feel better about it now. During an interview on 2/12/25, at 11:15 a.m. RN Employee E4 indicated I was trained on the Life Vest. Now I know how long it can be off for. During interviews on 2/12/25 - 2/13/25, a total of 64 in person interviews of clinical staff was conducted and verified Life Vest training had occurred, and they had understanding of the education. -Verified the DON trained 91.1% of nursing staff. -Verified Resident R811's care plan was revised to include use of the Life Vest. Physician orders were reviewed and include the operation of the Life Vest on 2/12/25, at 9:10 a.m. -Verified the NHA and DON reviewed and revised the policy for Life Vest and policy for ensuring equipment needs by admissions staff to nursing staff prior to admission. Admission Director was re-educated on 2/12/25. -Verified the NHA will audit all new admissions for 30 days to ensure all equipment needs for new admissions are being met and staff are educated on equipment prior to use. Education, policy revision, and ongoing audits will be shared with Quality Assurance and Performance Improvement (QAPI) committee. -Verified the DON completed an audit on 2/12/25, at 11:08 am of all new admissions as of 2/11/25. Next meeting is 2/27/25. The Immediate Jeopardy was lifted on 2/13/25, at 11:51 a.m. when the action plan was verified. During an interview on 2/11/25, at 10:35 a.m. the NHA and DON confirmed that the facility failed to ensure that nursing staff have the specific competencies, and skill sets necessary to provide care for a resident with a Life Vest which created a situation that placed one resident (Resident R811) in immediate jeopardy in which health and safety were impacted. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(a)(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)Resident rights. 28 Pa Code 211.5(f) Clinical records 28 Pa. Code: 211.10 (c)(d) Resident care policies 28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain a sanitary environment for food preparation, storage and transport, which created the potential for cross-contamination and food borne illness and placed 452 of 452 residents in Immediate Jeopardy. Finding include: Review of facility policy Sanitation dated 10/1/23, indicated the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Kitchen waste that are not disposed of by mechanical means shall be kept in clean, leak-proof, nonabsorbent, tightly closed containers and shall be disposed of daily. During an observation of the Main Kitchen with Dietary Manager Employee E9 on 6/25/24, at 11:30 a.m. the following was observed: - Numerous (greater than 50) bags of kitchen refuse stored in the dish room area. - The loading dock area directly off the kitchen (where food items and kitchen supplies are delivered), was piled with an uncountable number of garbage bags. Trash was lined up on the dock, and the dumpster was overflowing. The dock was being used for storage of refuse as the dumpster was full. - The kitchen entry way had notable odor; numerous piles of empty boxes were stacked up. Interview at this time with Dietary Manager E9 confirmed boxes were on the way to dumpsters, but there wasn't room on the loading dock to put the boxes as the dumpster was full, and that the dumpsters were full as the trash company did not come to pick up the waste. - Elevator extremely dirty and with a foul odor. During an interview on 6/25/24, at 11:45 a.m., Dietary Employee E26 stated, Trash is piling up inside the kitchen, dumpster was delivered this am. During an observation of the Main Kitchen on 6/25/24, at 12:15 p.m. the following was observed: - The floor with significant amounts of trash, spilled food, cartons of milk, and other refuse on it. - Food prep tables had trash and food items underneath them. - The shelving on prep tables was soiled with both food residue and trash. - A box of potatoes was on the floor, and next to it was a dead frog. - Mixing bowls were stored not inverted on a broken shelf, with one end of the shelf resting on the ground. - Other dishes and food preparation items were stored not inverted allowing dust and debris to collect in them. - Flatware was stored in dish racks with bins placed on top of them, coming into contact with the flatware. - A large hole in the wall of the storeroom. - Kitchen walls were unclean with dust and grease adhered to them. During an interview on 6/25/24, at 10:00 p.m. Dietary Cleaner E18 stated that he worked as the cook tonight, which has had to do frequently due to low dietary staffing. During an observation of the Main Kitchen on 6/26/24, at 9:30 a.m. the following was observed: - The floor had dirty with debris and liquids. [NAME] and white substances on floor. - Dirty washcloths placed on kitchen machines. - Cooler #89 leaking a brown liquid. When opened the door was opened there was bad odor. - The area under handwashing sink had numerous garbage items, fruit flies, and open drink cans. - Floor behind tray holder had trash and dead insects on it. - The areas under steam tables contained trash items including used gloves, crumbs, trash, and other debris, same as the previous evening. - The floor under cooking areas were covered with debris, same as were present the previous evening. On 6/26/24, at 12:18 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed, and the Immediate Jeopardy template was provided to facility administration. On 6/26/24, at 7:35 p.m. an acceptable Corrective Action Plan was received which included the following interventions: - On 6/25/24, all refuse bags and boxes not specifically in a refuse receptacle or in proper use in a refuse receptacle were properly disposed of from the kitchen area and outdoor loading dock. - The refuse vendor hauled refuse away on 6/25/24. - The area where refuse is disposed of, and service elevator were sanitized on 6/25/24. - The kitchen main floor will be swept and mopped and sanitized on 6/26/24. - Prep tables and shelving will be sanitized and refuse removed 6/26/24. - Mixing bowls and other dishes and food prep items will be cleaned and will be stored inverted on 6/26/24. - Kitchen walls will be cleaned 6/26/24. - Bins will be removed from on top of stored flatware and properly stored on 6/26/24. - Holes in the wall of the storeroom will be repaired 6/26/24. - Broken shelf will be repaired 6/26/24. - Cooler #89 odor and leak are due to being off and not in use as of 6/26/24, in order to be properly defrosted, and will be deodorized prior to being put back into use. - Cooking stations, steam table areas and behind tray holders will be cleared of debris on 6/26/24. - The employer is advertising on multiple community platforms and continues to work with the union to recruit and fill currently open positions. - The Director of food services and Administrator will audit the kitchen daily for cleanliness for a period of four weeks. - Food service staff who are scheduled on the shifts will be responsible for cleaning their work area. - All food service staff including the Director of Food Services will be re-in serviced by the Administrator and Educator the on the regulation for kitchen sanitation and the procedure for ensuring a clean workspace, in the kitchen, including proper disposal location of refuse to the dumpster/compactor as well as the procedure for identifying and communicating broken items that require repair. -The refuse vendor is scheduled to pick up bi-weekly Audit findings will be shared with QAPI committee at least quarterly. Inservice focus to include: - Thorough cleaning and sanitization practices, areas requiring cleaning, proper chemicals and best use. - Employee responsibility regarding sanitization of work area assignment - Employee hygiene, best practices when in the kitchen and handling food - Preventative measures for cross contamination - Hand washing and glove expectations - Proper storage of dishware, cleaning items and cleaning products - Proper reporting of items requiring repair During an observation of the Main Kitchen on 6/27/24, at 9:51 a.m. - Floors have been swept, most debris have been removed - Shelf fixed, and mixing bowls stored appropriately. - Area behind sink cleaned - The hole in the storage room wall was repaired. During an interview on 6/27/24, at 9:53 a.m. Dietary Employee E14 confirmed she received education on washing hands, sanitization, keeping the floors clean and work area clean. During an interview on 6/27/24, at 9:57 a.m. Dietary Employee E22 confirmed she received education this morning concerning cleaning, hair nets, and maintaining a clean workstation. During an interview on 6/27/24, at 9:58 a.m. Dietary Employee E23 confirmed she received education this morning concerning cleanliness and hand washing. During an interview on 6/27/24, at 10:00 a.m. Dietary Employee E24 confirmed she received education on hair nets, basically everything, glove around foods. cleaning outside of oven. During an interview on 6/27/24, at 10:02 a.m. the Dietary Manager Employee E9 confirmed that the wall in the storeroom was repaired, that he received education and that education was provided to all staff last night staff and this morning. During an interview on 6/27/24, at 10:06 a.m. Dietary Employee E25 confirmed she received education on cleaning, trays, and safety. During an interview on 6/27/24, at 10:08 a.m. Dietary Employee E26 confirmed she received education on cleaning and sanitization. During an interview on 6/27/24, at 10:10 a.m. Dietary Employee E26 received education and signed a paper making sure we clean and sanitize. During a review on 6/27/24, at 3:14 p.m. of the Dietary staff education sign-in sheets revealed 23 of 32 staff members received education related to the Immediate Jeopardy situation. Of the remaining nine staff members, six had not been scheduled during the time of the Immediate Jeopardy, and the Dietary Manager Employee E9 confirmed that they will receive education prior to commencing their work duties when they report later on 6/27/24, or 6/28/24, depending on their schedule. The two staff members on vacation will receive education when they return to work in the next week. One staff member was on medical leave, with an unknown return date and will be education if/or when returns to work. The Immediate Jeopardy was lifted on 6/27/24, at 3:20 p.m. when the action plan implementation was verified. During an interview on 7/2/24, at 3:20 p.m. the Nursing Home Administrator confirmed the facility failed to maintain a sanitary environment for food preparation, storage and transport, which created the potential for cross-contamination and food borne illness and placed 452 of 452 residents in Immediate Jeopardy. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code: 207.2 (a) Administrator's Responsibility. 28 Pa. Code 207.4 Ice containers and storage. 28 Pa. Code 211.6(c)(d)(f) Dietary services.

Based on a review of vendor invoices, facility financial documents, as well as interviews with vendors and staff, it was determined that facility failed to pay bills in a timely manner which caused interruption of services, and created an immediate jeopardy situation for 452 of 452 residents. Findings include: 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated 7/1/23, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. Review of a facility provided accounts payable ledger for Waste Disposal Vendor V1 revealed payments made on 3/6/24, with no further payments received until partial payments on 6/17/24. During an observation on 6/25/24, at approximately 9:15 a.m. refuse bags were observed on the loading dock, extending to the ceiling of the loading dock, and within the Main Kitchen, refuse bags with kitchen waste were observed stored in the dishwashing area. During an interview on 6/25/24, at 12:23 p.m. Waste Disposal Vendor V1 stated that waste pick-up was not provided to the facility due to non-payment of previous invoices. Vendor V1 stated that payment was required, with an additional retainer amount paid to restart waste disposal services to the facility. Review of an electronic communication dated 6/25/24, at 5:35 p.m. revealed, [Facility] has a tendency to get behind on their bills, and we have tried to work with them. Unfortunately, we are concerned about their viability. During a follow-up interview on 6/26/24, at 3:58 p.m. Waste Disposal Vendor V1 stated that the account was past-due on the pick-up date of 6/13/24. Vendor V1 state he provided a grace pick-up on that date, but did not provide waste removal service on 6/20/24, due to not receiving payment, Until I had the money, I didn't want to pick up. Review of a facility provided accounts payable aging schedule on 6/25/24, revealed Sewer Services Vendor V2 had a past due balance of $83,279.87. No payments were documented from 1/1/24, through 6/25/24. During an interview on 6/26/24, at 12:32 p.m. Sewer Services Vendor V2 confirmed the lack of payments received and stated that the Sewer Services solicitor has begun to take legal steps to stop sewer services to the facility. During an interview on 6/27/24, at 3:38 p.m., Sewer Services Vendor V2 stated new charges have been issues as of 6/26/24 ($35,487.59), bringing the total balance to $209, 867.96, $174,380.37 of which was past due. Review of a facility provided confirmation on 6/27/24, revealed a payment of $83,279.95, bring the total balance (including late fees) to $126,588.01, $91,100.42 of which was past due. During a confidential interview on 6/25/24, a staff member stated that facility ran out of oxygen for the residents. Review of a facility provided accounts payable ledger for Oxygen Vendor V3 revealed payments made on 4/5/24, with no further payments received until payments on 6/5/24. During an interview on 6/26/24, at 11:50 a.m. Oxygen Vendor V3 confirmed that they provide bulk (large oxygen holding tank outside of the facility that provides in-wall oxygen access to the residents in their rooms) and single cylinder oxygen. Oxygen Vendor V3 stated, I have to track them down to get payment. Oxygen Vendor V3 stated that they had been told that a check had been sent, so services were continued, but the check had not been received, so they did not provide refilling service to the bulk oxygen container. Services were continued when the account was made current, and a retainer was provided to Oxygen Vendor V3 against future charges. During a confidential interview on 6/26/24, a staff member stated that the biohazard area in the basement full of biohazard materials they are trying to get it out of here before you find it. During an interview and observation with Registered Nurse (RN) Employee E29 on 6/26/24, at 2:14 p.m. 21 large red containers of biohazardous waste and numerous sharps disposal containers laying on top of red biohazardous bags were observed in the basement storage area. During an interview on 6/26/24, at 2:33 p.m. Environmental Services (EVS) Employee E28 stated that it has been about two months since biohazardous waste was picked up, and that the regular schedule had been every two weeks. Review of a facility provided accounts payable ledger for Biohazardous Waste Vendor V4 revealed payments made on 3/31/24, with no further payments received until payments on 6/5/24. During an interview on 6/26/24, at 2:50 p.m. Biohazardous Waste Vendor V4 confirmed the last pick-up was on 5/14/24. Per Biohazardous Waste Vendor V4, the facility was placed on credit hold for non-payment effective 5/17/24. Facility made payments from 6/5/24, through 6/20/24, totaling $3915.85, and are due to have pick up on 6/27/24. Review of a facility provided accounts payable aging schedule on 6/25/24, revealed charges for Dialysis Vendor V5 for services in April 2024 and May 2024, totaling $23,880.00. Review of a facility provided accounts payable ledger for Dialysis Vendor V5 revealed payments made on 6/5/24 (totaling $24,340.00), for services received for February 2024 and March 2024. with no further payments documented. Review of an electronic communication dated 6/27/24, at 1:31 p.m. Dialysis Vendor V5 agreed to billing on a Net 60 (customers pay invoices within 60 calendar days from the invoice date), with the understanding that future invoices would be paid timely. Review of a facility provided accounts payable ledger for Ambulance Vendor V6 revealed the most recent payment made on 6/3/24. During an interview on 6/27/24, at 10:58 a.m. Ambulance Vendor V6 confirmed that their invoices are to be paid on a Net 30 (customers pay invoices within 30 calendar days from the invoice date) basis. Ambulance Vendor V6 stated she has to keep them on a short leash regarding payments. She stated that she provides a one-week warning, to remind the facility to pay the bill. Ambulance Vendor V6 confirmed that they have had to cease providing non-emergency transportation in the past, due to non-payment. During a review of a vendor provided electronic communication dated 6/27/24, at 12:11 p.m. revealed confirmation of a previous interruption of non-emergency service on 2/8/24, due to non-payment. Review of a facility provided accounts payable ledger on 7/3/24, revealed charges for Staffing Vendor V7 totaling $371,466.14. The last payment documented on the ledger was posted 4/30/24. During an interview on 6/26/24, at 12:04 p.m. Staffing Vendor V7 confirmed that last payment was made in April 2024, and stated, We have been promised payment will be issued in the next couple weeks. On 6/26/24, at 4:49 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed, and the Immediate Jeopardy template was provided to facility administration. On 6/26/24, at 7:35 p.m. an acceptable Corrective Action Plan was received which included the following interventions: - The refuse vendor was paid to terms, including a retainer as of 6/17/24. -The oxygen vendor was paid to terms per terms including a retainer as of 6/18/24. -The ambulance service is paid to terms as of 6/5/24. - The biohazard vendor was paid to terms 6/21/24 and a scheduled pick up of medical waste had been confirmed on 6/25/24 for 6/27/24. The staffing agency has agreed on 6/26/24 to continue services with a payment plan in place. - The dialysis center has agreed on 6/26/24 to continue services with a payment plan in place. - The facility will make an $80,000 payment to water management as of 6/27/24 and a second payment at the end of July 2024. - The Administrator will re in-service the accounts payable representative on the regulation to pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized. - The Administrator and Accounts Payroll processor will audit outstanding invoices for payment weekly for 4 weeks. - Audit findings will be shared with QAPI committee at least quarterly. During further review and follow-up interviews, the following information was provided: Waste Disposal Vendor V1: During an interview on 6/27/24, at 3:58 p.m. Waste Disposal Vendor V1 stated they will continue to provide service, on the condition the retainer is renewed if funds are used. Sewer Services Vendor V2: Review of an electronic communication dated 6/28/24, at 1:40 p.m. revealed Sewer Services Vendor V2 agreed to maintain services to the facility if a payment of $94,932.91 is made by 7/25/24 to the vendor. Oxygen Vendor V3: During an interview on 6/26/24, at 11:50 a.m. Oxygen Vendor V3 confirmed services were continued when the account was made current via a wired payment, and a retainer was provided to Oxygen Vendor V3 against future charges. Observation on the nursing units throughout the survey revealed wall-oxygen in use. Biohazardous Waste Vendor V4: Observation on 6/28/24, at 9:30 a.m. confirmed the packaged biohazardous waste was picked up by the vendor. Dialysis Vendor V5: Review of an electronic communication dated 6/29/24, at 11:14 p.m. revealed Dialysis Vendor V5 confirmed that there will not be a service interruption. Ambulance Vendor V6: During an interview on 6/27/24, at 10:58 a.m. Ambulance Vendor V6 confirmed that the bill is current, with the next bill not being due until 7/8/24. Staffing Vendor V7: Review of an electronic communication dated 6/27/24, at 2:53 p.m. revealed Staffing Vendor V7 confirmed that they are working on a payment plan with accounts payable to catch up on past due invoices, and confirmed they will continue to provide services. During the course of the survey, the following additional concerns with vendor payments were noted: Municipal Water Vendor V8: Review of a facility provided accounts payable aging schedule on 6/25/24, revealed charges for Municipal Water Vendor V8 for services in April 2024 and May 2024, totaling $73,897.13. During an interview on 7/2/24, at 9:55 a.m. Municipal Water Vendor V8 confirmed that the facility is past due on two months of water service ($67,571.60), and has one current month due ($37,102.18), totaling: $104,673.78. Municipal Water Vendor V8 confirmed that for the safety and well-being of the residents, services would not be terminated. Fire Alarm Vendor V9: During observations on multiple days of the survey, the emergency exit doors on the Three East and Four East unit stairwells had staff seated in front of them. Interviews with the staff confirmed that the door alarms were not operable. Review of a facility provided accounts payable ledger for Fire Alarm Vendor V9 revealed an invoice for services for May 2024. During an interview on 6/27/24, at approximately 12:00 p.m. Fire Alarm Vendor confirmed that the facility had been placed on a credit hold due to non-payment, and they were not providing services. When the doors broke (Three East and Four East) payment was made. Fire Alarm Vendor confirmed that they were scheduled to repair the doors next week. Electronic Medical Record Vendor V10: Review of a facility provided accounts payable ledger for Electronic Medical Record (EMR) Vendor V10 revealed a balance of $96,810.68. The most recent payment documented on the ledger was posted 9/20/23. During an electronic communication on 6/30/24, information on a point of contact with EMR Vendor V10 and/or confirmation that services will not be interrupted was requested. The facility was unable to provide this information as of the survey exit on 7/2/24. Electricity Vendor V11: Review of a facility provided accounts payable ledger for Electricity Vendor V11 revealed a balance of $119,409.30. No payments were posted from 1/1/24, though 7/2/24. During an interview on 6/27/24, at approximately 10:00 a.m. information on a point of contact with Electricity Vendor V11 was requested. The facility was unable to provide this information as of the survey exit on 7/2/24. Natural Gas Vendor V12: Review of a facility provided accounts payable ledger for Electricity Vendor V11 revealed a balance of $72,930.08. During an interview on 6/27/24, at approximately 10:00 a.m. information on a point of contact with Natural Gas Vendor V12 was requested. The facility was unable to provide this information as of the survey exit on 7/2/24. During an interview on 7/2/24, at 3:20 p.m. the Nursing Home Administrator confirmed the facility failed to pay bills in a timely manner which interruption of and services, and created an immediate jeopardy situation for 452 of 452 residents. 28 Pa. Code 201.14(g) Responsibility of licensee. 28 Pa. Code 201.18(e)(1)(2) Management.

