Every finding on record at Gardens at West Shore, The

Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). This failure resulted in an immediate jeopardy situation.Review of facility policy, titled Elopement, revised June 2023, read, in part, 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. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined by the State of Pennsylvania as a resident leaving a safe area of the facility without authorization. Federal guidance for elopement, as described in F689, is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Review of Resident 1's clinical record revealed diagnoses that included dementia (cognitive and memory changes that disrupt everyday function) and major depressive disorder (a serious, common mood disorder characterized by persistent sadness, loss of interest, and fatigue, lasting at least two weeks and impairing daily life). Review of Resident 1's plan of care revealed a focus area of: Resident has the potential for elopement and associated injury related to exit seeking behavior, with an intervention of: door alarms on at all times, and answer alarms promptly; with a date initiated of March 24, 2026; redirect from exits as needed based on behavior, initiated March 24, 2026; and wander guard device to right wrist-check placement and function every night shift, revised May 17, 2026. Review of Resident 1's physician orders revealed an order dated March 24, 2026, for wander guard to right wrist, check placement every shift and check functioning every night shift. Review of facility provided document, Elopement/Wander Risk Evaluation-V3, dated March 23, 2026, revealed that Resident 1 was a high risk for elopement. Further review of the additional comments section revealed, resident attempting to open the hallway door to leave, redirected he went to the elevator, pressed in the code and got in. Review of facility provided document, Nursing Evaluation-(Admit/Readmit/Quarterly/COC)- V16, dated May 12, 2026, in the section labeled, Section 2. Elopement/Wander Risk Evaluation, revealed Resident 1 was at high risk for wandering or elopement. Review of facility provided incident report dated June 25, 2026, at 4:20 PM, revealed that on June 24, 2026, at 10:50 PM, police came to the facility to inquire if a resident may have left the building because a confused person was found at a convenience store several blocks away and someone had called the police and ambulance. At that time, a full house count was completed and Resident 1 was unable to be located. Facility staff had verified wander guard placement on June 24, 2026, at 7:51 PM. Further review of the incident report revealed Resident 1 returned from the hospital on June 25, 2026, at 2:25 AM, with no injuries and no change from his baseline. At that time, his wander guard device was replaced on his left ankle and he was placed on 1:1 supervision. The Resident reported that after the staff checked his wander guard placement, he had cut the device off and threw it across the room. He was then able to take the elevator to the first floor where he was able to push the door open and exit the building. Review of a motion detection camera located in the lobby revealed that Resident 1 exited the building between 8:02 PM and 8:07 PM. Review of a witness statement from Employee 1 (Licensed Practical Nurse [LPN]), without date, revealed that Resident 1 was last seen by staff when he inquired about if the therapy gym was still open after the evening meal (no time stated). Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 30, 2026, at 11:30 AM, revealed that on June 24, 2026, after Resident 1 had his wander guard placement checked at 7:51 PM, he cut it off. After that, he propelled in his wheelchair down the hallway towards the elevator and when stopped by a nurse, told her that he was going to the therapy gym located across the hallway from the elevator. He then got on the elevator and went to the first-floor lobby, where the receptionist had just left for the night at 8:00 PM. Resident 1 was able to slide the front door open because of the fire release feature (when the door is forced open with this feature, an alarm sounds but only until the door is closed). The facility investigation revealed that no staff heard this alarm and, thus, did not respond. Resident 1 left his wheelchair at the front door when he exited the building. A motion detector camera in the lobby revealed that Resident 1 entered the lobby in his wheelchair at 8:02 PM, and the next photo showed his empty wheelchair sitting beside the entrance door at 8:07 PM. At that time, facility staff failed to respond to the door alarm and Resident 1 exited the facility and was found walking along the road. The facility failed to ensure adequate supervision to prevent elopement which placed Resident 1 in immediate jeopardy situation. The NHA was provided with the immediate jeopardy template on July 1, 2026, at 10:07 AM, and an immediate action plan was requested. On July 1, 2026, at 1:09 PM, the facility's immediate action plan was accepted, which included: On 6/25/26, Resident 1 was returned to facility post Emergency Department evaluation with no negative outcome. Wander guard device was reapplied to Resident's ankle, and he was placed on frequent monitoring at 1:1 level. A new elopement evaluation was completed, and wander guard function was verified. Completed upon resident's return on 6/25/26. Residents with wander guard devices were audited for placement and function of their devices. Audible door alarms were tested for detectability. Completed 6/24/26. Wander guards were audited for appropriate bands and replaced with heavy rubber/vinyl bands to decrease removability. Completed 6/27/26. Facility staff continuously monitored front door until door company arrived onsite 6/29/26 and adjusted front door to ensure it cannot be slid open manually. Director of Maintenance adjusted the 8/9 unit secondary audible alarm speaker which has enhanced detectability. Audible alarm now sounds when door is manually pushed open forward as part of its emergency safety feature, alarm remains sounding until sensors are reengaged when door is set back on track. Facility staff were re-educated on elopement policy; Maintenance staff were re-educated on door alarm testing including detectability. Completed 6/27/26. DON or designee will audit residents with wander guards to ensure placement 3x per week for 4 weeks, then weekly for 4 weeks, then monthly for 1 month. Director of Maintenance or designee will audit audible door alarms including front door and 8/9 unit secondary alarm 3x per week for 4 weeks, then weekly for 4 weeks, then monthly for 1 month. Results to QAPI. Date of Compliance June 27, 2026 During an interview with the NHA on July 1, 2026, at 1:15 PM, the NHA stated that on June 26, 2026, when Resident 1 returned from the hospital, his wander guard device was reapplied to his ankle and he was placed on 1:1 supervision. Another elopement evaluation was also completed at that time, and the wander guard function was verified. Further interview revealed that all residents with wander guard devices were audited for placement and function of their devices. All door alarms were also checked for function and detectability. Facility staff were monitoring the lobby door from the time of the incident until the door was able to be adjusted by the door company on June 29, 2026, to increase the difficulty to reset the door and turn off the alarm. Observations made during a tour of the facility on July 1, 2026, revealed that the door in the front lobby was locked unless you entered a code for it to open. To override the fire safety feature, you could no longer slide the door to the side to open it. Instead, it required pushing the door off track, which set off an audible alarm at the door and at the 800/900 nurses' station. Pushing the door off track increased the difficulty and time needed to put it back on track, thereby increasing the time the alarm is alerting staff. All residents who used a wander guard were observed to have a functional wander guard in place at that time with the new higher durability wander guard bands. Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of education regarding the facility elopement policy and their responsibility to immediately respond to door alarms. The Immediate Jeopardy was lifted on July 1, 2026, at 1:59 PM, after ensuring that the immediate action plan had been implemented. The facility failed to implement interventions, supervision, and effective safety measures to prevent Resident 1 from eloping from the facility. This failure placed Resident 1 in an Immediate Jeopardy situation. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on review of facility investigation, clinical record review, and staff interviews, it was determined that the facility displayed past noncompliance in its failure to ensure that abnormal test results were acted upon timely and in accordance with professional standards of practice for one of eight residents reviewed (Resident 6).Findings include: Review of Resident 6's clinical record revealed diagnoses that included fracture left hip, fracture right femur, fracture left femur, vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and history of falls. Further clinical record review documented Resident 6 sustained a fall on May 1, 2026; in-house x-rays of left and right hips and left and right femurs were obtained. Results of the x-rays revealed left hip fracture. The Resident was transferred to the hospital and underwent Internal Fixation (ORIF- surgical hardware [nails, screws] to stabilize a bone so it heals properly). Resident 6 sustained another fall on May 6, 2026, and no injuries were noted. Review of Resident 6's progress notes documented on May 7, 2026, during a follow-up Registered Nurse assessment post-fall that Resident 6 complained of lower left leg pain. At that time, an in-house x-ray of the left lower leg was completed. There was no evidence of fracture to the left tibia/fibula. On May 27, 2026, Resident 6 sustained another fall and no injury was noted. Further review of progress notes documented on June 5, 2026, revealed the Resident was noted to have blood in her urine. New orders were obtained for a urinalysis with culture and sensitivity and blood work. The facility attempted to obtain the urine sample via straight catheterization on June 6th, 7th, and 8th, 2026, and was unsuccessful. An abdominal x-ray obtained on June 8th, 2026, revealed a large round opacity (lacking transparency) emanating from the pelvis into the abdomen, moderate stool in the colon, mild degenerative disc disease (early age-related wear-and-tear of the spinal discs), ORIF left hip, and acute to subacute moderately displaced right intertrochanteric (top of the femur where the hip and leg meet) fracture. Employee 8 (CRNP-Certified Registered Nurse Practitioner) initialed the abdominal x-ray results on June 9th, 2026, and ordered MiraLAX and Dulcolax milk of magnesia; no acknowledgement/intervention for the right femur fracture. On June 9th, 2026, a STAT (immediate) order of an Ultrasound of the kidneys, ureters, and bladder was obtained and revealed left sided hydronephrosis and layering debris identified within the bladder with underlying mass not excluded. In response to the ultrasound, on June 9th, 2026, there was a new order for an urology consultation due to urinary retention and left-sided hydronephrosis. Review of the history and Physical completed by Employee 8, exam date June 9, 2026, read, in part, the Resident was seen and evaluated following retroperitoneal ultrasound results. Resident and nursing notes deny acute distress. Ultrasound reviewed showing left-sided hydronephrosis, significant bladder distention and layering bladder debris with underlying bladder mass not excluded. Plan discussed with nursing was to obtain a urology consultation for further evaluation, monitor for urinary output and assess for retention symptoms, consider bladder scan protocol and catheterization per facility protocol if clinically indicated, monitor for urinary tract infection, and consider CAT scan of the abdomen/pelvis and bladder as recommended by radiology, and to repeat labs (BMP/CMP) and monitor renal function on Friday. Summary of plan also included: ordered labs for Friday, check vitals if she allows, continue Physical and Occupational Therapy for precautions, neuro checks status post-fall, left hip fracture protocol as per orthopedic with follow up in two weeks, continue aspirin, left lower extremity weight bearing as tolerated, neuro checks initiate today after a fall no significant new injury. History and Physical was signed on June 11, 2026, and failed to acknowledge the right intertrochanteric fracture. Progress note, dated June 14, 2026, documented Resident 6 was noted to have vaginal bleeding with blood clots during care. Resident was transferred to the hospital at that time. Further review of progress notes documented the Resident returned to the facility on June 24th, 2026, and underwent ORIF to repair the right intertrochanteric fracture. Interview with Employee 9 (Regional Registered Nurse Coordinator) on July 1, 2026, at 1:30 PM, revealed that the CNRP initialed the abdominal x-ray, wrote orders and didn't address the right intertrochanteric fracture. Interview with Employee 8 on July 1, 2026, at 2:25 PM, it was revealed that her primary concern was Resident 6's bowel function, that is why the bowel meds were ordered. The Resident was on pain medication due to a hip fracture, with no increase to administration of as needed pain medication. Once the Resident had routine bowel movements and her bladder was emptied, Resident was feeling better and did acknowledge less pain. Resident wasn't getting out of bed at the time due to discomfort and her preference. It was also revealed that she should've been more concise in her note. Interview with Employee 9 on July 1, 2026, at 3:30 PM, revealed Employee 8 should've acknowledged the right intertrochanteric fracture in the physical. It was also revealed that nursing should've discussed the right intertrochanteric fracture with Employee 8. Prior to the survey the facility failed to acknowledge and address all aspects of an x-ray report. Resident 6 was noted to have a fractured right intertrochanter on June 9th, 2026, that wasn't addressed until she was sent to the hospital, due to rectal bleeding, on June 14th, 2026. Five days passed between initial diagnosis at the facility and Resident diagnosis and treatment at the hospital. On June 24, 2026, Resident 6 returned to the facility post-hospital admission for a rectal prolapse. Work up revealed an acute, displaced angulated right femoral neck fracture, and ORIF was completed. In an effort to prevent future incidents, the facility initiated a new procedure for all x-ray results to be reviewed at clinical meetings Monday through Friday, and x-ray results are to be communicated by the licensed staff to the Physician/CRNP immediately. Initiated June 22, 2026. Residents who had x-rays in the past 30 days were audited to ensure results were communicated to the physician/CRNP and Responsible Party, and to ensure no incidental findings of fractures. If a fracture is identified, it will be reviewed with the provider for any appropriate orders. No incidental fracture sere identified. Completed June 17, 2026. Licensed nursing staff were educated on review of x-ray results, communication to provider related to acute findings, and having report reviewed by clinical team in clinical meeting. Completed June 17, 2026.Audits of completed x-rays weekly, for three months, to ensure results reviewed by provider and in clinical meeting. Initiated June 20, 2026. During the onsite survey, a review of audits, staff education, and initiated procedures regarding x-ray results were reviewed and failed to reveal continued or additional concerns regarding x-ray results.Date of compliance June 22, 2026. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, facility policy review, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment on 5 nursing units, the 2nd floor and the main facility hallway.Findings include: Review of facility policy, titled Housekeeping Administration, effective date March 2015, read, in part, Policy Interpretation 1. Conducts rounds daily for identification of areas of improvement. 4. Develops and maintains a cleaning schedule for common areas (lobby, dayrooms, hallways, dining areas, activity rooms, outside areas, etc.). 6. Assures dining rooms will be cleaned after each meal and special functions. Tour of facility conducted on June 1, 2026, from 10:50 AM - 12:00 PM revealed the following concerns: Main hall of the facility revealed the following:Painters' tape was being used to hold part of the baseboard to the wall.Cracked/crumbing plaster noted under the windows.A strong urine smell was noted.Dirt buildup was noted in the door jams, along baseboards, and behind handrails. The ACU (100/200 halls, dining room and residents' lounge) revealed the following:Multiple broken and stained tiles in the hallway ceiling.Dirty walls, dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing the floor transition strip from the hallway into the resident room and the floor tiles were chipped.Multiple windows in Residents' rooms were dirty with a film on them.Dirty cabinets and dirt buildup was observed on the floors and under the sink in the dining room.Holes were in the wall plaster in the dining room.The walls were dirty with various marks, the door had black marks on it, and there were dirty tables with food debris in the dining room.Dirty walls with broken plaster was in the resident lounge.There was an electrical outlet with no cover in the dining room.There were stains on the ceiling tiles in corner of the dining room.The electric baseboard heater vent was rusted in the dining room. The AACU (300/400 halls, dining room and residents' lounge) revealed the following:Multiple hallway ceiling tiles had black/pink fuzzy staining.Multiple walls had cracked and broken plaster.Multiple broken and stained tiles in the hallway ceiling.There were bugs in the hallway light covers.Doors at the end of the hallways were dirty.The walls were dirty with various marks, there was dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing floor transition strips from the hallway and there were chipped floor tiles.Multiple windows in Resident's rooms were dirty.In room [ROOM NUMBER], the ceiling appeared to be patched but was cracked on top of the patchwork.The AACU lounge had broken, stained and sagging ceiling tiles.The AACU lounge had various markings on the walls, dirt buildup in door jams and along the baseboards.The AACU dining room had dirt on the walls and cracked plaster.The AACU dining room had multiple stained ceiling tiles.The baseboard electric heaters on left and right side of the AACU dining room was missing the front cover with coils exposed. The base board heater on the right side of the room had wires exposed.There were exposed wires on the corner of the wall on left side of the room in the AACU dining room.The AACU dining room had multiple holes in the wall plaster throughout the room.The AACU dining room kitchen cabinet had multiple doors and drawer fronts missing.The ceiling in the AACU dining room was cracked and crumbling and the wall plaster had brown staining in the back right corner by the window and bulkhead. The 500 Hall revealed the following:Multiple hallway ceiling tiles had black/pink fuzzy staining. Multiple walls had cracked and broken plaster.There were multiple broken/stained tiles in the hallway ceiling.There were bugs in hallway light covers.The doors at the end of the hallway were dirty.The walls were dirty with various markings, there was dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing floor transition strip from the hallway and there were chipped floor tiles.room [ROOM NUMBER] had paint by the wall AC unit that was cracked and pealing.The ceiling vent was rusted in hallway by rooms [ROOM NUMBERS].Multiple windows in Residents' rooms was dirty with a film. The 600 Hall revealed the following: Multiple hallway ceiling tiles had black/pink fuzzy staining.Multiple walls with cracked and broke plaster.Multiple broken and stained tiles in the hallway ceiling.Bugs were observed in the hallway light covers.The doors at the end of the hallway were dirty with various markings.The walls were dirty with various markings, there was dirt build up in the door jams, along the baseboards, and behind handrails.Multiple rooms were missing the floor transition strip from the hallway and there were chipped floor tiles.room [ROOM NUMBER] had a ceiling patch that was cracked.The windows in Residents' rooms were dirty with a film. The 700 Hall revealed the following:Multiple hallway ceiling tiles had black/pink fuzzy staining.Multiple walls had cracked and broken plaster.There were multiple broken and stained tiles in the hallway ceiling.Bugs were observed in the hallway light covers.The doors at the end of the hallway were dirty.The walls were dirty with various markings, there was dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing the floor transition strip from hallway and there were chipped floor tiles.The windows in Residents' rooms were dirty with a film. The 800 Hall revealed the following:Multiple hallway ceiling tiles had black/pink fuzzy staining.Multiple walls had cracked and broken plaster.There were multiple broken and stained tiles in the hallway ceiling.Bugs were observed in the hallway light covers.The doors at the end of the hallway were dirty.The walls were dirty with various markings, there was dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing the floor transition strip from hallway and there were chipped floor tiles.The windows in Residents' rooms were dirty with a film. The dining lounge on the 800/900 hall revealed the following:The floor was sticky and the tables were dirty with food debris.Wall plaster was cracked and crumbling.Multiple ceiling tiles were stained and cracked.Ceiling vents were rusted and had debris build up.Staff had personal belongings left unattended on the tables. The 900 Hall revealed the following:Multiple hallway ceiling tiles had black/pink fuzzy staining.Multiple walls had cracked and broken plaster.There were multiple broken and stained tiles in the hallway ceiling.Bugs were observed in the hallway light covers.The doors at the end of the hallway were dirty.The walls were dirty with various markings, there was dirt build up in door jams, along baseboards, and behind handrails.Multiple rooms were missing the floor transition strip from hallway and there were chipped floor tiles.The windows in Residents' rooms were dirty with a film. The second flood unit revealed the following:Multiple rooms with sink water running at a steady flow.Dirt, trash and debris scattered in all rooms and hallways observed.Broken and stained ceiling tiles observed in all rooms and hallways.Multiple rooms with broken/missing ceiling tiles. Broken ceiling tiles were lying on the floors.Toilets in multiple rooms observed had a thick, dried brown substance and paper in the toilets.Multiple room bathrooms had sheets and towels overserved on bathroom floors and wrapped around toilet and sink bases.Rooms marked with signage stating, emergency water source. In those rooms were stacked boxes of water. Some boxes were smashed with crushed water bottles inside. Dirt and debris scattered throughout the rooms. Water marks noted on the boxes and towels were on the floor. Several rooms were used for equipment storage for wheelchairs, mattresses, bedside commode, positioning devices. Mattresses were heaped on piles restricting access to the room. A box of resident records was being used to prop open the door.One room was marked for storage and contained current residents' belongings. Unsanitary conditions observed on the second floor of the facility made the unit uninhabitable for residents. The facility has not housed residents on the second floor for several years despite having licensed beds on that unit. Review of the TELS (building management platform for managing maintenance) report from March 2026 through current revealed that one TELS had been entered on May 13, 2026 regarding a missing outlet plate cover in the ACU dining room. No additional TELS had been entered for any of the aforementioned concerns. The above concerns were shown to the Nursing Home Administrator (NHA) during a tour of the facility on June 1, 2026 at 1:22 PM. The NHA stated the staining on ceiling tiles appeared to be moisture, and that the pink/black fuzzy staining could be anything. He stated that he cannot confirm that the staining is mold but would have maintenance replace the tiles. The NHA stated that ceiling tiles are replaced as needed and as concerns are reported. NHA stated that the missing electric based board heater covers are unacceptable and will be replaced immediately. He also stated that the cracked and crumbling plaster in the AACU dining room appears to be water damage and that he will have maintenance follow up. When shown the missing outlet cover in the ACU dining room, the NHA stated he was not sure if it had previously been replaced but that he would check with maintenance. He also stated that the cover will be replaced immediately. NHA stated that the second floor is used for storage and confirmed that facility's emergency drinking water is stored on the second floor. He stated that the sink water is left running so that the pipes do not freeze and that, since summer is coming, they will be shutting off the water. Follow up interview with the NHA at approximately 2:27 PM, revealed that the aforementioned ceiling tiles with pink, black, and fuzzy staining had been replaced and that maintenance was working on the other repairs. The NHA also stated that the second floor is licensed for 60 beds but has not been used in over a decade. An interview on June 1, 2026, at 2:54 PM, with Employee 1 (Maintenance Director) revealed that the electric base board heaters in the AACU dining room are not currently in use and that the exposed coils and wires do not have electric current unless the thermostat is turned on. Employee 1 stated he did not know if the outlet cover in the ACU dining room had been replaced since the TELS was entered on May 13, 2026. Pa. Code 207.2(a) Administration responsibility

Based on observations and staff interviews, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for one out of three floors (2nd floor unit).Findings include: Tour of the facility conducted on June 1, 2026, from 10:50 AM - 12:00 PM, revealed the following concerns on the second floor:Multiple rooms with sink water running at a steady flow.Dirt, trash and debris scattered on the floor in all rooms and hallways observed.Broken and stained ceiling tiles were observed in all rooms and hallways.Multiple rooms with broken/missing ceiling tiles and those broken ceiling tiles lying on the floor.Toilets in multiple rooms observed with a thick, dried brown substance and paper in the toilets.Multiple rooms/bathrooms with sheets and towels observed on bathroom floors and wrapped around toilet and sink bases.Several rooms marked with signage stating, emergency water source. Stacked boxes of water observed in the rooms. Some boxes were smashed with crushed water bottles inside. Dirt and debris scattered throughout the rooms.Several rooms were used for equipment storage for wheelchairs, mattresses, bedside commode, and positioning devices. Mattresses heaped on piles restricting access to the room. A box of resident records was being used to prop open the door.One room marked for storage of current residents' belongings. Unsanitary conditions observed on the second floor of the facility made the unit uninhabitable for residents. The facility has not housed residents on the second floor for several years despite having licensed beds on that unit. The above concerns were addressed to the Nursing Home Administrator (NHA) on June 1, 2026, at 1:22 PM. NHA stated that the second floor is used for storage and confirmed that facility's emergency drinking water is stored on the second floor. He stated that the sink water is left running so that the pipes do not freeze and that, since summer is coming, they will be shutting off the water. The NHA revealed that they use the second floor for storing extra resident mattresses and wheelchairs, and larger equipment, as well as over flow for resident belongings. Follow up interview with the NHA at approximately 2:27 PM, revealed that the second floor is licensed for 60 beds but has not been used in over a decade. Pa. Code 207.2(a) Administration responsibility