Based on a review of the Amercian Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by ensuring resident desire for CPR was consistent, clear and able to easily be determined by staff for one of three Residents (Resident R468), which placed 467 of 467 residents, in immediate jeopardy to their health and safety with the potential for death because of a similar occurrence. Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicates under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all the following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals. Review of the AHA Guidelines dated 2020, indicated if a person is not breathing and has no pulse for more than 10 seconds, start CPR. The facility's CPR policy titled Emergency Response Guideline reviewed [DATE], indicated the following guidelines are available and are to be utilized in the event of a resident emergency. First, determine resident's unresponsiveness, then notify or leave another staff member and immediately notify a licensed nurse. It was indicated to active emergency in house emergency communication system, verify the resident's code status, call 911, and if necessary, initiate cardiopulmonary resuscitation (CPR). It was indicated to chart completely all events leading up to the situation, what transpired during the situation, and the events that followed. All information along with the date, time, and the nurse's signature should be documented in the nurse's notes. Resident R468's clinical record revealed an admitted [DATE], with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and bipolar disorder (mental illness characterized by extreme mood swings.) Review of Resident R468's Minimum Data Set (MDS- a periodic assessment of care needs) dated [DATE], indicated the diagnoses were current. Review of Resident R468's physician order dated [DATE], through [DATE], indicated Resident R468 was a full code (allows for all interventions needed to restore breathing or heart functioning). The order was discontinued on [DATE], and in the notes section it was indicated the resident ceased to breathe on [DATE], at 9:50 p.m. Review of Resident R468's physician order dated [DATE], through [DATE], (after the resident ' s death) entered by Registered Nurse (RN), Employee E11 indicated do not resuscitate. Review of Resident R468's closed record revealed a POLST form dated [DATE], indicated if the resident has no pulse and is not breathing, do not attempt resuscitation (DNR). The form was signed by Nurse Practitioner, Employee E12 and it was indicated a verbal consent was provided from Resident R468's brother who was listed as an emergency contact. Review of Resident R468's care plan dated [DATE], indicated the resident was a full code. Interventions indicated CPR will be performed as ordered. Review of Resident R468's progress note dated [DATE], at 9:50 p.m. entered by Licensed Practical Nurse (LPN) Employee E2, indicated she and RN Supervisor Employee E3, were called to the unit due to the residents absent vital signs. It was indicated the resident ceased to breathe at that time. The resident's emergency contact and provider were notified. There was no documentation that CPR was administered as ordered. During an interview on [DATE], at 10:12 a.m. the Director of Nursing (DON) and Unit Manager RN, Employee E11 confirmed CPR was not initiated for Resident R468 on [DATE], because the facility staff referred to her POLST and it indicated to DNR. The DON stated she contacted the nurse practitioner who completed the POLST on [DATE], and confirmed the order to Do-Not-Resuscitate was not entered in Resident R468's electronic clinical record. The DON stated the nurse practitioner's notes are supposed to transfer to point click care, and it does not always do that. The DON confirmed the resident's DNR order on her POLST should have been reflective in her electronic record. Unit Manager RN Employee E11 stated when she came back to work the following day, she reviewed Resident R468's death, and discovered the order to not resuscitate wasn't transcribed and she entered an order to Do-Not-Resuscitate on [DATE], after the resident was dead. The resident's POLST form did not align with the code status on electronic record, placing all residents at risk if they became unresponsive and pulseless, which resulted in an Immediate Jeopardy situation. On [DATE], at 2:19 p.m. the Director of Nursing was notified that an immediate jeopardy was identified and was provided a copy of the completed IJ template, and a written IJ removal plan was requested at 2:20 p.m. On [DATE], at 6:23 p.m. an Immediate Action Plan was accepted with the following actions: Immediate Action: -All residents were reviewed for code status, including orders, POLST, and care plan are accurate by [DATE], by the Director of Nursing or Designee. -All nursing staff must be educated on ensuring code status is implemented as ordered by Director of Nursing or Designee prior to the next scheduled shift. -CPR policy will be reviewed and revised by [DATE]. -The Director of Nursing or Designee will conduct audits of residents code status to ensure accuracy and repot findings to Quality Assurance and Performance Improvement (QAPI) meetings. The facility's CPR policy titled Emergency Response Guideline was revised and reviewed on [DATE], and indicated to first determine unresponsiveness, notify, or have another staff member immediately notify a licensed nurse, then verify the resident's code status, activate in-house emergency communication system if required, call 911, and initiate CPR if necessary. 467 of 467 residents code status, including orders, POLST and care plan were reviewed and accurate as of [DATE]. On [DATE], at 10:20 a.m. 207 of 207 nursing staff verified they were educated prior to start of their shift via signature sheet. All nursing staff in facility on [DATE], were interviewed and confirmed training and understanding. All nursing staff were educated on what to do in an event of an emergency. Staff must determine unresponsiveness, notify a license nurse immediately, verify resident's code status. If an emergency response required, activate in-house emergency communication system, and call 911. If necessary, initiate cardiopulmonary resuscitation (CPR) and chart completely all events up to situation, what transpired during situation, and the events that followed. The physician and responsible must be notified. The facility will continue to educate all nursing staff prior to the start of the shift. The Director of Nursing or designee will conduct audits to ensure policy is being followed and findings will be reported in upcoming QAPI meetings. On [DATE], the Immediate Jeopardy was lifted at 1:34 p.m. after ensuring the Immediate Plan of Correction had been implemented. During an interview on [DATE], at 10:46 a.m. LPN, Employee E16 stated if a resident is not breathing, she would check the resident's POLST. LPN, Employee E16 stated the order on the POLST form must be carried over to the resident's clinical record immediately. It was indicated staff can check a resident's code status on the electronic record or their paper chart depending on their preference. During an interview on [DATE], at 10:40 a.m. LPN, Employee E18 stated if a resident ceases to breathe, the resident's code status is checked in the resident's paper chart, It was indicated the orders must be updated in the resident's electronic chart. During an interview on [DATE], at 10:49 a.m. LPN, Employee E8 stated if she needs to check a resident's code status, she always uses the electronic record and looks at the physician order. LPN, Employee E8 stated it is quicker to check a resident's code status in the electronic record. Us floor nurses would look in the electronic record rather than the paper chart. During an interview on [DATE], at 12:01 p.m. LPN, Employee E2 indicated to check a resident's code status, staff can look at computer or paper chart. It was stated if a POLST was completed or updated, it must instantly be changed in the electronic record. During an interview on [DATE], at 12:45 p.m. Registered Nurse Supervisor, Employee E44 stated staff can find a resident's code status either in the computer or in their paper chart. RN, Supervisor stated, I am going to go with the one that is currently up to date and It definitely creates a delay trying to find which one is more up to date, time is of the essence. It was indicated on [DATE], RN Supervisor Employee E44 was called to Resident 468's room and stated her medical chart was in the room and her POLST indicated she was a DNR. It was indicated the resident was warm to touch, her time of death was confirmed by him and LPN, Employee E2. The resident did not have a blood pressure or apical pulse (a pulse point on your chest at the bottom tip of your heart). RN, Supervisor, Employee E44 stated LPN, Employee E2 documented everything regarding Resident R468. During an interview on [DATE], at 1:13 p.m. LPN, Employee E2 stated when she was called to Resident R468's room, the first question she asked was, what was her code status, and stated LPN, Employee E48 had her paper chart pulled. It was verified she was a DNR by her POLST, and CPR was not adminstered. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(d)(j) Resident rights. 28 Pa. Code 211.10(c) Resident care policies.

Based on review of facility policy, observations, clinical records, and staff interviews it was determined that the facility failed to make certain residents received adequate supervision to smoke safely for five of six residents observed (Residents R21, R116, R425, R448, and R464), failed to complete safe smoking assessments, to obtain physician orders for smoking, to have/implement care plans reflective of residents' smoking needs, and to have adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 74 of 74 residents that smoked. The facility failed to make certain residents were free from accidents and hazards related to smoking resulting in actual harm of a burn for one of six residents (Resident R384). Findings include: Review of the facility policy Smoking Policy, dated 10/1/23, indicated the facility is a smoke free facility. Designated smoking areas have been established outside the building for those residents, staff or visitors who choose to smoke. -Upon admission, residents who smoke will be reviewed for safety with independence in smoking. -Licensed staff will be responsible for completion of the resident smoking review upon admission. -Residents who are assessed to be unsafe to smoke independently will be supervised. -Residents who require supervision will be reviewed by the interdisciplinary team to determine appropriate interventions to allow them to smoke in the safest manner possible. -Interventions will be individualized based on the needs of the resident. -These interventions will include but not be limited to wearing a smoking apron (prevent burns in clothing and keep hot ashes from burning the skin), smoking only when supervised by staff or a responsible party, etc. -Smokers will be assessed for safety on admission, quarterly, and as needed based on individual circumstances and changes in the resident's condition. -To ensure the safety of all residents, smoking supplies for residents who require supervised smoking will be kept locked in the smoking cart and provided to the resident upon request. Review of the facility policy, Incident and Accident Reports dated 10/1/23, indicated the facility will document all unusual occurrences and events, including injuries of unknown origin. The following occurrences warrant an incident report: Changes in skin integrity, including burns. Resident R21 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/25/24, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar), seizures (sudden uncontrolled movements), and bilateral amputations (surgical removal of a limb) above the knee. Resident R21's Nursing Smoking Safety Screening V1 dated 7/7/23, revealed the following: -Resident smokes 5-10 cigarettes a day. -Likes to smoke in the morning, afternoon, evenings, and nights. -Resident needs adaptive equipment of a smoking apron and supervision. -Resident is aware that the facility needs to store lighter and cigarettes - Yes. -Plan of care is used to assure resident is safe while smoking - Yes. Review Resident R21's care plan dated 1/2/24, indicated at risk for smoking related injury related to: -History of smoking incidents - smoking in non-designated areas. -Does not follow facility smoking policy. -Assist to and from Designated Smoking area -Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, and immediately inform facility management. -Patient not to have cigarettes or smoking material on person. -Review smoking policy with patient. -Storage of smoking materials per facility policy. Review of Resident R21's physician orders as of 2/26/24, at 11:00 a.m. failed to include orders for smoking, and adaptive equipment needed for smoking safely. During an observation on 2/27/24, at 9:54 a.m., Resident R21 was observed in a wheelchair, lighting a cigarette, and stated, This is all we have here. Resident R21 failed to have a smoking apron on and had cigarettes and a lighter in his hand. No staff were present. Resident R116 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the diagnoses of diabetes, high blood pressure, and stroke. Resident R116's Nursing Smoking Safety Screening V1 dated 4/11/22 (22 months prior), at 2:26 p.m. and revealed the following: -Resident smokes 2-5 cigarettes a day. -Likes to smoke in the morning, afternoon, evenings, and nights. -Resident needs adaptive equipment of a smoking apron. -Resident is aware that the facility needs to store lighter and cigarettes - Yes. -Plan of care is used to assure resident is safe while smoking - Yes. Review Resident R116's care plan dated 5/15/23, indicated potential for safety hazard, injury related to smoking: -History of smoking incidents - in Cafe Mocha by computer and in room. -Resident will exhibit safe smoking habits and follow facility safe smoking practices set up by staff. -Activities to keep all smoking materials in cart per policy. -Provide a copy of facility smoking policy. -Smoking allowed only in designated area. -Smoking apron to be worn at all times while smoking. -While smoking, will have direct supervision by staff or family member. Review of Resident R116's physician orders as of 2/27/24, at 11:05 a.m. failed to include orders for smoking need, and adaptive equipment needed for smoking safely. During an observation on 2/27/24, at 9:45 a.m., Resident R116 was observed in a wheelchair, with a lit cigarette in his hand. His hand was resting on the oversized crouch area of his pants. Resident R116 failed to have a smoking apron and had a cigarette and lighter on his person. No staff were present. Resident R425 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the diagnoses of diabetes, high blood pressure, anemia (the blood doesn't have enough healthy red blood cells), and hepatitis (inflammation of the liver). Resident R425's Nursing Smoking Safety Screening V1 dated, 9/5/23 (16 months prior) revealed the following: -Resident smokes 2-5 cigarettes a day. -Likes to smoke in the morning, and afternoon. -Resident needs adaptive equipment of a smoking apron. -Resident is aware that the facility needs to store lighter and cigarettes - Yes. -Plan of care is used to assure resident is safe while smoking - Yes. -Safe to smoke with direct supervision. Review Resident R425's care plan dated 9/25/23, indicated: -risk for side effects/injury from smoking extremity range of motion limitations. -Resident will exhibit safe smoking habits and follow facility safe smoking practices set up by staff. -Complete safe smoking assessment per facility policy. -Resident's cigarettes and lighter will be provided by staff at appropriate times. -Resident will smoke in designated area. Review of Resident R425's physician orders as of 2/27/24, at 11:07 a.m. failed to include orders for smoking, and adaptive equipment needed for smoking safely. During an observation on 2/27/24, at 9:45 a.m., Resident R425 was observed standing in the far corner of the area with a lit cigarette in his hand. No staff were present. Resident R448 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the diagnoses of high blood pressure, seizures, and ulcerative colitis (chronic inflammatory bowel disease of the digestive tract). Review of Resident 448's clinical record on 2/27/24, failed to include a Nursing Smoking Safety Screening V1. Review Resident R448's care plan dated 1/4/23, failed to include a care plan that reflected the resident's smoking needs, and adaptive equipment needs for smoking safely. Review of Resident R448's physician orders as of 2/27/24, at 11:38 a.m. failed to include orders for smoking. During an observation on 2/27/24, at 9:45 a.m., Resident R448 was observed standing in the area and lit a cigarette with a lighter from his pocket and indicated This place is run like a prison. No staff were present. Resident R464 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the diagnoses of stroke, hemiparesis (weakness/paralysis on one side of the body), and high blood pressure. Review of Resident R464's Nursing Smoking Safety Screening V1 dated 2/5/24, revealed the following: -Does the resident have cognitive loss? - Yes -Does the resident have visual deficit? - Yes -Resident smokes 1-2 cigarettes a day. -Likes to smoke in the evenings. -Resident needs adaptive equipment of supervision. -Resident is aware that the facility needs to store lighter and cigarettes - Yes. -Plan of care is used to assure resident is safe while smoking - Yes. -Supervised smoking per policy. Review Resident R464's care plan dated 2/5/24, indicated: -resident has a history of smoking. -Resident is at risk for side effects/injury from smoking. -Resident will not smoke while utilizing nicotine patch. -Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff. -Do smoking assessment if resident requests to smoke for safety of smoking. -Encourage resident not to smoke related to recent stroke and health reasons. -Resident's cigarettes and lighter will be provided by staff at appropriate times. -Resident will smoke in designated area. During an observation on 2/27/24, at 9:45 a.m., Resident R464 was observed in a wheelchair with a lit cigarette in his hand. Resident had cigarettes on his lap. No staff were present. During an observation of the lobby to the outside pavilion area (designated smoking area) on 2/26/24, at 8:45 a.m., revealed a sign that stated Smoking Times: 9:15 a.m., 11:30 a.m., 1:30 p.m., 3:45 p.m., and 7:45 p.m. During an observation on 2/26/24, at 10:00 a.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West. During an observation on 2/26/24, at 12:00 p.