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance by failing to provide adequate supervision to prevent an elopement of a resident identified as being at risk for elopement (Resident 3). Resident 3 was found in the street approximately 0.3 miles away from the facility. This failure placed a total of eight additional residents in an Immediate Jeopardy situation who were identified as at risk for elopement and not on a locked unit (Residents 6, 7, 8, 9, 10, 11, 12 and 13). Findings Include:Review of facility policy, titled Elopement, revised June 2023, revealed, 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. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises of the facility without the knowledge and supervision of facility staff.Review of Resident 3's clinical record revealed diagnoses that included alcoholic cirrhosis of the liver (advanced, irreversible scarring of the liver caused by long-term heavy alcohol consumption, often resulting in liver failure), hepatic encephalopathy (a serious condition that occurs when the liver is unable to filter toxins from the blood. A buildup of toxins affects the brain's ability to function), and gastroesophageal reflux disease (GERD-when stomach acid flows back up into the esophagus and causes heartburn). Review of Resident 3's physician orders revealed an order, dated December 13, 2025, and discontinued February 5, 2026, for a wander guard to the right ankle (a bracelet that alerts staff by an alarm if they go beyond a specified area), check placement every shift and check functioning every night shift. Review of Resident 3's current physician orders revealed an order, dated February 5, 2026, for a wander guard to the left ankle, check placement every shift and check functioning every night shift. Review of Resident 3's care plan revealed an elopement care plan dated November 3, 2025, with a focus of Potential for elopement and associated injury related to exit seeking behavior. The resident is an elopement risk/wanderer AEB [as evidenced by] mood risk r/t [related to] expresses desire to go home. Review of the interventions revealed: assist in reorientation to room and facility using verbal cues and reminders; encourage group activity and attempt to keep occupied; provide diversional activities when exit seeking; redirect from exits as needed based on behavior; and wander guard device- check placement and function each shift.Further review of Resident 3's care plan revealed an intervention, dated February 27, 2025, Resident evaluated for safe outside. Requires direct supervision while outdoors, and an intervention dated January 23, 2026, for ambulation- one assist with walker.Review of Resident 3's elopement/wander risk evaluation, dated November 1, 2025, revealed a score of 9, meaning Resident 3 is a moderate risk. Review of Resident 3's incident report, dated February 4, 2026, at 8:45 PM, revealed that at 8:45 PM, Employee 2 (Registered Nurse [RN]) was made aware that Resident 3 could not be located on the unit. When Employee 2 arrived to the unit, a search was already underway. Staff also began searching the entire facility for the resident, to no avail. Resident had not signed out on the sign out sheet. At 8:55 PM, Employee 2 called Resident 3's cell phone, which went directly to voicemail. At 8:56 PM, Employee 2 called Resident 3's Responsible Party, who stated she did not know the whereabouts of Resident 3.Further review of the incident report revealed that, at that time, staff searched the outside perimeter of the building and Employee 4 (RN) drove to the local [NAME] store to search for Resident 3. Employee 4 called Employee 2 to notify her he had spoken to Resident 3's Responsible Party, who stated she spoke with Resident 3 and he said he was at [NAME], but was walking back to the facility. Employee 4 did not see Resident 3 between the facility and [NAME]. Employee 4 drove in the opposite direction and at 9:10 PM, Employee 4 located Resident 3 in the street in the opposite direction, approximately 0.3 miles north of the facility and [NAME]. Resident 3 got into Employee 4's car without issues and Resident 3 was returned to the facility. The incident report further stated that upon returning to the facility, Resident 3 was noted to be warmly dressed in a long sleeve heavy T-shirt, flannel shirt and a winter coat, as well as a sweater hat and thick gloves. Resident 3 was also observed to be wearing thick trousers, socks and shoes. Resident 3 reported that he was going to [NAME] to buy something and to get some money out of the machine.Outside temperatures on February 4, 2026, for the facility's location, per online historical data, was high of 28 degrees F and a low of 16 F. It was also dark, and Resident 3 walked across a heavily trafficked roadway. Review of resident's clinical record revealed a nursing progress note, dated February 4, 2026, at 11:21 PM, stating Resident 3 was assessed by the RN. Resident 3 denied pain or discomfort, circulation and sensation are intact to all extremities. All skin was noted to be intact with no redness noted. Vital signs were within normal limits. Wander guard was applied to Resident 3's left ankle. The facility provided the surveyor with a picture of Resident 3 exiting the main entrance door of the facility, dated February 4, 2026, and timed 5:33 PM. In addition to the Resident in the picture, a second person can be seen around the corner, further up ahead of the Resident, on the sidewalk going towards the parking lot. That person was identified by the facility as Employee 5 (Assistant Housekeeping Director).Review of facility's investigation revealed an interview with Employee 5, conducted by the Nursing Home Administrator (NHA), undated. The interview revealed Employee 5 was asked if she observed Resident 3 standing in the lobby prior to exiting. Employee 5 stated that she observed some people/residents sitting in the lobby chairs but stated she did not observe anyone who resembled Resident 3. Review of Employee 4's witness statement, dated February 4, 2026, revealed that the Resident was last seen at dinner time. Nurse aide reported that the Resident had not been seen lately. Employee 4 stated that after searching the building, he drove to [NAME]. During the drive, Employee 4 spoke with Resident 3's Responsible Party, who had been in contact with Resident 3. The witness statement further stated that Resident 3 was lost and could not describe location. Employee 4 stated he found Resident 3 two blocks north of [NAME], walking on the street. Resident 3 got into Employee 4's vehicle and was returned to the facility. The witness statement further stated that Resident 3 stated that he was withdrawing money at [NAME] and that Resident 3 was wearing device on ankle. Review of Employee 6's (Nurse Aide) witness statement, dated February 4, 2026, revealed the Resident was last seen in his room at dinner time. Employee 6's statement further stated that she answered a call light for Resident 3's roommate, Resident 14. She stated that when assisting Resident 14, she asked him where his roommate, Resident 3, was. Resident 14 replied Don't know he's been gone a long time. Employee 6 stated she then went to the nurse's station to see if anyone else had seen Resident 3 and they said no.Review of Employee 2's witness statement, dated February 4, 2026, revealed she last saw Resident 3 at 5:30 PM when she was in his room interviewing him for another issue. She stated Resident 3 had eaten his dinner and staff were collecting trays. Employee 2 stated that Resident 3 was standing at the foot of his bed, using his walker and was noted to be fully clothed. Review of facility's telephone interview with Employee 7 (Receptionist) on February 6, 2026, at 2:39 PM, revealed that Employee 7 stated she did not notice anyone by the door, did not see Resident 3 go out the door, and did not take a break. During an interview with the NHA on February 9, 2026, at 10:15 AM, he stated that based on the facility investigation, it was determined there was an issue with the wander guard system at the door, and the door did not alarm when the Resident exited, even though he was wearing a wander guard. He stated that the door is to alarm when someone with a wander guard gets close to it, but they determined that the door was only alarming intermittently. He further stated that the door has a delay when closing so after the code is put in for the door to open, if someone else approaches the door prior to it closing, it will open again, without the code. He stated that it is not confirmed, but possible that Resident 3 could have gotten out the door because of that delay. During the interview, the NHA also stated that the door company has ordered parts to fix the door and until it is fixed, a staff member is assigned to sit at the door 24/7 to monitor anyone entering and exiting. The facility has also disabled the button at the receptionist desk that opens the door; therefore, the receptionist needs to go to the door and physically enter the code every time someone enters or exits the building. The NHA stated that they have also added signs to the door to remind staff and visitors to be mindful of anyone behind you when exiting, to ensure a resident is not following behind. Information provided by the facility indicated that there are eight additional residents identified as elopement risks that reside on the unlocked units (Residents 6, 7, 8, 9, 10, 11, 12 and 13). Review of the clinical records for Residents 6-13 revealed orders for a wander guard and to check placement every shift and function every night shift. The facility failed to provide adequate supervision to prevent an elopement. Camera footage confirmed that Resident 3 left the building on February 4, 2026, at 5:33 PM but was not noticed to be missing until approximately 8:45 PM. Resident 3 was found in the street approximately 0.3 miles away from the facility, approximately three hours and 40 minutes after exiting the facility.The NHA was provided the immediate jeopardy template on February 9, 2026, at 1:29 PM, and an immediate action plan was requested.The facility initiated immediate interventions on February 4, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included: -Resident 3 had wander guard device replaced and an updated elopement evaluation. -Residents with active orders for wander guards had devices checked for function. House wide elopement scores were reviewed for accuracy and care plans in place as indicated. Elopement binder reviewed to include residents with wander guards. Door system was evaluated for function. -Door company scheduled to inspect door system function. Over-ride button behind reception to be taken out of operation until door function validated. Camera to be placed in lobby to capture area exiting through inside double doors. Signage placed on doors to check your surroundings. Door to be monitored 24 hours and will continue until door is repaired and function verified. -Education to staff on elopement policy. Education to reception staff on no over-ride button available and manual code must be entered to unlock the door. Education to staff that when entering code to open the door, monitor for residents attempting to exit before door fully closes. -Observational audits of lobby area to validate code entered and door monitored until fully closed. Door function to be checked weekly once door repaired. Wander guards to be checked for function every day on the 11-7 shift. The facility's plan, as noted above, was reviewed on February 9, 2026, during the onsite survey. On February 9, 2026, at 4:35 PM, the facility's immediate action plan was accepted, which included:-Resident 3 was returned to facility with no adverse outcome, a new wander guard was placed on resident, and a new updated elopement evaluation was completed on 2/5/26. -All facility residents with active orders for wander guards had devices checked for function. All facility resident elopement scores were reviewed for accuracy and that care plans were in place as indicated. Elopement binders were reviewed to include residents with wander guards. Completed on 2/5/26. -The over-ride button at the receptionist desk was disengaged until door/wander guard system is repaired. Service call placed to door company who arrived onsite 2/6/26, parts were ordered and repairs will be made by 2/13/26. A surveillance camera was installed in the lobby to continuously monitor lobby area. Signage was installed on lobby exiting doors to remind visitors/staff to check surroundings when exiting facility. Building entrance door to be monitored continuously by receptionist/designee until repairs completed and door/system is fully operational. -Facility staff were re-educated on facility elopement policy. Facility reception staff were educated on the disabling of over-ride button until proper repairs are completed. Facility staff were educated on when exiting facility to be mindful of who is behind you when exiting. Completed on 2/6/26. -DON (Director of Nursing)/designee will conduct observational audits when door code is entered to ensure that door is monitored until fully closed three times per week for four weeks and then three times per month for two months. Maintenance Director/designee will conduct door/wander guard function audits weekly once door is repaired. Wander guard audits will be checked daily on 11-7 shift. Results to QAPI. -Date of Compliance February 6, 2026. Facility staff of different disciplines were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of education regarding the facility's elopement policy, that the over-ride button has been disabled, that staff are currently monitoring the main entrance door 24/7, and to be mindful of who is around when entering and exiting the facility. The Immediate Jeopardy was lifted on February 9, 2026, at 4:35 PM, after ensuring that the immediate action plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to ensure each resident the right to be free from neglect, which resulted in actual harm as evidenced by superficial incontinence associated dermatitis for one out of three residents reviewed (Resident 2). Findings include:Review of facility policy, titled Abuse Policy read, in part, The resident has the right to be free from neglect. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Review of Resident 2's clinical record revealed diagnoses that included major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and hypertension (high blood pressure).Review of Resident 2's comprehensive care plan revealed a focus area of at risk for skin breakdown and pressure injury development related to incontinence, mobility deficit, last revised September 1, 2022, with an intervention for assist with AM/PM care as needed and report abnormal skin observations, initiated on May 25, 2022.Review of select documents detailed an incident on January 29, 2026, that read [Employee 3] (Nurse Aide) was just starting her evening shift when resident, [Resident 2], rang her call bell. [Employee 3] went to room to answer call bell. [Resident 2] stated, 'could you change my brief? I have not been changed since this morning.' Resident was found to be incontinent of both urine and bowel movement. Incontinence cares provided. RN notified. RN assessment revealed the presence of superficial incontinence associated dermatitis [a form of skin irritation caused by prolonged contact with urine or feces, leading to redness, swelling, and potential skin breakdown]. Zinc oxide order obtained and applied. Statements/interviews gathered. MD and resident representative notified. Nurse aide who was assigned day shift was [Employee 1], she has been suspended pending investigation. February 2, 2026, follow-up RN assessment to buttocks and peri-area reveals no open areas and decreased redness.Review of statement written by Employee 4 (Registered Nurse [RN]) revealed [Employee 3] summoned me to patient's room to report the condition of patient. Patient's bed was soaked from side to side; the brief was so soaked that it dripped. Diarrhea was caked from upper groin all the way to both thighs. Bilateral buttocks were bright red. Patient stated that she hadn't been touched since night shift. Patient stated that she is fearful of retaliation from this aide because she believes this aide will think she reported her.Review of statement written by Employee 2 (RN Supervisor) on behalf of Resident 2 read, [I] didn't receive care all day. Resident states she put her light on 'before noon' and an aide answered it. She told the aide she'd had a bowel movement and needed changed. She said aide said, 'I'll tell your aide.' She turned the light off and left the room. She further stated, 'I don't even know who my aide is. She then described the aide to Employee 2. Review of statement from Employee 1 revealed Interview with [Employee 1], dated January 30, 2026, at 1:10 PM, [Employee 1] was called with union representative present. [Employee 1] was told there is an allegation of neglect from yesterday dayshift. [Employee 1] was asked about the cares she gave to [Resident 2]. She stated that Resident 2 was not in her [work assignment]. She did not give her any cares. The document was signed by the Director of Nursing. Included with the statement document was a nurse aide assignment sheet noting Resident 2 was part of Employee 1's work assignment for day shift on January 29, 2026. During an interview with the Nursing Home Administrator (NHA) on February 9, 2026, at 12:48 PM, he revealed the nurse aide assignments are created by licensed nursing staff and stored at the nursing stations. He further revealed it is the responsibility of nurse aides to review and understand their assignments prior to the start of their shift. Review of Resident 2's nurse aide task documentation failed to reveal nurse aide incontinence care was provided for her on dayshift on January 29, 2026. Employee 2 retrieved statements from all other residents in Employee 1's work assignment on January 29, 2026, and no other issues were identified. The facility substantiated neglect and Employee 1 was terminated following the investigation.Review of nursing progress note from January 29, 2026, at 4:33 PM, revealed, At change of shift today, resident was noted to have several areas of reddened, non-blanchable skin to her right buttock & right gluteal fold as well and her left buttock. The area was cleansed and zinc oxide applied. The resident does complain of mild pain in the area. She is offered Tylenol for comfort. Will continue to monitor areas and refer to the wound team if indicated. The provider and POA are aware.Review of nursing progress note from January 30, 2026, at 11:55 AM, revealed, RN assessment reveals skin to be intact with blanching redness to buttocks and rectal area. Resident at baseline is incontinent of bowel and bladder. Reviewed with provider, magic mix treatment order in place.Review of Resident 2's physician orders revealed an active order for Silver Sulfadiazine Cream 1 %, Apply to Buttocks/rectum topically every shift for Wound Care, dated January 30, 2026. Review of Resident 2's skin and wound note from February 3, 2026, revealed The patient was noted to have moisture trapped in her peri area and some redness. Recommend washing area with soap and water and pat dry thoroughly. Keep areas clean and dry and prevent skin to skin contact. Prevent excessive moisture and apply barrier protection as needed.Interview with the NHA on February 9, 2026, at 1:33 PM, revealed he would expect nurse aides to care for their assigned residents and residents to be free from neglect.The facility failed to ensure each resident the right to be free from neglect, which resulted in actual harm for Resident 2 as evidenced by superficial incontinence associated dermatitis.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management28 Pa. Code 201.29 (a) Resident rights

Based on facility policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to maintain complete clinical records for one of 14 residents reviewed (Resident 3). Findings Include:Review of facility policy, titled Elopement, revised June 2023, revealed, Post Elopement/upon return to the facility, the Director of Nursing Services or Charge Nurse shall: complete and file an Incident Report; and Document the event in the resident's medical record.Review of Resident 3's clinical record revealed diagnoses that included alcoholic cirrhosis of the liver (advanced, irreversible scarring of the liver caused by long-term heavy alcohol consumption, often resulting in liver failure), hepatic encephalopathy (a serious condition that occurs when the liver is unable to filter toxins from the blood. A buildup of toxins affects the brain's ability to function), and gastroesophageal reflux disease (GERD-when stomach acid flows back up into the esophagus and causes heartburn). Review of facility reported incident revealed that on February 4, 2026, at approximately 8:45 PM, facility staff were unable to locate Resident 3. At approximately 9:10 PM, Resident 3 was found on the street approximately 0.3 miles away from the facility. Review of Resident 3's incident report, dated February 4, 2026, revealed a detailed description of Resident 3's elopement from the facility. Further review of the incident report revealed that at the bottom of the form, it read Privileged and Confidential-Not part of the Medical Record.Review of Resident 3's clinical record on February 9, 2026, at 9:48 AM, revealed no progress notes or any other documentation regarding Resident 3's elopement on February 4, 2026. During an interview with the Nursing Home Administrator (NHA) and Employee 13 (Regional Director of Clinical Services) on February 9, 2026, at 1:55 PM, Employee 13 stated she needed to confirm, but it is possible that when the nurse put the risk management note in the incident report, a button may not have been clicked for the note to populate into the clinical record. During a follow up interview with Employee 13 on February 9, 2026, at 2:21 PM, Employee 13 stated that the note on the incident report/risk management should have populated to the clinical record progress note but the button must not have been hit for the note to populate into the progress notes in the clinical record. 28 Pa Code 211.5(f)(ii)(iii) Medical records.

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in one of three shower rooms observed.Findings include:Review of facility policy, titled Environmental Services, Clean, Safe and Orderly Environment with an effective date of March 2024, read, in part, The exterior and interior of the facility will be maintained in a clean, safe, and orderly manner. Housekeeping, Laundry and Maintenance services will be provided properly with precautions taken to prevent infection and cross contamination.Observation in the 800/900 Hall shower room on December 26, 2025, at 10:31 AM, revealed there was a spotty black substance on one side as well as one corner of the ceiling above the shower, a pink substance along the wall of the shower, and black and brown substance on the floor of the shower. The pink substance as well as the black and brown substance on the floor were able to be wiped away with a paper towel. The shower room exhibited a strong foul odor consistent with mildew. Further observation in the 800/900 Hall shower room on December 26, 2025, at 10:35 AM, revealed five shampoo bottles toppled over and scattered across the shower floor, as well as several white wipe materials on the shower floor.During an interview with the Nursing Home Administrator (NHA) on December 26, 2025, at 10:35 AM, he revealed he would get the shower room cleaned immediately. Interview with Resident 1 on December 26, 2025, at 10:51 AM, revealed she had concerns that the shower room was dirty and contained mold.Interview with Resident 2 on December 26, 2025, at 10:52 AM, revealed she had concerns that the shower room was dirty and contained mold.Follow up interview with the NHA on December 26, 2025, at 11:52 AM, revealed he would expect the shower room to be kept clean and residents to be provided with a safe, clean, comfortable and home-like environment.28 Pa. Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for one of 35 residents reviewed (Resident 8).Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered, with a last revision date of March 2022, and a last review date of August 24, 2024, revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 8's clinical record revealed diagnoses that included type II diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin), post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions), and pressure ulcers. Review of Resident 8's current physician orders revealed the following orders: do not resuscitate dated May 20, 2025; and wound care to left lateral malleolus (ankle) pressure ulcer cleans with normal saline, apply betadine to base of wound, and leave open to air twice a day and as needed, dated July 31, 2025. Review of Resident 8's care plan revealed a care plan focus for Resident has an advanced directive of full code, with an initiated date of May 6, 2025. Email communication received from the Director of Nursing (DON) on August 6, 2025, at 12:35 PM, indicated that Resident 8's care plan had been changed to do not resuscitate. She further indicated that he changed his code status after admission and that his care plan was not updated at that time. Email communication received from the DON on August 6, 2025, at 6:37 PM, indicated that she would expect Resident 8's care plan to have been updated when his code status changed. Review of Resident 8's care plan failed to revealed that his pressure ulcer to his left lateral malleolus was included on his current care plan. Further review of Resident 8's care plan revealed a care plan focus for Resident has PICC line (peripherally inserted central catheter, is a long, flexible tube inserted into a vein in the upper arm, used for long-term intravenous access to deliver medications, fluids, or draw blood) related to infectious process, with an initiated date of May 29, 2025. Review of Resident 8's clinical record revealed that his PICC line was discontinued on June 9, 2025. Email communication received from the DON on August 6, 2025, at 3:39 PM, indicated that Resident 8's care plan had been updated to include his new pressure ulcer and that the PICC line was resolved from his care plan. During a final interview with Employee 2 and the Nursing Home Administrator and Employee 2 on August 7, 2025, at 11:05 AM, the NHA confirmed that he would expect Resident 8's care plan to have been revised when all the changes occurred. 42 CFR 483.21(b)(2) Comprehensive Care Plans28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure pharmacy recommendations were acted on appropriately for two of 35 residents reviewed (Residents 25 and 51). Findings include:Review of facility policy, titled Consultant Pharmacist Reports. IIIA1: Medication Regimen Review (Monthly Report), undated, revealed Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.Review of Resident 25's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of Resident 25's December 2024 pharmacy review revealed a recommendation to consider a GDR (gradual dose reduction) for the medications Zolpidem (used to treat insomnia), Hydroxyzine (used to treat anxiety), and Haloperidol (antipsychotic medication used to treat resident's bipolar disorder). Review of Resident 25's clinical record failed to reveal evidence that the physician responded to the pharmacy recommendation. On August 7, 2025, at 12:19 PM, the Nursing Home Administrator (NHA) stated that they were unable to locate Resident 25's December 2024 pharmacy recommendation with physician response. Review of Resident 51's clinical record revealed diagnoses that included depressive disorder (persistent sadness, loss of interest, and difficulty functioning in daily life) and hypertension (elevated/high blood pressure).Review of Resident 51's physician orders revealed a physician order for Seroquel (antipsychotic medication) 12.5 milligrams (mg - metric unit of measure), twice a day, which was dated August 14, 2024; and zolpidem (a psychotropic hypnotic medication) 5 mg at bed time which was dated July 18, 2024.Review of pharmacy recommendation dated January 15, 2025, revealed a recommendation to attempt a GDR of the zolpidem 5 mg. Review of the physician response portion of the pharmacy recommendation revealed that the GDR recommendation was declined and a written rational of Followed by psych[iatric services] was included.Again on April 11, 2025, the pharmacist recommended a GDR of the zolpidem 5 mg. Review of the physician response revealed it was declined due to Resident 51 being, Followed by psych.The recommendation to GDR the zolpidem 5 mg was made a third time on July 9, 2025. The physician declined an attempt of the GDR with the rational of, Followed by psych. However, review of Resident 51's clinical record revealed the last psychiatric consultation was conducted on August 6, 2024, and was not actively being monitored or followed by psychiatric services during the aforementioned GDR recommendations made on January 15, 2025; April 11, 2025; and July 9, 2025.During a staff interview on August 7, 2025, at approximately 11:35 AM, Employee 2 (Regional Director of Clinical Services) confirmed that he facility was unable to locate any psychiatric consultation reports/visits completed for Resident 51 after August 6, 2024. During the interview, Employee 2 revealed that it was the facility's expectation that pharmacy recommendations that are declined have an appropriate clinical rational for declining the recommendation.28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, review of safety data sheet, review of facility temperature logs, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.Findings include:Observation of the dish machine in the main kitchen on August 4, 2025, at 10:02 AM, revealed kitchen staff were washing dishes from breakfast and the rinse temperature on the machine read 93 degrees Fahrenheit (F-unit of measure). Interview with Employee 1 (Assistant Dietary Manager) on August 4, 2025, at 10:02 AM, revealed she was not sure why the dish machine was recording such a low rinse temperature, and she would contact maintenance to come look at the machine. Observation of the dish machine in the main kitchen on August 4, 2025, at 1:38 PM, revealed kitchen staff were washing dishes from lunch and the rinse temperature on the machine read 96 degrees F.Interview with Employee 6 (Dietary Employee) on August 4, 2025, at 1:38 PM, revealed no one from maintenance had come to the kitchen thus far to look at the dish machine. During an interview with Employee 1 and the Nursing Home Administrator (NHA) on August 4, 2025, at 2:58 PM, they revealed the dish machine is a high temperature dish machine with a minimum safe rinse temperature of 180 degrees F, but low temperature sanitizer solution is connected to the machine so it can run at a lower temperature. Review of safety data sheet document titled Low Temperature Machine Sanitizer under Directions for Use revealed The rinse water temperature should be between 120 and 140 degrees Fahrenheit.Review of the dish machine temperature logs utilized by the kitchen stated at the bottom of the document: The wash temperature must be at least 160 degrees and the final rinse temperature at least 180 degrees. If the temperature is not at the proper temperature, do not use the machine- notify your supervisor for instructions.Review of the August 2025 dish machine temperature log revealed rinse temperatures had been recorded below 120 degrees F during breakfast, lunch, and dinner on August 1-5, 2025. Further review failed to reveal any corrective action noted. Review of the July 2025 dish machine temperature log revealed wash and rinse temperatures failed to be recorded on July 1, 2, 6, 9, 12, 13, 15, 18, 23, 25, 26, 29, and 30 at breakfast and lunch; and failed to be recorded on July 1-3, 5-7, 9, 11-21, 23-27, 29, and 30 at dinner. Review of the June 2025 dish machine temperature log revealed wash and rinse temperatures failed to be recorded on June 1, 6, 8, 11, 15, 16, 20, 22, 25, and 29 at breakfast and lunch; and failed to be recorded on June 1 and 5-30 at dinner. Review of the May 2025 dish machine temperature log revealed wash and rinse temperatures failed to be recorded on May 5-31 at dinner. Review of the November 2024 kitchen equipment temperature logs revealed temperatures failed to be recorded on November 25-28 for Refrigerator #1, Refrigerator #2, and the Milk Cooler Refrigerator.Interview with the NHA on August 6, 2025, at 11:49 AM, he revealed his expectation that kitchen equipment is utilized in accordance with professional standards.During a follow-up interview with the NHA on August 7, 2025, at 11:44 AM, he revealed the facility was unable to locate any kitchen equipment temperature logs for the month of January 2025, including for Refrigerator #1-3, the Milk Cooler Refrigerator, the walk-in refrigerator and freezer, and the dish machine. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.6(f) Dietary services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for three of 35 residents reviewed (Residents 5, 51, and 85). Findings include:Review of Resident 5's clinical record revealed diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 5's physician orders revealed an order for a soft padded helmet on at all times, as Resident allows, and release every two hours, dated September 5, 2024. During a staff interview with Employee 7 on August 4, 2025, at 10:22 AM, Employee 7 indicated that Resident 5 removes his helmet frequently because he does not like it . At the time of interview, Employee 7 was reapplying Resident 5's helmet. The helmet was noted to be a soft padded helmet with no securing device, which would prevent Resident 5 from removing the helmet as he desired. Review of Resident 5's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of November 28, 2024, indicated in Section P. Restraints and Alarms revealed he was coded as having an other restraint utilized when in chair or out of bed on a daily basis during the assessment period. Review of Resident 5's Quarterly MDS with the assessment reference date of February 26, 2025, indicated in Section P. Restraints and Alarms revealed he was coded as having an other restraint utilized when in chair or out of bed on a daily basis during the assessment period. Review of Resident 5's Quarterly MDS with the assessment reference date of May 28, 2025, indicated in Section P. Restraints and Alarms revealed he was coded as having an other restraint utilized when in chair or out of bed on a daily basis during the assessment period. Review of Resident 5's Quarterly MDS with the assessment reference date of June 17, 2025, indicated in Section P. Restraints and Alarms revealed he was coded as having an other restraint utilized when in bed on a daily basis during the assessment period. Email communication received from the Director of Nursing (DON) on August 7, 2025, at 9:58 AM, indicated that Resident 5's helmet was being used at the preference of the family and hospice for injury prevention. During a staff interview with the Nursing Home Administrator (NHA) and Employee 2 (Regional Director of Clinical Services) on August 7, 2025, at 11:20 AM, Employee 2 further indicated that the family and hospice wanted the helmet to be used to prevent head trauma if he were to fall. Employee 2 confirmed that Resident 5 can and does remove it as he desires. Employee 2 confirmed Resident 5's helmet should not have been coded as a restraint on his MDS assessments since it did not meet the definition of a restraint.Review of Resident 51's clinical record revealed diagnoses that included depressive disorder (persistent sadness, loss of interest, and difficulty functioning in daily life) and hypertension (elevated/high blood pressure).Review of Resident 51's physician orders revealed an order for zolpidem (a psychotropic hypnotic) 5 mg at bedtime, dated July 18, 2024.Review of Resident 51's most recent annual MDS with an assessment reference date of May 2, 2025; and most recent quarterly MDS with an assessment reference date of April 10, 2025, revealed that section N Medications, was not coded to include the use of a hypnotic medication.In an electronic communication on August 6, 2025, at 2:10 PM, the DON confirmed that Resident 51's annual and quarterly MDS's were coded incorrectly for the use of a hypnotic medication.Review of Resident 85's clinical record revealed diagnoses that included dementia and schizoaffective disorder (a mental health condition marked by symptoms that include hallucinations and delusions). Review of Resident 85's physician orders revealed an active order for Haloperidol Lactate Concentrate 2 mg/ml (antipsychotic medication), give 1 ml by mouth one time a day related to schizoaffective disorder, with a start date of October 25, 2024. Review of Resident 85's Quarterly MDS with assessment reference date of June 18, 2025, under section N0450. Antipsychotic Medication Review A. Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? Resident 85 was marked No- antipsychotics were not received.Review of Resident 85's June MAR (Medication Administration Record- documentation for treatments/medication administered or monitored) revealed she was marked as having received the haloperidol antipsychotic medication on all days of that month. During an interview with the NHA on August 7, 2025, at 11:39 AM, he confirmed Resident 85's aforementioned MDS assessment was marked in error, and he would expect MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records