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West. During an observation on 2/26/24, at 2:10 p.m., revealed residents freely coming in and out of the door to the smoking area from the unlocked door outside of Unit 2 West. During an interview on 2/26/24, at 2:10 p.m. Nurse Aide (NA) Employee 43, indicated residents are in and out all-day smoking in between the scheduled smoking times that are supervised with the Activities Department. During an interview on 2/26/24, at 2:30 p.m., Resident R205 indicated Oh, they just let us go. We're out here all day with or without the staff. During an interview on 3/12/24, at 10:36 a.m., Unit Manager RN Employee E11 indicated we have no smokers currently. When asked how residents were able to be outside unsupervised and smoke, she indicated the alert and oriented smokers would come at the tail end and then just stay out there after the supervised session was over. During an interview on 3/12/24, at 10:46 a.m., LPN Employee E16 indicated the door to the smoking area has been unlocked for a while now so the residents can go in and out as they wish. During an interview on 3/12/24, at 11:45 a.m., NA Employee E20 indicated she's worked there since January 2024, and they go out on their own to smoke and others just go out for fresh air and to be outside. When asked where the residents got the cigarettes and lighters, she indicated they have them on them all the time. During an interview on 3/12/24, at 11:49 a.m., LPN Employee E8 indicated I've been here ten years, originally there was a smoking room inside just for the smokers. It was all cement blocks. When Covid-19 first hit, they moved it outside to the 2-West pavilion area. Later, the Covid-19 got so bad, nobody smoked at all. They made the original cement smoking room into a recreation room for the residents. It was always scheduled times and Activities Staff would take them out. At one point, the pavilion was unlocked because of all the alert and oriented residents that smoked out there all day by themselves. During an interview on 3/12/24, at 1:52 p.m., Activity Assistant Employee E46 indicated the residents who smoke have gone back and forth from supervised to unsupervised over the years. There was a cement block room inside at one time. Covid-19 hit, and nobody smoked. They opened 2-West pavilion area, it was locked, supervised times, smoking aprons, and the medication cart to hold the cigarettes. During an interview on 3/12/24, at 1:53 p.m., Activity Assistant Employee E47 indicated supervised smoking all stopped because the facility had too many alert and oriented smokers and it got out of control. There were only a few smokers who were compliant. During an interview with the Director of Nursing (DON) on 2/26/24, at 3:00 p.m., indicated the process for smoking is supervised by the Activity's Department at the scheduled times of 9:15 a.m., 11:30 a.m., 1:30 p.m., 3:45 p.m., and 7:45 p.m. They have an old medication cart that has all the smokers' cigarettes and lighters inside it, and they distribute them to each individual during the supervised times. During an observation on 2/27/24, at 9:54 a.m., the smoking area outside of the Unit 2-West, five residents (Residents R21, R116, R425, R448 and R464) were outside smoking without staff presence and supervision. The observations and resident interviews revealed that the residents were outside smoking for 23 minutes without staff supervision. Resident R384 was admitted to the facility on [DATE]. The MDS dated [DATE], indicated the diagnoses of high blood pressure, diabetes, and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident R384's Nursing- Smoking Safety Screening revealed it was last completed on 11/23/22 (16 months prior), at 3:27 p.m. revealed the following: -Resident smokes 5-10 cigarettes a day. -Likes to smoke in the morning, afternoon, and evenings. -Resident needs adaptive equipment of a smoking apron and supervision. -Due to elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) risk, Resident R384 is to have a staff member from the unit to accompany at all breaks. -Resident is aware that the facility needs to store lighter and cigarettes - Yes. -Plan of care is used to assure resident is safe while smoking - Yes. Review Resident R384's care plan dated 10/12/23, indicated resident is at risk for side effects/injury from smoking. -Injury on 10/12/23. Resident educated to not sit so close to other residents at smoke times. -Resident will exhibit safe smoking habits and follow safe smoking practices set up by staff. -Complete safe smoking assessment per facility policy. -Resident's cigarettes and lighter will be provided by staff at appropriate times. -Observe resident for unsafe smoking behaviors. Report to supervisor if noted. -Report any injuries to staff. -Resident's cigarettes and lighter will be provided by staff at appropriate times. -Resident deemed unsafe with standard supervised smoke break. For safety will be supervised at all times by unit staff, to during, and from smoke break, dated 11/23/22. Review of Resident R384's physician orders dated 5/3/23, indicated ok to smoke at designated smoking times. Must wear appropriate footwear. Review of incident and accident logs indicated on 10/11/23, at 7:54 a.m., Resident R384 was out smoking on last smoke break and another resident flicked the ashes of their cigarette, and an [NAME] hit his ankle and burned him. Review of Resident R384's incident report smoking injury dated 10/12/23, indicated that resident has a blister to left inner ankle with measurements of 3.5 centimeters (cm) x 4 cm. Resident R384 indicated he was out smoking at last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an [NAME] hit his ankle and burned him. Review of Resident R384's progress note dated 10/12/23, at 8:11 a.m. indicated the resident has a blister to left inner ankle. Resident R384 stated he was out smoking on last smoke break on 10/11/23, and another resident flicked the ashes of their cigarette and an [NAME] hit his ankle and burned him. During an interview on 3/12/24, at 12:10 p.m., NA Employee E49 indicated she was caring for Resident R384 on 10/11/23, when the burn occurred; however, the resident never mentioned he was burned. We all take turns to escort residents who require it to smoking and have to stay with them at all times. NA Employee E49 did recall Resident R384 requiring a dressing from the nurses on that leg. Review of the Nurse Practitioner Employee E10's wound note dated 10/12/23, at 8:47 a.m., indicated, Resident R384 was seen for a left ankle blister/burn for ongoing treatment and recommendations, and evaluation. Resident stated he was sharing a cigarette with another resident outside when a hot ash dropped on his ankle causing a burn/blister. The resident indicated he's not aware it's there until he looks at it. Integumentary (hair/skin/nails): left ankle burn. Fluid filled blister with brownish discoloration. During an interview with the DON on 2/27/24, at 12:00 p.m., confirmed Resident R384 acquired a blister/burn while out smoking and the facility failed to keep residents free from accidents and hazards related to smoking resulting in actual harm of a burn for one of six residents (Resident R384). During an interview on 2/27/24, at 1:00 p.m., the DON indicated the facility failed to make certain residents received adequate supervision, for five of six residents observed smoking (Residents R21, R116, R425, R448, and R464), and failed to complete safe smoking assessments, obtain physician orders for smoking, have/implement care plans reflective of residents' smoking needs, and adaptive equipment needs for smoking safely. This created an Immediate Jeopardy situation for 74 of 74 residents that smoke. On 2/27/24, at 4:12 p.m., the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed and was provided the IJ Template at that time and a corrective action plan was requested. During an interview on 2/27/24, at 5:54 p.m. the NHA stated he was implementing education for his Corrective Action Plan with the department heads. Survey Agency (SA) informed the NHA the Corrective Action Plan had to be approved prior to implementation. He verbalized understanding. On 2/27/24, at 6:16 p.m. the facility handed in a Corrective Action Plan. On 2/27/24, at 6:20 p.m. the NHA was informed that the Corrective Action Plan handed in was not accepted. On 2/27/24, at 7:53 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Upon identification from the survey team 2/27/24, at 4:12PM the following items shall be implemented. 1. All other resident smokers will be assessed for injuries related to smoking 2/28/24. 2. The smoking policy will be reviewed immediately and updated as of 2/27/24. 3. All resident smokers will have updated smoking assessments as of 2/28/24. 4. All resident smokers will have obtained orders for supervised smoking as of 2/28/24. 5. All resident smokers will have care plan reviewed and updated as of 2/28/24. 6. All resident smokers will be educated on the changes to the smoking policy as of 2/28/24. 7. All employees working in the building at the time of issuance will be re in serviced by director of nurses or designee on the changes to the smoking policy as of 2/27/24. a. All remaining employees will be educated on the changes to the smoking policy prior to the start of their next scheduled shift. b. Policy addition - resident smoking area will be closed and alarmed during none smoking times. c. Policy addition - Added Residents will not have the code? d. Policy addition - If residents are observed using the code maintenance will be informed to change the code immediately upon identification? 8. Resident smokers will be allowed to smoke in the designated smoking areas at designated smoking times, under supervision, with flame retardant equipment. a. Residents will be offered smoking cessation materials in the interim. b. Activities staff will be re in-serviced on ensuring resident smokers are wearing appropriate flame-retardant equipment prior to being permitted to smoke within the smoking area as of 2/28/24. 9. The smoking area shall be audited for supervision daily. 10. Resident outdoor smoking area was locked and alarmed as of 2/27/24, and code for door was changed to ensure residents do not have access to the designated smoking area unsupervised. a. Activities staff will be re-inserviced by the Nursing Home Administrator (NHA) on not providing the code to residents as of 2/28/24. 11. The Director of Nursing (DON) and NHA/designee shall monitor the progress of this corrective action. This corrective action shall be reviewed at QA (Quality Assurance) to monitor compliance. During an observation on 2/28/24, at 11:32 a.m,. the supervised smoking was observed. Activities staff were present with medication cart containing cigarettes, lighters, and smoking aprons. During an interview on 2/28/24, at 11:34 a.m., Activity Director Employee E36 indicated all residents were to wear protective aprons per the education they received. During an observation on 2/28/24, at 11:35 a.m., 14 residents observed outside smoking with three activities staff members. Adaptive equipment of 18 aprons and six fire retardant blankets were being utilized. A review of the facility's Corrective Action Plan audit on 2/28/24, indicated that all residents who smoke were listed as unsafe and made to wear aprons regardless of if they required one for safety. The review indicated that seven of the 73 smokers did not have a new Smoking Assessment completed as indicated in the plan, and that the assessments and care plans initiated were not resident specific or individualized. All education, assessments, care plans, and physician orders would have to be re-conducted. Review of facility's immediate action plan was verified and completed on 2/29/24, at 5:44 p.m. as follows: 1. All other resident smokers will be assessed for injuries related to smoking 2/28/24. Verified 73 of 73 smokers were reassessed 2/29/24. 2. The smoking policy will be reviewed immediately and updated as of 2/27/24. Completed 2/28/24. 3. All resident smokers will have updated smoking assessments as of 2/28/24. Verified 73 of 73 smoking assessments completed as of 2/29/24. 4. All resident smokers will have obtained orders for supervised smoking as of 2/28/24. Verified 73 of 73 smokers have physician orders for smoking as of 2/29/24. 5. All resident smokers will have care plan reviewed and updated as of 2/28/24. Verified 73 of 73 resident smoking care plans were updated as of 2/29/24. 6. All resident smokers will be educated on the changes to the smoking policy as of 2/28/24. Verified 73 of 73 smokers were educated. 7. All employees working in the building at the time of issuance will be re in-serviced by director of nurses or designee on the changes to the smoking policy as of 2/27/24. a. All remaining employees will be educated on the changes to the smoking policy prior to the start of their next scheduled shift. b. Policy addition - resident smoking area will be closed and alarmed during non-smoking times. Observation on 2/28/24, at 9:00 a.m. revealed a secure keypad on the entrance to the smoking area that was locked and alarmed with a secured keypad. c. Policy addition - Added Residents will not have the code for the secured keypad smoking entrance. d. Policy addition - If residents are observed using the code maintenance will be informed to change the code immediately upon identification? All staff education verified via signature sheets 207 of 207, and all nursing staff in facility on 2/29/24, were interviewed 113 of 113, and confirmed training and understanding. 8. Resident smokers will be allowed to smoke in the designated smoking areas at designated smoking times, under supervision, with flame retardant equipment. Verified via observations of supervised smoking times on three of four occasions without issues. a. Residents will be offered smoking cessation materials in the interim. Verified this was completed 2/29/24. b. Activities staff will be re in-serviced on ensuring resident smokers are wearing appropriate flame-retardant equipment prior to being permitted to smoke within the smoking area as of 2/28/24. Verified 2/29/24. 9. The smoking area shall be audited for supervision daily. Verified as complete 2/29/24. 10. Resident outdoor smoking area was locked and alarmed as of 2/27/24, and code for door was changed to ensure residents do not have access to the designated smoking area unsupervised. Observed and confirmed 2/29/24. a. Activities staff will be re-inserviced by NHA on not providing the code to residents as of 2/28/24. Verified education and interviewed activities staff. Observed interactions during smoking sessions twice on 2/29/24. 11. The DON and NHA/designee shall monitor the progress of this corrective action. This corrective action shall be reviewed at QA to monitor compliance. The IJ was lifted on 2/29/24, at 5:44 p.m. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services 28 Pa. Code: 211.10 (c)(d) Resident care policies 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(a)(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to follow physician orders for two of two residents who were at risk for aspiration (Resident R318 and Resident R406). The facility failed to assess, monitor, and follow physician orders as required after a resident fell , resulting in death for one of five residents (Resident R468). This failure resulted in death and placed two of five residents at risk for injury and death if they had a fall and required post fall monitoring, which resulted in an Immediate Jeopardy situation. Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards through the Department of State indicates under the Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals. The facility's Fall Protocols policy dated 9/2014, last reviewed 10/1/23, indicated after a resident has a fall an immediate assessment will be conducted my nursing, and medical attention will be obtained as needed. It was indicated post fall monitoring shall be documented in the medical record. The resident's cognitive status (confused, lethargic, disoriented, aggressive, combative, acute change in status) will be monitored for any change in condition related to a possible or confirmed head injury. Review of the facility Nursing Department Staff policy last reviewed 10/1/23, indicated the nurse supervisor or charge nurse must record in the resident's medical record information relative to changes in the resident's medical or mental condition or status. to ensure the safety and well-being of residents, a resident check will be made at least every two hours throughout each 24-hour shift by nursing service personnel. Changes in the resident's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the nurse supervisor or charge nurse at once. The nurse supervisor or charge nurse must maintain documentation supporting the time, identity of person making the check, and outcome of each check. Review of the facility's Supervision of Resident Nutrition policy dated 10/1/23, indicated each resident shall receive proper nutrition in accordance with the resident's assessment, care plan, and physician orders. It was indicated residents needing assistance in eating must be promptly assisted upon being served. Review of the facility policy Flow of Care dated 10/1/23, stated care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning. It was indicated staff must be aware of special precautions, such as aspiration precautions (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the wind pipe.) Staff must follow the dining instructions on the tray card and care plan. Review of Resident R318's clinical record revealed an admitted [DATE], with diagnoses that included dementia (A group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and Gastroesophageal Reflux Disease (GERD-a common condition in which the stomach contents move up into the esophagus.) Review of Resident R318's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/8/24, indicated the diagnoses were current. Review of Resident R318's care plan dated 3/14/23, indicated the resident had GERD and to maintain aspiration precautions. Review of Resident R318's physician order dated 11/3/23, indicated for the resident to be upright 90 degrees for meals for safety. During an observation on 2/27/24, at 1:26 p.m. Resident R318 was observed being fed by NA, Employee E20. The resident was not positioned at 90 degrees. Review of Resident R406's clinical record indicated an admitted [DATE], with diagnoses that included Alzheimer's Disease (a type of brain disorder that causes problems with memory, thinking and behavior) high blood pressure, and Gastroesophageal Reflux Disease (GERD-a common condition in which the stomach contents move up into the esophagus.) Review of Resident R406's MDS, dated [DATE], indicated the diagnoses were current. Review of Resident R406's care plan dated 3/14/23, indicated the resident had GERD and to maintain aspiration precautions. Review of Resident R406's physician order dated 1/26/24, indicated the resident was a one-to-one feed with strict aspiration precautions. It was indicated the resident must be in an upright 90 degrees or head of bed elevated to 90 degrees for all meals and for more than 30 minutes after. During an observation on 2/27/24, at 1:42 p.m. Resident R406 was observed being fed by NA, Employee E20 and was not in an upright 90-degree position. The resident started coughing after being fed. Review of Resident R406 progress note dated 2/27/24, entered by Unit Manager, RN, Employee E18 stated it was reported that resident coughed during lunch feeding, educated CNA to raise HOB to 90 degrees during feedings. It was indicated the resident was assessed and no adverse outcomes occurred. During an interview on 2/27/24, at 1:48 p.m. Unit Manager, RN, Employee E18 confirmed the facility failed to follow physician orders for two of two residents who were at risk for aspiration (Resident R318 and Resident R406). Resident R468's clinical record revealed an admitted [DATE], with diagnoses that included heart failure (progressive heart disease that affects pumping action of the heart muscles), high blood pressure, and bipolar disorder (mental illness characterized by extreme mood swing). Review of Resident R468's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/7/23, indicated the diagnoses were current. Review of Resident R468's fall assessment titled NSG-MORSE FALL SCALE (PCC) dated 12/2/23, indicated the resident was a moderate risk for falling. Review of Resident R468's care plan initiated 12/4/23, and revised 12/21/23, indicated the resident had a potential for falls related to anxiety, depression, incontinence, medications, muscle weakness, and pain. It was indicated the resident had a fall on 12/10/23, and 12/20/23. Interventions included: complete fall risk assessment per facility protocol, ensure resident is not leaning forward while sitting in wheelchair, and monitor toilet needs. Review of Resident R468's progress note dated 12/10/23, indicated the resident had a fall and hit her head. The resident's right eye was bruised. Neurological checks (exam consists of a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves) were intiated. Family and physician were notified. Review of Resident R468's progress note dated 12/20/23, indciated the resident was leaning forward in her wheelchair and fell . Resident hit her head, neurological checks were initiated. Family and physician were notified. Review of Resident R468's clinical record failed to include a fall assessment that was completed as per the facility's policy after the resident fell on [DATE] and 12/20/23. Review of Resident progress note dated 12/25/23, at 1:38 p.m., Licensed Practical Nurse (LPN) Employee E14 stated patient was seen throwing herself on the floor in front of the nurse's station and twice down the hallway. The resident leans herself forward and dives down to the floor. No injures noted with each event. They were approximately 5 minutes apart from each other. It was indicated the physician and family were notified. Review of Resident R468's physician order dated 12/25/23, indicated, starting at 3:00 p.m. to monitor the resident for nine shifts post fall for a decreased in activities of daily living, change in vitals, pain, range of motion decrease, lethargy, decrease in appetite, any new ecchymosis (bruising) or swelling, and neuro checks if resident sustained a head injury. The order was discontinued on 12/25/23, at 10:38 p.m., the resident ceased to breathe at 9:50 p.m. Review of Resident R468's December 2023 Treatment Administration Record (TAR), failed to include documentation of the resident's vital signs that were ordered on 12/25/23, at 3:00 p.m. It was left blank, and not signed off for completion. Review of Resident R468's clinical record and closed record failed to include documentation of the resident's post fall monitoring and vital signs on 12/25/23. Review of Resident R468's progress note dated 12/25/23, at 9:50 p.m. entered by LPN Employee E2 indicated she and RN Supervisor Employee E3 were called to the unit due to the resident's absent vital signs. It was indicated the resident ceased to breathe at that time. During an interview on 2/29/24, at 10:03 a.m. the Director of Nursing (DON) confirmed the facility failed to assess, monitor, and follow physician orders after a resident fell , resulting in death, for one of five residents (Resident R468). This failure placed residents at a high risk for injury and death if they had a fall and required post fall monitoring, which resulted in an Immediate Jeopardy situation. During an interview on 3/12/24, at 11:42 a.m., LPN Employee E53 stated she worked 7:00 a.m. to 11:00 p.m. on 12/25/24, and Resident R468 was a handful, she kept throwing herself on the ground. It was indicated it was witnessed three times. She notified the physician of the behaviors and ordered a one-time dose of Risperdal. She indicated she then called downstairs and told the scheduler she wanted moved. I was done with the unit, I was the only nurse up there, It was not a good time. LPN, Employee E53 stated. It was indicated she went somewhere else at 3:00 p.m. and does not recall who she gave report to. LPN, Employee E53 stated since the three falls were within five minutes, she completed one lump assessment. LPN, Employee E53 stated it should all be in the computer. During an interview on 3/12/24, at 12:01 p.m. LPN, Employee E2 indicated I do remember someone said she fell , they were supposed to do the risk assessment. She stated she entered the order for fall monitoring every shift of the next nine shifts. It was expected at 3:00 p.m. the nurse completed an assessment and documented vital signs in the clinical record. It was indicated after a resident falls, the nurse needs to complete a head-to-toe assessment, then once safe obtain vitals and call and update the supervisors. LPN, Employee E2 stated RN, Employee E50 was expected to obtain vitals for Resident R468 on 12/25/23, at 3:00 p.m. and monitoring for the next nine shifts is required each shift if a resident falls regardless of a head injury. During an interview on 3/12/24, at 12:11 p.m. Nurse Aide, Employee E52 stated she doesn't recall Resident R468 having a fall on 12/25/23, but she had a history of placing herself on the ground. She indicated the last time seen Resident R468 on 12/25/23, was around 2:00 p.m. or 2:30 p.m. and she cleaned her up and put oxygen on her. During an interview on 3/12/24, at 1:19 p.m. Employee E51, confirmed RN, Employee E50 worked from 3:00 p.m. to 7:00 p.m. on 12/25/23, on the unit Resident R468 resided. During a phone interview on 3/13/24, at 10:56 a.m. RN, Employee E50 stated if a resident falls, an assessment, and their vital signs are documented in the resident's clinical record. RN, Employee E49 stated if a resident had a witnessed fall, an order is entered to complete an assessment and vital signs every shift for the next three days. RN, Employee E49 stated she works agency, and confirmed she worked Christmas. She indicated she does not remember Resident R468, and when she works at the facility she is often moved to another floor after four hours. On 2/29/24, at 2:19 p.m. the Director of Nursing was notified that an immediate jeopardy was identified and was provided the IJ template, and a written IJ removal plan was requested at 2:20 p.m. On 2/29/24, at 6:23 p.m. an Immediate Action Plan was accepted with the following actions: Immediate Action: -All residents will have a fall assessment completed by 3/1/24. -An audit will be conducted of all physician orders to ensure accuracy and implementation will be done by 3/1/24. -Fall policy will be reviewed and revised by 3/1/24. -Fall care plans for all residents will be reviewed and revised as appropriate by 3/1/24. -All nursing staff will be educated to ensure all residents are assessed for fall risks upon admission, readmission, quarterly, and with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate casual factors and prevent further falls. A fall risk assessment must be completed post fall if the resident was not previously identified as a high risk for falls. Once a resident falls, they are considered a high risk for falls. Staff will be educated to ensure the resident's plan of care is individualized and developed based on the fall assessment and cause of previous falls. The education is to be completed by the Director of Nursing or Designee prior to the nursing staff's next scheduled shift. -The Director of Nursing or Designee will conduct audits of residents falls to ensure accuracy and repot findings to Quality Assurance and Performance Improvement (QAPI) meetings. The facility's Fall Protocols policy was revised and reviewed on 2/29/24, to ensure all residents are assessed for fall risk upon admission, readmission, quarterly, and with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate casual factors and prevent further falls. It was indicated a fall risk assessment is completed post fall only if the resident was not previously identified as a high risk for falls. Once a resident has had a fall, they are considered a high risk for falls. It was indicated the resident's plan of care will be individualized and developed based on fall assessment and root cause analysis of any subsequent falls. A post fall investigation will be completed in the next clinical meeting following each fall to determine root cause and appropriate intervention. Following a fall, nursing will complete a head to toe assessment for injury, including vital signs. Neurological checks will be initiated if the resident struck their head or if the fall was unwitnessed. All assessment data will be documented in the medical record. The medical provider and responsible party will be notified of the fall and notifications documented in the medical record. 467 of 467 residents fall assessments were completed as of 3/1/24. An audit of 467 resident's physician orders were reviewed. It was indicted nine of nine residents had a fall, and required neurological assessments and vital signs post fall. It was confirmed nine of nine residents who had physician orders for post fall monitoring were being followed as ordered. 467 of 467 residents care plans were reviewed and revised on 3/2/24, to include the resident's fall risk and interventions. On 3/1/24, at 1:18 p.m. it was verified 113 of 115 nursing staff confirmed they were educated prior to start of their shift and was verified via signature sheet. All nursing staff were educated to conduct a fall assessment upon admission, quarterly, and with a significant change in the resident's status. Residents who were not previously identified as a high fall risk prior to fall must have a fall risk assessment completed. The care plans must be individualized and developed based on fall assessment and root cause analysis of any subsequent falls. An investigation must be conducted following a fall. Following a fall, nursing will complete a head to toe assessments, including vital signs. Neurological checks will be initiated if the resident struck their head or if the fall was unwitnessed. All assessment data will be documented in clinical record and medical provider and responsible party will be notified of fall and documented in medic al record. Director of Nursing and designee will conduct audits to ensure policy is being followed and findings will be reported to QAPI. On 3/2/24, at 12:37 p.m., the Immediate Jeopardy was lifted after ensuring the Immediate Plan of Correction had been implemented. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility polices, clinical records, facility documentation, and staff interview, it was determined that the facility failed to implement adequate safeguards to protect residents from sexual abuse that resulted in actual harm for a resident being sexually abused (Resident R2) by another resident who was a known sexual offender (Resident R1) for two of six reviewed (Resident R1 and R2). The facility failed to implement adequate safeguards to ensure that two residents (Resident R3 and Resident R4) were free from non-consensual sexual contact, by failing to assess residents capacity to engage in consensual sexual contact prior to providing residents sexual education with condoms, for two of six residents reviewed (Resident R3, and R4). Findings include: Review of facility policy, Abuse Prohibition Standard of Practice, dated 9/17/20, and a revision date of 12/2020, indicated The purpose of the abuse policy is to prohibit and prevent abuse neglect exploitation, misappropriation of resident property. Types of abuse include: Sexual abuse non-consensual sexual contact of any type with a resident/patient. Protection: If the suspected perpetrator is another resident/patient the residents will be separated so they do not have access to each other until the circumstances of the alleged incident can be determined and assessment completed and if applicable interventions put into place. Examine the resident/patient for any sign of injury, including a physical assessment or a psychosocial assessment if indicated. The admission record indicated Resident R1 was admitted on [DATE], and readmitted on [DATE], with cancer (abnormal cells in a part of the body), and heart failure (a condition in which the heart doesn't pump blood as well as it should). These diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS section C BIMS (Brief Interview for Mental Status) dated 10/13/20, indicated Resident R1 has a BIMS (Brief Independent Mental status) of 9 - moderately impaired. Review of the admissions information provided from medical records for Resident R1 showed that Resident R1 lived in a half-way house prior to admission to the hospital - with no other information included in the hospital information. Review of Resident R1 clinical record showed resident was in hospital prior to facility but no other prior living information was included. During an interview on 1/8/21, at 10:40 a.m. the DON confirmed that knowledge of a resident residing in a halfway house should have triggered an assessment. During a separate review of information (web site) the following was indicated about the halfway house: The halfway house is transitional housing and a service center for veterans/reentry residents to include DOC (department of corrections) parolees. The halfway house screens residents for sexual abusiveness per the facility policy dated 1/30/16 - PREA (a screening tool used for victimization and abusiveness). During an interview on 1/8/21, at 1:14 p.m. with Employee E3 DOSS (Director of Social Services), indicated that Resident R1 was on probation (offender type lifetime - for involuntary deviate sexual intercourse), and that the facility (Employee E3 DOSS) keeps a list of when residents who are on Megan's Law need to report. Employee E3 DOSS, indicated that prior to 12/29/20, the facility was aware Resident R1 was on parole, as the parole officer reached out to notify the facility of their involvement with the resident. During the interview Employee E3 DOSS was asked why the Megan's Law searches were run on 12/29/2020, and Employee E3 DOSS stated they wanted to be sure there was no residents that they missed for potential involvement with registration on the Megan's Law registry. During the interview, it was asked why no care plans were made regarding Resident R1 previous charges or current Megan's Law requirements and the social worker did not have an explanation why this did not occur. Further review of Resident R1 clinical record failed to reveal a psychosocial assessment that addressed parole and/or Resident R1 being a sexual offender prior to 12/30/20 (after the incident). The admission record indicated Resident R2 was admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of quarterly MDS dated [DATE], confirmed the diagnosis. A review of the clinical record Documentation Survey V2 Report (a report for residents that documents behaviors, weights, activities of daily living, etc.) for December included behaviors to monitor for Resident R2, which included repeat movements and wandering. Review of additional clinical information Kardex included redirect Resident R2 from other resident rooms. A review of psychological services: crisis intervention note dated 12/30/20, indicated Pt not appropriate for ongoing tx (treatment) due to level of impairment. A review of Resident R2's clinical record on 1/7/21, did not include any care plans noted for behaviors or sexually acting out. A review of documentation submitted by the facility on 12/29/20, indicated an incident took place on 12/29/20, when Resident R1 was observed by Employee E1 NA (Nurse Aide) in Resident R1 room with Resident R2. Resident R1's hand was over the back of Resident R2's head, holding Resident R2's head down in Resident R1's groin area. Facility documentation witness statement dated 12/29/20, NA Employee E1 revealed Resident R1 was sitting down (later clarified in wheelchair) and Resident R2 was on the end of the bed, when NA Employee E1 came into the room Resident R2 was attempting to push her head up. Further review of witness statement indicated NA Employee E1 told Resident R1 to stop and Resident R1 stated that Resident R2 knew what they were doing. A review of Resident R1's clinical record on 1/7/21, did not include a care plan for being a sexual offender. Review of the clinical record did not include Resident R1's history (places incarcerated, treatment history, etc.) for previous sexual offenses. During an interview on 1/8/21, at 5:50 p.m. Resident R1 revealed multiple incarcerations, and was unable to recall receiving any sex offender's treatment. Facility documentation Psychological Crisis Intervention Note, dated 12/30/20, indicated the following: Resident R1 had no current MH (mental health) diagnosis, this was a follow up to a reported incident, patient alert /oriented x4. Acknowledged incident and stated it was not his fault as Resident R2 wandered into room and wanted it. The admission record indicated Resident R3 was admitted to the facility on [DATE], with conduct disorder (disruptive behaviors that persist over time or are severe), unspecified intellectual disabilities (multiple factors or co-occurring mental illness - onset begins in childhood and can include deficits in adaptive functioning that hamper development through adulthood as Resident R2 was born in 1982-[AGE] years old) personality disorder (a type of mental disorder in which a person had a rigid and unhealthy pattern of thinking, functioning and behaving. A person with this disorder has trouble perceiving and relating to situations), and unspecified [CONDITION(S)] (includes psychotic symptoms i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior). Review of the quarterly MDS dated [DATE], confirmed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS section C BIMS dated 11/6/20, indicated Resident R3 has a BIMS of 14 - cognitively aware. The admission record indicated Resident R4 was admitted to the facility on [DATE], with [CONDITION(S)] disorder (major mood episode manic or depressive in addition to schizophrenia; the major depressive episode must include depressed mood) and vascular dementia (slowness of thought, difficulty with planning and understanding, problems with concentration). Review of the quarterly MDS dated [DATE], confirmed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS section C BIMS dated 12/17/20, indicated Resident R4 had a BIMS of 9 - indicating moderately impaired cognitively. Documentation submitted by the facility on 12/24/20, when Resident R3 and R4 were observed in a sexual act. Employee E2 NA was doing rounds upon entering the room of Resident R4, Resident R4 was observed lying in the bed with Resident R3 on top of Resident R4 and engaged in sexual intercourse. Documentation submitted by the facility dated 12/24/20, indicated that the facility gave Resident R3 and R4 sexual education and condoms. During an interview on 1/8/21, at 1:15 p.m. Employee E3 DOSS (Director of Social Services) indicated that sex education and condoms were given/provided for Resident R3 and R4. Documentation submitted by the facility on 12/29/20, indicated an incident took place on 12/29/20. Resident R3 and Resident R4 were observed in a sexual act. Resident R3 was observed going into Resident R4 room. When staff went into Resident R4's room - Resident R3 and R4 were engaged in a sexual act. A review of Resident R3 clinical record on 1/8/21, did not include a care plan regarding sexual behavior. A review of Resident R4 clinical record on 1/8/21, did not include a care plan regarding sexual behavior. During an interview on 1/8/21, at 1:17 p.m. Employee E3 DOSS indicated that Resident R3 and Resident R4 did not use the condoms during the incident on 12/29/20. Facility documentation psychotherapy note dated 12/29/20, revealed the following: Resident R4 was oriented to time, place person, and purpose. However, resident demonstrated impairments in the information, working memory and delayed recall. Additionally, resident demonstrated executive functioning impairments including difficulties with reasoning problem solving, planning/organization and abstract thinking. Resident having low insight and judgement/decision making skills. Difficulty with forward planning and insight related to risks of unprotected sexual activity. During an interview on 1/8/21, at 12:14 p.m. with Nursing Home Administrator (NHA) and Director of Nursing (DON) , it was confirmed that the incident on 12/29/20, where Resident R1 was found holding Resident R2 head down in groin area, and confirmed that Resident R3 and R4 were found twice on 12/24/20 and 12/29/20 engaged in sexual intercourse. During the interview on 1/8/21, NHA and DON confirmed that Resident R2 is not able to consent due to intellectual capabilities. NHA and DON confirmed that Resident R4 is not able to consent due to intellectual capabilities. During an interview on 1/11/21, at 3:00 p.m. with ANHA (Assistant Nursing Home Administrator) and DON, confirmed that Resident R3 and Resident R4 were provided with sex education and condoms, and Resident R4 BIMS of 9 makes the resident cognitively impaired. The ANHA and DON confirmed that Resident R3 was not assessed to determine if able to have consensual sexual intercourse till 12/29/20 (after the second incident). The facility staff failed to implement adequate safeguards to protect residents from sexual abuse by protecting a Resident from a registered sexual offender (Resident R1 holding Resident R2 head in Resident R1 groin area). The failure allowed Resident R1 to sexually abuse Resident R2. The facility failed to implement adequate safeguards to protect Resident R3 and Resident R4 by failing to assess the resident's capacity to engage in consensual sexual intercourse. 28 Pa. Code 201:14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management 28. Pa. Code: 201.18(e)(1)Management 28 Pa. Code: 201.29 Resident rights 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on facility policy and clinical record reviews, facility documentation review, and staff and resident interviews, it was determined that the facility failed to promptly identify, correct, intervene and report timely an incident of alleged abuse placing 281 of 353 residents on nine nursing units (5 Main, 2 Main, 2 East, 3 East, 4 East, 2 West, Grove 1, Grove 2 and Grove 3) in Immediate Jeopardy. Findings include: The facility Abuse Protection policy dated 9/30/20, indicated that abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Anyone who witnesses an incident of suspected resident abuse, neglect, misappropriation or exploitation is to intervene immediately and stop the abuse. They are to report it to the charge nurse or supervisor immediately. All reports of alleged or suspected abuse must be reported to the administrator immediately. The attending physician and responsible party shall be notified of the incident/allegation. During clinical record review on 10/16/20, it was revealed that Resident R1 was admitted to the facility on [DATE], and Quarterly Minimum Data Set (MDS-periodic assessment of care needs) dated 9/7/20, confirm diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly MDS dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 10 of 15 revealing moderately impaired cognition. During an interview on 10/16/20, at 12:05 p.m. Resident R1 inquired who we were, before an introduction could be made, and then proceeded to show us the bruises on her right upper arm and indicated that she got them the day before when she was held down and they put the stick in my nose. During a phone interview on 10/16/20, at 12:15 p.m. Respiratory Therapist, Employee E1 indicated that she heard residents were being physically restrained that were refusing to have COVID testing done on the three and the five main nursing units by the COVID intervention team. Upon further interview, she stated that she did not inform any supervisory staff of this. During a review of the Certified Registered Nurse Practioner's (CRNP) progress note dated 10/15/20, it was revealed that staff reported to the CRNP that two workers from the COVID-19 intervention team held Resident R1 down while swabbing her nose. The CRNP saw the resident afterwards and she was visibly tearful, crying and repeatedly stating that she wanted to go home. The CRNP note indicated that social services was aware, and intervening. Additionally, the unit manager, as well as the Director of Nursing were also aware. A review of the facility's internal incident report investigation dated 10/15/20, revealed that Resident R1 bit her lip causing it to bleed during a COVID swab test as reported by RN/UD (Registered Nurse/Unit Director) Employee E5. The CRNP was on the unit at this time, assessed the area and no new orders were needed. A review of the facility internal incident report investigation dated 10/16/20, revealed that upon RN/UD Employee E5's arrival to the nursing unit, NA (Nurse Aide) Employee E3 informed her that Resident R1 showed her new bruises to her right upper arm. The areas were assessed and appear aligned in a way that resembles a handprint and measured as follows: large upper bruise 6 cm (centimeter-a metric unit of length) wide by 10 cm long. first smaller bruise 3 cm wide by 6 cm long. second smaller bruise 3 cm wide by 3 cm long. third smaller bruise 4 cm wide by 5 cm long. Resident R1 stated that those guys just came in here yesterday and was grabbing on me and hurting me. The CRNP was notified and the resident was seen for assessment of her injuries. During a review of the CRNP progress note dated 10/16/20, it was revealed this was a follow-up visit of the events of 10/15/20. Nursing staff reported bruises to her right upper arm. Upon exam, there were three side by side bruises in the medial (near the center) aspect of the right upper arm and a single contusion in the lateral (on the side) aspect of the right upper arm. The resident told the CRNP that two men came in and beat me up and also tells that they stuck something in my nose. She is less tearful today. The resident is able to relay most of the events from yesterday. During a review on 10/16/20, of the Event Report(I think we call this information submitted to the Department) submission dated 10/16/20, it was revealed that Resident R1 sustained bruising to her right upper arm, and she stated that two men came into her room on 10/15/20, talked to her and grabbed her arm and stuck a stick up her nose. A review on 10/16/20, of the Mandatory Abuse Report filed on 10/16/20, at 4:00 p.m. indicated that the facility notified the licensing agency, Area Agency on Aging, physician, next of kin and local law enforcement. A review of the Psychological Services: Crisis Intervention Note dated 10/16/20, indicated that the resident reported that staff from the COVID Intervention team held her down and forcibly swabbed her for COVID, despite asking them to stop. The resident denies distress at this time, but