Based on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for four of 35 residents reviewed (Residents 43, 82, 128, and 141). Findings include:Review of facility policy, titled Catheter Insertion and Care Midline Dressing Changes, with an effective date of July 2017, and a last review date of August 24, 2024, revealed Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. Review of facility policy, titled IIA2: Medication Administration-General Guidelines, undated with a last review date of August 24, 2024, revealed, in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 11. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 15. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. Review of Resident 43's clinical record revealed diagnoses that included bacterial pneumonia, urinary tract infection, and hypertension (high blood pressure). During a resident interview with Resident 43 on August 4, 2025, at 11:32 AM, Resident 43 was observed to have a dressing in place on her right inner elbow (antecubital space) covering a midline intravenous catheter, dated July 23, 2025. Review of Resident 43's Treatment Administration Record for July 2025 revealed that she was documented as having received a dressing change to this site on July 30, 2025. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 6, 2025, at 11:38 AM, the DON confirmed that the midline intravenous dressing should have been changed on July 30, 2025, as per order and facility policy. The DON indicated that she could not speak as to why the nurse signed as completing the dressing change but did not do so.Review of Resident 82's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and anxiety (a feeling of worry, nervousness, or unease). Review of Resident 82's physician orders revealed the following active orders: May go on LOA (leave of absence- signed out of the facility) supervised without medications May go on LOA supervised with medications,During an email correspondence with the DON on August 5, 2025, at 1:03 PM, the surveyor questioned Resident 82's conflicting physician orders. Return email correspondence from the DON on August 6, 2025, at 10:15 AM, she wrote May go LOA supervised without medications is the correct order. The other has been discontinued. The order was confirmed with the Certified Registered Nurse Practitioner.During an interview with the NHA on August 7, 2025, at 11:39 AM, he revealed his expectation that residents would not have conflicting physician orders.Review of Resident 128's clinical record revealed diagnoses that included dementia and moderate calorie protein malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets).Review of Resident 128's physician orders revealed an active order for Enhanced Barrier Precautions (EBP- an infection control intervention) related to open wound.Observation of Resident 128 in her room on August 4, 2025, at 2:32 PM; August 5, 2025, at 1:19 PM; and August 6, 2025, at 11:04 AM; failed to reveal EBP materials or a sign on her door; and during the observations on August 4 and 5, 2025, staff were observed in her room not following EBP. Review of Resident 128's clinical record revealed she had a history of a wound that resolved in April of 2025.During an interview with the DON on August 6, 2025, at 11:49 AM, the surveyor questioned the EBP order for Resident 128. Interview with the NHA on August 7, 2025, at 11:39 AM, revealed he would expect orders to be discontinued if no longer indicated.Review of Resident 141's clinical record revealed diagnoses that included Hodgkin's lymphoma (a cancer of the immune system) and moderate protein-calorie malnutrition (the state of inadequate food intake) During a resident interview with Resident 141 on August 4, 2025, at 11:22 AM, there was a medication cup containing several pills noted on her overbed table. Resident 141 indicated that the nurse had left them there for her while she went to get a shower. Resident 141 indicated that she was going to take them and that the nurses normally do not leave them there. Resident 141 shared an incident where she had spilled her medications on the floor when she went to take them and that she put on her call light and a nurse aide came in to answer the light. Resident 141 said she asked the nurse aide what she should do like let the nurse know or what and Resident 141 said the nurse aide picked up all the pills on the floor and told her she would have to take those. Resident 141 said she was not sure when this occurred. She did not indicate whether or not she took the medications. Review of Resident 141's Medication Administration Records for May 2025, June 2025, July 2025, and August 1-5, 2025, revealed that she had been documented as receiving all her medications as ordered at times specified in orders. During an interview with the NHA and DON August 6, 2025, at 11:30 AM, observation and Resident 141's interview findings were shared for further follow-up. Email communication received from the DON on August 5, 2025, at 2:59 PM, indicated that Resident 141 would be evaluated for self-administration of medications. The email further indicated that [Employee 3] had stated that there was a day when Resident 141's medications were on the floor and that [Employee 4] picked up the medications and gave them back to resident, but that Employee 4 did not report the occurrence until several days later. The DON further indicated that Employee 3 educated Employee 4 that medications should not be given back to a resident after being on the floor, but rather bring them to nurse and new ones would be given. During a staff interview with Employee 3 (Registered Nurse) on August 7, 2025, at 9:36 AM, she confirmed that she leaves medications at Resident 141's bedside for her to take because Resident 141 does not like to take them all at once. She indicated that there was an occasion a couple of months ago or so where either Resident 141 or someone bumped the medication cup that was on the overbed table, which caused pills to be spilled onto the overbed table. Employee 3 indicated that Employee 4 did not know that she was not supposed to touch a resident's medications. Employee 3 indicated that she was not completely sure but that she did not think Resident 141 took the medications that had spilled. Employee 3 indicated that Employee 4 told her about later in the day, possibly the end of the shift. Employee 3 said she educated Employee 4 immediately and that Employee 4 said she would not do it again, but thought it was ok since that was what she does at home. Employee 3 further indicated that Resident 141 was an exceptional case as she does not like to take all her medications at one time. Employee 3 again confirmed that she leaves Resident 141's medications at the bedside and goes back to check to see if Resident 141 has taken them. She said that today she tried just giving Resident 141 just two medications at a time. During a staff interview with Employee 4 (Nurse Aide) on August 7, 2025, at 9:42 AM, Employee 4 indicated that when she went into Resident 141's room to deliver her meal tray there were two pills on her overbed table beside an overturned cup. Employee 4 indicated that she picked the pills up, put them back in the cup, and left them on the over bed table. Employee 4 said she could not remember if she told Resident 141 to take them or not. Employee 4 said she told Resident 141's nurse at the end of the shift on the day this happened, but could not recall exact date. Employee 4 indicated that she received education the day it happened and that she was now aware that she cannot handle a resident's medication. During a staff interview with the NHA and Employee 2 (Regional Director of Clinical Services) on August 7, 2025, at 12:15 PM, Employee 2 indicated she would have expected nursing staff to complete a self-administration of medications assessment on Resident 141 prior to leaving medications at the bedside. The NHA indicated that he would expect the nurse aide to have reported it to supervisor immediately for further guidance and to not handle a resident's medications. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, record review, and staff interviews, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call system is within reach of the resident for one of 35 residents reviewed (Resident 155).Findings include: Review of the facility policy, titled Answering the Call Light, last reviewed August 21, 2024, revealed to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Review of Resident 155's clinical record revealed diagnoses that included type 2 diabetes mellitus (a chronic metabolic disorder characterized by the body's inability to properly use insulin, leading to high blood glucose levels) and hypertension (high blood pressure). Observation of Resident 155 on August 4, 2025, at 9:57 AM, revealed the Resident lying in bed, with their call bell on the floor on a fall mat to the left side of their bed, out of reach for the Resident. Observation conducted of Resident 155 on August 4, 2025, at 11:26 AM, revealed the Resident lying in bed, with their call bell on the floor on a fall mat to the left side of their bed, out of reach for the Resident. Observation conducted of Resident 155 on August 4, 2025, at 1:22 PM, revealed the Resident lying in bed, with their call bell on the floor on a fall mat to the left side of their bed, out of reach for the Resident. Review of Resident 155's MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated May 30, 2025, revealed that Section B. Hearing, Speech, and Vision B0700. Makes Self Understood, Ability to express ideas and wants, consider both verbal and non-verbal expression, is marked 0. Understands; as well as section B0800 Ability to Understand Others, Understanding verbal content, however able, was marked 0. Understands. During an interview with the Director of Nursing (DON) on August 5, 2025, at 3:54 PM, it was revealed that per the unit nursing manager, Resident 155 is able to use their call bell. During an interview conducted with the DON on August 6, 2025, at 11:29 AM, she revealed that she would have expected Resident 155's call bell to have been within reach. Pa. Code 211.12(d)(1) Nursing Services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited range of motion and mobility received appropriate services, equipment, and assistance to maintain or improve range of motion or mobility for one of one residents reviewed (Resident 17).Findings include: Review of Resident 17's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left dominant side and hypertension (high blood pressure). During an interview with Resident 17 on August 4, 2025, at 10:38 AM, Resident 17 indicated she was supposed to be getting a brace for my left leg and it is taking forever. Review of Resident 17's clinical record revealed a CRNP (Certified Registered Nurse Practitioner) visit note dated July 10, 2025, that indicated PT [Physical Therapy] Consult Request: Please evaluate the patient for lower left extremity (LLE) brace qualification and/or necessity. Assess for any deficits in strength, joint stability, alignment, gait mechanics, or neurological function that may warrant orthotic support. Recommendations for appropriate bracing options and mobility assistance are appreciated. Further review of Resident 17's clinical record revealed that the CRNP notes for July 14, 16, 17, 21, 23, 24, 28, 30, and 31, 2025, and August 4, 2025, all indicated the same documentation about a PT consult. In addition, there was physician's note dated July 18, 2025, that also indicated the same documentation about a PT consult. Review of Resident 17's physician orders revealed an order for PT evaluation and treat as indicated as needed dated January 31, 2025, but orders failed to reveal any current PT treatment orders. Review of Resident 17's care plan revealed a care plan focus for limited physical mobility related to left sided weakness with a revision date of February 6, 2025, with interventions that included but were not limited to PT, OT [Occupational Therapy] referrals as ordered, PRN [as needed] with an initiated date of January 31, 2025. Email communication received from the Director of Nursing on August 5, 2025, at 2:59 PM, indicated Therapy will be evaluating for LLE brace. CRNP [Certified Registered Nurse Practitioner] be educated on ordering therapy evaluations. During a staff interview with the Nursing Home Administrator and Employee 2 (Regional Director of Clinical Services) on August 7, 2025, at 11:04 AM, Employee 2 indicated that the nurse practitioner did not put in the therapy request for a screen, which is what therapy reviews to know if have outstanding screens to complete. She said she would have expected there to be communication between the nurse practitioner and the nursing staff regarding the request since it was an ongoing request by the provider in the notes. She said the practitioner will be educated on the proper facility process to ensure services are provided timely. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of seven residents reviewed for unnecessary medications (Resident 8).Findings include: Review of facility policy, titled Psychotropic Medication Use, with a last revised date of February 2025, revealed in section titled PRN Medication that 3. PRN [as needed] orders for psychotropic medications are limited to 14 days. a. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. Review of Resident 8's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 8's physician orders revealed an on order for Klonopin (clonazepam) [a psychoactive medication used to treat anxiety] 0.5 mg (milligrams) give 0.25 mg every 12 hours as need for anxiety, dated June 30, 2025. The order failed to include a 14 day stop date. Review of Resident 8's Medication Administration Record's for June 2025, July 2025, and August 2025 revealed that he had not received any doses of the Klonopin. Email communication received from the Director of Nursing on August 6, 2025, at 2:59 PM, indicated that Resident 8's as needed Klonopin order had been discontinued. During a staff interview with the Nursing Home Administrator and Employee 2 (Regional Director of Clinical Services) on August 7, 2025, at 11:05 AM, Employee 2 indicated that the facility electronic health record program does not identify clonazepam as a benzodiazepine (a psychoactive medication), but rather an anticonvulsant 9 (antiseizure medication) so the order would not have flagged as needing a 14-day stop date. She indicated that a 14-day stop date should have been included in the order given that it was being utilized to treat anxiety. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards and failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed for dialysis (Resident 158). Findings include: Review of facility policy, titled End stage renal disease, Care of a Resident with, last revised January 2019, read, in part, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Examples of education and training of staff may include: The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis as required; Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed and may include: How information will be exchanged between the facilities. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of Resident 158's clinical record revealed diagnoses that included ESRD (failure of kidney function to remove toxins from blood), hypertension (elevated/high blood pressure), and diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). Review of Resident 158's care plan revealed a focus area of Resident has hemodialysis with the potential for infection, fluid volume excess/deficit, pain, trauma ESRD, with an intervention for Dialysis and No venipuncture/blood pressures in extremity with shunt (dialysis access), initiated on January 24, 2024. Review of Resident 158's dialysis communication sheets provided revealed there were missing communication sheets on January 26, 2024; February 2, 9, 12, 14, and 21, 2024; April 26, 2024; and May 20 and 31, 2024. Further review of Resident 158's dialysis communication sheets provided failed to reveal the following: pre- or post- dialysis weights on June 21, 2024, and July 5, 2024; post-dialysis weights on May 1, 2024, and June 3, 2024; and a pre-dialysis weight on July 29, 2024. Review of Resident 158's blood pressure measures revealed blood pressures were documented in his arm with his dialysis access (left arm) 73 times since his admission to the facility January 23, 2024. Interview with Employee 1 (Regional Director of Clinical Services), in the presence of the Nursing Home Administrator (NHA), on September 26, 2024, at 10:08 AM, revealed they are unable to locate the missing communication sheets or missing documentation from the reviewed communication sheets. Follow-up interview with the NHA on September 26, 2024, at 1:15 PM, revealed the documentation of blood pressures taken in the left arm are inaccurate, as staff do not take Resident 158's blood pressure in his left arm. He further revealed he would expect dialysis communication sheets to be available and nursing documentation to be accurate. 28 Pa code 211.5(f) Medical records 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for 11 of 38 residents reviewed (Residents 6, 7, 17, 43, 67, 74, 80, 83, 85, 109, and 142). Findings include: Review of Resident 6's clinical record revealed diagnoses that included atherosclerotic heart disease of the native coronary artery (cardiovascular disease involving plaque buildup in artery walls) and urinary tract infection (UTI - infection of any part of the urinary system). Review of Resident 6's current physician orders revealed an order to admit her to hospice services (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness), effective September 6, 2024. Review of Resident 6's September 9, 2024, significant change comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) revealed that it was not coded to indicate that Resident 6 had received hospice services while at the facility. During an interview with the Nursing Home Administrator (NHA) on September 25, 2024, at 2:37 PM, he confirmed that Resident 6's September 9, 2024, MDS was coded incorrectly and was being amended. Review of hospital discharge paperwork dated September 3, 2024, revealed that Resident 6 was diagnosed with and treated for a UTI while hospitalized . Review of Resident 6's September 9, 2024, significant change comprehensive MDS revealed that this assessment was not coded to indicate that Resident 6 had a UTI in the prior 30 days. During an interview with the NHA on September 26, 2024, at 1:10 PM, he confirmed that the MDS was coded in error, and that a correction was underway. Review of Resident 7's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and history of falling. Review of Resident 7's August 21, 2024, Annual MDS, revealed in Section J. Health Conditions that the Resident was coded as having one fall with no injury since their prior Quarterly MDS completed on August 3, 3024. Review of Resident 7's clinical record failed to reveal any documentation that the Resident had experienced a fall between August 3 and 21, 2024. During an interview with the NHA and Employee 1 (Regional Director of Clinical Services) on September 26, 2024, at 1:24 PM, Employee 1 confirmed that Resident 7 had not experienced any falls during the aforementioned timeframe and that the MDS was coded in error. The NHA also confirmed the MDS was coded in error and indicated he would expect a resident's MDS to be coded accurately. Review of Resident 17's clinical record revealed diagnoses that included repeated falls, delusional disorder (a mental health condition characterized by unshakable beliefs in something that's untrue), and muscle weakness. Review of Resident 17's Quarterly MDS with ARD (assessment reference date- last day of the assessment period) of August 23, 2024, revealed under P0100. Physical Restraints, H. Other, was coded as used less than daily. Observations of Resident 17 throughout the day on September 23, 2024, failed to reveal use of a physical restraint. During an email correspondence with the NHA and Employee 1 on September 24, 2024, at 11:10 AM, the surveyor requested information if Resident 17's MDS was coded accurately for use of restraint. Follow-up interview with the NHA on September 25, 2024, at 10:42 AM, revealed Resident 17's aforementioned MDS assessment was coded inaccurately for use of a physical restraint. Review of Resident 43's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD- a mental health condition that develops following a traumatic event, characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) and repeated falls. Review of Resident 43's Admission MDS with ARD of April 4, 2024, revealed it was marked No under active diagnoses - PTSD. During an interview with Employee 7 (Registered Nurse Assessment Coordinator) on September 26, 2024, at 12:13 PM, she revealed Resident 43's MDS assessment was coded inaccurately as she was admitted with a diagnosis of PTSD. Follow-up interview with the NHA on September 26, 2024, at 1:15 PM, revealed he would expect resident's MDS assessments to be coded accurately. Review of Resident 67's clinical record revealed diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear) and fibromyalgia (chronic condition that causes widespread pain and tenderness). Further review of Resident 67's clinical record revealed Resident 67 was admitted to the facility on [DATE], and a smoking evaluation was completed. Review of the smoking evaluation revealed Resident 67 used tobacco products and could smoke independently. Review of Resident 67's admission MDS dated [DATE], revealed that it was not coded to indicate that Resident 67 currently used tobacco. During an interview with the NHA on September 26, 2024, at 12:53 PM, he confirmed that Resident 67's September 9, 2024, MDS was coded incorrectly, and that it was the facility's expectation MDS assessments be accurate. Review of Resident 74's clinical record revealed diagnoses that included hypertension (high blood pressure) and bradycardia (slow heart rate). Review of Resident 74's comprehensive care plan revealed the following interventions for a pressure ulcer focus area: pressure reducing wheelchair cushion, with an initiation date of February 12, 2021, and pressure reduction mattress, with an initiation date of July 14, 2019. Review of Resident 74's clinical record revealed a task for pressure reducing device bed, which was checked off as being in use daily for the past 30 days; as well as a task for pressure reducing device chair, which was checked off as being in use daily for the majority of the past 30 days. Review of Resident 74's MDS dated [DATE], revealed that Section M1200. Skin and Ulcer/Injury Treatments, A. Pressure reducing device for chair, and B. Pressure reducing device for bed, were both marked No, indicating they have not been in use with Resident 74 during the look back period. During an interview with the NHA on September 25, 2024, at 1:45 PM, he revealed that a Modification MDS assessment has been initiated to reflect Resident 74 had a pressure reducing device for chair and bed during the look back period on the MDS dated [DATE]. Review of Resident 80's clinical record revealed diagnoses that included dementia and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side. Further review of Resident 80's clinical record revealed that the Resident had their stroke prior to their admission to the facility on [DATE]. Review of Resident 80's Physical Therapy Evaluation and Plan of Treatment dated September 23, 2024, revealed that Resident 80 has no limited range of motion to their lower extremities because of their prior stroke. Review of Resident 80's Occupational Therapy Evaluation and Plan of Treatment dated July 23, 2024, revealed that Resident 80 has had a limitation in their left upper extremity since the Resident experienced their stroke. Review of Resident 80's March 15, 2024, Quarterly MDS, in Section GG. Functional Abilities and Goals revealed that the Resident was coded as having no range of motion impairments. Review of Resident 80's June 28, 2024, Quarterly MDS that the Resident was coded as having limited range of motion to both their upper and lower extremities on one side. During an interview with the NHA and Employee 1 on September 26, 2024, at 10:39 AM, the NHA confirmed that there were some coding errors and that modifications were being completed. He further indicated that he would expect a resident's MDS assessment to be coded accurately. Review of Resident 83's clinical record revealed diagnoses that included chronic kidney disease stage 4 (the kidneys are moderately or severely damaged and are not working as well as they should to filter waste from the blood) and major depressive disorder (a serious mental disorder that affects how a person feels, thinks, and acts. It's characterized by a depressed mood, loss of interest in activities, and other symptoms that last for at least two weeks). Review of Resident 83's quarterly MDS dated [DATE], revealed in Section K0520. Nutritional Approaches, D. Therapeutic Diet, that Resident 83 has not received a therapeutic diet in the previous 7 days while a resident. Review of Resident 83's current physician's orders on September 24, 2024, revealed an order for Liberal Renal diet, Regular texture, Thin consistency, with a start date of March 23, 2024. Interview with the NHA on September 26, 2024, at 11:35 AM, revealed that Resident 83's MDS completed on August 23, 2024, was marked in error and that Resident 83 had received a therapeutic diet on the 7 days prior to the MDS. Review of Resident 85's clinical record revealed diagnoses that included dementia and PTSD. Review of Resident 85's current physician orders revealed that the Resident had an order for an antipsychotic medication, dated May 22, 2024. Review of Resident 85's clinical record revealed a psychiatric visit note dated June 25, 2024, that indicated that a gradual dose reduction (GDR) of their antipsychotic medication was clinically contraindicated. Review of Resident 85's July 16, 2024, Quarterly MDS, revealed in Section N. Medications that the date for physician documented clinically contraindication for a GDR was May 28, 2024. During an interview with the NHA and Employee 1 on September 26, 2024, at 1:23 PM, the NHA confirmed that Resident 85's MDS was coded in error and that modification would be completed. He further indicated that he would expect a resident's MDS assessment to be coded accurately. Review of Resident 109's clinical record revealed diagnoses that included frontotemporal neurocognitive disorder (result of damage to neurons in the frontal and temporal lobes of the brain) and unsteadiness on feet (gate disorder or postural instability). Further review of Resident 109's clinical record revealed that he was a lateral admission to the facility on [DATE], and Resident 109 had been receiving hospice services prior to being transferred. Additional review of Resident 109's clinical record revealed that, at the time of admission, Resident 109 had a physician's order for a soft padded helmet to be worn at all times and to be released every two hours. Review of Resident 109's admission MDS, dated [DATE], revealed that the facility failed to code Resident 109's MDS to reflect hospice services and the use of a restraint. During an interview with the NHA on September 25, 2024 at 2:17 PM, he confirmed that Resident 109's August 30, 2024, MDS was coded incorrectly, and that it was the facility's expectation MDS assessments be accurate. Review of Resident 142's clinical record revealed diagnoses that included bipolar disorder (a mental health condition that causes extreme mood swings from depression to mania or hypomania) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident 142's physician orders revealed an order for Olanzapine Oral Tablet 15 mg, give 15 mg by mouth at bedtime for depression, with a start date of July 27, 2024. Review of Resident 142's Quarterly MDS with ARD of August 2, 2024, and Modification of Quarterly MDS with ARD of August 2, 2024, he was marked No for bipolar disorder. During an interview with Employee 7 on September 26, 2024, at 12:16 PM, she revealed the MDS assessment was coded inaccurately as the Olanzapine was added for bipolar depression. Follow-up interview with the NHA on September 26, 2024, at 1:15 PM, revealed he would expect resident's MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility personnel documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least annually for four of five nurse aides reviewed (Employees 11, 12, 13, and 15). Findings Include: Review of personnel information revealed that Employee 11's hire date was August 20, 2001; Employee 12's hire date was November 28, 2005; Employee 13's hire date was April 7, 2010; and Employee 15's hire date was January 11, 2022. Further review of personnel information for Employees 11, 12, 13, and 15, failed to reveal that annual performance reviews were completed. During an interview with the Nursing Home Administrator on September 26, 2024, at 12:35 PM, he acknowledged that he had no additional documentation to provide for the selected employees. He confirmed that he would expect annual performance reviews to be completed annually around an employee's date of hire. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.19(2) Personnel policies and procedures