noted that she is still unhappy regarding the incident. Plan is to address ongoing issues as they arise. During an interview on 10/16/20, at 12:20 p.m. NA Employee E3 indicated that she heard Resident R1 yelling and saw a COVID intervention team man holding her arms and Nurse Aide (NA) Employee E4 holding Resident R1's hands above her head. NA Employee E3 confirmed that she did not inform administration as required, and that she has been trained in resident abuse and resident rights policies. During an interview on 10/16/20, at 12:25 p.m. Registered Nurse/Unit Director Employee E5 indicated that she had concerns regarding the COVID testing team and Resident R1. She stated that she walked into Resident R1's room and heard screaming. She saw two men from the COVID testing team and she told the men to please stop, she has the right to refuse. They then stated that they got the swab and were done. During an interview on 10/16/20, at 12:40 p.m. RN/UD Employee E6 indicated that she heard from another staff member that there were concerns regarding the COVID testing team making residents get tested . She then placed herself and the two other nurses on her unit in the hallways to monitor the residents' response to the COVID testing team and to intervene should anyone refuse so that they could intervene, if needed. RN/UD Employee E6 did not experience any problems with the COVID testing team while they were on her unit and she did not report the concerns that she heard to administration as she stated she heard them as a rumor and it was not firsthand knowledge. RN/UD Employee E6 confirmed that she has been trained in resident abuse and resident rights policies. During an interview on 10/17/20, at 10:00 a.m. LPN Employee E7 heard other staff members while on break stating that the COVID testing team was testing residents against their will. She informed her RN/UD Employee E6 so she was aware. She was not sure if residents were able to refuse the testing since this was a state appointed team for COVID testing. She confirmed that she did not tell anyone in administration. She also confirmed that she has been trained in resident abuse and resident rights policies. During an interview on 10/17/20, at 10:40 a.m. NA Employee E8 heard other staff members while on break stating that the COVID testing team was testing residents against their will. He indicated that he did not witness this on his unit and that he did not report what he heard to administration. He also confirmed that he has been trained on resident abuse and resident rights policies. During a clinical record review on 10/16/20, it was revealed that Resident R2 was admitted to the facility on [DATE], and Quarterly MDS dated [DATE], revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, also revealed a BIM's score of 14 of 15 indicating intact cognition. During an interview on 10/16/20, at 2:45 p.m. with Resident R2, who is in the bed directly across from Resident R1, She stated that Resident R1 was yelling to get away as four people held her down to get the test done. Resident R2 did not have concerns about testing but felt that there was no choice. During a review on 10/19/20, of the map of the facility nursing units visited by the COVID testing team on 10/15/20, it was revealed that after completion of testing of Resident R1 on the 4 Main nursing unit there were an additional 281 residents on nine nursing units left to be tested . During an interview on 10/19/20, at 11:10 a.m. the Director of Nursing (DON) confirmed that by staff not promptly identifying, correcting, intervening and reporting timely, the suspected abuse of Resident R1, the remaining nine nursing units/281 of 353 residents were subjected to possible abuse. Immediate Jeopardy was called on 10/16/20, due to the facility's failure to promptly identify, correct, intervene, and report timely an incident of alleged abuse placing the residents of the facility in Immediate Jeopardy. On 10/16/20, at 11:00 p.m. the Nursing Home Administer (NHA) and the Director of Nursing were informed of Immediate Jeopardy at the facility and a written Corrective Action Plan was requested. 1. Associated employees have been suspended pending review and investigation. Visiting COVID-19 swabbing team is no longer at the center. Future COVID-19 swabbing will be conducted by facility personnel moving forward. 2. House audit completed to identify any residents for psychosocial concerns and other injuries related to COVID-19 swabbing. 3. Identified residents have had/will have, physical and psychosocial assessments completed, and secondary follow up visits as indicated by original assessments. 4. The Director of Nursing and/or designees will immediately provide re-education to nursing staff on resident rights. a. All incoming staff will be educated prior to starting their shift, ongoing until all staff have received education. b. Education will include: -Resident's rights, specifically to the right to refuse treatment. c. A master list of education will be maintained and any outstanding staff, to include agency, will be cross referenced upon entry to the facility, those persons identified as not having received education will report to Clinical Leadership and/or designee on duty for completion of education prior to starting their shift. During interviews with facility nursing staff (RN's, LPN's, and NA's) on 10/17/20, from 10:30 a.m. through 12:15 p.m. twenty-eight staff were interviewed and confirmed that they had received training on the facility's policies on Abuse Protection, Abuse Reporting and Investigation, Refusal of Medications and Treatments, and Resident Rights prior to starting their shift. A review of the documentation received from the facility on 10/19/20, indicated that 85% of the facility nursing staff received training on the facility's policies on Abuse Protection, Abuse Reporting and Investigation, Refusal of Medications and Treatments, and Resident Rights. The Immediate Jeopardy was lifted on 10/19/20, at 1:00 p.m. when the action plan implementation was verified. During continued onsite monitoring from 10/20/20, through 10/22/20, of the facility it was revealed the following: On 10/20/20, from 10:30 a.m. through 11:10 a.m. an additional fourteen facility staff were interviewed regarding receiving training on Abuse Protection, Abuse Reporting and Investigation, Refusal of Medications and Treatments, and Resident Rights, all indicated that they had received the training. During interviews and observations on 10/20/20, from 10:30 a.m. through 11:10 a.m. an additional twenty-seven residents were interviewed regarding the COVID testing performed on 10/15/20, there were no additional concerns voiced. During continued observations during the on-site monitoring from 10/20/20, through 10/22/20, there were no additional concerns identified related to the COVID testing performed on 10/15/20, and no other concerns of the facility failing to identify, correct, intervene and report an incident of alleged abuse. A review of the facility allegation of abuse investigation of 10/15/20 incident, the facility did substantiate that a breakdown in the reporting of potential abuse occurred and has addressed this with nurse involved and through staff education of facility policies for Abuse, Abuse Reporting and Resident Rights. During an interview on 10/22/20, at 1:00 p.m. the NHA and DON confirmed that they are continuing to follow their Corrective Action Plan and are at approximately at 97% of nursing staff educated and will continue to educate staff prior to working and will monitor for all staff completion. 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 1/28/19; 2/1/19; 2/16/19; 8/14/19; 9/13/19; 12/13/19; 5/5/20; 9/21/20. 28 Pa. Code: 201.18 (b) (1) (2) (e) (1) Management. Previously cited 1/28/19; 2/16/19; 5/16/19; 8/14/19; 9/13/19; 4/17/20; 5/5/20; 9/21/20. 28 Pa. Code: 201.20 (a) (b) (c) (d) Staff development. Previously cited 9/13/19; 4/17/20; 5/5/20. 28 Pa. Code: 201.29 (a) (c) (d) (j) (m) Resident rights. Previously cited 1/28/19; 5/5/20; 9/13/20. 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 1/28/19; 2/16/19; 5/16/19; 8/14/19; 9/13/19; 4/17/20. 28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services. Previously cited 1/28/19; 2/1/19; 2/16/19; 5/16/19; 8/14/19; 9/13/19; 5/5/20.

Based on a review of facility policies, manufacturer guidelines, observations, and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program which ensured proper cleaning and disinfecting of multi-use equipment for three of 11 residents (Resident R4, R5, and R6) and that facility staff failed to use proper Personal Protective Equipment (PPE), perform proper hand-hygiene, and store/handle linens in the proper manner to prevent the potential for cross contamination of disease which created the potential for cross-contamination and placed residents of nine of eleven nursing units in Immediate Jeopardy (Two East, Three East, Four East, Two Main, Two West, Four Main, Five Main, Grove Two, and Grove Three). Review of the facility policy Infection Control Committee By-Laws dated 8/12/19, indicated the committee's objectives are to control infections within the Center by insuring a clean and healthful environment and to evaluate the infection potential of the related environment. Review of the facility policy Infection Control dated 8/27/19, indicated the the purpose of isolation is to provide care for the resident, confine the contamination to the smallest area as possible and prevent transmission of the disease, by either direct or indirect contact. Review of the facility policy Infection Control Isolation dated 8/27/19, indicated that the purpose of isolation is to prevent contact between between potentially pathogenic micro-organisms and uninfected residents. Review of the facility policy Standard Precautions-Personal Protective Equipment (PPE) dated 8/27/19, indicated that the type of PPE should be appropriate for the procedure and the type of exposure anticipated. Review of the facility policy Hand Hygiene dated 8/27/19, indicated that the purpose of hand hygiene is to decrease the risk of transmission of infection. Handwashing is performed when hands are visibly dirty or contaminated with proteinaceous material, are visible soiled with blood or other body fluids, before performing an invasive procedure, and after providing care to a resident. Review of the facility policy Glucometer Decontamination (a device used to test the amount of sugar in a person's blood) dated 8/27/19, indicated that the glucometer shall be decontaminated with the facility approved wipes following use on each resident. Review of the glucometer manufacturer's recommendation provided by the facility under Cleaning and Disinfecting Procedure for the Meter revealed, the meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach, [MEDICATION(S)] Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes and [MEDICATION(S)] Micro-Kill Bleach Germicidal Bleach Wipes. Review of the facility policy Cleaning, Disinfection and Sterilization dated 8/27/19, indicated that the purpose is to provide supplies and equipment that are adequately cleaned, disinfected or sterilized. Supplies and equipment will be cleaned immediately after use. Thermometers are cleaned with hospital disinfectant. Review of the facility policy Glove Use indicated that gloves are disposable single-use and to perform hand hygiene after removing gloves. Gloves should be used when touching excretions, secretions, blood, body fluids, mucous membranes, handling potentially contaminated items, when hands will possible come in contact with blood, body fluids, or other potentially infectious material. Review of the facility policy Laundry Collection dated 8/27/19, indicated that soiled linen carts are to be covered while in resident areas. During an observation on 5/1/20, at 4:35 p.m. Receptionist Employee E28 was sitting at the desk at the Main Entrance eating a meal without a mask on and two staff members who were not wearing masks walked past Receptionist Employee E28 less than 6 foot distance. During an interview on 5/1/20, at 4:40 p.m. with Receptionist Employee E28 and Nursing Assistant (NA) Employee E29-(who was monitoring staff members enter building) confirmed that the two staff members and Receptionist E28 failed to wear proper Personal Protective Equipment (PPE) while in the building which created the potential for cross-contamination and the spread of disease and infections. During an observation on 5/1/20, at 4:45 p.m. on the 2 West Nursing Unit, Licensed Practical Nurse (LPN) Employee E30 exited a resident room, removed gloves, touched equipment on medication cart, pick up pen and wrote on paper, then typed on keyboard, then pushed medication cart down the hallway, failing to perform hand hygiene after glove removal. During an interview on 5/1/20, at 4:55 p.m. LPN Employee E30 confirmed that by failing to perform hand hygiene after removal of gloves which created the potential for the possibility of cross contamination and the spread of disease and infections. During an observation on 5/1/20, at 4:56 p.m. of the 2 West Nursing Unit two linen carts were in the hallway uncovered and open to air. During an interview on 5/1/20, at 4:56 p.m. LPN Unit Manager Employee E31 confirmed that leaving linen exposed creates the potential for cross-contamination and the spread of disease and infection. During an observation on 5/1/20, at 4:50 p.m. of the Grove 2 soiled Utility room there was no soap or paper towels at the handwashing sink. During an interview on 5/1/20, at 4:54 p.m. LPN Unit Manager Employee E31 confirmed that the facility failed to provide the proper supplies to perform handwashing which creates the potential for cross-contamination and the spread of disease and infection. During an observation on 5/1/20, at 5:06 p.m. of the Grove 3 Nursing Unit the following was observed: -open drink can on top of the medication cart in the hallway. -NA Employee E32 walked out of resident room, removed gloves, towel from clean linen cart and returned back to room to provide care. -NA Employee E33 was walking in the unit hallway with mask down around chin. During an interview on 5/1/20, at 5:25 p.m. LPN Employee E34, NA Employee E32 and E33 confirmed that leaving open drinks in resident care areas, failing to properly perform hand hygiene after glove removal and failing to wear PPE- mask in the proper manner create the potential for cross-contamination and the spread of disease and infection. During an observation on 5/1/20, at 4:42 p.m. Resident R2 was laying in his bed. Food spillage was present on the floor next to Resident R2's bed, the waste basket in the room was overflowing onto the floor, and used gloves were present on the floor. During an observation on 5/1/20, at 4:52 p.m. the floor next to Resident R3's bed had food spilled on it. During an observation on 5/1/20, at 4:56 p.m. Registered Nurse (RN) Employee E18 entered room [ROOM NUMBER] with gloves on and used a glucometer to obtain Resident R4's blood sugar level. After completing the check, RN Employee E18 cleaned the glucometer with hand sanitizer, and a brown paper towel. At this time, RN Employee E18 proceeded across the room to Resident R5, and without changing gloves or performing hand hygiene, obtained Resident R5's blood sugar level, and again cleaned the glucometer with hand sanitizer and a brown paper towel. RN Employee E18 did not remove her gloves or perform hand hygiene. During an observation on 5/1/20, at 5:00 p.m., RN Employee E18 exited room [ROOM NUMBER], proceeded down the hall to the medication cart outside the nurses' station, unlocked the cart, and looked through multiple drawers on the cart. RN Employee E18 then changed gloves, using hand sanitizer prior to putting new gloves on. During an observation on 5/1/20, at 5:03 p.m. Registered Nurse (RN) Employee E18 entered room [ROOM NUMBER] with gloves on and used a glucometer to obtain Resident R6's blood sugar level. After completing the check, RN Employee E18 cleaned the glucometer with hand sanitizer, and a brown paper towel. During an observation on 5/1/20, between 5:08 p.m. and 5:14 p.m. Nurse Aide (NA) Employee E13 entered Resident R7's (diagnosed with COVID-19) room while wearing gloves with a temporal thermometer (a type of thermometer that is slid across the skin on the forehead to take body temperature) and pulse oximeter (a small handheld device that encloses a patient's fingertip and measures the oxygen saturation in the blood), setting them on the overbed table. NA Employee E13 exited room [ROOM NUMBER] with a half full urinal, which she brought to the soiled utility room down the hall. NA Employee 13 entered the soiled utility room, and promptly exited it with an empty urinal. NA Employee E13 reentered Resident R7's room and proceeded to obtain Resident R7's temperature and oxygen saturation. NA Employee 13 exited room [ROOM NUMBER], and entered room [ROOM NUMBER], obtaining Resident R8's and Resident R9's temperature and oxygen saturation. Residents R8 and R9 have not been diagnosed with COVID-19. Throughout this observation, NA Employee 13 did not remove her gloves, perform hand hygiene, or clean her equipment between patients. During an interview on 5/1/20, at 6:05 p.m. RN Employee E18 confirmed that she failed to use an approved disinfectant to clean the glucometer and confirmed that NA Employee E13 failed to change gloves, perform hand hygiene, and confirmed that by not disinfecting the equipment between patients, created the possibility of cross contamination between residents. During an observation on 5/1/20, between 5:25 p.m. through 5:50 p.m. on the Four Main nursing unit, the following was observed: -The large 4M North linen cart had four uncovered pillows on top of it. -The patient restroom on Four Main North had no paper towels, and one cloth towel hanging on a hook next to the sink, with its ends draped against a garbage can. -room [ROOM NUMBER] had dirty gloves in the sink. -The soiled linen hampers in the hallway were open, and partially full. -The Four South medication cart did not have supplies to correctly clean the glucometer. -The patient restroom on Four Main South had an inoperable paper towel dispenser. -The large 4M South linen cart had its cover folded behind the cart, exposing all of the clean linen. During an interview on 5/1/20, at 5:50 p.m. LPN Employee E19 confirmed the above observations on the Four Main nursing unit. During an observation on 5/2/20, between 12:35 p.m. through 1:05 p.m. on the Three Main nursing unit, the following was observed: -One uncovered small linen cart in the North hall. -room [ROOM NUMBER] had dirty linen on the floor. -room [ROOM NUMBER] had a bag of green soap on the patient sink. -The soiled utility room in the South hall did not have running cold water. -One partially covered small linen cart in the South hall. During an interview on 5/2/20, at 1:05 p.m. LPN Employee E25 confirmed the above observations on the Three Main nursing unit. During an observation on 5/4/20, between 8:00 p.m. through 8:10 p.m. on the Five Main nursing unit, the following was observed: -room [ROOM NUMBER] had food spillage on the floor. -NA Employee E13 placing soiled linen in the hallway hamper without gloves on. During an interview on 5/4/20, at 8:10 p.m. LPN Employee E26 confirmed the above observations on the Five Main nursing unit. During an observation on 5/4/20, between 8:15 p.m. through 8:30 p.m. on the Four Main nursing unit, the following was observed: -The small 4M South linen carts only partially covered. -Two large clear bags of personal clothing labeled with Resident R8's name, in wheelchair in the hallway. -The small 4M North linen cart was uncovered. -NA Employee E27 carried soiled linen to the hallway linen hamper without gloves, then removed clean linen from the linen cart without performing hand hygiene. During an interview on 5/4/20, at 8:30 p.m. LPN Employee E19 confirmed the above observations of the linen carts on the Four Main nursing unit, and confirmed that NA Employee E27 did not use correct hand hygiene when carrying soiled and clean linen. During an observation on 5/4/20, between 8:35 p.m. through 8:50 p.m. on the Two Main nursing unit, the following was observed: -The 2M South patient restroom had multiple soiled towels in the sink, and a visibly soiled washcloth on the floor. Additionally, a partially full soiled linen bag was on the floor next to the restroom hopper. During an interview on 5/4/20, at 8:50 p.m. LPN Employee E22 confirmed the above observations on the Two Main nursing unit. During an observation on 5/5/20, between 1:55 p.m. through 2:05 p.m. on the Two Main nursing unit, the following was observed: -The 2M South patient restroom had a soiled brief rolled up, placed on top of a cart labeled infectious waste, next to a small black, partially full plastic bag. During an interview on 5/5/20, at 2:05 p.m. Environmental Services Employee E23 confirmed the above observations on the Two Main nursing unit. On 5/2/20, at 4:45 p.m. the Nursing Home Administrator and DON were informed of Immediate Jeopardy at the facility and a request for a written Corrective Action Plan. On 5/2/20, at 10:43 p.m. the Corrective Action Plan was approved which included the following interventions: 1. The Director of Nursing and/or designees will immediately provide re-education to nursing staff on infection control procedures for cleaning of glucometers, pulse oximeter and thermometers. Re-education will also encompass hand hygiene and glove use to include changing gloves between residents and disease transmission. In addition, nursing staff will be educated on appropriate mask use for resident care and community areas of the center. Staff will complete competencies on education received. a. All nursing staff on duty will be educated prior to leaving their shift today. b. All incoming nursing staff will be educated prior to starting their shift, ongoing until all nursing staff have been educated. c. A master list of education will be maintained and any outstanding staff, to include agency, will be cross referenced upon entry to the facility, those persons identified as not having received education will report to Clinical Leadership on duty for completion of education; prior to starting their shift. i. Glucometers, pulse oximeter, and thermometers used between residents will be cleaned with disinfectant per manufacturers' guidelines. ii. Hand hygiene will be performed before and after each use of glucometers, pulse oximeter and thermometers. iii. Hand hygiene will be completed before and after direct care contact with residents to include removal of gloves after each resident. iv. Masks will be donned upon entering and worn throughout. Masks may be removed for brief periods outside of the resident care areas, while social distancing is respected. 