Based on policy review, resident observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for seven of 38 residents reviewed (Residents 7, 80, 85, 96, 124, 142, and 171), and failed to give the opportunity to participate in the development, review, and revision of his/her care plan for one of 38 residents reviewed (Resident 61). Findings include: Review of facility policy, titled Care Planning - Interdisciplinary Team , last reviewed August 2024, revealed that each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review, and revision of his/her care plan. Review of Resident 7's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning),Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (high blood pressure). Observation of Resident 7 on September 23, 2024, at 10:35 AM, revealed the presence of reddish-purplish discoloration to bilateral thighs and posterior calves. Review of Resident 7's physician orders revealed an order for fluconazole oral suspension reconstituted 40 MG (milligrams)/ML (milliliter) give 3.8 ml by mouth one time a day every Friday for yeast for four weeks, dated September 6, 2024. Review of Resident 7's care plan failed to reveal a focus area for their fungal infection. During an interview with the Nursing Home Administrator (NHA) and Employee 1 (Regional Director of Clinical Services) on September 26, 2024, at 12:15 PM, Employee 1 indicated that Resident 7's care plan was revised to reflect their fungal infection. The NHA confirmed that the care plan should have been revised when the fungal infection was identified. Review of Resident 61's clinical record revealed diagnoses that included muscle weakness (decreased strength in muscles) and major depressive disorder (persistent feeling of sadness and loss of interest and can interfere with your daily life). During an interview with Resident 61 on September 23, 2024, at 9:48 AM, revealed she has never been invited to care plan meetings. Review of Resident 61's clinical record revealed her most recent care plan review date was on August 12, 2024. During an interview with the NHA on September 26, 2024, at 10:27 AM, revealed that Resident 61 did not receive a care plan invitation for the care plan meeting held on August 12, 2024. Review of Resident 80's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning) and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting left non-dominant side. Further review of Resident 80's clinical record revealed that the Resident was diagnosed with an urinary tract infection (UTI) on September 21, 2024. Review of Resident 80's physician orders revealed an order for ciprofloxacin hydrochloride tablets 500 mg give one tablet by mouth two times a day related to UTI for five days, dated September 21, 2024. Review of Resident 80's care plan failed to reveal a focus area for their UTI. During an interview with the NHA and Employee 1 on September 25, 2024, at 11:15 AM, Employee 1 indicated that Resident 80's care plan was revised yesterday to reflect their UTI. The NHA confirmed that the care plan should have been revised when the UTI was identified. Review of Resident 85's clinical record revealed diagnoses that included dementia and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions). Review of Resident 85's physician orders revealed an order for Do Not Resuscitate dated August 29, 2024. Review of Resident 85's completed POLST (Pennsylvania Orders for Life Sustaining Treatment) form dated August 29, 2024, revealed that if Resident 85 was found with no pulse and not breathing, resuscitative measures were not to be rendered and comfort measures were to be maintained. Review of Resident 85's care plan revealed a care plan focus for resident has an advanced directive of Full Code [full resuscitative efforts], with a last revised date of June 3, 2020. During an interview with the NHA and Employee 1 on September 26, 2024, at 10:41 AM, the NHA confirmed that Resident 85's care plan should have been revised when the order changed on August 29, 2024. Review of Resident 96's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue), and unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact can be lost with reality). Observation of Resident 96 on September 23, 2024, at 1:35 PM, revealed the presence of a wound dressing to their left lower leg. Review of Resident 96's physician orders revealed an order for Cleanse left shin skin tear with normal saline, secure with an ABD [a type of absorbent dressing] daily and as needed, dated September 23, 2024; and remove sutures from left leg laceration in 14 days, dated September 17, 2024. Review of Resident 96's care plan failed to reveal their wound care interventions or suture removal. Further review of Resident 96's physician orders revealed an order for risperidone (a medication used to treat certain psychiatric conditions) 0.25 milligrams give two tablets twice a day, dated July 3, 2024. Further review of Resident 96's care plan failed to reveal their use of an antipsychotic medication, but indicated that the Resident was receiving an antianxiety medication. A review of Resident 96's physician order history revealed that their antianxiety medication had been discontinued on May 22, 2024. During an interview with the NHA on September 26, 2024, at 12:35 PM, he confirmed that Resident 96's care plan should have been revised timely. A review of the clinical record for Resident 124 revealed diagnoses that include psychosis (a mental disorder characterized by a disconnection from reality) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). A review of the clinical record for Resident 124 revealed a 34-pound weight loss (-15.32 % loss) between July 17, 2024, and August 17, 2024. A review of Resident 124's care plan for nutrition was last reviewed on September 24, 2023. During an interview with the NHA and Regional Director of Clinical Services on September 26, 2024, at 10:38 AM, both indicated that Resident 124's care plan should have been revised to reflect the actual weight loss. Review of Resident 142's clinical record revealed diagnoses that included presence of cardiac pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), bipolar disorder (a mental health condition that causes extreme mood swings from depression to mania or hypomania), and type 2 diabetes mellitus. Review of Resident 142's physician orders revealed an order for cardiologist follow up in 4 months from today, with a start date of September 3, 2024. Review of cardiology visit on September 3, 2024, revealed Resident 142 was seen by cardiology for his pacemaker with a plan to return in four months. Review of Resident 142's care plan failed to reveal notation of his cardiac pacemaker. During an interview with Employee 1, in the presence of the NHA, on September 25, 2024, at 10:35 AM, revealed Resident 142's pacemaker had now been added to his care plan, and that it should have been on his care plan. Review of Resident 171's clinical record revealed diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms (a condition that causes the prostate [male reproductive gland] to grow larger than normal and prevent normal urine stream or prevent fully emptying the bladder when urinating) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Observation of Resident 171 on September 23, 2024, revealed that he had a supra-pubic catheter (tube that drains urine from the bladder through a small cut in the lower belly). Resident 171 was admitted with the suprapubic catheter on July 5, 2024. Review of Resident 171's care plan revealed the focus area with the following statement, The resident has a Condom/Intermittent/Indwelling/Suprapubic) Catheter. During an interview with the Regional Director of Clinical Services on September 25, 2024, at 10:15 AM, the Regional Director stated the focus areas are pulled from a library of options, and that Resident 171's care plan should have specified suprapubic catheter in the focus area. 28 Pa. Code 211.10(c)Resident care policies 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services

Based on clinical record review, document review, observations, resident and staff interviews, and facility policy review, it was determined that the facility failed to provide suprapubic catheter care and monitoring, which resulted in actual harm, as evidenced by an active infection requiring antibiotic treatment. The facility also failed to promptly initiate urology specialist recommendations for treatment of the infection for one of two residents reviewed for catheter use (Resident 2). Findings include: Review of current facility policy, titled Catheter Care, Urinary, last revised September 2014, revealed the policy purpose was to, .prevent catheter-associated urinary tract infections. Review of policy's subsection, titled Complications, revealed it included, If the resident indicates that his or her bladder is full or that he or she needs to void (urinate), notify the physician or supervisor. Review of the policy's Documentation section revealed the steps of documentation included, The following information should be recorded in the resident's medical record .The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care .All assessment data obtained when giving catheter care .Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor .Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain .Any problems or complaints made by the resident related to the procedure .How the resident tolerated the procedure .If the resident refused the procedure, the reason(s) why and the intervention taken .The signature and title of the person recording the data. Review of Resident 2's clinical record revealed diagnoses that included neuromuscular dysfunction of the bladder (loss of bladder control due to brain, spinal cord or nerve problems) and hypertension (elevated/high blood pressure). Further review of Resident 2's clinical record revealed that, upon admission on October 27, 2023, Resident 2 had a suprapubic catheter (catheter inserted into the bladder through an incision in the abdomen used to drain the bladder of urine). Review of Resident 2's physician orders revealed an order for catheter care dated October 27, 2023. The order included instructions to cleanse the suprapubic catheter site with normal saline and to apply a dry dressing every shift. However, review of Resident 2's Treatment Administration Record (TAR - record of administered treatments that prompts staff to perform and document treatments) revealed that the order for cleansing and applying a dry dressing was not on the TAR. Further review of the clinical record revealed no evidence that Resident 2's suprapubic catheter was being cleansed and a new dressing applied per physician order. During an interview with Employee 2 (Licensed Practical Nurse - LPN) on February 22, 2024, at approximately 2:10 PM, Employee 2 displayed the TAR orders that were prompted for staff to perform for Resident 2. It was observed that the ordered catheter care for Resident 2 was not present in Resident 2's TAR. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 22, 2024, at approximately 2:30 PM, they revealed that Resident 2's order for catheter care was incorrectly transcribed into the electronic health record and, therefore, did not carry over to the TAR. Review of Resident 2's clinical record revealed no evidence that Resident 2 was receiving catheter care as ordered since admission on October 27, 2023. Observation of Resident 2's catheter insertion site on February 22, 2024, in the presence of Employee 2, at approximately 2:25 PM, revealed Resident 2 had no dressing to the catheter insertion site. Observation revealed a moderate amount of yellow-white drainage at the catheter site and on Resident 2's brief. During the observation, Employee 2 confirmed that there was no dressing to Resident 2's catheter insertion site. Further review of Resident 2's clinical record revealed that on December 5, 2023, Resident 2 was sent to the hospital with catheter related complications. Further review of Resident 2's clinical record revealed that he was treated for a urinary tract infection. Review of Resident 2's comprehensive plan of care revealed that on December 6, 2023, a care plan was initiated with a focus of, [Resident 2] has a urinary tract infection related to catheter use. The care plan included the interventions of, Administer meds as ordered .encourage increased fluid consumption .evaluate residents response to treatment and meds .observe characteristics of urine, color, odor, sediment. Review of Resident 2's urology consultation report from December 14, 2023, revealed [Suprapubic] tube not draining for three weeks per patient report. He reports voiding out of urethra. Seen in [emergency room ] 12/5/23 and started on [ciprofloxacin] for pyelonephritis [infection of the kidneys] . The report also noted that Resident 2's suprapubic tube was blocked. Recommendations included a follow-up in one month for a catheter change. Review of Resident 2's urology consultation report from January 18, 2024, revealed no concerns, recommendations to follow-up in one month for a catheter change, and instructions to contact urology with any catheter concerns. Review of the clinical record revealed no evidence of a urology consultation report for the visit in February 2024. During an interview with the NHA and DON on February 22, 2024, at approximately 2:00 PM, a request was made for Resident 2's February 2024 urology report. At approximately 2:30 PM, DON provided a urology consultation report for Resident 2's February 15, 2024, urology appointment titled Urology Outpt Note *Final Report*. When provided, the NHA revealed that the facility sends a report of consultation form with a Resident to outside services, and typically receives the form back with information provided by the consultative service. The facility then receives a typed report from the office within 7 to 10 days. The NHA confirmed there was no report of consultation from the February 15, 2024, urology appointment for Resident 2 in his clinical record. Review of urology consult report dated February 15, 2024, revealed, Today [Resident 2] presents for monthly [suprapubic] tube catheter changes. Further, the February 15, 2024, urology report stated, Resident 2 voided a thick pus like drainage from his urethra. There has been no urinary drainage from his [suprapubic] tube for two weeks. He reports voiding into a urinal. Bladder scan in office showed 296 [milliliters][of urine in Resident 2's bladder] and, [suprapubic catheter] tube removed with large amounts of pus-like drainage mixed with yellow urine. A new suprapubic catheter was inserted and it was noted that Resident 2 has another 25 ml of clumpy drainage. Due to pus drainage will send a urine culture and start him on antibiotics . The report also included recommendations to start ciprofloxacin twice a day for seven days, to obtain a urine culture, and to increase the catheter change to every two weeks. Review of Resident 2's physician orders failed to reveal any orders for antibiotics, urine culture, or catheter change since the February 15, 2024, urology consultation. During a Resident interview on February 22, 2024, at approximately 2:17 PM, Resident 2 expressed that he sometimes voids through his urethra into a urinal. Further, Resident 2 stated that he had not received his antibiotics that he was supposed to receive. During an interview with the DON on February 22, 2024, at approximately 3:30 PM, DON revealed that the facility did not have a urology consultation report from Resident 2's February 15, 2024, urology consultation, prior to the surveyor requesting the consult. During the interview, NHA revealed that staff should follow-up with outside consultative services when a report is not provided upon a Resident's return to the facility. The facility failed to follow facility policy, care planned interventions, and physician orders for catheter care and monitoring which resulted in failure to identify signs of infection and complications with Resident 2's suprapubic catheter. Additionally, the facility failed to implement urology recommendations to include: administration of antibiotics to treat an identified infection, obtainment of lab work, and an increase in the frequency of catheter changes. 28 Pa code 201.18(b)(1) Management 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility document review, and resident representative and staff interviews, it was determined that the facility failed to ensure the resident environment was free of accident hazards resulting in harm, as evidenced by a right hip fracture, for one of six residents reviewed (Resident 2). Findings include: Review of facility Housekeeping & Laundry Policy and Procedures, not dated, procedure for, Room Cleaning Step by Step, revealed subsection seven, Wet Mop, stated, Start in the far corner of the room working your way to the door. Make sure a wet floor sign is in sight. Review of Resident 2's clinical record revealed diagnoses including vascular dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and history of cerebral infarction (stroke - sudden loss of blood flow or bleeding in the brain that results in the death of brain cells). Further review of Resident 2's clinical record revealed that Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's most recent Quarterly Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, cognitive, and psychosocial needs), with an assessment reference date of April 13, 2023, revealed Resident 2 scored a 13 of 15 on the Brief Interview for Mental Status questionaire, indicating Resident 2 was cognitively intact. Review of Resident 2's functional evaluation from the Quarterly MDS revealed Resident 2 was independent with bed mobility, transfers (moving between surfaces, including to or from bed, chair, wheelchair, and standing position), and walking in the Resident room and in the unit corridor. Review of Section J, subsection J1800 - Any falls since admission or prior MDS (prior MDS assessment conducted with assessment reference date of January 11, 2023), was assessed as, No, indicating Resident 2 had no prior falls. Review of Resident 2's comprehensive plan of care revealed Resident 2's Activities of Daily Living care plan, initiated on September 20, 2019, identified Resident 2 as independent with transfers, which was dated August 1, 2022. Review of Resident 2's comprehensive plan of care revealed no indication that Resident 2 was non-compliant with transfers or ambulation within the resident room or resident corridor. Review of Resident 2's interdisciplinary progress notes [IPN] revealed a progress note entered by Registered Nurse 1, dated May 11, 2023, at 11:27 AM, which stated, Called to resident room at approx[imately] 0830[AM] [due to] resident fall. Resident found on floor by housekeeping staff, fall not witnessed. Resident denies hitting head, reports landing on his right hip and [complaints of] 6/10 [right lower extremity] pain from thigh to knee. Resident unable to extend his leg or support weight to stand .Resident sent to [hospital] for [x-ray]. Resident 2 subsequently was transported from the facility to a hospital via ambulance at approximately 9:15 AM. Review of IPN documented at 12:16 PM, revealed Resident 2 was admitted to the hospital with a diagnosis of right hip fracture. Review of facility investigation report revealed that on May 11, 2023, Resident 2 suffered a fall at the end of Resident 2's bed shortly before 8:30 AM. Review of Resident 2's record revealed Resident 2's bed was one of two beds located in the resident room and that Resident 2's bed was closest to the window, furthest from the entrance to the room. Review of Resident 2's clinical record revealed that, prior to May 11, 2023, Resident 2 did not have a history of falls. Further review of the investigation report revealed that Registered Nurse 1 documented RN [Registered Nurse] Observed that floor is freshly mopped and very wet. Wet floor sign present in entryway. Review of the investigation report, section titled Resident Description, revealed it stated [Resident 2] stood up and slipped and fell on my hip. Review of the investigation report, section titled Predisposing Environmental Factors, revealed the box labeled wet floor was marked in the affirmative. Review of Resident 2's fall care plan revealed interventions of: Eye glasses - encourage to wear and keep clean and in good repair, initiated September 19, 2019; Keep bed in lowest position, initiated September 19, 2019; Keep call bell within reach, initiated September 19, 2019; and, Keep environment clutter free, initiated September 19, 2019. As a result of the fall on May 11, 2023, an new intervention of, Caution sign on bedside table when floors are mopped and resident is in bed, was initiated on May 12, 2023. Review of Resident 2's comprehensive plan of care revealed Resident was not care planned for assistance with ambulation, nor did Resident 2's care plan include any footwear to be worn when ambulating. Review of witness statement by Housekeeper 1, dated May 11, 2023, revealed Housekeeper 1 stated I, [Housekeeper 1] was cleaning the [resident] hallway on 5-11-2023, I had just got done cleaning [Resident 2's] room as he was sleeping after i got done[.] I sat the wet floor sign in the doorway where you can see it and i went to clean the next room and that's when I heard somebody call my name and I turned around and seen [Resident 2] on the floor. During an interview on May 16, 2023, at approximately 12:06 PM, Resident 2's Power of Attorney [POA - designated legal representative] stated that Resident 2 reported that, the morning of the fall, Resident 2 was asleep in bed during the room cleaning and did not know that the floor of the room had been mopped. Resident 2 also stated that floor was sopping wet, and noticed that there was a puddle of water on the floor when he fell . Further, Resident 2's POA stated that, on the morning of the fall, Resident 2 was getting up for the day to go to breakfast, as he does every morning, and that he spends most of the day out of his room. Resident 2's POA confirmed that Resident 2 has not had any falls in over three years, and the reason he fell was because the floor was wet and he was not made aware. During a staff interview with Housekeeper 1 on May 16, 2023, at approximately 12:30 PM, Housekeeper 1 stated that Resident 2 was observed to be asleep while Housekeeper 1 cleaned and mopped Resident 2's room. Housekeeper 1 revealed that Housekeeper 1 did not speak to Resident 2, as it was believed Resident 2 was asleep. During a staff interview on May 16, 2023, Director of Nursing (DON) confirmed that Resident 2 had no prior fall history while at the facility since admission on September 19, 2019. During the staff interview, DON stated that Housekeeper 1 placed a wet-floor sign at the doorway of Resident 2's room and confirmed that Resident 2 was not notified verbally of the wet floor. DON revealed that housekeeping staff do not wake residents to notify them of wet floors if they are asleep. Resident 2 was not made aware that the floor was wet. The only signage that was present was at the entry way of the door to alert staff entering the room that the floor was wet. Resident 2 woke up in the morning and proceeded to the bathroom with plans to go to the dining room for breakfast. Resident 2 slipped on the wet floor and fell resulting in a right hip fracture. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to follow accepted professional standards and principles for administering medications to ensure the prevention of significant medication errors for 29 out of 33 residents sampled (Residents 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32) on the ACU (Alzheimer Care Unit). This resulted in an Immediate Jeopardy situation since the missed medications had the potential to cause the residents discomfort or pain, to exacerbate behaviors and medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety of 29 of 33 residents reviewed. Findings include: Review of Resident 2's clinical record revealed diagnoses that included dementia with behavioral disturbance (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (a mental state marked by loss of contact with reality, disorganized speech and behaviors, and often hallucinations or delusions), and hypertension (high blood pressure). Orders included diltiazem daily for hypertension, Risperdal (antipsychotic) daily for psychotic disorder, and Namenda (used to treat confusion) for dementia. Review of medication administration record revealed that Resident 2 was not administered these medications on December 25, 2022. Review of Resident 3's clinical record revealed diagnoses that included major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations) and vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory). Orders included venlafaxine daily for major depressive disorder. Review of medication administration record revealed that Resident 3 was not administered the aforementioned medication on December 25, 2022. Review of Resident 4's clinical record revealed diagnoses that included vascular dementia. Orders included memantine (used to treat confusion) daily for vascular dementia. Review of medication administration record revealed that Resident 4 did not receive the aforementioned medication on December 25, 2022. Review of Resident 5's clinical record revealed diagnoses that included hypertension. Orders included Norvasc and hydrochlorothiazide daily for hypertension. Review of medication administration record revealed that Resident 5 was not administered the aforementioned medications on December 25, 2022. Review of Resident 6's clinical record revealed diagnoses that included type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), dementia with behavioral disturbance, major depressive disorder, and atrial fibrillation (irregular heart beat). Orders included Zoloft (antidepressant) daily for major depressive disorder, Eliquis (anticoagulant) two times a day for atrial fibrillation, metoprolol two times per day for hypertension, Namenda two times a day for dementia, Novolin (insulin) twice a day for diabetes mellitus, and Zyprexa (antipsychotic) two times a day for dementia with behavioral disturbance. Review of medication administration record revealed that Resident 6 was not administered the Zoloft on December 25, 2022. It also revealed that Resident 6 was not administered the Eliquis, metoprolol, Namenda, Novolin, or Zyprexa in the morning on December 25, 2022. Review of Resident 7's clinical record revealed diagnoses that included dementia with behavioral disturbance and cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). Orders included apixaban (anticoagulant) two times a day for cerebral infarction, and Zyprexa two times per day for dementia with behavioral disturbance. Review of medication administration record revealed that Resident 7 was not administered the morning dose of the aforementioned medications on December 25, 2022. Review of Resident 8's clinical record revealed diagnoses that included Alzheimer's (gradually progressive brain disorder that causes problems with memory, thinking and behavior), dementia with behavioral disturbance, major depressive disorder, and hypertension. Orders included amlodipine daily for hypertension, escitalopram (antidepressant) daily for major depressive disorder, and Seroquel (antipsychotic) two times a day for dementia with behavioral disturbance. Review of medication administration record revealed that Resident 8 was not administered amlodipine and escitalopram on December 25, 2022. It also revealed that Resident 8 did not receive the morning dose of Seroquel on December 25, 2022. Review of Resident 10's clinical record revealed diagnoses that Alzheimer's disease, major depressive disorder, and hypertension. Orders included amlodipine daily for hypertension, Celexa (antidepressant) daily for major depressive disorder, lisinopril-hydrochlorothiazide daily for hypertension, and Namenda two times a day for Alzheimer's. Review of medication administration record revealed that Resident 10 was not administered the amlodipine, Celexa, and lisinopril-hydrochlorothiazide on December 25, 2022. It also revealed that Resident 10 was not administered the morning dose of Namenda on December 25, 2022. Review of Resident 11's clinical record revealed diagnoses that included hypertension. Orders included Cozaar daily for hypertension, hydrochlorothiazide daily for hypertension, and Norvasc daily for hypertension. Review of medication administration record revealed that Resident 11 was not administered the aforementioned medications on December 25, 2022. Review of Resident 12's clinical record revealed diagnoses that included Alzheimer's disease. Orders included memantine two times a day for Alzheimer's. Review of medication administration record revealed that Resident 12 was not administered the morning dose of memantine on December 25, 2022. Review of Resident 13's clinical record revealed diagnoses that included dementia. Orders included escitalopram daily for depression. Review of medication administration record revealed that Resident 13 was not administered the aforementioned medication on December 25, 2022. Review of Resident 14's clinical record revealed diagnoses that included hypertension and anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events). Orders included Buspar (antianxiety medication) two times a day for anxiety, Losartan two times a day for hypertension, and hydralazine every eight hours for hypertension. Review of medication administration record revealed that Resident 14 was not administered the morning dose of Buspar and Losartan and the 2:00 PM dose of hydralazine on December 25, 2022. Review of Resident 15's clinical record revealed diagnoses the included schizophrenia (mental disease characterized by loss of reality contact, delusions, hallucinations, and/or feelings of persecution), hypertension, and Alzheimer's disease. Orders included Lisinopril daily for elevated blood pressure readings, Risperdal .5 mg daily for schizophrenia, torsemide daily for hypertension, and memantine daily for Alzheimer's. Review of medication administration record revealed that Resident 15 was not administered the aforementioned medications on December 25, 2022. Review of Resident 16's clinical record revealed diagnoses that included dementia, psychotic disorder, and major depressive disorder. Orders included depakote 250 mg daily for agitation and bipolar manic episodes, Zoloft daily for major depressive disorder, and quetiapine two times a day for psychosis. Review of medication administration record revealed that Resident 16 was not administered depakote and Zoloft, nor the morning dose of quetiapine on December 25, 2022. Review of Resident 17's clinical record revealed diagnoses that included dementia and psychosis. Orders included Risperdal daily for psychosis and depakote two times per day for mood stabilization. Review of medication administration record revealed that Resident 17 was not administered Risperdal nor morning dose of depakote on December 25, 2022. Review of Resident 18's clinical record revealed diagnoses that included Alzheimer's disease and unspecified psychosis. Orders included olanzapine daily for psychosis. Review of medication administration record revealed that Resident 18 was not administered olanzapine on December 25, 2022. Review of Resident 19's clinical record revealed diagnoses that included bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), atherosclerotic heart disease of the native coronary artery (condition where arteries get narrow or hardened), and major depressive disorder. Orders included depakote 125 mg daily for major depressive disorder, isosorbide nitrate (used to prevent chest pain) daily for angina (chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood), Zoloft daily for major depressive disorder, depakote 325 mg two times a day for bipolar disorder, and Eliquis two times a day for deep vein thrombosis prevention. Review of medication administration record revealed that Resident 19 was not administered depakote 125 mg, isosorbide nitrate, and Zoloft on December 25, 2022. It also revealed that Resident 19 was not administered the morning dose of depakote 325 mg or Eliquis on that date. Review of Resident 20's clinical record revealed diagnoses that included frontotemporal neurocognitive disorder (result of damage to nerve cells in the frontal and temporal lobes of the brain that gradually causes difficulties in thinking and behaviors normally controlled by these parts of the brain). Orders included Prozac (antidepressant) daily for frontotemporal neurocognitive disorder and depakene two times per day for manic episodes. Review of medication administration record revealed that Resident 20 was not administered Prozac nor the morning dose of depakene on December 25, 2022. Review of Resident 21's clinical record revealed diagnoses that included major depressive disorder. Orders included Zoloft daily for major depressive disorder. Review of medication administration record revealed that Resident 21 was not administered Zoloft on December 25, 2022. Review of Resident 22's clinical record revealed diagnoses that included Alzheimer's, type 2 diabetes mellitus, major depressive disorder, and hypertension. Orders included enalapril daily for hypertension, hydrochlorothiazide daily for hypertension, Zoloft daily for major depressive disorder, and metformin two times per day for diabetes mellitus. Review of medication administration record revealed that Resident 22 was not administered enalapril, hydrochlorothiazide, or Zoloft on December 25, 2022. Review also revealed that Resident was not administered the morning dose of metformin on December 25, 2022. Review of Resident 23's clinical record revealed diagnoses that included hypertension, major depressive disorder, and dementia. Orders included amlodipine daily for hypertension, metoprolol daily for hypertension, Seroquel 50 mg daily for dementia, and sertraline daily for major depressive disorder. Review of medication administration record revealed the aforementioned medications were not administered to Resident 23 on December 25, 2022. Review of Resident 24's clinical record revealed diagnoses that included hypertension, major depressive disorder, and pain in unspecified left foot. Orders included amlodipine daily for hypertension, Lexapro daily for major depressive disorder, and gabapentin (used to relieve nerve pain) three times per day for pain. Review of medication administration record revealed that amlodipine and Lexapro were not administered to Resident 24 on December 25, 2022, and that the 2:00 PM dose of gabapentin was not administered on this date. Review of Resident 25's clinical record revealed diagnoses that included major depressive disorder and dementia with behavioral disturbance. Orders included Lexapro daily for major depressive disorder and Risperdal two times per day for dementia with behavioral disturbance. Review of medication administration record revealed that Lexapro as well as the morning dose of Risperdal were not administered to Resident 25 on December 25, 2022. Review of Resident 27's clinical record revealed diagnoses that included major depressive disorder, dementia with behavioral disturbance, hypertension, and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues). Orders included citalopram daily for major depressive disorder, rivastigmine patch (used to treat confusion related to Alzheimer's) daily for dementia with behavioral disturbance, Toprol daily for hypertension, furosemide (diuretic) two times per day for congestive heart failure, and hydralazine three times per day for hypertension. Review of medication administration record revealed that citalopram, rivastigmine, and Toprol were not administered to Resident 27 on December 25, 2022. Review also revealed that the 2:00 PM doses of furosemide and hydralazine were also not administered on that date. Review of Resident 28's clinical record revealed diagnoses that included dementia with behavioral disturbance, and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined). Orders included escitalopram daily for dementia with behavioral disturbance and olanzapine two times per day for delusional disorder. Review of medication administration record revealed that escitalopram as well as the morning dose of olanzapine was not administered on December 25, 2022. Review of Resident 29's clinical record revealed diagnoses that included schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and vascular dementia. Orders included fluoxetine (antidepressant) daily for schizoaffective disorder and Namenda daily for vascular dementia. Review of medication administration record revealed that the aforementioned medications were not administered to Resident 29 on December 25, 2022. Review of Resident 30's clinical record revealed diagnoses that included unspecified psychosis, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), type 2 diabetes mellitus, and dementia with agitation. Orders included Seroquel 75 mg daily for psychosis, Keppra (anticonvulsant) two times per day for seizures, metformin two times per day for diabetes mellitus, and Namenda two times per day for dementia. Review of medication administration record revealed that Seroquel 75 mg was not administered to Resident 30 on December 25, 2022. Review also revealed the the morning doses of Keppra, metformin, and Namenda were also not administered on this date. Review of Resident 31's clinical record revealed diagnoses that included Alzheimer's disease and major depressive disorder. Orders included Zoloft daily for major depressive disorder. Review of medication administration record revealed that Zoloft was not administered to Resident 31 on December 25, 2022. Review of Resident 32's clinical record revealed diagnoses that included heart failure and psychotic disorder with hallucinations. Orders included lasix (diuretic) daily for fluid overload and Zyprexa daily for psychotic disorder. Review of medication administration record revealed that the aforementioned medications were not administered to Resident 32 on December 25, 2022. During an interview with the Director of Nursing (DON) on January 10, 2023, at approximately 12:27 PM, she revealed that on December 25, 2022, a nurse overslept and came in late, resulting in a missed medication pass. She also revealed that she was sick and quarantining at home on the date in question. During a telephone interview with Employee 1 (Licensed Practical Nurse) on January 11, 2023, at 11:45 AM, she revealed that she was scheduled to come into the facility at 3:00 PM on December 25, 2022, but was called into the facility early since coverage was needed. She revealed that the scheduled nurse on the ACU, Employee 4 (Licensed Practical Nurse), had been quarantined due to COVID-19, was permitted to return on December 25, 2022, but did not return on that date and did not notify anyone before the scheduled shift. Review of employee time card revealed that Employee 1 punched in at 11:46 AM on December 25, 2022. During the telephone interview, Employee 1 confirmed that this was the time she arrived at the facility. Employee 1 stated that she reported to the 1300 unit at that time. She then revealed that she received a call from Employee 2 (Registered Nurse Supervisor) sometime after lunch to assist with passing medications on the ACU. Employee 1 revealed that when she arrived on the ACU unit, she discovered that morning and noon medication passes were not completed. She stated that around approximately 1:30 PM - 2:00 PM she contacted the Medical Director via text to inform him of the missed medications. She stated that his reply was OK. Employee 1 revealed that she began notification of responsible parties and documentation in resident records at that time. Employee 1 revealed that she did not notify administration of the missed medications on December 25, 2022, but confirmed that they became aware of the concern at the next morning meeting. During an additional interview with the DON on January 12, 2023, at 8:35 AM, she confirmed that Employee 4 was scheduled for dayshift on the ACU on December 25, 2022. She also revealed that Employee 4 had been quarantined, was due to come back on that date, and hadn't notified anyone that she was not planning to return on that date. DON stated that she spoke with Employee 2 around 8:30 AM - 8:45 AM to discuss that Employee 4 had not shown for her shift. DON stated that she advised Employee 2 to call Employee 1. DON stated that she then called Employee 4 who stated she did not come to work because she was not yet feeling up to it. DON stated that, since Employee 2 was busy passing medications, she attempted to get in contact with Employee 1. DON states she finally reached Employee 1 somewhere between 8:30 AM - 9:30 AM, at which time Employee 1 told DON she was on her way. DON stated did not know if she was actually enroute at that time. DON revealed that, after she found out Employee 1 was coming in, she dropped it since she figured they were covered. DON revealed that she did not realize medications were not administered until it was discussed at morning meeting on Tuesday, December 27, 2022. During an interview with Employee 2 (Registered Nurse Supervisor) on January 12, 2023, at 10:46 AM, she revealed that she was scheduled to work from 7:00 AM to 7:00 PM on December 25, 2022. She revealed she was assigned as house supervisor and was also assigned a medication cart on the 1300 unit. Employee 2 revealed that she contacted the DON at 7 something to inform her that Employee 4 did not show for her shift on the ACU. Employee 2 stated that DON informed her that she wound attempt to contact Employee 1 since she had said she could work. Employee 2 stated she did not wait around to see if Employee 4 showed, since she had a medication pass that needed to be completed on another unit. She stated that she followed-up with the DON via text at 8:30 AM to see if she was able to reach Employee 1. Employee 2 stated that Employee 1 reported to work around 12:00 PM. She stated that Employee 1 reported to the 1300 unit when she arrived and began to pass lunchtime medications. Employee 2 revealed that she was on the ACU when Employee 1 arrived, attempting to look through missed medications to see what could still be given. Employee 2 stated that she requested Employee 1's assistance on the ACU. When Employee 1 arrived on the ACU, Employee 2 stated Employee 1 suggested they just let the physician know medications weren't administered. Employee 2 revealed that Employee 1 contacted the physician. Employee 2 stated she was unaware of what the physician's response was. Employee 2 stated they then split the responsibility of notifying the responsible parties and documenting in resident records. Employee 2 revealed she was aware of missed morning medications on the ACU, and had not contacted the physician earlier to notify of these missed medications since she was planning to go through resident orders to see what could be still be administered. The Nursing Home Administrator (NHA) and DON were notified of the concern and were provided with the immediate jeopardy template on January 10, 2023 at 3:35 PM. An immediate action plan was requested at that time. On January 10, 2023, at 6:24 PM, the facility's immediate action plan was accepted, which included: - The facility is maintaining sufficient licensed nursing staff onsite during all nursing shifts by offering additional shifts and incentives, utilizing agency staff to provide nursing care including medications and treatments, and ensuring these meds and treatments are administered timely as per physician orders. - The identified residents were reviewed to determine any negative effects. - All residents in house will be reviewed per the missed medication report for the past 72 hours. Any residents identified will be evaluated for signs and symptoms of adverse reactions to missed medications, they will have a Medication Error Report completed and the physician and responsible party will be made aware. - Administrative staff will ensure the appropriate number of nursing staff are provided daily. If not, administrative staff will be contacted and the on-call system will be implemented, also utilizing administrative staff to meet these needs. - Current licensed nursing staff will be educated by January 12, 2023, on ensuring medications and treatments are administered timely as per physician orders, that residents will be free from significant medication errors caused by omitted medications. Any new staff will be educated prior to the start of their next shift. - The NHA and DON were educated on January 10, 2023, on ensuring sufficient nursing staff is onsite 24/7 to provide medications and treatments per physician orders. - DON, NHA, or designee will audit missed medication reports every shift for two weeks, then daily for four weeks to ensure medications and treatments are administered timely as per physician orders. Results will be reported to QAPI for review and further recommendations. On January 12, 2023, at 10:35 AM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.9(d) Pharmacy services

Based on clinical record review, review of facility staffing data, and resident and staff interviews, it was determined that the facility failed to provide adequate and sufficient nursing staff to provide medication administration in accordance with professional standards of practice and physician orders for 32 out of 33 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32) on the Alzheimer's Care Unit (ACU). These staffing failures resulted in missed medication doses, missed nursing assessments including insulins, antipsychotics, antibiotics, antihypertensives, seizure medications, heart medications, pain medications, nutritional supplements, blood sugar level checks, neurological checks, and blood pressure checks. These missed medications and assessments had the potential to cause the residents discomfort or pain, to exacerbate behaviors and medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety, resulting in Immediate Jeopardy. Additionally, the facility failed to ensure appropriate staffing coverage on three of five nursing units (ACU, 800/900 unit, 1300 unit) to ensure that medications, nutritional supplements or assessments were administered/completed timely and per physician order for 18 of 104 residents residing on those units (Residents 1, 3, 4, 7, 9, 13, 16, 17, 18, 21, 25, 26, 27, 28, 30, 31, 39, 40). Findings include: During an interview with Employee 7 on January 10, 2023, at 9:05 AM Employee 7 expressed concern that residents on the ACU unit did not receive all of their medications on December 25, 2022 and again on January 8, 2023, due to staffing shortages. Review of medication administration records and nursing progress notes revealed the following: Resident 1: one nutritional supplement was not administered on December 25, 2022, and a total of six medications and two nutritional supplements were not administered on January 8, 2023. Resident 2: two nutritional supplements and five medications were not administered on December 25, 2022. Resident 3: five medications and two nutritional supplements were not administered on December 25, 2022, and on January 8, 2023. Resident 4: eight medications and two nutritional supplements were not administered on December 25, 2022, and on January 8, 2023. Resident 5: eight medications and one nutritional supplement were not administered on December 25, 2022. Resident 6: 13 medications were not administered and one blood sugar check was not completed on December 25, 2022. Resident 7: 12 medications and two nutritional supplements were not administered on December 25, 2022, and eight medications and two nutritional supplements were not administered on January 8, 2023. Resident 8: eight medications were not administered on December 25, 2022. Resident 9: eight medications were not administered on December 25, 2022, and on January 8, 2023. Resident 10: 11 medications and one nutritional supplement were not administered on December 25, 2022. Resident 11: five medications were not administered on December 25, 2022. Resident 12: six medications and one nutritional supplement were not administered on December 25, 2022. Resident 13: five medications were not administered on December 25, 2022, and five medications and one nutritional supplement were not administered on January 8, 2023. Resident 14: five medications were not administered on December 25, 2022. Resident 15: five medications and one nutritional supplement were not administered on December 25, 2022. Resident 16: six medications were not administered on December 25, 2022. Additionally, neurological checks following a fall were not completed on one occasion on December 25, 2022. Furthermore, six medications and two nutritional supplements were not administered on January 8, 2023. Resident 17: four medications and one nutritional supplement were not administered on December 25, 2022, and on January 8, 2023. Resident 18: two medications were not administered on December 25, 2022, and on January 8, 2023. Resident 19: 13 medications were not administered on December 25, 2022. Resident 20: two medications were not administered on December 25, 2022. Resident 21: one medication and one nutritional supplement were not administered on December 25, 2022, and two medications and one nutritional supplement were not administered on January 8, 2023. Resident 22: 12 medications were not administered on December 25, 2022. Resident 23: six medications were not administered on December 25, 2022. Resident 24: seven medications were not administered on December 25, 2022. Resident 25: seven medications and two nutritional supplements were not administered on December 25, 2022, and on January 8, 2023. Additionally, orthostatic blood pressure and pulse readings were not completed as ordered on December 25, 2022. Resident 26: two medications were not administered on December 25, 2022, and two medications and two nutritional supplements were not administered on January 8, 2023. Resident 27: 12 medications were not administered on December 25, 2022, and one medication was not administered on January 8, 2023. Resident 28: four medications were not administered on December 25, 2022, and on January 8, 2023. Resident 29: two medications were not administered on December 25, 2022. Resident 30: four medications were not administered on December 25, 2022, and five medications were not administered on January 8, 2023. Resident 31: one medication was not administered on December 25, 2022, and on January 8, 2023. Resident 32: one vital sign monitoring for COVID-19 positive status was not completed on December 25, 2022. Resident 39: one nutritional supplement was not administered on January 8, 2023. Resident 40: one nutritional supplement was not administered on January 8, 2023. During an interview with the Director of Nursing (DON) on January 10, 2023, at approximately 12:27 PM, she revealed that on December 25, 2022, a scheduled nurse overslept and came in late, resulting in missed medication pass. She also revealed that she was sick and quarantining at home on the date in question. During a telephone interview with Employee 1 (Licensed Practical Nurse) on January 11, 2023, at 11:45 AM, she revealed that she was scheduled to come into the facility at 3:00 PM on December 25, 2022, but was called into the facility early since coverage was needed. She revealed that the scheduled nurse on the ACU, Employee 4 (Licensed Practical Nurse), had been quarantined due to COVID-19, was permitted to return on December 25, 2022, but did not return on that date and did not notify anyone before the scheduled shift. Review of employee timecard revealed that Employee 1 punched in at 11:46 AM on December 25, 2022. During her interview, Employee 1 confirmed that this was the time she arrived at the facility. Employee 1 stated that she reported to the 1300 unit at that time. She then revealed that she received a call from Employee 2 (Registered Nurse Supervisor) sometime after lunch to assist with passing medications on the ACU. Employee 1 revealed that when she arrived on the ACU unit, she discovered that morning and noon medication passes were not completed. She stated that around approximately 1:30 PM - 2:00 PM she contacted the Medical Director via text to inform him of the missed medications. She stated that his reply was OK. Employee 1 revealed that she began notification of responsible parties and documentation in resident records at that time. Employee 1 revealed that she did not notify administration of the missed medications on December 25, 2022, but confirmed that they became aware of the concern at the next morning meeting. During an additional interview with the DON on January 12, 2023, at 8:35 AM, she confirmed that Employee 4 was scheduled for dayshift on the ACU on December 25, 2022. She also revealed that Employee 4 had been quarantined, was due to come back on that date, and hadn't notified anyone that she was not planning to return on that date. DON stated that she spoke with Employee 2 around 8:30 AM - 8:45 AM to discuss that Employee 4 had not shown for her shift. DON stated that she advised Employee 2 to call Employee 1. DON stated that she then called Employee 4 who stated she did not come to work because she was not yet feeling up to it. DON stated that since Employee 2 was busy passing medications, she attempted to get in contact with Employee 1. DON states she finally reached Employee 1 somewhere between 8:30 AM - 9:30 AM, at which time Employee 1 told DON she was on her way. DON stated did not know if she was actually enroute at that time. DON revealed that after she found out Employee 1 was coming in, she dropped it since she figured they were covered. DON revealed that she did not realize medications were not administered until it was discussed at morning meeting on Tuesday, December 27, 2022. During an interview with Employee 2 (Registered Nurse Supervisor) on January 12, 2023, at 10:46 AM, she revealed that she was scheduled to work from 7:00 AM to 7:00 PM on December 25, 2022. She revealed she was assigned as house supervisor and was also assigned a medication cart on the 1300 unit. Employee 2 revealed that she contacted the DON at 7 something to inform her that Employee 4 did not show for her shift on the ACU. Employee 2 stated that DON informed her that she wound attempt to contact Employee 1 since she had said she could work. Employee 2 stated she did not wait around to see if Employee 4 showed, since she had a medication pass that needed to be completed on another unit. She stated that she followed-up with the DON via text at 8:30 AM to see if she was able to reach Employee 1. Employee 2 stated that Employee 1 reported to work around 12:00 PM. She stated that Employee 1 reported to the 1300 unit when she arrived and began to pass lunchtime medications. Employee 2 revealed that she was on the ACU when Employee 1 arrived, attempting to look through missed medications to see what could still be given. Employee 2 stated that she requested Employee 1's assistance on the ACU. When Employee 1 arrived on the ACU, Employee 2 stated Employee 1 suggested they just let the physician know medications weren't administered. Employee 2 revealed that Employee 1 contacted the physician. Employee 2 stated she was unaware of what the physician's response was. Employee 2 stated they then split the responsibility of notifying the responsible parties and documenting in resident records. Employee 2 revealed she was aware of missed morning medications on the ACU and had not contacted the physician earlier to notify of these missed medications since she was planning to go through resident orders to see what could still be administered. During an interview with the Assistant DON on January 10, 2023, at 12:52 PM, she confirmed a staffing shortage on January 8, 2023. She revealed that the physician was notified of the situation, and that he instructed them to administer cardiac and diabetic medications. She revealed that this was done and, for the residents who received either diabetic or cardiac medications, all of their other medications were also administered. During a later interview with the DON on January 12, 2023, at 11:07 AM, she revealed that on January 8, 2023, they did not have sufficient staff scheduled to cover all medication carts. She revealed that the Assistant DON, unit manager, and an agency nurse were called in to cover medication carts. She revealed that one of the nurses was assigned two medication carts. The DON revealed that it was known that medication administration was going to be late for some of the residents. She confirmed that the physician was notified of the situation. The Nursing Home Administrator (NHA) and DON were notified of the concern regarding missed medication and treatment administration that occurred on December 25, 2022, and were provided with the immediate jeopardy template on January 10, 2023, at 3:35 PM. An immediate action plan was requested at that time. On January 10, 2023, at 6:24 PM, the facility's immediate action plan was accepted, which included: - The facility is maintaining sufficient licensed nursing staff on site during all nursing shifts by offering additional shifts and incentives and utilizing agency staff to provide nursing care including medications and treatments are administered timely as per physician orders. - The identified residents were reviewed to determine any negative effects. - All residents in house will be reviewed per the missed medication report for the past 72 hours. Any residents identified will be evaluated for signs and symptoms of adverse reactions to missed medications, they will have a Medication Error Report completed, and the physician and responsible party will be made aware. - Administrative staff will ensure the appropriate number of nursing staff are provided daily. If not, administrative staff will be contacted and the on-call system will be implemented also utilizing administrative staff to meet these needs. - Current licensed nursing staff will be educated by January 12, 2023, on ensuring medications and treatments are administered timely as per physician orders, and that residents will be free from significant medication errors caused by omitted medications. Any new staff will be educated prior to the start of their next shift. - The NHA and DON were educated on January 10, 2023, on ensuring sufficient nursing staff is onsite 24/7 to provide medications and treatments per physician orders. - DON, NHA, or designee will audit missed medication reports every shift for two weeks, then daily for four weeks to ensure medications and treatments are administered timely as per physician orders. Results will be reported to QAPI for review and further recommendations. On January 12, 2023, at 10:35 AM, the Immediate Jeopardy was lifted during an onsite survey after ensuring that the immediate action plan had been implemented. 28 Pa. Code 211.12 (a)(c)(d)(1)(4)(5) Nursing Services 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2)(3)(6) Management 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and interviews with staff, it was determined that the facility failed to ensure that necessary care and services were provided and that pressure ulcers were identified, assessed, and monitored, resulting in actual harm from development and worsening of pressure ulcers for one out of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed resident was readmitted to the facility November 5, 2021, following a hospitalization . Review of Resident 1's readmission assessment dated [DATE] revealed that Resident 1 was admitted post hospitalization with redness to her left elbow, skin exfoliation to her coccyx (sacral area), redness to her rear right thigh, and a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to her left outer ankle. The assessment did not detail any further assessment or measurements of the wounds. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This wound was not identified on the resident's readmission assessment completed November 5, 2021. Review of Resident 1's clinical record revealed no further assessment regarding the wound. Further review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the contracted wound care company note dated November 8, 2021, noted Resident 1 with full-thickness ulceration of the left lateral malleolus (ankle) measuring 1.8 x 2.0 x 0.0 cm, with recommendations to cleanse the affected area with NSS or wound cleanser and apply Medi honey (decreases bacterial growth in wound) daily and cover with foam. Review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order follows the recommendations from Wound Healing Solutions note dated November 8, 2021. Review of weekly nursing skin assessment form dated November 10, 2021, revealed documentation stating, treatment in place for left outer ankle and Right distal lateral leg. The assessment does not document size or characteristics of wounds on ankle or lateral leg. Nursing documentation also does not address exfoliation to coccyx (sacral area), redness to rear right thigh, or redness to left elbow that was identified on November 5, 2021. Review of the contracted wound care company note dated November 15, 2021 revealed Resident 1 with four wounds. The first wound was identified as a full-thickness ulceration of the left lateral malleolus (ankle) measuring 2.8 x 2.5 x 0.0 cm which has increased in size since previous assessment, with recommendations to cleanse affected area with NSS or wound cleanser, apply Medi honey daily and cover with foam. The second wound was identified as a new full-thickness ulceration of the right thigh measuring 1.5 x 1.0 x 0.1 cm, with recommendations to cleanse the site with normal saline or wound cleanser, apply Medi honey to open area daily and as needed and cover with bordered dressing. There is no evidence that the facility had identified or assessed this wound. The third wound was identified as a new full-thickness ulceration of the superior medial right thigh measuring 2.5 x 1.5 x 0.1 cm with recommendations to clean site with NSS or wound cleanser, apply skin prep to wound base twice a day and cover with foam dressing - not heavy white dressing. There is no evidence that the facility had identified or assessed this wound. The fourth wound was identified as a new full-thickness ulceration of the right inferior lateral thigh measuring 1.6 x 1.2 x 0.1 cm with recommendations to clean site with NSS or wound cleanser, apply skin prep to wound base twice a day and cover with foam dressing - not heavy white dressing. There is no evidence that the facility had identified or assessed this wound. Review of Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of weekly nursing skin assessment form dated November 17, 2021, revealed documentation stating, treatment in place for left outer ankle and Right distal lateral leg. The assessment does not document size or characteristics of wounds on ankle or lateral leg. Nursing documentation does not address wound on coccyx (sacral area), redness to rear right thigh, or redness to left elbow that was identified on November 5, 2021 or ulcerations of the superior medial thigh and right inferior lateral thigh that were identified by Wound Solutions on November 15, 2021. Review of the contracted wound care company note dated November 22, 2021 revealed Nursing staff report patient now has a sacral wound. Staff report that sacral area was red and discolored upon readmission from her last hospitalization and site has rapidly declined. The note stated Resident 1 with a new infected wound that is a full-thickness ulceration of the sacral region measuring 7.0 x 5.0 x 2.5 cm with 7.0 cm tunnel, wound with odor, necrosis, purulent drainage, [CONDITION(S)], and induration. There is no evidence that this wound has been assessed by staff since readmission to facility on November 5, 2021. The note further shows resident with a full-thickness ulceration of the left lateral malleolus (ankle) measuring 3.0 x 3.5 x 0.5 cm with bone exposure, which has increased in size and depth since prior assessment. Two additional wounds were identified on the resident's right lateral thigh, a full-thickness ulceration of the right lateral thigh measuring 2.0 x 1.5 x 0.3 cm, and a full-thickness ulceration of the right lateral thigh (superior site) measuring 0.3 x 0.3 x utd cm. There is no evidence that the facility had assessed, identified, or treated these wounds. The recommendations made by Wound Healing Solutions were to send resident to ER for evaluation of new stage 4 pressure injury of sacral region with wound infection. Review of nursing progress note dated November 22, 2021 revealed resident with sacral deep tissue injury that has opened, wound CRNP recommended resident be sent to hospital due to area looking infected. Resident 1 was sent to the Emergency Department on November 22, 2021 for wound evaluation. While in the hospital Resident 1 received a full skin assessment on November 23, 2021 by the hospital's Wound Ostomy and Continence Nurse (WOCN). The WOCN assessment identified the wounds present upon admission to the hospital. Those wounds consisted of a stage 4 pressure injury over the sacrum that measured 8.2 x 8 x 3.5cm, a stage 4 pressure injury of the left lateral ankle with visible tendon, and an unstageable pressure injury noted on right lateral thigh (there are 2 areas measured as 1 injury). The assessment revealed two additional wounds that had not been identified by the facility prior to the hospital admission consisting of a deep tissue injury to the right lateral ankle and a stage 1 pressure injury located on the posterior head. While in the hospital, Resident 1 underwent debridement (the removal of damaged tissue) of the sacral wound under general anesthesia. The Operative Report dated November 24, 2021, detailed the procedure to involve excising (removing) the necrotic tissue along the right side, removing the underlying necrotic (dead) tissue down to the presacral fascia as well as exposing her underlying gluteus muscle. The wound was debrided enough for a wound VAC (a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) verified on December 13, 2021 at 2:10 PM, that the resident did not have any updated orders following the Wound Healing Solutions recommendations made on November 15, 2021, that included treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 13, 2021 at 3:05 PM, the Director of Nursing (DON) explained the process that should be followed regarding wound assessments. The DON revealed the wound team assesses the resident weekly, that information regarding the wounds and recommendations is then given to the unit managers within 24 hours. The unit managers are then responsible to notify the physician of the wound team's recommendations and obtain orders. The Director of Nursing stated she spoke with the unit manager regarding the wound team assessment that was completed on November 15, 2021, the unit manager revealed the assessment was received by Wound Healing Solutions, but it was overlooked and the physician was not notified and treatments were not put in place. The DON was unable to locate any documentation from the nurses or physician regarding the wound to the coccyx (sacral area) since readmission to the facility on [DATE]. The DON was also unable to find any documentation regarding the newly identified wounds to the thigh. The DON stated the weekly skin assessment completed by the nurse should have included the progression of the sacral wound as well as the other wounds identified and did not contain that information. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5 (f)(h) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. code 211.12(d)(1)(3)(5) Nursing Services

APPEAL FILED Based on facility policy review, observation, staff interview, and clinical record review, it was determined that the facility failed to ensure care and services were provided in accordance with physicians orders for three of 56 residents reviewed (Residents 128, 169 and 176), failed to accurately document the code status choice for two of 56 residents reviewed (Residents 65 and 169) and failed to ensure that residents were served foods according to their physician ordered diet for one of 56 residents reviewed (Resident 666), which resulted in harm by the resident choking, requiring Cardiopulmonary Resuscitation and hospitalization . Findings include: Review of facility's policy titled, Advance Directives revised (MONTH) (YEAR), revealed in the section labeled, Policy Interpretation and Implementation step 19 Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if the changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. and step 20 The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident 65's clinical record revealed [DIAGNOSES REDACTED].) Review of physician orders [REDACTED]. Review of Resident 65's care plan revealed a care plan entitled Patient has an advance directive as evidenced by: Full code with a date initiated of (MONTH) 31, (YEAR), and intervention of CPR (cardiopulmonary resuscitation) will be performed as ordered. Review of Resident 65's POLST (Pennsylvania Orders for Life-Sustaining Treatment: a medical order for the specific medical treatments you want during a medical emergency) dated (MONTH) 4, 2019, indicates Resident 65 does not wish to have Cardiopulmonary Resuscitation (CPR). Review of Resident 128's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 128's current physician orders [REDACTED]. The order failed to specify what size catheter staff are to use for Resident 128. Further review of Resident 128's current physician orders [REDACTED]. During staff interview on (MONTH) 11, 2019, at 3:30 PM the Nursing Home Administrator (NHA) stated that the order should specify what size catheter to use. On (MONTH) 12, 2019, at 11:18 AM the NHA stated that the order for the catheter care did not print correctly for staff to be able to sign off that they were completing it. Review of Resident 169's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 169's current care plan revealed, Patient has an Advanced Directive as evidenced by Full Code. Review of Resident 169's current physician orders [REDACTED]. status was a Full Code. On (MONTH) 11, 2019, at 9:43 AM Resident 169's POLST was provided to the surveyor, which was signed and dated (MONTH) 27, (YEAR), indicating that Resident 169 was to be a DNR. On (MONTH) 11, 2019, a physician order [REDACTED]. On (MONTH) 11, 2019, a care plan was initiated for Resident 169 stating, The resident has an advanced directive of DNR. During staff interview on (MONTH) 11, 2019, at 9:35 AM the Director of Nursing stated that staff should look at the POLST to determine a code status. The Nursing Home Administrator stated that the staff should look at the physician order [REDACTED]. Resident 169 did not have a physician order [REDACTED]. Review of Resident 169's current physician orders [REDACTED]. During staff interview on (MONTH) 11, 2019, at 9:42 AM the Nursing Home Administrator stated the Prevalon boots should have been in place. Review of the facility's policy titled, Wound Care last revised (MONTH) 2010, states to mark tape with initial, time and date, and apply to dressing. The policy also states to document if the resident refused the treatment and the reason(s) why, and to notify the supervisor if the resident refuses the wound care. Review of the clinical record for Resident 176 on (MONTH) 8, 2019, at 1:00 PM revealed [DIAGNOSES REDACTED]. Venous ulcers develop from damage to the veins caused by an insufficient return of blood back to the heart). Review of the current quarterly MDS (Minimum Data Set-periodic assessment of resident needs) for Resident 176 revealed that his BIMS (brief interview of mental status) scored a 14 out of a possible 15, indicating he is cognitively intact. During an interview with Resident 176 on (MONTH) 8, 2019, at 9:58 AM he stated that the staff never did his wound care yesterday. Resident 176 also stated this isn't the first time that staff didn't do his wound care. The resident stated that when they failed to provide the wound care on day shift, that he requested the evening shift to provide the care, and they also failed to do the wound care. Observation of Resident 176 on (MONTH) 8, 2019, at 9:58 AM revealed his right foot and ankle wrapped with Kling wrap (sterile, self-adhering gauze roll that gently sticks to itself as you wrap it around arm or leg). The Kling wrap was not dated or initialed to determine when the treatment was last performed. An interview with LPN 4 who was present on Resident 176's area agreed that the dressing should be dated, initialed, and timed, and that the elastic bandage should have been applied over the gauze dressing. Review of Resident 176's (MONTH) 2019 physician orders [REDACTED]. Cover with elastic bandage from toes to knee. Daily every day shift. Review of the Treatment Administration Record for the wound care administration dated (MONTH) 7, 2019, revealed that it was documented that the resident refused wound care on that date. There was no documentation in the nurse's notes indicating that he refused the wound care or why he refused. Review of a grievance report submitted by Resident 176, dated (MONTH) 2, 2019, stated that the resident reported his dressing was not changed. The facility was questioned regarding the grievance filed on (MONTH) 2, 2019, and the investigation and resolution to this concern was requested. The facility provided a disciplinary action report that stated a verbal warning was given to the staff member that failed to provide the wound care and the staff person was educated. During an interview with the Nursing Home Administrator on (MONTH) 11, 2019, at 8:53 AM she stated that the resident is occasionally non-compliant but agreed that wound care should be provided as ordered by the physician. Review of the facility's current policy titled Therapeutic Diet revealed that snacks will be compatible with the therapeutic diet. Review of the clinical record for Resident 666 revealed [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. On (MONTH) 8, 2019, at approximately 4:00 AM, Resident 666 was restless and was brought to the nurses' station for closer monitoring. Nurse Aide (NA) 1 was covering for NA 2 while she was on a break. NA 1 was sitting at the nurses' station with Resident 666. During an interview with NA 1 on (MONTH) 8, 2019, at 11:39 AM she stated that Resident 666 was restless, and she didn't want him to fall. She said that there were peanut butter crackers laying on the desk at the nurses' station, so she gave the resident the crackers. NA 1 sat beside the resident while he fed himself the crackers. NA 1 stated in the interview that she doesn't usually work on that unit and wasn't familiar with the residents. She confirmed that she did not know what the resident's diet order was and that she did not look anywhere to find out. Review of NA 1's witness statement revealed that when NA 2 got back from lunch she left Resident 666 to go answer a call bell. When she returned to the nurses' station NA 2 stated that Resident 666 wasn't breathing right. The nurse was paged. At approximately 4:30 AM, Registered Nurse (RN) 1 assessed the resident who was found with no heartbeat or respirations. Cardiopulmonary resuscitation (CPR) (an emergency technique used on someone whose heart or breathing has stopped) was initiated. 911 was called. At approximately 4:44 AM emergency medical services arrived and resumed care. The resident was transported to the hospital. During an interview with the Director of Nursing on (MONTH) 9, 2019, at 3:50 PM she confirmed that the diet order for Resident 666 should have been followed. The facility failed to ensure that residents were served foods according to their ordered diet for one of 56 residents reviewed (Resident 666), which resulted in harm by the resident choking, which resulted in Cardiopulmonary Resuscitation and hospitalization . 42 CFR 483.25 Quality of Care. Previously cited [DATE], [DATE], [DATE]. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.5(f) Clinical records. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on observation, review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by an elopement risk by residents for one of four residents reviewed (Resident 4) who broke a window in a room and eloped from the ACU (secure unit) resulting in potential high risk for injury to the resident. This failure placed the residents at a high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and [MEDICAL CONDITION] with Behavioral Disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Resident 4 was admitted to the facility on (MONTH) 19, (YEAR). Review of a discharge instruction sheet regarding Resident 4 from the facility she resided in prior to the current facility admission and part of her current clinical record revealed that the resident was fully ambulatory. Review of a facility's Elopement Risk assessment (a form used by the facility to assess the elopement risk of a resident) completed on (MONTH) 19, (YEAR), by the Assistant Director of Nursing (ADON) revealed that Resident 4 was at high risk for elopement. Review of Resident 4's (MONTH) (YEAR), physician orders [REDACTED]., with use to her right ankle at all times. Further review of documentation from Resident 4's previous facility dated (MONTH) 15, (YEAR), revealed that Resident 4 was found in the parking lot of the facility. Review of Resident 4's admission Minimum Data Set assessment (MDS-a tool used to assess all care areas specific to the resident), dated (MONTH) 26, (YEAR), revealed Section E-Behavior, subsection E0900 Wandering-Presence and Frequency was coded as 2, Behavior of this type occurred 4 to 6 days, but less than daily (during the seven-day lookback). Review of Resident 4's plan of care for identified focus area of At risk for elopement related to: Resident states, I am leaving, going home. Wandering, attempting to elope at other facilities, hx (history) of elopement revealed an initiation date of (MONTH) 19, (YEAR), with a revision date of (MONTH) 9, 2019. This care plan revealed the intervention, I will reside on secured unit (ACCU/ACU). Review of Resident 4's nursing progress notes dated (MONTH) 19, (YEAR), revealed that the resident had exit seeking behaviors twice on this day and on (MONTH) 20, (YEAR), had exit seeking behaviors one time. Review of a note dated for (MONTH) 19, (YEAR), and written at 3:48 PM (identified as an admission assessment) by Assistant Director of Nursing (ADON) revealed, .Expresses desire to leave facility and is currently ambulating throughout unit with coat and purse in hand. Review of a progress note written on (MONTH) 19, (YEAR), at 4:26 PM by Licensed Practical Nurse 2 (LPN) 2 revealed, .became increasingly agitated; banging on door and window to nurses' station. Exit seeking; attempting to leave unit when others are entering. Review of a progress note dated for (MONTH) 20, (YEAR), at 9:42 PM by LPN 3 revealed, Resident was agitated and exit seeking most of the shift. Review of a progress note dated for (MONTH) 21, (YEAR), at 5:37 PM by Social Services (SS 1) revealed IDT (Interdisciplinary Team) meeting held this afternoon, Baseline care plan was reviewed. Resident has been agitated, making derogatory comments to staff and other residents .plan for LTC (Long Term Care) in secure unit. Review of Resident 4's care plan revealed no evidence that the care plan was updated at this time. Review of a late entry nursing progress note dated for (MONTH) 27, (YEAR), at 4:45 AM revealed that a Nurse Aide had reported to LPN 3 that Resident 4 had come to her with a bleeding wrist. The progress note revealed that further assessment of the incident revealed that a window in Resident 4's room was broken out. Review of an additional note written on (MONTH) 27, (YEAR), at 5:00 AM by Registered Nurse/Nursing Supervisor (RN) 1 revealed that she was called to the unit and resident noted pacing and actively seeking exits while holding R (right) wrist. Review of Resident 4's care plan revealed that it was updated on (MONTH) 27, (YEAR), to have Resident 4 on one-on-one supervision (facility did not define the meaning of one-on-one) during night shift and line of sight (facility did not define the meaning of line of sight) during day hours. During an interview with the Nursing Home Administrator (NHA) on (MONTH) 17, 2019, at 8:45 AM the NHA revealed that they did not have a policy for one-on-one supervision or line of sight. NHA was asked what her expectation would be for one-on-one supervision and response was to stay with them and when asked what her expectation would be for line of sight her response was to visually see. During an interview with the NHA on (MONTH) 17, 2019, at 3:00 PM the NHA revealed confirmation from the facility's corporate entity that they did not have a policy for one-on-one supervision or line of sight supervision. Review of facility incident report regarding this event dated for (MONTH) 27, (YEAR), revealed under Notes with an identified date of (MONTH) 27, (YEAR), that the Resident would be placed on line of sight safety observation by day and 1:1 HS (hour of sleep) safety observation until 24 hours free of volatile aggressive behaviors and evaluated by psych services. Review of the facility required reporting form dated for (MONTH) 27, (YEAR), revealed interventions for this incident to be line of sight observation during day hours and 1:1 (one-on-one) supervision in the evening until seen by psych services and has a minimum of 24 hours without behaviors. Further review of this report revealed it was submitted by the ADON. Review of Resident 4's care plan failed to reveal inclusion of these intervention parameters. During an interview with the NHA on (MONTH) 14, 2019, at 11:00 AM the NHA was asked regarding what type of behaviors would exclude resident from requiring the 1:1 and line of sight interventions. NHA responded that these would include aggressive behaviors such as, physically acting out in a manner posing potential harm to self or others. Review of clinical record documents revealed that an order for [REDACTED]. Review of the clinical records revealed that on (MONTH) 1, 2019, the facility IDT (interdisciplinary team) met, determined that Resident 4 had not presented with any further aggressive behaviors to warrant maintaining 1:1 supervision since (MONTH) 27, (YEAR), and removed the 1:1. During an interview with the NHA on (MONTH) 17, 2019, at 11:50 AM the NHA was unable to provide information as to what time the IDT meeting was held. Review of nursing progress notes revealed an entry dated (MONTH) 31, (YEAR), at 6:38 AM revealing, one min (minute) resident pleasant calm and thanking staff and amb (ambulating) in hall, less than 5 min later agitated, name calling, accusing staff, demanding to call family and friends, uncooperative, punching and hitting door at NS (Nursing Station). Review of a nursing note dated (MONTH) 1, 2019, at 1:33 AM by LPN 3 revealed, easily annoyed agitated, cursing and name calling refused to allow staff to touch her, banging on nursing station office door with her fist. no easily directed. Review of nursing progress note dated (MONTH) 1, 2019, at 6:49 AM by LPN 3 revealed, .very controlling, become very angry aggressive when she does not get her own way. Review of nursing progress note dated (MONTH) 2, 2019, at 1:46 AM by LPN 3 revealed, cont. (continues) to place tables behind doors-both hall way door and bathroom door. Review of nursing progress noted dated (MONTH) 2, 2019, at 2:44 PM by (LPN) 2 revealed, .Banging on door and window to nurse's station. Review of a nursing progress note dated (MONTH) 2, 2019, at 4:30 PM the LPN 1 revealed, .resident was last seen on the Unit at 4:30 PM, by one of the CNA (Certified Nursing Assistant). She has been exit seeking. Staff has been monitoring her movement. As staff were getting ready for supper this resident was not found. Supervisor was notified and code orange (overhead announcement to alert staff of an elopement (missing resident) and to put procedures in place to locate missing person) was announced. Finally, there was a call that resident has been found. Review of a nursing progress note dated (MONTH) 2, 2019, at 9:13 PM by RN 2 revealed, Approx. 1700 (approximately 5:00 PM) a person from the community entered building and spoke with receptionist (R 1) stating there was a lady down at the red light who was in a hurry and seem confused. Further review of the nursing note revealed that the facility receptionist called all units for a head count at this time, that a Charge Nurse (LPN 3) reported to receptionist that Resident 4 was missing, and that at approximately 5:20 PM, the Code Orange (overhead announcement made to inform all nursing units and facility staff that a resident had possibly eloped and to count heads in all units to identify any missing residents and report to a central number) was called by RN 2. Review of this progress note also revealed that at approximately 5:30 PM, the facility received a call from EMS (Emergency Medical Services) to determine if facility was missing a resident as there was a res. (resident) on the CAT bus at the train station. Train station is noted to be approximately three miles from the facility. Further review of this progress note revealed that as the facility had no one to pick up the resident, the CAT bus driver called 911 and Resident 4 was returned to facility via police officer (PO 1). This progress note also revealed that the Director of Nursing (DON) was notified at approximately 5:35 PM. Resident 4 had a Wanderguard placed and was put on 1:1 supervision. Review of this same progress note also revealed that at approximately 6:15 PM, unit investigation revealed a broken window in a room not resided by Resident 4, with a walker outside the window and a partially broken window in a room also not resided in by Resident 4. Review of Resident 4's current active care plan provided to surveyor on (MONTH) 14, 2019, in the AM revealed an identified care focus area of At risk for elopement related to Resident states (I am leaving, going home), Wandering, attempting to elope at other facilities and hx (history) of elopement with an initiation date of (MONTH) 19, (YEAR). Review of interventions for this focus area revealed, Attempt 302, if res. (resident) returns, to remain 1:1 supervision indefinitely with an initiation date and revision date of (MONTH) 2, 2019. On (MONTH) 17, 2019, at 5:45 AM the surveyor entered the building, accompanied by the night Registered Nurse Supervisor (RNS), and went directly to the room of Resident 4. At 5:56 AM, the surveyor observed Resident 4 awake in her bed with no one from the facility watching the resident. There was a chair across the hallway with staff members possessions on it but no staff member. The surveyor and the RNS observed NA 1 leaving another resident's room at approximately the same time. The surveyor approached NA 1 and asked if she was assigned to the 1:1 with Resident 4? She replied, No, no one is assigned to the 1:1 tonight. The surveyor asked LPN 1, who oversaw the unit, for a copy of the assignment sheet for that night. The Daily Group Assignment documentation revealed no staff members assigned to the 1:1 with Resident 4. The Daily Group Assignment form had an entry for 1:1 with a circle with a slash through it. LPN 1 revealed, No 1:1 assignment tonight because there isn't anyone to give it to. Interview with RNS revealed that she called off yesterday. RNS did not expand on this statement, when asked as to the procedure they went through to try and replace the person who called off. At this time NA 1 sat in the chair observing Resident 4 and remained there until the surveyor left the unit. During an interview with the NHA on (MONTH) 17, 2019, at 8:00 AM it was revealed that (Resident 4), should definitely have been on 1:1. On (MONTH) 18, 2019, at 11:30 AM the facility was told that an Immediate Jeopardy situation had been identified. The ADON was informed that the facility would need to provide an action plan to ensure the safety of the residents. The facility provided a draft of the plan of action at 4:09 PM. An updated draft of the action plan was presented at 7:11 PM. The plan of action included: -A sweep of the ACU and AACU was completed on (MONTH) 18, 2019, and no additional residents were identified as actively aggressively exit seeking. -Any resident with active exit seeking behaviors would be placed on 1:1 by the RN supervisor immediately until evaluated by IDT. -Exit seeking is defined as actual and purposeful attempts with the intent to leave the ACU dementia unit by doors or windows. -1:1 will be documented by the nurse and or the CNA and will be identified on the resident's care plan. A new policy on 1:1 has been initiated as follows: -1:1 Monitoring/ACU Dementia Unit -This facility ensures safety of all residents. Residents on the ACU dementia unit that exhibit active and aggressive exit seeking behavior will be placed on 1:1 monitoring. After 24 hours they will be evaluated by licensed staff for further active and aggressive exit seeking behaviors and if a decrease has been noted they will be weaned to Q (every) 15-minute checks for 24 hours then Q (every) 1 hour checks for 24 hours and re-evaluated as needed. -All licensed staff will be educated on the expectation that the RN needs notified of any resident exhibiting active exit seeking behavior who will then place on 1:1 and the DON and the NHA will be notified immediately. -An audit of 1:1 supervision will be completed by the DON or designee daily x 2 weeks and then 2 times a week for 2 months by the NHA or designee. The action plan was accepted at 7:25 PM at which time the facility was notified that the action plan had been accepted. On (MONTH) 19, 2019, at 9:15 AM surveyor entered facility to determine if the action plan was implemented. Two Nurse Aides and two Licensed Practical Nurses on the ACU and ACCU were interviewed and were able to verbalize what they would do if they found a resident with exit seeking behaviors. At 9:25 AM Resident 4 was observed with 1:1 supervision. Education and audits provided were reviewed. On (MONTH) 19, 2019, at 10:10 AM the Immediate Jeopardy was lifted. The facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by elopement risk for Resident 4 who broke a window in a room and eloped from the ACU/ACCU unit resulting in potential high risk for injury to (Resident 4). This failure placed the residents at a high risk for injury and resulted in an Immediate Jeopardy situation. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 10/19/18, 8/22/18, 3/16/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/29/18, 8/22/18, 3/16/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/29/18, 3/16/18. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 3/16/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 211.12(c) Nursing services. Previously cited 10/29/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/3/19, 10/29/18, 8/22/18, 8/6/18, 3/16/18, 1/19/18, 12/19/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/29/18, 8/22/18, 8/6/18, 3/16/18, 12/19/17.