2. The Director of Nursing/designee will audit infection control procedures, with a focus on cleaning glucometers, pulse oximeter and thermometers, hand hygiene related to changing gloves and proper use of masks on every shift, 30 observations per day, for 1 month. 3. The Quality Assurance Performance Improvement Committee will determine continuation and frequency of auditing after 1 month. On May 5, 2020, at 4:00 p.m. during an on-site survey, verification was made that the Corrective Action Plan was being implemented. It was verified that the facility immediately re-educated the nursing staff on infection control procedures for cleaning glucometers, pulse oximeters, thermometers, hand hygiene, glove use and appropriate use of PPE. The staff did complete competencies on education they received. All nursing staff on duty were educated prior to leaving their shift and incoming nursing staff were educated prior to starting their shift. Observations of the staff using glucometers, pulse oximeters, and thermometers and cleaning with disinfectant per manufacturers' guidelines were conducted. Observations of proper hand hygiene, use of proper PPE and social distancing were conducted. Observations of the management team conducting audits of the infection control procedures was conducted. The NHA was notified that the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 2/16/19. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/16/19. 28 Pa. Code 201.18(b)(3) Management. Previously cited 2/16/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/16/19. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 2/16/19. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect from not performing safe bed mobility that resulted in actual harm (fractured humerus) for one of seven residents (Resident R2). Findings include: The facility policy Resident Abuse/Neglect dated 8/31/18, indicated that the residents have the right to be free from abuse/neglect. The facility policy Turning and Repositioning Resident in Bed dated 8/31/18, indicated that staff was to review the Activities of Daily Living (ADL) sheet for current orders and specialty positioning instructions. The facility policy ADL Book dated 8/31/18, indicated that each resident has an ADL sheet which is a one page plan of care for nurses and nursing assistants (NA) to follow when providing ADL care. NA's or staff providing care are expected to know and follow the plan of care outlined in the ADL Sheet. The admission record (face sheet) indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 5/5/19, indicated that those [DIAGNOSES REDACTED]. A physician order [REDACTED]. Resident's R2's plans of care for activities of daily living including fall prevention, assistance with ADL needs and a vulnerability to skin bruising, indicated that assist of two staff was required for bed mobility, staff was to follow the plan of care outlined in the ADL book, and use adequate staff for pulling up and repositioning Resident R2 in a chair or bed. A review of the facility ADL book revealed an ADL sheet that indicated Resident R2 required assist of two staff for repositioning and care. Review of facility Event Report dated 6/23/19, at 5:40 a.m. indicated that Nursing Assistant Employee E1 was providing care to Resident R2. While repositioning, the mattress went out from under Resident R2 resulting the resident to fall to the floor. The report indicated that Resident R2 required the assistance of two staff for bed mobility was was being assisted by one staff member at the time of the incident. Employee witness statements obtained by the facility on 6/23/19, revealed that Nurse Assistant (NA) Employee E1 indicated that while she was bathing and repositioning Resident R2 on to her left side the mattress moved and the resident rolled and fell to the floor. There were 14 witness statements obtained from the other staff that all indicated that they had not assisted NA Employee E1 in the care of Resident R2 that day. Review of a facility reported incident indicated that on 6/24/19, at 2:00 p.m. Resident R2 was noted with new onset swelling to right chest and shoulder extending to right elbow. An X-ray was obtained which showed an acute fracture to right humerus (upper arm) and the resident was transferred to the hospital for treatment. Review of the 6/24/19, Emergency Department (ED) documentation indicated that she was nonverbal and additional information is difficult. The ED report indicated that the resident presented to the emergency department with reports of a right humerus fracture. Patient was placed in a splint for her humerus fracture and was admitted to the hospital for continued medical management evaluation. Review of facility documentation dated 6/28/19, indicated that on that date the facility Medical Director and Director of Nursing reviewed the facility's investigation, witness statements, Orthopedic notes and X-ray reports regarding the incident involving Resident R2. The review resulted in the following statement: The Medical Director determined the cause of Right arm fracture to be likely caused by fall from bed on 6/23/19. The documentation is signed and dated 6/28/19, by the Medical Director and Director of Nursing. Review of facility documentation revealed that on 7/2/19, the Assistant Director of Nursing Employee E2 met with Nursing Assistant E1 regarding Resident R2's fall. The Assistant Director of Nursing documented that during the meeting Nursing Assistant Employee E2 admitted to turning the resident in bed by herself, and further admitted she was aware of the 'bed mobility with two assist' order on the ADL book. Nursing Assistant Employee E2 stated she knew it was her mistake and not anyone else's fault. During an interview on 7/17/19, at 12:15 p.m. the Director of Nursing confirmed that based on the information, Nurse Assistant Employee E1 performed bed mobility and repositioning of Resident R2 without assistance which resulted in a fall from bed and subsequent right humerus fracture resulting in actual harm. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 2/6/19,2/14/18, and 7/11/17. 28 Pa Code: 201.18(b)(1) Management. Previously cited: 5/16/19, 3/20/19, 2/6/19, 1/28/19, 12/14/18, and 9/22/17. 28 Pa Code: 201.18(b)(3) Management. Previously cited: 2/6/19, 12/14/18, and 9/22/17. 28 Pa. Code: 201.18(e)(1) Management. Previously cited: 2/6/19, 12/14/18, and 9/22/17. 28 Pa. Code: 211.10(d) Resident Care policies. Previously cited: 5/16/19, 1/28/19, and 8/7/18. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 5/16/19, 2/6/19, 2/1/19, 1/28/19, 8/7/18, and 7/11/17. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 5/16/19, 2/1/19, 1/28/19, 8/7/18, and 9/22/17.

Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to make certain that residents' environment was at a safe temperature. The facility failed to identify the environmental hazard, assess individual residents, evaluate, analyze the hazard and implement measures to reduce the risk and hazard and implement timely interventions for three of 12 nursing units observed (Grove 1, Grove 2 and Grove 3) placing 87 of 87 residents on three nursing units in an immediate jeopardy situation. Findings include: Review of the facility's Emergency Preparedness Program and Plan policy, Temperature Extremes last reviewed 1/16/19, indicated that the facility will provide a comfortable and safe temperature between 71 and 81 degrees Fahrenheit (F). In the event of an AC/Heat failure the highest ranking staff member will be notified and assume the incident commander role. Environmental temperatures are monitored and logged by assigned person continuously throughout the facility. During an interview on 1/22/19, at 10:25 a.m. the Nursing Home Administrator (NHA) and Maintenance Director, Employee E1, confirmed that there was no heat on the Grove Nursing Units. Maintenance Director, Employee E1, confirmed at approximately 7:30 a.m. when he arrived at the facility, that the Grove Units temperatures were about 60 degrees F. Maintenance Director, Employee E1, stated that the problem has been identified and the facility team would be changing out a pump on the heating system that heats the Grove Nursing Units. The NHA said that he checked on all residents and that the residents on Grove 1, 2 and 3 said they are o.k. NHA was asked if all residents were assessed, but no assessments by the clinical staff could be provided. During an interview on 1/22/18, at 10:33 a.m. the Director of Nursing (DON) provided a list of all residents living on the Grove Nursing Units. Grove 1 housed 31 residents, Grove 2 housed 26 residents and Grove 3 housed 30 residents at this time, and all 87 residents were still on the Grove Nursing Units. During a tour on 1/22/19, from 10:39 a.m. through 11:00 a.m., with the NHA and the Director of Maintenance of the Grove 1, 2 and 3 nursing units, several residents were observed wearing hats, coats and some were layered with blankets. Some of the staff members on the units were also wearing coats. During an observation on 1/22/19, at 11:08 a.m. in the fire alarm room, where the monitoring system is located for the facility to monitor air temperatures throughout the facility, the Director of Maintenance confirmed that the temperatures on the Grove Nursing Units were the following: Grove 1-East 64 degrees F -West 58 degrees F Grove 2-West 59 degrees F Grove 3-East 66 degrees F -West 61 degrees F All other temperatures on the other nursing units were within the acceptable range of 71 to 81 degrees F. During observation and interview on 1/22/19, at 11:37 a.m. the NHA confirmed that the facility was now in the process of relocating all 87 residents from the Grove 1, 2, and 3 Nursing Units. During an interview on 1/22/19, at 12:11 p.m. on the Grove 1 Nursing Unit, the Construction Consultant (CC), Employee E2, stated that the maintenance staff had a problem with the Grove Heating System on 1/21/19, at 9:30 a.m. and was fixed by 10:30 a.m. CC, Employee E2, was unaware the maintenance staff needed to repair the heating system or what problems arose with the Grove Nursing Unit Heating System. During the three day investigation CC, Employee E2, could only confirm that the maintenance staff fixed an issue on 1/21/19, but could not provide a report of what was done. During an observation on 1/22/19, at 12:19 p.m. on the Grove 2 Nursing Unit there were three space heaters at the nurses' station. During an interview on 1/22/19, at 12:20 p.m. the Registered Nurse Unit Manager, Employee E3, confirmed that the space heaters were being used on the unit for heat. During an observation on 1/22/19, at 12:40 p.m. on the Grove 3 Nursing Unit three space heaters in the resident lounge were in use with four residents in chairs covered with several blankets sitting around the heaters, all residents were unattended. One unattended space heater was in the hallway between rooms [ROOM NUMBERS]. During an interview on 1/22/19, at 12:43 p.m. the Registered Nurse Unit Manager, Employee E4, confirmed that the space heaters were provided by maintenance staff to heat the unit and unattended they created a potential hazard. Registered Nurse Unit Manager, Employee E4, confirmed that she worked on 1/21/19, until 3:30 p.m. and there was no heat and they had to provide extra blankets to the residents. During an observation and interview on 1/22/19, at 1:50 p.m. and 1:55 p.m. all 87 residents from the Grove 1, 2 and 3 Nursing Unit were relocated to other locations within the facility and the NHA and the DON confirmed that all Grove residents had been relocated to other locations in the facility with a safe and warm environment. During an interview on 1/22/19, at 2:38 p.m. the NHA confirmed the heat will not be restored to the Grove Nursing Units today, as the system needs another part. The part was expected at the facility on 1/23/19, at 7:00 a.m. During an interview on 1/22/19, at 3:30 p.m. Maintenance Director, Employee E1, confirmed that on 1/21/19, at 10:30 a.m. his maintenance staff resolved a problem with the Grove Nursing Unit heating system, but is unaware of what exactly was done. During an interview on 1/22/19, at 5:00 p.m. Resident Family RF1 (RF) confirmed that she visited on 1/21/19, from 12:00 p.m. until 5:00 p.m. and that Grove 1 Nursing Unit was cold. She could not remove her coat and Resident R1 needed several blankets. During an interview on 1/22/19, at 5:15 p.m. Resident R3 confirmed that it has been cold on Grove 1 for a few days. Resident R3 said that it started to get cold ever since the fire alarm went off and the pipe broke. Staff brought her more blankets when she complained of being cold. During an interview on 1/22/19, at 5:47 p.m. Resident Family RF2 confirmed that she visited on 1/21/19, in the afternoon and the Grove 1 Nursing Unit was cold and that Resident R2 complained of being cold, so she needed to get him more blankets. During an interview on 1/22/19, at 6:00 p.m. Resident R4 confirmed that it has been cold on the Grove 1 Nursing Unit for a few days. Resident R4 stated that she would need 6 blankets and cover her head and use her oxygen cannula to help her breath when she was covering her head. During an interview on 1/22/19, at 6:16 p.m. Registered Nurse Unit Manager, Employee E3, confirmed that the Grove Nursing Units have not had heat since 1/21/19, in the morning. Registered Nurse Unit Manager, Employee E3, went to administration and made them aware of the temperature conditions. Employee E3 was advised that they were working on the problem. Residents were still left on the Grove Nursing Units. During an interview on 1/22/19, at 6:20 p.m. Resident R5 who lives on the Grove 2 Nursing Unit stated that his room was warm because his roommate had a space heater in the room that came from home and the staff members would come into their room complaining of how cold it was on the Grove 2 Nursing Unit. The staff would stay in the room to get warm. During an interview on 1/22/19, at 6:29 p.m. Resident R6 who lives on the Grove 1 Nursing Unit stated that since the pipe broke and the fire alarm went off the nursing unit has not had any heat. Resident R6 stated that when it was brought to the staff's attention, they gave her more blankets. During an interview on 1/22/19, at 6:35 p.m. the Director of Maintenance, Employee E1, confirmed that the facility had a fire alarm on Monday 1/21/19, at approximately 1:00 a.m. due to a pop off valve releasing steam in the Grove 2 Nursing Unit mechanical room, which is related to the heating system on the Grove Nursing Units. The Brighton Township Fire Department responded and cleared the room, but no maintenance staff responded to evaluate the situation. Director of Maintenance, Employee E1, indicated that his staff did respond to the facility on [DATE], at 3:00 a.m. as his maintenance staff were called to the facility because residents on the Grove Nursing Units were complaining of being cold and that staff said there was no heat. Director of Maintenance, Employee E1, could not provide a log of temperatures on the Grove Nursing Units. Director of Maintenance, Employee E1, stated that when the maintenance staff fixed the problem with the Grove Nursing Unit heating system they did not go to the nursing units and document the temperatures on the units and that no facility staff were assigned to monitor environmental temperatures and log continuously throughout the facility. Director of Maintenance, Employee E1 confirmed that on 1/21/19, from approximately 3:00 p.m. to 8:00 p.m. he was in the facility working on the Grove Nursing Units heating and that the problem was resolved but he could not provide monitoring of environmental temperatures on the units. Director of Maintenance, Employee E1, revealed that on 1/22/19, at 7:30 a.m. he received a call from the facility staff stating that there was no heat on the Grove Nursing Units. He stated that when he arrived the lowest temperature on the Grove Nursing Unit was at 55 degrees F. The Director of Maintenance, Employee E1, could not provide a monitoring of environmental temperatures and could not provide any documentation that maintenance was performed. A review of documentation from the Beaver County Emergency Services Center (911 Center) indicated that the fire alarm was received on 1/21/19, at 1:16 a.m. and the fire department was clear at 1:48 a.m. During an interview on 1/22/18, at 6:55 p.m. the NHA and the DON confirmed that on 1/21/19, they were aware that the Grove Nursing Units heating system was not functioning properly and the facility failed to provide a comfortable and safe temperature for the residents of the Grove Nursing Units, failed to assign staff person to continuously monitor and log environmental temperatures throughout the facility and failed to have the clinical staff assess individual residents exposed to the environmental hazard. Immediate Jeopardy was called on 1/22/18, due to the facility's failure to check, monitor and log environmental temperatures on the Grove Nursing Units and assess residents exposed to the environmental hazard on the Grove Nursing Units and implement measures to reduce the risk of hazard and implement timely interventions. The facility was notified of the Immediate Jeopardy on 1/22/19, at 7:06 p.m. and an immediate corrective action plan was received on 1/22/19, at 11:59 p.m. The plan included: after the issue was identified as an environmental hazard all 87 residents were temporarily relocated to a safe environment in the facility and were permanently relocated when the fix was not going to be completed until 1/23/19; hourly monitoring of environmental air temperatures for all nursing units; nursing personnel assessed all 87 residents to ensure there was no negative outcomes; maintenance staff will be educated on checking unit temperatures along with system checks whenever concerns are reported; and the facility staff will be educated on the appropriate temperatures and reporting. During an interview on 1/23/19, at 10:15 p.m. Registered Nurse Unit Manager, Employee E5, confirmed that the Grove Nursing Units were cold and had no heat on the 7 a.m. to 3 p.m. shift. During a phone interview on 1/23/19, at 2:30 p.m. Resident Family (RF) RF3 indicated that they were called by the facility and told to bring a warm coat and hat because there was no heat on the unit. Resident lives on the Grove 2 Nursing Unit. During an interview on 1/23/19, at 10:15 p.m. Registered Nurse (RN), Employee E6, confirmed that on 1/21/19, during the 3-11 p.m. shift RN, Employee E6, went to the Nursing Supervisor and expressed concerns about how cold the Grove 3 Nursing Unit was and the unit was sent another cart of blankets. During an interview on 1/24/19, at 3:00 p.m. the NHA confirmed that the Grove Nursing Unit Heating System is functioning, and the temperatures are being monitored to ensure that they remain within the acceptable range of 71 to 81 degrees F prior to moving residents back on to the units. All residents are in rooms within the facility. The Immediate Jeopardy was called on 1/22/19, at 7:06 p.m. the Immediate Jeopardy was lifted on 1/24/19, at 4:00 p.m. when the updated immediate corrective action plan was received and implementation was verified which included: As of 3:00 p.m. on 1/24/19, the Grove 3 Nursing Unit temperatures were 76 degrees F. and the facility moved several residents back to the Grove 3 Nursing Unit with the exception of a resident that desired to stay on the unit they were relocated to. The Grove 2 Nursing Unit temperatures were at 71 degrees F. The facility did not reopen the Grove 2 Nursing Unit and continued to monitor the unit's temperatures. The facility was able to identify open beds throughout the facility and open beds on the Grove 3 Nursing Unit to place the remainder of the residents that had been relocated in the auditorium. The Grove 1 Nursing Unit temperature was at 68 degrees and the facility did not relocate residents back to the unit and continued to monitor temperatures hourly. The Grove 1 residents all remained in their current bed locations. The facility continued to monitor temperatures on the Grove Nursing Units hourly. The facility requested to have an occupancy survey of the 68 bed renovated 2 West Nursing Unit and temporary occupancy was granted on 1/24/19, at 3:33 p.m. 42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment. Previously cited 8/7/18, 9/22/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/14/18, 4/2/18, 9/22/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/22/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 12/14/18, 8/7/18, 9/22/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/14/18, 4/2/18, 9/22/17. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 8/7/18, 9/22/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/7/18, 4/2/18. 28 Pa. Code 211.12(c) Nursing services. Previously cited 12/14/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/7/18, 4/2/18, 9/22/17. 28 Pa. Code 211.12(d)(2)(3) Nursing services. Previously cited 8/7/18, 9/22/17.

Based on review of job descriptions, facility policies and clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to make certain that the residents were protected from unsafe temperatures in the facility which placed the residents in an Immediate Jeopardy situation. Findings include: Review of the facility's Emergency Preparedness Program and Plan policy Temperature Extremes last reviewed 1/16/19, indicated that facility will provide a comfortable and safe temperature between 71 and 81 degrees F. In the event of an AC/Heat failure the highest ranking staff member will be notified and assume the incident commander role. The job description for the NHA specified the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state and local standards, guidelines and regulations that govern long term care facilities. To ensure the highest degree of quality care is provided to all residents at all times. The job description for the DON specified the purpose of the job position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is maintained at all times. Based on the findings in this report that identified that the facility's Grove 1, 2 and 3 Nursing Units temperatures were not maintained between 71 and 81 degrees F. The facility staff failed to monitor the hazardous environmental temperatures, evaluate residents, implement and act on a plan in a timely manner to remove residents from the hazard. The NHA and the DON failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed, thereby placing the residents in an Immediate Jeopardy situation. Refer to F584, 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/14/18, 9/22/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/22/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 12/14/18, 8/7/18, 9/22/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/14/18, 4/2/18, 9/22/17. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 8/7/18, 9/22/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/7/18, 4/2/18, 9/22/17. 28 Pa. Code 211.12(d)(2)(3) Nursing services. Previously cited 8/7/18, 9/22/17.

Based on review of facility policy and clinical records, as well as a staff interview, it was determined that the facility failed to prevent neglect resulting in a fractured arm for one of eight residents reviewed (Resident R1). Findings include: The facility policy entitled, Turning and Positioning a Resident in Bed dated 9/1/16, indicated that staff should review the ADL (Activities of Daily Living) book for current orders/specialty positioning information. Content included in facility staff education titled, Bed Mobility, conducted on 5/2/17, indicated that when a resident was turned in bed, staff should turn the resident toward themselves. Content also included that the air mattress should be adjusted to firm prior to turning the resident. Review of the clinical face sheet indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 6/21/17, indicated that Resident R1 had moderate cognitive impairment and required extensive assistance of two persons for bed mobility. Review of the current ADL Nurse Aide information records indicated that Resident R1 was non-weight bearing on the right lower extremity, was to have two persons assist for all transfers, had an air mattress on her bed and was to be repositioned every two hours. Review of the information dated 6/26/17, submitted by the facility, indicated that Resident R1 was being repositioned by Nurse Aide (NA), Employee E2, when the resident slid off of the air mattress and fell on to her right arm, resulting in a [MEDICAL CONDITION] humerus (upper arm bone). Review of a statement completed on 6/27/17, at 7:50 a.m. and signed by Employee E2 indicated that she had turned Resident R1 away from her and had failed to obtain assistance from another person stating, I can usually do it by myself, and failed to adjust the air mattress mode prior to attempting to reposition the resident. The 6/27/17, statement indicated that Resident R1 started to slide off the air mattress and that NA Employee E2 couldn't stop her. Review of the hospital physician's progress notes dated 6/26/17, indicated that Resident R1 had a right distal (lower end) humerus fracture and a chronic right femoral neck (upper thigh bone) fracture. Review of the facility staff education entitled, Bed Mobility, conducted on 5/2/17, indicated that Employee E2 had signed the attendance sheet. During an interview on 7/3/17, at 11:20 a.m. the Assistant Director of Nursing, Employee E1, indicated that Resident R1 required two persons for repositioning. Employee E1 indicated that Employee E2 failed to obtain assistance, properly turn the resident toward her and to adjust the mode on the air mattress to prevent falls resulting in injury. 42 CFR 483.12(b)(1)-(3) Prohibit Mistreatment/Neglect/Misappropriation. Previously cited 3/23/17. 28 Pa. Code 201.14(a) Responsibility of the licensee. Previously cited 3/23/17, 2/13/17, 1/30/17, 7/11/16, 10/23/15. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 3/23/17, 10/23/15. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 3/23/17, 10/23/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/23/17, 2/13/17, 3/9/16, 10/23/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/23/17, 10/23/15.

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to implement timely interventions through the care plan, to prevent the development and/or worsening of pressure ulcers for six of nine residents (Resident R2, R3, R4, R5, R6, and R7). Findings include: Review of the facility policy entitled Skin Integrity dated 9/1/16, indicated that the facility strives to ensure that a resident entering the facility without a pressure ulcer (also called bedsore- an injury to the skin and underlying tissue resulting from prolonged pressure at the site) does not develop pressure ulcers. Wounds will be measured and evaluated at least weekly by a Licensed Nurse, and residents will have head to toe skin observations performed weekly by a Licensed Nurse to observe for alterations in skin integrity. The results of the skin observations will be documented in the medical record. Review of the facility policy entitled, Wound Classification dated 9/1/16, indicated that the facility will classify and stage wounds accurately for proper treatment. The facility utilizes the pressure ulcer staging guidelines developed by the National Pressure Ulcer Advisory Panel to describe and stage pressure ulcers: Stage 2 - partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (a type of necrotic tissue). Stage 4 - full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark scab) may be present on some parts of the wound bed. Unstageable full thickness skin or tissue - full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Suspected deep tissue injury (SDTI) depth unknown - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (a mixture of pressure and friction). Review of Resident R2's comprehensive Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 2/24/17, indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R2's Skin Risk Observation Form, dated 2/18/17, a review of the resident's foot assessment did not indicate any skin conditions. Review of Resident R2's Skin-Weekly Pressure Ulcer Evaluation Report, dated 2/28/17, at 10:51 a.m. indicated the resident had a left foot, plantar surface (bottom of the foot), 1 x 2 cm (centimeter) deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (a mixture of pressure or friction)) and had a right foot, plantar surface, unstageable (full thickness tissue loss in which the actual depth of the ulcer is obscured) area measuring 2 x 2 cm., and a bariatric bed (a larger bed) was ordered for better (resident) fit. Review of Resident R2's physician's orders dated 2/28/17, indicated, bed extender, elevate feet from bed, pad footboard in meantime until able to extend bed. During an interview on 3/8/17, at 12:05 p.m. and on 3/17/17, at 3:00 p.m. the Director of Nursing (DON) confirmed that Resident R2 slid down in bed and the bottom of his feet were against the footboard which caused the DTIs. Review of Resident R3's comprehensive MDS assessment dated [DATE], indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R3's Skin - Weekly Pressure Ulcer Evaluation Report indicated the following: 2/13/17, indicated no alterations in skin integrity present. 2/22/17, indicated a Stage 2 pressure ulcer on his coccyx that measured 1.5 cm x 1 cm x .01 cm. Review of Resident R3's physician's orders dated 2/22/17, indicated, strict turning and repositioning every two hours. Review of Resident R3's Medication/Treatment Administration Record dated 2/2017, indicated, Strict turning and Repositioning Every Two Hours documentation as follows: 7:00 a. m.-3:00 p.m. 3:00 p.m.-11:00 p.m., and 11:00 p.m.-7:00 a.m. included an entry for the shift on 2/22/17, through 2/28/17, and not for specific hours. Review of the Point of Care History (electronic documentation by the facility staff) for Resident R3 2/2017, indicated that the resident received physical assist for bed mobility as follows: 2/22/17, at 8:28 p.m. 9:29 a.m. and 1:20 a.m. 2/23/17, at 8:22 p.m. 8:39 a.m. and 1:25 a.m. 2/24/17, at 3:38 p.m. 2/25/17, at 10:41 p.m., and 2:49 p.m. 2/26/17, at 6:54 p.m. 10:16 a.m., and 1:31 a.m. 2/27/17, at 3:58 p.m., and 11:29 a.m. 2/28/17, at 4:48 p.m., and 10:31 a.m. 3/1/17, at 8:35 p.m. 11:54 a.m., and 1:12 a.m. 3/2/17, at 11:35 a.m., and 1:08 a.m. 3/3/17, at 11:30 a.m. 3/4/17, at 2:45 p.m. 3/5/17, at 11:11 a.m., and 1:34 a.m. 3/6/17, at 10:03 a.m., and 1:12 a.m. Review of Resident R3's Skin - Weekly Pressure Ulcer Evaluation Report, dated 3/6/17, indicated an unstageable pressure ulcer on his coccyx (tailbone) that measured 4 cm x 7 cm. Review of Resident R3's nurses' progress notes dated 3/10/17, at 12:01 p.m. indicated the resident was transferred to an acute care hospital and his problem/assessment plan indicated sepsis (presence of harmful bacteria in tissues) - multiple potential sources: possible from sacral decubitus wound (pressure ulcer between the two hip bones of the pelvis). Review of Resident R4's quarterly MDS assessment dated [DATE], indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R4's Skin - Weekly Head to Toe Skin Evaluation indicated the following: 2/1/17, and 2/7/17, indicated no alterations in skin integrity present. 2/13/17, 2/22/17, and 2/28/17, indicated left heel SDTI. Review of Resident 4's physician's orders dated 2/13/17, indicated to have Occupational Therapy (OT) provide offloading (transfer for pressure from a specific point) measures/footwear, resident has SDTI left heel. The pysician's orders on 2/21/17, indicated to float the heel at all times while in and out of bed and on 2/27/17, recommended a heel lift cushion at all times in bed. Review of Resident R4's wound consultant report indicated the following: 2/23/17, she has a heel lift in her bed today but her heels are still pressing on the bed due to improper placement. 2/28/17, she has an oversized heel lift in her room but not on the bed, her heels are pressing on the bed today due to improper placement, 1.2 cm x 1.8 cm. 3/2/17, her foot is resting on the bed today. Review of Resident R4's Skin - Weekly Pressure Ulcer Evaluation Report, dated 3/9/17, indicated that the, dark brown eschar is starting to lift, 1.2 cm x 1.6 cm. Review of Resident R5's quarterly MDS assessment dated [DATE], indicated that the resident was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R5's Skin - Weekly Non-Pressure Wound Evaluation revealed the following: 2/6/17, indicated open area just lower than his coccyx (tailbone) wound appears to be from pulling off border dressing. 2/14/17, indicated a shearing area above buttocks 3.2 cm x .8 cm x 3 cm. Review of Resident R5's physician's orders, dated 2/15/17, indicated coccyx unstageable pressure ulcer, OT please provide gel or other pressure relief wheelchair cushion. Review of Resident R5's OT report dated 2/17/17, indicated, OT evaluation - wounds originally identified as left butt denuded (erosion of the skin) area and maceration (softening and breaking down of skin) wound between buttocks crease, now labeled as pressure areas. Review of Resident R5's wound consultant report dated 2/16/17, indicated the, resident was found to have shearing on his coccyx, he also has a left buttock wound thought to have started as tape burn, it appears as an unstageable, also found two excoriation's on his posterior (back) scrotum today, he states the area is sore; limit chair time. Review of Resident R5's OT's pain test (assessment of pain impact on daily life) dated 2/17/17, indicated, resident reports butt (buttocks) pain this afternoon, has been in chair approximately four to five hours. Review of Resident R5's wound consultant report dated 2/21/17, indicated, coccyx unstageable pressure injury (PI), left buttocks unstageable PI; limit chair time. Review of Resident R5's Pressure Ulcer care plan dated 2/23/16, indicated that the resident was at risk of alteration to skin integrity and resident's skin will be clear and intact. During an interview on 3/8/17, at 1:40 p.m. the DON confirmed that Resident R5's care plan had not been updated to reflect the impaired skin integrity of his buttock, coccyx and scrotum and did not include an intervention to limit chair time. Review of Resident R6's quarterly MDS assessment dated [DATE], indicated that the resident was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R6's Skin - Weekly Pressure Ulcer Evaluation revealed the following: 2/16/17, indicated that the resident had a right ischial (ischium - the sit bones) unstageable (pressure) ulcer 1.8 cm x 1.5 cm. Review of Resident R6's physician's orders indicated the following: 2/16/17, encourage frequent rest periods in bed. 2/21/17, recommend resident to take rest breaks in bed for pressure relief. 2/23/17, please limit chair time and resident should be put back in bed between activities etc., due to new pressure ulcer right ischium. Review of Resident R6's clinical record failed to reveal evidence trhat these interventions had been implemented. Review of Resident R6's Pressure Ulcer care plan last dated 12/12/16, indicated that the resident had a, Stage 4 pressure ulcer to coccyx. During an interview on 3/8/17, at 1:45 p.m. the DON confirmed that Resident R6's care plan had not been updated to reflect the impaired skin integrity of her right ischium and did not include interventions to encourage rest breaks and limit the resident's chair time. Review of Resident R6's wound consultant report dated 2/23/17, indicated, newer development of right ischial unstageable PI. Assessment - she is reportedly in her chair much longer than advised. Review of Resident R7's admission MDS assessment dated [DATE], indicated that the resident had [DIAGNOSES REDACTED]. The resident had two unstageable deep tissue injuries to the heels and his functional status for bed mobility was extensive assistance, requiring two + persons physical assist and his functional limitation in range of motion was impairment on both sides, lower extremity. Review of Resident R7's physician order dated 1/10/17, indicated bilateral Prafo boots (ankle/foot orthotic with an anti-rotation bar) at all times with skin checks and except for hygiene (remove for hygiene). Review of Resident R7's Skin - Weekly Pressure Ulcer Evaluation, dated 2/23/17, indicated new wound to bottom right foot over bony prominence, SDTI 4 cm x 4 cm, red and purple in color. Review of Resident R7's physician order dated 2/23/17, indicated discontinue Prafo boot for now and substitute with a soft off loading boot - consult therapy for off loading recommendations and OT to get resident new off loading boots. Review of Resident R7's OT report dated 2/24/17, indicated OT consulted for discontinue Prafo boot for now and substitute (sub) with a soft off loading boot; Prafo boots are worn down, padding over toe insert worn out causing internal pressure on bony prominence during weight bear. Review of Resident R7's Nurse Aid Sheet (form utilized to document tasks) dated 2/2017, indicated Spenco (foam to hold ankles in position) boots at all times, instead of Prafo boots, and the form did not include skin checks and hygiene tasks. Review of Resident R7's OT Discharge Summary dated 3/10/17, indicated Roylan (positioning boot) heel boots issued (provided). Review of Resident R7's nurses' progress notes dated 3/13/17, indicated spoke with therapy this a.m. about staff concerns with right foot wanting to internal rotation, to look into getting another boot to right foot. During an interview on 3/14/17, at 11:27 a.m. the DON confirmed that Resident R7's Roylan boots were ordered on [DATE], and the resident didn't receive them until 3/10/17, fifteen days after they were ordered. During an interview on 3/21/17, at 3:15 p.m., the DON confirmed that the facility failed to implement timely interventions through the care plan, to prevent the development and/or worsening of pressure ulcers for six of nine residents (Resident R2, R3, R4, R5, R6, and R7). During an interview on 3/23/17, at 3:48 p.m., the DON confirmed that the nurse aides were documenting Spenco boots on the 2/2017 Nurse Aide Sheet instead of Prafo boots, and the facility did not have a policy for training nurse aides who were responsible for applying resident's Prafo boots, and did not have a policy indicating who was reponsible to check the boots for wear. 28 Pa. Code 201.14(a) Responsibility of the licensee. Previously cited 2/13/17, 1/30/17, 8/5/16, 7/11/16, 10/23/15. 28 Pa. Code 201.18(b)(1) Management. Previously cited 8/5/16, 10/23/15. 28 Pa. Code 201.18(b)(2) Management. Previously cited 10/23/15. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 8/5/16, 10/23/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 2/13/17, 8/5/16, 3/9/16, 10/23/15.