Based on observation, clinical record review, review of select facility documents and staff interviews, it was determined that the facility failed to have enough nursing staff to provide one to one (1:1) observation for one of one resident reviewed (Resident 4) who has a history of elopement, placing Resident 4 in an Immediate Jeopardy situation. Findings include: Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and [MEDICAL CONDITION] with Behavioral Disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 4's current active care plan presented to surveyor on (MONTH) 14, 2019, revealed the care focus area: I sometimes have behaviors which include refusing care and assessments, refusing medications, making negative comments towards staff, physical aggression, breaking windows with an indicated initiation date of (MONTH) 19, (YEAR), and a revision date on (MONTH) 27, (YEAR). Review of goal section revealed, I will remain free of further injury with staff intervention with an indicated initiation date of (MONTH) 19, (YEAR), and a revision date of (MONTH) 9, 2019. Further review of the care plan revealed under interventions: 1:1 supervision during night shift with an initiation date of (MONTH) 27, (YEAR), and a revision date of (MONTH) 27, (YEAR), and Line of sight observation during day hours with an initiation date of (MONTH) 27, (YEAR), and revision date of (MONTH) 27, (YEAR). Review of same above noted care plan also revealed the care focus area: At risk for elopement related to: Resident states (I am leaving, going home), Wandering, attempting to elope at other facilities, hx (history) of elopement with an initiation date of (MONTH) 19, (YEAR), and revision date of (MONTH) 9, 2019. Review of interventions section revealed, Attempt 302 (involuntary commitment or civil commitment is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is ordered by a court into treatment in a psychiatric hospital (inpatient) or in the community (outpatient)), if resident returns, to remain 1:1 supervision indefinitely with an initiation date of (MONTH) 2, 2019, and revision date of (MONTH) 2, 2019. On (MONTH) 14, 2019, the Nursing Home Administrator (NHA) verbally identified that Resident 4 was the only facility resident receiving 1:1 supervision. On (MONTH) 14, 2019, review of facility nursing staffing assignments, delineated per specific nursing units, revealed no evidence that a staff person was assigned 1:1 supervision of Resident 4 on (MONTH) 31, (YEAR), during the night shift (10:30 PM to 7:00 AM). Review of other night shifts' staffing assignments revealed the notation 1:1 along with either the name of a staff person assigned to this task or Resident 4's name. Review of forms: Daily Group Assignments (form used by individual Nursing Aides which specifically indicates their assignments to rooms and tasks for rooms including a section for Additional Info or any appointments scheduled) revealed that from (MONTH) 27, (YEAR), through (MONTH) 1, 2019, with the exception of the night shift on (MONTH) 31, (YEAR), that in the additional information section of the form was noted 1:1 and a staff member's name. Facility was unable to provide information/documentation that Resident 4 received 1:1 supervision during the night shift on (MONTH) 31, (YEAR). During an interview with NHA on (MONTH) 14, 2019, at approximately 4:00 PM the NHA confirmed that no documentation was available to confirm that Resident 4 received 1:1 supervision during the night shift of (MONTH) 31, (YEAR), and that she would have expected the resident to have received the 1:1. On (MONTH) 17, 2019, at 5:45 AM the surveyor entered the building, accompanied by the night Registered Nurse Supervisor (RNS), and went directly to the room of Resident 4. At 5:56 AM the surveyor observed Resident 4 awake in her bed with no one from the facility watching the resident. There was a chair across the hallway with staff members possessions on it but no staff member. The surveyor and the RNS observed Nurse Aide (NA) 1, leaving another resident's room at approximately the same time. The surveyor approached NA 1 and asked if she was assigned to the 1:1 with Resident 4? She replied; No, no one is assigned to the 1:1 tonight. The surveyor asked Licensed Practical Nurse 1 (LPN) 1, who oversaw the unit, for a copy of the assignment sheet for that night. The Daily Group Assignment documentation revealed no staff members assigned to the 1:1 with Resident 4. The Daily Group Assignment form had an entry for 1:1 with a circle with a slash through it. At 6:02 AM the LPN 1 revealed, No 1:1 assignment tonight because there isn't anyone to give it to. Interview with RNS at approximately the same time revealed, she (the staff member assigned the 1:1 with Resident 4) called off yesterday. RNS did not expand on this statement, when asked, as to the procedure they went through to try and replace the person who called off. At this time NA 1 sat in the chair observing Resident 4 and remained there until the surveyor left the unit. During an interview with NHA on (MONTH) 17, 2019, at 8:00 AM it was revealed that (Resident 4), should definitely have been on 1:1. On (MONTH) 18, 2019, at 11:30 AM the facility was told that an Immediate Jeopardy situation had been called. The ADON was informed that the facility would need to provide an action plan to ensure the safety of the residents. The facility provided a draft of the plan of action at 4:09 PM. An updated draft of the action plan was presented to this surveyor at 7:11 PM, which included: -A sweep of the ACU and AACU was completed on (MONTH) 18, 2019 and no additional residents were identified as actively aggressively exit seeking. -Any resident with active exit seeking behaviors will be placed on 1:1 by the RN supervisor immediately until evaluated by IDT (Inter Disciplinary Team). -Exit seeking is defined as actual and purposeful attempts with the intent to leave the ACU dementia unit by doors or windows. -1:1 will be documented by the nurse and or the CNA and will be identified on the resident's care plan. A new policy on 1:1 was initiated as follows: -1:1 Monitoring/ACU Dementia Unit. -The facility ensures safety of all residents. Residents on the ACU dementia unit that exhibit active and aggressive exit seeking behaviors will be placed on 1:1 monitoring. After 24 hours they will be evaluated by licensed staff for further active and aggressive exit seeking behaviors and if a decrease has been noted they will be weaned to Q (every) 15-minute checks for 24 hours, then Q (every)1 hour checks for 24 hours and re-evaluated as needed. -All licensed staff will be educated on the expectation that the RN needs notified of any resident exhibiting, active exit seeking behavior, who will then be placed on 1:1 and the DON and NHA will be notified immediately. -An audit of 1:1 supervision will be completed by the DON or designee daily x (times) 2 weeks and then 2 times a week for 2 months by the NHA or designee. The action plan was accepted at 7:25 PM at which time the facility was notified that the action plan had been accepted. On (MONTH) 19, 2019, at 9:15 AM the surveyor entered the facility to determine if the action plan was implemented. Two Nurse Aides and two Licensed Practical Nurses on the ACU and ACCU were interviewed and were able to verbalize what they would do if they found a resident with exit seeking behaviors. At 9:25 AM Resident 4 was observed with 1:1 observation. Education and audits provided were reviewed. On (MONTH) 19, 2019, at 10:10 AM the IJ was lifted. The facility failed to have enough nursing staff to provide 1:1 observation for one of one resident reviewed (Resident 4) who had a history of [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/29/18, 8/22/18, 3/16/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 211.12(a)(c) Nursing services. Previously cited 10/29/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/3/19, 10/29/18, 8/22/18, 8/6/18, 3/16/18, 1/19/18, 12/19/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/29/18, 8/22/18, 8/6/18, 3/16/18, 12/19/17. 28 Pa. Code 211.12(d)(4) Nursing services.

Based on review of job descriptions, facility policies and clinical records, observations 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 ensure that the residents were protected from elopement for one of nine residents reviewed (Resident 4), who eloped from the facility and was found approximately 3 miles away at the train station, this failure placed the residents in an Immediate Jeopardy situation. Findings include: 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 always provided to all residents. 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 always maintained. During an interview with the NHA on (MONTH) 17, 2019, at 8:45 AM the NHA revealed that the facility did not have a policy for one-on-one (1:1) supervision or line of sight. NHA was asked what her expectation would be for 1:1 supervision and the response was to stay with them and when asked what her expectation would be for line of sight her response was to visually see. During an interview with NHA on (MONTH) 17, 2019, at 3:00 PM the NHA revealed confirmation from facility corporate office entity that they did not have a policy for 1:1 supervision or line of sight. Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED]. mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and [MEDICAL CONDITION] with Behavioral Disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Resident 4 was admitted to the facility on (MONTH) 19, (YEAR). Review of a discharge instruction sheet regarding Resident 4, from the facility she resided in prior to the current facility admission and part of her current clinical record, revealed that the resident was fully ambulatory. Review of a facility's elopement risk assessment (a form used by the facility to assess the elopement risk of a resident) completed on (MONTH) 19, (YEAR), by the Assistant Director of Nursing (ADON) revealed that Resident 4 was at high risk for elopement. Review of Resident 4's (MONTH) (YEAR), physician orders [REDACTED]., with use to her right ankle at all times. Further review of documentation from Resident 4's previous facility dated (MONTH) 15, (YEAR), revealed that Resident 4 was found in the parking lot of the facility. Review of Resident 4's admission Minimum Data Set assessment (MDS-a tool used to assess all care areas specific to the resident), dated (MONTH) 26, (YEAR), revealed Section E-Behavior, subsection E0900 Wandering-Presence and Frequency was coded as 2, Behavior of this type occurred 4 to 6 days, but less than daily (during the seven day look back). Review of Resident 4's plan of care for identified focus area of At risk for elopement related to: Resident states, I am leaving, going home. Wandering, attempting to elope at other facilities, hx (history) of elopement revealed an initiation date of (MONTH) 19, (YEAR) with a revision date of (MONTH) 9, 2019. This care plan revealed the intervention, I will reside on secured unit (ACCU/ACU). Review of Resident 4's nursing progress notes dated (MONTH) 19, (YEAR), revealed that the resident had exit seeking behaviors twice on this day and on (MONTH) 20, (YEAR), had exit seeking behaviors one time. Review of a note dated for (MONTH) 19, (YEAR), and written at 3:48 PM (identified as an admission assessment) by ADON revealed, .Expresses desire to leave facility and is currently ambulating throughout unit with coat and purse in hand. Review of a progress note written on (MONTH) 19, (YEAR), at 4:26 PM by Licensed Practical Nurse 2 (LPN) 2 revealed, .became increasingly agitated; banging on door and window to nurses' station. Exit seeking; attempting to leave unit when others are entering. Review of a progress note dated for (MONTH) 20, (YEAR), at 9:42 PM by LPN 3 revealed, Resident was agitated and exit seeking most of the shift. Review of a progress note dated for (MONTH) 21, (YEAR), at 5:37 PM by Social Services (SS) 1 revealed IDT (Interdisciplinary Team) meeting held this afternoon, Baseline care plan was reviewed. Resident has been agitated, making derogatory comments to staff and other residents .plan for LTC (Long Term Care) in secure unit. Review of Resident 4's care plan revealed no evidence that the care plan was updated at this time. Review of a late entry nursing progress note dated for (MONTH) 27, (YEAR), at 4:45 AM revealed that a Nurse Aide had reported to LPN 3 that Resident 4 had come to her with a bleeding wrist. The progress note revealed that further assessment of the incident revealed that a window in Resident 4's room was broken out. Review of an additional note written on (MONTH) 27, (YEAR), at 5:00 AM by Registered Nurse/Nursing Supervisor (RN) 1 revealed that she was called to the unit and resident noted pacing and actively seeking exits while holding R (right) wrist. Review of Resident 4's care plan revealed that it was updated on (MONTH) 27, (YEAR), to have Resident 4 on 1:1 supervision (facility did not define the meaning of 1:1) during night shift and line of sight (facility did not define the meaning of line of sight) during day hours. During an interview with NHA on (MONTH) 17, 2019, at 8:45 AM the NHA revealed that the facility did not have a policy for 1:1 supervision or line of sight. NHA was asked what her expectation would be for 1:1 supervision and response was to stay with them and when asked what her expectation would be for line of sight her response was to visually see. During an interview with NHA on (MONTH) 17, 2019, at 3:00 PM the NHA revealed confirmation from facility corporate entity that they did not have a policy for 1:1 supervision or line of sight. Review of facility's provided documentation regarding this event dated for (MONTH) 27, (YEAR), revealed under Notes with an identified date of (MONTH) 27, (YEAR), that the Resident would be placed on line of sight safety observation by day and 1:1 HS (hour of sleep) safety observation until 24 hours free of volatile aggressive behaviors and evaluated by CHE psych services (CHE- professional designation, Certified Health Executive) provider of behavioral health services, providing comprehensive behavioral health services to improve the quality of life of residents and assist the interdisciplinary care team in achieving best person-centered care practices) and that the note was identified with the name of the DON. Review of the facility required reporting form dated for (MONTH) 27, (YEAR), revealed interventions for this incident to be line of sight observation during day hours and 1:1 supervision in the evening until seen by psych services and has a minimum of 24 hours without behaviors. Further review of this report revealed it was submitted by the ADON. Review of Resident 4's care plan failed to reveal inclusion of these intervention parameters. During an interview with the NHA on (MONTH) 14, 2019, at 11:00 AM the NHA was asked regarding what type of behaviors would exclude resident from requiring the 1:1 and line of sight interventions. NHA responded that these would include aggressive behaviors such as, physically acting out in a manner posing potential harm to self or others. Review of clinical record documents revealed that an order for [REDACTED]. Review of the clinical records revealed that on (MONTH) 1, 2019, the facility IDT (interdisciplinary team) met, determined that Resident 4 had not presented with any further aggressive behaviors to warrant maintaining 1:1 supervision since (MONTH) 27, (YEAR), and removed the 1:1. During an interview with the NHA on (MONTH) 17, 2019, at 11:50 AM the NHA was unable to provide information as to what time the IDT meeting was held. Review of nursing progress notes revealed an entry dated (MONTH) 31, (YEAR), at 6:38 AM revealing one min (minute) resident pleasant calm and thanking staff and amb (ambulating) in hall, less than 5 min later agitated, name calling, accusing staff, demanding to call family and friends, uncooperative, punching and hitting door at NS (Nursing Station). Review of a nursing note dated (MONTH) 1, 2019, at 1:33 AM by LPN 3 revealed, easily annoyed agitated. cursing and name calling refused to allow staff to touch her. banging on nursing station office door with her fist. no easily directed. Review of nursing progress note dated (MONTH) 1, 2019, at 6:49 AM by LPN 3 revealed, .very controlling, become very angry aggressive when she does not get her own way. Review of nursing progress note dated (MONTH) 2, 2019, at 1:46 AM by LPN 3 revealed, cont. (continues) to place tables behind doors-both hall way door and bathroom door. Review of nursing progress noted dated (MONTH) 2, 2019, at 2:44 PM by LPN 2 revealed, .Banging on door and window to nurse's station. Review of a nursing progress note dated (MONTH) 2, 2019, at 4:30 PM, LPN 1 revealed, .resident was last seen on the Unit at 4:30 PM by one of the CNA (Certified Nursing Assistant). She has been exit seeking. Staff has been monitoring her movement. As staff were getting ready for supper this resident was not found. Supervisor was notified and code orange (overhead announcement to alert staff of an elopement (missing resident) and to put procedures in place to locate missing person) was announced. Finally, there was a call that resident has been found. Review of a nursing progress note dated (MONTH) 2, 2019, at 9:13 PM by Registered Nurse (RN) 2 revealed, Approx. 1700 (approximately 5:00 PM) a person from the community entered building and spoke with receptionist (R 1) stating there was a lady down at the red light who was in a hurry and seem confused. Further review of the nursing note revealed that the facility receptionist called all units for a head count at this time, that a Charge Nurse (LPN 3) reported to receptionist that Resident 4 was missing, and that at approximately 5:20 PM the code orange (overhead announcement made to inform all nursing units and facility staff that a resident had possibly eloped and to count heads in all units to identify any missing residents and report to a central number) was called by RN 2. Review of this progress note also revealed that at approximately 5:30 PM the facility received a call from Emergency Medical Services to determine if the facility was missing a resident as there was a res. (resident) on the CAT bus at the train station. Train station is noted to be approximately three miles from the facility. Further review of this progress note revealed that as the facility had no one to pick up resident, the CAT bus driver called 911 and Resident 4 was returned to facility via police officer. This progress note also revealed that the DON was notified at approximately 5:35 PM. Resident 4 had a Wanderguard placed and was put on 1:1 supervision. Review of this same progress note also revealed that at approximately 6:15 PM, unit investigation revealed a broken window in a room not resided by Resident 4, with a walker outside the window and a partially broken window in a room also not resided in by Resident 4. Review of Resident 4's current active care plan provided to surveyor on (MONTH) 14, 2019, in the AM revealed an identified care focus area of At risk for elopement related to Resident states (I am leaving, going home), Wandering, attempting to elope at other facilities and hx (history) of elopement with an initiation date of (MONTH) 19, (YEAR). Review of interventions for this focus area revealed, Attempt 302, if res. (resident) returns, to remain 1:1 supervision indefinitely with an initiation date and revision date of (MONTH) 2, 2019. On (MONTH) 17, 2019, at 5:45 AM the surveyor entered the building, accompanied by the night Registered Nurse Supervisor (RNS), and went directly to the room of Resident 4. At 5:56 AM, the surveyor observed Resident 4 awake in her bed with no one from the facility watching the resident. There was a chair across the hallway with staff members possessions on it but no staff member. The surveyor and the RNS observed Nurse Aide (NA) 1 leaving another resident's room at approximately the same time. The surveyor approached NA 1 and asked if she was assigned to the 1:1 with Resident 4? She replied, No, no one is assigned to the 1:1 tonight. The surveyor asked LPN 1, who oversaw the unit, for a copy of the assignment sheet for that night. The Daily Group Assignment documentation revealed no staff members assigned to the 1:1 with Resident 4. The Daily Group Assignment form had an entry for 1:1 with a circle with a slash through it. LPN 1 revealed, No 1:1 assignment tonight because there isn't anyone to give it to. Interview with RNS revealed that she called off yesterday. RNS did not expand on this statement, when asked, as to the procedure they went through to try and replace the person who called off. At this time NA 1 sat in the chair observing Resident 4 and remained there until the surveyor left the unit. During an interview with NHA on (MONTH) 17, 2019, at 8:00 AM it was revealed that Resident 4, should definitely have been on 1:1. On (MONTH) 18, 2019, at 11:30 AM the facility was informed that an Immediate Jeopardy situation had been called. The ADON was informed that the facility would need to provide an action plan to ensure the safety of the residents. The facility provided a draft of the plan of action at 4:09 PM. An updated draft of the action plan was presented to this surveyor at 7:11 PM which included: -A sweep of the ACU and AACU was completed on (MONTH) 18, 2019, and no additional residents were identified as actively aggressively exit seeking. -Any resident with active exit seeking behaviors will be placed on 1:1 by the RN supervisor immediately until evaluated by IDT (Inter Disciplinary Team). -Exit seeking is defined as actual and purposeful attempts with the intent to leave the ACU dementia unit by doors or windows. -1:1 will be documented by the nurse and or the CNA and will be identified on the resident's care plan. A new policy on 1:1 had been initiated as follows: -1:1 Monitoring/ACU Dementia Unit. -The facility ensures safety of all its residents. Residents on the ACU dementia unit that exhibit active and aggressive exit seeking behavior will be placed on 1:1 monitoring. After 24 hours they will be evaluated by licensed staff for further active and aggressive exit seeking behaviors and if a decrease has been noted they will be weaned to Q (every) 15-minute checks for 24 hours then Q 1-hour checks for 24 hours and re-evaluated as needed. -All licensed staff will be educated on the expectation that the RN needs notified of any resident exhibiting active exit seeking behavior who will then place on 1:1 and the DON and NHA will be notified immediately. -An audit of 1:1 supervision will be completed by the DON or designee daily x 2 weeks and then 2 times a week for 2 months by the NHA or designee. The action plan was sent to Department of Health Administration and was accepted at 7:25 PM, at which time the facility was notified that the action plan had been accepted. On (MONTH) 19, 2019, at 9:15 AM the surveyor entered the facility to determine if the action plan was implemented. Two Nurse Aides and two Licensed Practical Nurses on the ACU and ACCU were interviewed and were able to verbalize what they would do if they found a resident with exit seeking behaviors. At 9:25 AM Resident 4 was observed with 1:1 observation and education and audits provided were reviewed. On (MONTH) 19, 2019, at 10:10 AM the Immediate Jeopardy was lifted. The NHA and the DON failed to ensure that the facility adequately supervised and maintained each residents' environment to ensure that the residents remained free of accident hazards created by elopement risk by residents for Resident 4 who broke a window in a room and eloped from the ACU/ACCU unit resulting in potential high risk for injury to (Resident 4). This failure placed the residents at a high risk for injury and resulted in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 201.18(a)(e)(2) Management. 28 Pa. Code 201.18(b)(1) Management. Previously cited 10/29/18, 8/22/18, 3/16/18. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/29/18, 3/16/18, 12/19/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/29/18, 3/16/18. 28 Pa. Code 211.12(a) Nursing services. Previously cited 10/29/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 1/3/19, 10/29/18, 8/22/18, 8/6/18, 3/16/18, 1/19/18, 12/19/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/29/18, 8/22/18, 8/6/18, 3/16/18, 12/19/17.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop care plans that adequately addressed residents' needs and the services to be furnished for two of 11 residents reviewed (Resident 2, 7,) resulting in to Resident 2 harm requiring transfer to the hospital. Findings include: Review of the facility's Fall Management Guideline last reviewed (MONTH) 10, (YEAR), revealed that following a resident's fall, the licensed nurse assesses the resident for injuries and provides necessary treatment, and initiates the Change in Condition Report - Post Fall/Trauma; the physician and residents' representatives are notified; appropriate interventions are implemented; and the care plan is updated. Review of the Interdisciplinary Care Plan policy last reviewed (MONTH) 22, (YEAR), revealed Social services staff, as members of the interdisciplinary care plan (ICP) team, will participate in the development of a comprehensive care plan for each resident. The interdisciplinary care plan will be reviewed quarterly to evaluate effectiveness and be revised and updated as necessary to address resident needs in accordance with the most current assessment. Interventions that have proved ineffective must be changed on the care plans immediately. Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. Based on the review of Resident 2's quarterly MDS (Minimum Data Summary- assessment of each resident's functional capabilities) dated (MONTH) 8, (YEAR), revealed BIMS (brief interview for mental status) level as 2 (cognitively impaired). Review of Resident 2's functional status for walking in corridor was a 2 (limited assistance); 2 (one person physical assist). Review of Resident 2's functional status for locomotion on unit, was a 3 (extensive assistance); 2 (one person physical assist). Based on review of the fall reports for Resident 2 on (MONTH) 3, (YEAR), he had a fall with no injuries reported; and on (MONTH) 13, (YEAR), he had a fall with a skin tear to the face. Review of a fall report dated (MONTH) 2, (YEAR), at 4:48 p.m. revealed Resident 2 had gait imbalance (walking balance), impaired memory and history of falls. Incident description from the fall report revealed, Resident lost his balance and fell back into the double door entrance and hit his head. Resident was continuously seated in wheelchair but did not want to stay seated. VSS (vital signs) 149/78 (blood pressure)-98.3(temperature)-93 (pulse)-20 (respirations) Resident right eye pin point (pupil). Abrasion on rear back of head 0.5 cm (metric unit of measure) L (length) X 0.5 cm W (width). NP (nurse practitioner) aware. Resident is being sent to out to (hospital). Resident left at 1743 (5:43 p.m.). Review of Resident 2's care plan, with a resident admitted (MONTH) 8, (YEAR), and a revision date of (MONTH) 2, (YEAR), revealed no care plan for falls or interventions. Review of Resident 2's quarterly MDS (Minimum Data Summary- assessment of each resident's functional capabilities) dated (MONTH) 8, (YEAR), revealed BIMS (brief interview for mental status) level as 2 (cognitively impaired). Review of Resident 2's functional status for walking in corridor was a 2 (limited assistance); 2 (one person physical assist). Review of Resident 2's functional status for locomotion on unit, was a 3 (extensive assistance); 2 (one person physical assist). During an interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 16, (YEAR), they alleged the resident was care planned for falls; however, no fall care plan was provided at the time of the survey. The facility failed to develop care plans that adequately addressed the resident's needs and the services to be furnished for Resident 2 resulting in falls, and on (MONTH) 2, (YEAR), a fall with harm and an abrasion to the back of the head, pin point pupil of the right eye (change in nerve function), pain and resident sent to the emergency room where the resident was admitted . Review of Resident 7's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 7's plan of care with an initiated date of (MONTH) 31, (YEAR), and the last revision date of (MONTH) 29, (YEAR), revealed no plan of care created for skin integrity (skin health). On (MONTH) 25, (YEAR), Resident 7 was seen by a Certified Registered Nurse Practitioner (CRNP) 1 for a history of present illness consult. The progress notes from the consultation revealed Resident 7 had 14 unstageable pressure ulcer/injuries (skin loss in which the extent of the tissue damage cannot be confirmed due to slough or eschar (dead tissue) that develop when soft tissue is compressed between a bony area and external surface for a long period of time), one full-thickness ulceration (wound bed area with exposed bone, tendon or muscle), one partial-thickness ulceration (area with skin loss exposing red/pink wound bed) and one stage 1 pressure ulcer (intact skin with nonblanchable redness of a localized area, usually over a bony area). The plan was as follows: #1- Unstageable pressure ulcer/injury of the center mid-back, secondary to deep tissue injury (DTI). #2- Unstageable pressure ulcer/injury of the left mid-back, secondary to DTI. #4- Unstageable pressure ulcer/injury of the right mid-back, secondary to DTI. Cleanse affected area with Normal Saline Solution (NSS-salt water) or wound cleanser. Apply skin prep to affected site/s twice daily. Allow to air dry. Apply Zinc MB (treatment) to affected sites BID (twice daily) and PRN (as needed). Off-load pressure to affected areas. Continue repositioning according to facility policy. #3- Unstageable pressure ulcer/injury of the right posterior (back) calf, secondary to DTI and eschar (dead tissue). #13- Unstageable pressure ulcer/injury of the left posterior calf, secondary to DTI. Cleanse affected area with NSS or wound cleanser. To the periwound (tissue surrounding wound): Apply skin prep treatment with each dressing change. To the wound bed: Apply [MEDICATION NAME] (medication) to the affected sites BID and PRN. Cover with ABD (type of dressing) pad and wrap with rolled gauze/kling (type of dressing). Off-load pressure to affected areas. Continue repositioning according to facility policy. #16- Full-thickness ulceration of the left foot-and lateral (outer) side, 1.5 x 1.0 x 0.0 cm (metric unit of measurement for length, width and depth). Non-blanchable maroon or purplish discoloration of intact skin. No drainage. Periwound without [DIAGNOSES REDACTED] (redness) or induration. Off-load pressure to affected areas. Continue repositioning according to facility policy. #17- Unstageable pressure ulcer/injury of the left shoulder, secondary to DTI. Cleanse affected area with NSS or wound cleanser. To the periwound: Apply skin prep with each dressing change. To the wound bed: Apply [MEDICATION NAME] to the affected sites BID and PRN. Cover with a large bordered foam dressing. Off-load pressure to affected areas. Continue repositioning according to facility policy. #5- Unstageable pressure ulcer/injury/injury of the coccyx, secondary to eschar. #6- Unstageable pressure ulcer/injury/injury of the right medial (midline) knee, secondary to eschar. Cleanse affected area with NSS or wound cleanser. To the periwound: Apply skin prep with each dressing change. To the wound bed: apply nickel-thick layer of Santyl (wound treatment) daily and PRN. Cover the wound with calcium alginate (wound treatment) and then a bordered foam dressing. Off-load pressure to affected areas. Continue repositioning according to facility policy. #7- Unstageable pressure ulcer/injury of the left medial (inner) knee, secondary to deep tissue injury (DTI). #8- Partial- thickness ulceration of the left knee, of unknown etiology (cause) (mechanical vs Stage 2 PU (pressure ulcer- where the outer layer of skin is lost). #9- Unstageable pressure ulcer/injury of the left dorsal (top) ankle, secondary to deep tissue injury (DTI). #10- Unstageable pressure ulcer/injury of the right dorsal (top) ankle, secondary to deep tissue injury (DTI). #11- Unstageable pressure ulcer/injury of the right medial heel, secondary to deep tissue injury (DTI). #12- Stage 1 Pressure ulcer/injury of the left medial heel. #14- Unstageable pressure ulcer/injury of the left lateral knee, secondary to deep tissue injury (DTI). #15- Unstageable pressure ulcer/injury of the left posterior (back) heel, secondary to deep tissue injury (DTI). #15- Unstageable pressure ulcer/injury of the left foot, lateral side, secondary to deep tissue injury (DTI). Cleanse affected area with NSS or wound cleanser. Apply skin prep to affected site/s twice daily. Allow to air dry. Cover with gauze dressing if friction is a concern. Off-load pressure to affected areas. Continue repositioning according to facility policy. Review of Resident 7's plan of care with a revision date of (MONTH) 9, (YEAR), revealed no created plan of care for the above mentioned skin integrity concerns. Review of Resident 7's physician orders, dated (MONTH) 1, (YEAR), at 11:57 a.m. with an active order date (MONTH) 27, (YEAR), revealed the above treatment orders from the consult on (MONTH) 25, (YEAR), where documented. Review of treatment record for Resident 7 dated (MONTH) 27, (YEAR), Day (shift) revealed a treatment was done to coccyx (triangular shaped bone at the end of the spine), cleanse with NSS, pat dry, apply skin prep, to the periwound with each dressing change. Apply nickle-thick layer of Santyl, cover wound bed with calcium alginate and cover with bordered foam dressing daily and PRN as the only wound dressing documented as done. During an interview (MONTH) 27, (YEAR), at 12:15 p.m. Licensed Practical Nurse 1 revealed he did the dressing to the coccyx. During an interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 16, (YEAR), they alleged the resident was care planned for skin integrity; however, no skin integrity care plan was provided at the time of the survey. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/19/17, 10/17/17, 7/27/17, 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/21/17, 10/17/17, 7/27/17, 6/23/17, 3/31/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/17/17, 7/27/17, 6/23/17, 5/18/17, 10/14/16, 9/16/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 12/19/17, 11/21/17, 10/19/17, 9/8/17, 6/23/17, 1/5/17, 9/16/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/19/18, 12/19/17, 11/21/17, 10/19/17, 10/17/17, 9/1/17, 9/8/17, 7/27/17, 6/23/17, 5/25/17, 5/18/17, 3/27/17, 11/17/16, 9/16/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/19/17, 11/21/17, 10/17/17, 7/27/17, 6/23/17, 5/18/17, 9/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/19/18, 12/19/17, 11/21/17, 10/19/17, 10/17/17, 9/1/17, 9/8/17, 7/27/17, 6/23/17, 5/18/17, 3/27/17, 11/17/16, 9/16/16.