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to complete accurate and timely pressure ulcer assessments, implement preventative interventions and obtain orders and/or evaluate effectiveness of treatments for six of nine residents who developed facility acquired pressure ulcers (Resident R2, R3, R4, R5, R6, and R7). Findings include: Review of the facility policy entitled Skin Integrity dated 9/1/16, indicated that the facility strives to ensure that a resident entering the facility without a pressure ulcer (also called bedsore- an injury to the skin and underlying tissue resulting from prolonged pressure at the site) does not develop pressure ulcers. Wounds will be measured and evaluated at least weekly by a Licensed Nurse, and residents will have head to toe skin observations performed weekly by a Licensed Nurse to observe for alterations in skin integrity. The results of the skin observations will be documented in the medical record. Review of the facility policy entitled, Wound Classification dated 9/1/16, indicated that the facility will classify and stage wounds accurately for proper treatment. The facility utilizes the pressure ulcer staging guidelines developed by the National Pressure Ulcer Advisory Panel to describe and stage pressure ulcers: Stage 2 - partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (a type of necrotic tissue). Stage 4 - full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dark scab) may be present on some parts of the wound bed. Unstageable full thickness skin or tissue - full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Suspected deep tissue injury (SDTI) depth unknown - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (a mixture of pressure and friction). Review of Resident R2's comprehensive Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 2/24/17, indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R2's Skin Risk Observation Form, dated 2/18/17, a review of the resident's foot assessment did not indicate any skin conditions. Review of Resident R2's Skin-Weekly Pressure Ulcer Evaluation Report, dated 2/28/17, at 10:51 a.m. indicated the resident had a left foot, plantar surface (bottom of the foot), 1 x 2 cm (centimeter) deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear (a mixture of pressure or friction)) and had a right foot, plantar surface, unstageable (full thickness tissue loss in which the actual depth of the ulcer is obscured) area measuring 2 x 2 cm., and a bariatric bed (a larger bed) was ordered for better (resident) fit. Review of Resident R2's physician's orders dated 2/28/17, indicated, bed extender, elevate feet from bed, pad footboard in meantime until able to extend bed. During an interview on 3/8/17, at 12:05 p.m. and on 3/17/17, at 3:00 p.m. the Director of Nursing (DON) confirmed that Resident R2 slid down in bed and the bottom of his feet were against the footboard which caused the DTIs. Review of Resident R3's comprehensive MDS assessment dated [DATE], indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R3's Skin - Weekly Pressure Ulcer Evaluation Report indicated the following: 2/13/17, indicated no alterations in skin integrity present. 2/22/17, indicated a Stage 2 pressure ulcer on his coccyx that measured 1.5 cm x 1 cm x .01 cm. Review of Resident R3's physician's orders dated 2/22/17, indicated, strict turning and repositioning every two hours. Review of Resident R3's Medication/Treatment Administration Record dated 2/2017, indicated, Strict turning and Repositioning Every Two Hours documentation as follows: 7:00 a. m.-3:00 p.m. 3:00 p.m.-11:00 p.m., and 11:00 p.m.-7:00 a.m. included an entry for the shifts on 2/22/17, through 2/28/17, and not for specific hours. Review of the Point of Care History (electronic documentation by the facility staff) for Resident R3 2/2017, indicated that the resident received physical assist for bed mobility as follows: 2/22/17, at 8:28 p.m. 9:29 a.m. and 1:20 a.m. 2/23/17, at 8:22 p.m. 8:39 a.m. and 1:25 a.m. 2/24/17, at 3:38 p.m. 2/25/17, at 10:41 p.m., and 2:49 p.m. 2/26/17, at 6:54 p.m. 10:16 a.m., and 1:31 a.m. 2/27/17, at 3:58 p.m., and 11:29 a.m. 2/28/17, at 4:48 p.m., and 10:31 a.m. 3/1/17, at 8:35 p.m. 11:54 a.m., and 1:12 a.m. 3/2/17, at 11:35 a.m., and 1:08 a.m. 3/3/17, at 11:30 a.m. 3/4/17, at 2:45 p.m. 3/5/17, at 11:11 a.m., and 1:34 a.m. 3/6/17, at 10:03 a.m., and 1:12 a.m. Review of Resident R3's Skin - Weekly Pressure Ulcer Evaluation Report, dated 3/6/17, indicated an unstageable pressure ulcer on his coccyx (tailbone) that measured 4 cm x 7 cm. Review of Resident R3's nurses' progress notes dated 3/10/17, at 12:01 p.m. indicated the resident was transferred to an acute care hospital and his problem/assessment plan indicated sepsis (presence of harmful bacteria in tissues) - multiple potential sources: possible from sacral decubitus wound (pressure ulcer between the two hip bones of the pelvis). Review of Resident R4's quarterly MDS assessment dated [DATE], indicated that the resident was admitted on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R4's Skin - Weekly Head to Toe Skin Evaluation indicated the following: 2/1/17, and 2/7/17, indicated no alterations in skin integrity present. 2/13/17, 2/22/17, and 2/28/17, indicated left heel SDTI. Review of Resident 4's physician's orders dated 2/13/17, indicated to have Occupational Therapy (OT) provide offloading (transfer for pressure from a specific point) measures/footwear, resident has SDTI left heel. The pysician's orders on 2/21/17, indicated to float the heel at all times while in and out of bed and on 2/27/17, recommended a heel lift cushion at all times in bed. Review of Resident R4's wound consultant report indicated the following: 2/23/17, she has a heel lift in her bed today but her heels are still pressing on the bed due to improper placement. 2/28/17, she has an oversized heel lift in her room but not on the bed, her heels are pressing on the bed today due to improper placement, 1.2 cm x 1.8 cm. 3/2/17, her foot is resting on the bed today. Review of Resident R4's Skin - Weekly Pressure Ulcer Evaluation Report, dated 3/9/17, indicated that the, dark brown eschar is starting to lift, 1.2 cm x 1.6 cm. Review of Resident R5's quarterly MDS assessment dated [DATE], indicated that the resident was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R5's Skin - Weekly Non-Pressure Wound Evaluation revealed the following: 2/6/17, indicated open area just lower than his coccyx (tailbone) wound appears to be from pulling off border dressing. 2/14/17, indicated a shearing area above buttocks 3.2 cm x .8 cm x 3 cm. Review of Resident R5's physician's orders, dated 2/15/17, indicated coccyx unstageable pressure ulcer, OT please provide gel or other pressure relief wheelchair cushion. Review of Resident R5's OT report dated 2/17/17, indicated, OT evaluation - wounds originally identified as left butt denuded (erosion of the skin) area and maceration (softening and breaking down of skin) wound between buttocks crease, now labeled as pressure areas. Review of Resident R5's wound consultant report dated 2/16/17, indicated the, resident was found to have shearing on his coccyx, he also has a left buttock wound thought to have started as tape burn, it appears as an unstageable, also found two excoriation's on his posterior (back) scrotum today, he states the area is sore; limit chair time. Review of Resident R5's OT's pain test (assessment of pain impact on daily life and quality of life) dated 2/17/17, indicated, resident reports butt (buttocks) pain this afternoon, has been in chair approximately four to five hours. Review of Resident R5's wound consultant report dated 2/21/17, indicated, coccyx unstageable pressure injury (PI), left buttocks unstageable PI; limit chair time. Review of Resident R5's Pressure Ulcer care plan dated 2/23/16, indicated that the resident was at risk of alteration to skin integrity and resident's skin will be clear and intact. During an interview on 3/8/17, at 1:40 p.m. the DON confirmed that Resident R5's care plan had not been updated to reflect the impaired skin integrity of his buttock, coccyx and scrotum and did not include an intervention to limit chair time. Review of Resident R6's quarterly MDS assessment dated [DATE], indicated that the resident was re-admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of Resident R6's Skin - Weekly Pressure Ulcer Evaluation revealed the following: 2/16/17, indicated that the resident had a right ischial (ischium - the sit bones) unstageable (pressure) ulcer 1.8 cm x 1.5 cm. Review of Resident R6's physician's orders indicated the following: 2/16/17, encourage frequent rest periods in bed. 2/21/17, recommend resident to take rest breaks in bed for pressure relief. 2/23/17, please limit chair time and resident should be put back in bed between activities etc., due to new pressure ulcer right ischium. Review of Resident R6's clinical record failed to reveal evidence trhat these interventions had been impelmted. Review of Resident R6's Pressure Ulcer care plan last dated 12/12/16, indicated that the resident had a, Stage 4 pressure ulcer to coccyx. During an interview on 3/8/17, at 1:45 p.m. the DON confirmed that Resident R6's care plan had not been updated to reflect the impaired skin integrity of her right ischium and did not include interventions to encourage rest breaks and limit the resident's chair time. Review of Resident R6's wound consultant report dated 2/23/17, indicated, newer development of right ischial unstageable PI. Assessment - she is reportedly in her chair much longer than advised. Review of Resident R7's admission MDS assessment dated [DATE], indicated that the resident had [DIAGNOSES REDACTED]. The resident had two unstageable deep tissue injuries to the heels and his functional status for bed mobility was extensive assistance, requiring two + persons physical assist and his functional limitation in range of motion was impairment on both sides, lower extremity. Review of Resident R7's physician order dated 1/10/17, indicated bilateral Prafo boots (ankle/foot orthotic with an anti-rotation bar) at all times with skin checks. Review of Resident R7's Skin - Weekly Pressure Ulcer Evaluation, dated 2/23/17, indicated new wound to bottom right foot over bony prominence, SDTI 4 cm x 4 cm, red and purple in color. Review of Resident R7's physician order dated 2/23/17, indicated discontinue Prafo boot for now and substitute with a soft off loading boot - consult therapy for off loading recommendations and OT to get resident new off loading boots. Review of Resident R7's OT report dated 2/24/17, indicated OT consulted for discontinue Prafo boot for now and substitute (sub) with a soft off loading boot; Prafo boots are worn down, padding over toe insert worn out causing internal pressure on bony prominence during weight bear. Review of Resident R7's Nurse Aid Sheet (form utilized to document tasks) dated 2/2017, indicated Spenco (foam to hold ankles in position) boots at all times, nurse aides entered initials/shift. Review of Resident R7's OT Discharge Summary dated 3/10/17, indicated Roylan (positioning boot) heel boots issued (provided). Review of Resident R7's nurses' progress notes dated 3/13/17, indicated spoke with therapy this a.m. about staff concerns with right foot wanting to internal rotation, to look into getting another boot to right foot. During an interview on 3/14/17, at 11:227 a.m. the DON confirmed that Resident R7's Roylan boots were not provided to him until 3/10/17, fourteen days later. The above concerns were discussed with the DON on 3/21/17, at 3:15 p.m. regarding the facility failing to complete accurate and timely pressure ulcer assessments, implement preventative interventions and obtain orders and/or evaluate effectiveness of treatments for six of nine residents who developed facility acquired pressure ulcers (Resident R2, R3, R4, R5, R6, and R7). During an interview on 3/23/17, at 3:48 p.m., the DON confirmed that the nurse aides were documenting Spenco boots on the 2/2017 Nurse Aide Sheet instead of Prafo boots, and the facility did not have a policy for training nurse aides who were responsible for applying resident's Prafo boots, and no policy indicating who was reponsible to check the boots for wear. 42 CFR 483.25(b)(1) Treatment/Services To Prevent/Heal Pressure Sores. Previously cited 10/23/15. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 8/5/16, 10/23/15. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 10/23/15. 28 Pa. Code 211.10(b) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 8/5/16, 10/23/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/5/16, 10/23/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/13/17, 8/5/16, 3/9/16, 10/23/15.

Based on review of clinical records, observations and staff interviews, it was determined that the facility failed to provide adequate monitoring and supervision to prevent a fall which resulted in actual harm with injuries for one of 55 residents reviewed, (Resident R1) and the facility failed to identify hazardous low sound levels for stairwell alarms on two of 12 nursing units (2 and 3 Annex Nursing Units). Findings include: The Minimum Data Set (MDS, a periodic assessment of care needs) assessment dated [DATE], indicated that Resident R1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The MDS also indicated that Resident R1 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognitive abilities. The MDS also indicated the resident used a walker or wheelchair for mobility and required the assistance of one person and supervision for locomotion off the unit. The physician order [REDACTED]. The plan of care for "wandering" for Resident R1, dated 6/6/11, indicated that Resident R1 will not leave the 2 West Nursing Unit, where he resided, unless accompanied by staff/family and the staff was to redirect the resident when near exit doors. Review of the Nurses' Notes entered on 7/22/11 at 9:45 p.m., indicated that Nurse Aide (NA) Employee E7, stated Resident R1 was last seen at 8:00 p.m., at the 2 West Nurses Station. When Employee E7 went to provide care to Resident R1, the resident could not be found. At 8:15 p.m., Registered Nurse (RN) Employee E10 was informed that Resident R1 was missing. At 8:35 p.m., Code W (facility code for a missing resident) was initiated and the resident was found face down while still in the wheelchair, with the seatbelt still attached, at the bottom of the steps in a stairwell on the 2 Annex Nursing Unit. Review of the facility submitted Event Reporting System (ERS) entry to the State Agency dated 7/22/11, indicated that Employee E7 went to provide care to Resident R1 at approximately 8:15 p.m. and could not locate the resident. At. 8:40 p.m., the resident was found in the wheelchair at the bottom of the steps in the 2 Annex Nursing Unit stairwell with the seatbelt still applied. The resident was found with an approximate 3 cm. (centimeter) laceration to the forehead, with a large amount of blood noted and the resident's abdomen was red on the right side. The resident denied pain to the abdomen but did complain of pain to the head. Pressure was applied to the laceration and the resident remained conscious until the medics arrived at 9:40 p.m. The Emergency Department Report dated 7/22/11 at 11:01 p.m., indicated that Resident R1 sustained multiple abrasions, contusions (bruises), a large forehead laceration (cut) requiring sutures (stitches), and had a fracture to the right distal radius (fracture of the forearm near the wrist). During an interview on 8/2/11, at 1:30 p.m., Nurse Aide (NA), Employee E8, indicated that he/she worked on 2 West Nursing Unit on 7/22/11, and last saw Resident R1 around 6:00 p.m. or 7:00 p.m., in a wheelchair and did not see Resident R1 leave the 2 West Nursing Unit. During an interview on 8/2/11, at 1:40 p.m., Nurse Aide (NA), Employee E7, indicated that he/she worked 2 West Nursing Unit on 7/22/11, and last saw Resident R1 at "a little before 8:00 p.m.", near the 2 West Nurses Station, and Resident R1 gave no indication of wanting to leave the unit. During an interview on 8/2/11, at 1:50 p.m., Nurse Aide (NA), Employee E4, indicated that he/she worked the 2 Annex Nursing Unit on 7/22/11, was on the unit at the time Resident R1 was found in the stairwell, but never saw Resident R1 on the 2 Annex Nursing Unit. During an interview on 8/2/11, at 2:00 p.m., Licensed Practical Nurse, Employee E9, indicated that he/she worked 2 West Nursing Unit on 7/22/11, and last saw Resident R1 between 6:00 p.m. and 6:30 p.m. During an interview on 8/2/11, at 2:15 p.m., Registered Nurse (RN), Employee E5, indicated that he/she worked 2 Annex Nursing Unit on 7/22/11, was on the unit in the solarium at the time of the incident, but never saw Resident R1 on the 2 Annex Nursing Unit. During an interview on 8/2/11, at 2:30 p.m., Nurse Aid (NA), Employee E6, indicated that he/she worked 2 Annex Nursing Unit on 7/22/11, was on the unit at the time Resident R1 was found in the stairwell, but never saw Resident R1 on the 2 Annex Nursing Unit. During an observation on 8/2/11, at 9:30 a.m., it was revealed that Resident R1's room was located on the 2 West Nursing Unit across from an unlocked/unalarmed double door which lead to the 2 Annex Nursing Unit. The 2 Annex Nursing Unit had a straight hallway which was 120 feet in length, in which the last 48 feet was closed and under renovation. There were two free standing single panel privacy screens, approximately 3 feet by 6 feet, that separated the occupied half of the 2 Annex Nursing Unit from the closed and unoccupied portion of the 2 Annex nursing unit. At the end of the unoccupied portion of the 2 Annex Nursing Unit was the stairwell where Resident R1 was found. It was also revealed that both of the 2 Annex stairwell door alarms were not loud enough to be heard from the nurses desk, the dining area or from the resident rooms. During an interview on 8/2/11 at 9:40 a.m., Registered Nurse, Employee E1, confirmed that the stairwell alarms on the 2 Annex Nursing Unit were not sufficiently loud to be heard throughout the 2 Annex Nursing Unit. During an observation on 8/2/11 at 11:30 a.m., the following was revealed: The 2 Annex stairwell door sound box located above the nurses station was not connected; During a test of the 2 Annex stairwell door alarms, the alarms were barely audible throughout the 2 Annex Nursing Unit where staff would have been located; There was a reset delay of 12 to 20 seconds for the stairwell doors on the 2 Annex and 3 Annex units resulting in an opportunity to reopen a door without triggering an alarm; The 3 Annex stairwell door alarms were audible but not loud. During an interview on 8/2/11, at 11:35 a.m., the Director of Maintenance Employee E2 confirmed that the stairwell alarm sound box was disconnected at the 2 Annex nursing unit's nurses station and confirmed there was a reset delay on the door alarms During an interview on 8/2/11, at 11:30 a.m., the Security Director, Employee 3, confirmed that the stairwell alarms were not loud enough to be heard on parts of the 2 Annex Nursing Unit. Employee E3 also indicated that security checks for stairwell alarms are done from the point of the stairwell door and not from the point where nursing staff are stationed. There was no evidence that staff were aware that Resident R1 was missing from the 2 West Nursing Unit and the resident went undetected on the 2 Annex Nursing Unit. Further searching by facility staff found Resident R1 face down, while in the wheelchair, with the seat belt still attached, at the bottom of the steps in the stairwell of the 2 Annex Nursing Unit. The facility failed to adequately monitor and supervise Resident R1 who was identified with "wandering" behavior resulting in actual harm to the resident. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 9/25/09, 3/4/10 28 Pa. Code: 201.18(b)(1)(e)(1) Management Previously cited 9/25/09, 3/4/10 28 Pa. Code: 207.2(a) Administrator's responsibility Previously cited 8/20/10 28 Pa. Code: 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(5) Nursing services Previously cited 8/20/10