Based on review of the clinical record, facility incident reports and staff interviews, it was determined that the facility failed to implement interventions to prevent accidents for one of 11 residents (Resident 2) reviewed, resulting in a fall with harm and hospitalization of Resident 2. Findings include: Review of the facility's Fall Management Guideline last reviewed (MONTH) 10, (YEAR), revealed following a resident's fall, the licensed nurse assesses the resident for injuries and provides necessary treatment; initiates the Change in Condition Report - Post Fall/Trauma (report on change in condition of the resident); the physician and residents' representatives are notified; appropriate intervention is implemented; and the care plan is updated. Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED]. Based on the review of Resident 2's quarterly MDS (Minimum Data Summary- assessment of each resident's functional capabilities) dated (MONTH) 8, (YEAR), the resident was cognitively impaired and required limited assistance of one person for walking. Additionally, the resident was not steady but was able to stabilize himself without staff assistance. Based on fall reports completed by the facility, on (MONTH) 3, (YEAR), Resident 2 had a fall with no injuries reported; and on (MONTH) 13, (YEAR), Resident 2 had a fall with a skin tear to the face. Based on review of a fall report dated (MONTH) 2, (YEAR), at 4:48 p.m. revealed Resident 2 had gait imbalance (walking balance), impaired memory and history of falls. The incident description from the fall report revealed, Resident lost his balance and fell back into the double door entrance and hit his head. Resident was continuously seated in wheelchair but did not want to stay seated. VSS (vital signs) 149/78 (blood pressure)-98.3(temperature)-93 (pulse)-20 (respirations) Resident right eye pin point (pupil). Abrasion on rear back of head 0.5 cm (metric unit of measure) L (length) X 0.5 cm W (width). NP (Nurse Practitioner) aware. Resident is being sent to out to (hospital). Resident left at 1743. (5:43 p.m.) Review of a facility event report dated (MONTH) 3, (YEAR), at 10:46 a.m. for Resident 2, that was written by the Director of Nursing for an event that occurred on (MONTH) 2, (YEAR), at 4:30 p.m. revealed the Registered Nurse (RN) Supervisor and Unit Charge Nurse witnessed resident fall backwards from standing position, striking his head on the entry door to unit. Resident was immediately assessed by the RN Supervisor. He was noted to have a small abrasion to the back of his head measuring 0.5 x 0.5 cm (metric unit of measurement). His vital signs were within normal limits. T (Temperature)-98.3, P (Pulse)-93 R (Respirations)-20 BP (Blood Pressure)149/87). Per nursing documentation, resident responded at his baseline level of confusion with c/o (complaint of) head pain. Neuro checks (nerve function) were initiated and the right pupil was reported as pinpoint (abnormal), left was sluggish (abnormal). Resident's physician was contacted with new orders to send resident to the ER for evaluation and treatment. RP (Responsible Party) was updated on new orders to transfer and resident's current clinical status. Resident was admitted to the hospital for a subdural hematoma (bleeding in the brain which can be caused by minor accidents or major trauma to the head). Resident 9's mobility status will be reassessed and his care plan updated upon readmission. Review of Resident 2's care plans with a resident admitted (MONTH) 8, (YEAR), and a revision date of (MONTH) 2, (YEAR), revealed no care plan for falls or interventions. Review of Resident 2's quarterly MDS (Minimum Data Summary- assessment of each resident's functional capabilities) dated (MONTH) 8, (YEAR), revealed BIMS (brief interview for mental status) level of 2 (cognitively impaired). Review of Resident 2's functional status for walking in corridor was a two (limited assistance), 2 (one person physical assist). Review of Resident 2's functional status for locomotion on unit was a 3 (extensive assistance), 2 (one person physical assist). Section G0300 (Balance During Transition and Walking is coded as a (1) Not steady, but able to stabilize without staff assistance. Section G0600 Mobility Devices is coded as a (Z) None used. During an interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 16, (YEAR), they alleged the resident was care planned for falls; however, they did not provide any verification during the investigation. The facility failed to implement interventions that accurately reflected the services to be furnished for Resident 2 resulting in falls, and on (MONTH) 2, (YEAR), a fall with harm and an abrasion to the back of the head, pin point pupil of the right eye and sluggish left eye (change in nerve function), pain and resident was sent to the emergency room where the resident was admitted with a Subdural Hematoma. Review of the facility policy, Medication Administration - General Guidelines dated (MONTH) (YEAR), revealed that during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide The cart must be clearly visible to the personnel administering medications. Observation on (MONTH) 27, (YEAR), at 12:16 p.m. on the 300 unit revealed a medication cart in the hall by the dining room. The medication nurse was around the corner from the cart, which was in the front of the nurses' station. The medication nurse was not in the line of sight of the medication cart and could not see the cart. At the time of the observation the medication cart was unlocked. Upon the return of the medication nurse to the medication cart she was asked to identify herself. She falsely gave the name of LPN (Licensed Practical Nurse) 1, when interviewed she stated she was around the corner giving medications to a resident. When ask if she could see the medication cart she responded no. At 12:50 p.m., the DON revealed that the medication nurse had misidentified herself and that she was in fact RN 2, an agency nurse, and that she was being removed from the building. An interview with the DON and the NHA on (MONTH) 27, (YEAR), at 2:20 p.m. revealed that they expect the medication carts to be locked and within the line of sight of the medication nurse. On (MONTH) 27, (YEAR), at 12:00 p.m. during a tour of the 3rd floor nursing station, it was observed that the door to the room by end of the nurses' station was open and in the unlocked cabinets were syringes and medications. During an interview with Licensed Practical Nurse (LPN) 1 on (MONTH) 27, (YEAR), at 12:00 p.m. revealed the door is always open because we do not have a key to the copier in the room. An interview with the DON and the NHA on (MONTH) 27, (YEAR), at 2:20 p.m. revealed that they expect the door to be locked. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 11/21/17, 7/27/17, 6/23/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/19/17, 10/17/17, 7/27/17, 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 11/21/17, 10/17/17, 7/27/17, 6/23/17, 3/31/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 12/19/17, 11/21/17, 7/27/17, 6/23/17, 10/14/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/17/17, 7/27/17, 6/23/17, 5/18/17, 10/14/16, 9/16/16. 28 Pa. Code 201.29(a)(d) Resident rights. Previously cited 7/27/17, 6/23/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 10/17/17, 7/27/17, 5/18/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/17/17, 9/8/17, 7/27/17, 6/23/17, 5/18/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/19/18, 12/19/17, 11/21/17, 10/19/17, 10/17/17, 9/1/17, 9/8/17, 7/27/17, 6/23/17, 5/25/17, 5/18/17, 3/27/17, 11/17/16, 9/16/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/19/17, 11/21/17, 10/17/17, 7/27/17, 6/23/17, 5/18/17, 9/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/19/18, 12/19/17, 11/21/17, 10/19/17, 10/17/17, 9/1/17, 9/8/17, 7/27/17, 6/23/17, 5/18/17, 3/27/17, 11/17/16, 9/16/16.

Based on observation, interview and record review of resident records, the facility failed to investigate injuries of unknown origin to determine if abuse occurred and identify a perpetrator for two of nine residents (Resident 1 and 5) who received injuries of unknown origin and whose injuries resulted in altered mental status requiring hospitalization . This failure resulted in Immediate Jeopardy to all 186 residents of the facility. Findings include: Review of the facility, Abuse Policy, last reviewed on November 28, 2016, revealed the facility shall have processes in place to include screening, training, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered. Injuries of Unknown Origin will be evaluated for potential or suspected abuse. An investigation is implemented and witness statements are obtained. Review of Resident 1's clinical record revealed an admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident 1's Quarterly Minimum Data Set assessment (MDS-periodic assessment of resident needs) dated May 16, 2017, revealed Resident 1 was unable to complete the Brief Interview for Mental Status (BIMS-a screening tool to determine cognitive ability) and that her cognitive skills for daily decision making was severely impaired. Review of an incident report dated July 23, 2017, at approximately 7:00 p.m. revealed that Licensed Practical Nurse (LPN) 1 noticed Resident 1 walking in the hallway with a skin tear near her right elbow and a bruise on her head and that there were no witnesses to these injuries. Further review of the clinical record revealed that on July 23, 2017, at 7:00 p.m. Registered Nurse (RN)1 was called to assess Resident 1 and upon entering the unit she observed Resident 1 sitting on a chair in the Dining Room. A skin tear was present on Resident 1's right forearm. The progress note also revealed there were two hematomas (a solid swelling of clotted blood within the tissues) on the top of her scalp. Review of a clinical record for Resident 1 dated July 24, 2017, at 2:03 p.m. revealed the following documentation by Registered Nurse (RN) 2. An assessment related to the report of 3 hematomas to the right side and top of head, as well as injury to resident's right hand. Vital Signs were Blood Pressure 100/56. Heart Rate 101 and Respiratory Rate 16 and oxygen saturation 89% on room air. RN2 documented that Resident 1 was, lying in bed, alert to movement/pain but lethargic (sluggish and apathetic.) RN2 also documented that the regular staff and agency LPN (Licensed Practical Nurse) 2 noted that Resident 1 was not her self today. Resident 1 was reported to RN 2 to be laying down all day. In morning report, the staff was advised Resident 1 was assisted to bed at 5:00 a.m. that morning and reported that Resident 1 was not up or walking around like her usual self all day or since then. RN 2 assessed the 3 hematomas on Resident 1's head (two on the right side and one on the top). The 3 hematomas on the head were new and the skin was intact. Resident 1 was unable to follow simple commands which is her baseline. The pupils were sluggish but reactive, she was much more lethargic than normal. Per phone conversation with LPN 2 on July 25, 2017 at 10:00a.m. she stated that the shift supervisor felt that there may be an internal head bleed and stated, my goodness if this really happened meaning if Resident 2 really did beat Resident 1 in the head with his cane felt that there may be an internal head bleed. The physician was notified and he gave a new order to send Resident 1 to the hospital for evaluation. LPN 2 called 911 and initially called Resident 1's previously documented hospital to give report. Per the documentation and a telephone interview with LPN 2, the ambulance arrived and they decided to take the resident to a closer hospital. Review of the hospital report dated July 24, 2017, at 3:21 p.m. revealed the hospital accepted resident as a patient with presumed assault. Resident 1 was admitted also due to her reported altered mental status with several bruises in various locations and in various stages of healing and a concern for abuse. A Social Worker was involved in the evaluation of the Resident 1 and it was determined that Resident 1 would not be a safe discharge back to the nursing home and Resident 1 was being admitted to the hospital. The hospital performed examinations on Resident 1's chest, abdomen, spine, cervical spine, and brain. Results revealed healed and healing rib fractures, a healing sternal fracture, a right gluteus maximus muscle (buttock area) with a heterogeneous (different in kind) mass, which is partially included, measuring at least 7.1 x 4.2 x 9.1 centimeters (cm- metric measurement 2.5 cm equals 1 inch) in size. The findings of the buttock area are documented by the radiologist as a hematoma in length and acute trauma. There was also noted on the radiology report the presence of Hyperdense (an abnormality of brightness) areas superior (in front of) frontal region and right parietal (one of the four major lobes of the cerebral cortex) area present for scalp hematomas. Review of Resident 2's clinical record on July 23, 2017, at 6:00 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 2's plan of care dated September 8, 2016, revealed the resident had behaviors which included hitting during activities, throwing items at others, hitting others during care, and shouting and cursing. Further review of Resident 2's plan of care failed to reveal that he utilized a single point cane for ambulation and failed to mention any past events of utilizing the cane as a weapon. Review of Resident 2's Psychiatric evaluation dated September 26, 2016, revealed Resident 2 informed the evaluator that he doesn't want to be here. I have to go home, and Get along with roommate, but annoyed by other residents rattling my door and approaching me. Further review of the clinical record revealed that on October 1, 2016, Resident 2 had an altercation with Resident 9 and struck Resident 9 with his cane. This altercation did not result in any injury. Resident 2 was placed on every 15 minute checks and behavior log and a request for re-evaluation via psych consult. Review of the clinical record dated October 3, 2016, revealed that Resident 2 stated in an interview with the social worker that he will defend himself if necessary. During an interview with the Nursing Home Administrator (NHA) on July 24, 2017, at 8:30 p.m. he was asked to provide the investigation for the event that took place on July 23, 2017, at 7:00 p.m. that caused injury to Resident 1. The NHA informed the surveyors that no investigation was initiated. During an interview with the NHA on July 24, 2017, at 5:00 p.m. he revealed that Resident 2's cane was removed from Resident 2 and was stored in his office. Observation of the cane revealed the presence of a dried red substance on the rubber point of the cane. During an interview with Resident 2 on July 24, 2017, at 8:45 p.m. the resident stated that he did not see Resident 1 and did see someone wiping blood off the floor. The surveyor asked Resident 2 if he hit Resident 1 and he in turn asked if the surveyor was a detective or something? The surveyor informed Resident 2 that it was routine to ask questions since the injury to Resident 1 was not witnessed by staff. He said, I did not see her. An Immediate Jeopardy related to suspected resident assault and the facility failure to investigate to rule out assault and/or abuse, and failure to report to the appropriate authorities, was called on July 24, 2017, at 9:40 p.m. The facility provided an immediate action plan on July 24, 2017, at 10:15 p.m. to initiate statements from staff that were present on July 23, 2017, and to initiate educating the staff on the facility abuse policy at that time. The immediate action plan was not accepted by the surveyors because it failed to include that proper authorities would be notified, such as, AAA (Area Agency on Aging), PDA (Pennsylvania Department of Aging), Police, and the abuse investigation reports. On July 25, 2017, at 12:40 a.m. a revised immediate action plan was accepted that included the following: The facility will educate staff on the definition of abuse, prevention of abuse, protection of the resident and reporting policy on abuse. The facility will notify AAA, PDA, and Police. The facility will report on the incident report system and complete the abuse investigation report for the incident with Resident 1. Facility will complete the investigation into the injury of Resident 1. The facility will keep one-on-one supervision with Resident 2 until seen by Med Options (Psychiatric Evaluation Team) to ensure that he is not at risk to injuring anyone. The facility will QA all injuries of unknown origin to rule out abuse. All results will be reviewed with the QAPI committee. Review of Resident 4's clinical record revealed [DIAGNOSES REDACTED].) Review of Resident 4's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated June 1, 2017, revealed Resident 4 Brief Interview for Mental Status (BIMS) and cognitive skills for daily decision making were moderately impaired. During an interview with Resident 4 on July 24, 2017 at 8:45 p.m. (Resident 2's roommate) he whispered to the surveyor, he knows he did it (referring to Resident 2). The surveyor asked him to confirm his comment by stating to him he did? and Resident 4 nodded affirmatively. During an interview with the NHA on July 24, 2017, at 9:30 p.m. the surveyor informed him immediately of the comments made by Resident 4. The NHA then went to ask Resident 4 if he felt safe and also asked if he wanted to change his room. Resident 4 stated that he will stay in his room and does feel safe. The facility provided a statement from RN 1 dated July 24, 2017, at approximately 8:00 p.m. RN 1 stated that she was called to Resident 1's unit on July 23, 2017, about 7:00 p.m. and observed Resident 1 with a skin tear on her right arm that was 5 cm long. She stated she observed a little blood, placed a dressing on it and placed ice on her hematoma. She stated she did not feel there was an assault, and that she didn't note any blood coming from any resident rooms and stated she did not interview any nurse aides regarding the incident with Resident 1. During an interview with Nurse Aide (NA) 1 on July 24, 2017, at 9:00 p.m. she informed the surveyor that she observed at approximately 7:00 p.m. on July 23, 2017, Resident 1 who walked into the Dining Room and she observed 3 hematomas on her head and her right arm actively bleeding. Referring to the hematomas she stated, they were very big and looked like they were ready to burst and she stated that she followed the blood trail to Resident 2's room and observed blood all over his bed. NA 1 stated somebody hit her and Resident 4 (Resident 2's roommate) stated he knew Resident 2 did it. NA 1 stated that Resident 2 was wiping up blood from the floor when she arrived to his room. NA 1 asked Resident 2 if he hit Resident 1 and he walked away with his head down and said no. NA 1 stated that she reported abuse (Resident to Resident) to LPN 1 and to RN 1 immediately. The facility provided a statement from NA 3 dated July 25, 2017, at approximately 11:30 a.m. and he stated that he was in the dining room when NA 1 brought Resident 1 into the dining room and Well we noticed blood on Resident 1's forearm and her head was swollen too. The nurse called for the supervisor and was ordered to get some ice so that the nurse can apply it to Resident 1's head. Because I was in the dining room, I did not know what happened down the hall way in one of my resident's room. So, after my turn ends in the dining room, I went down my hall in the Resident's room to clean the blood. I did not have to change the bed because there was no blood on the bed but there was a few drops of blood down the hall way and in my resident room, on the floor. So, I went and got some bleach wipes, I got a few wipes, and cleaned the blood both on the floor in the room and down the hall way because there was a track of blood from Resident 1 coming out from the other resident room (Resident 2) to the Dining Room. I followed the blood as I cleaned it and it was not a lot of blood. The facility provided a statement from NA 1 on July 25, 2017, at 11:35 a.m. stating the following: Resident 1 noted lump on her head then noted blood dripping on her arm. Told LPN 1 who called RN 1. They took Resident 1 to the Dining Room. I saw blood and showed NA 3, it was all over the place. I found Resident 1 in the beginning (entrance) of the dining room. RN/LPN said the blood was from [MEDICAL CONDITION]. I saw specks of blood from the Dining Room to Resident 2's room. Blood was on the bed and blood was on Resident 2's cane and blood was on Resident 2's leg. I asked Resident 2 if he hit Resident 1 and he said no but Resident 4 stated Resident 2 hit Resident 1 with his cane and then went yelling down the hall that he hit her with his cane and stated he has blood on his cane, he hit her. NA 1 stated she was not sure who changed the bed and cleaned up the blood because she went back to the Dining Room to stay with Resident 1. Review of Resident 5's clinical record revealed [DIAGNOSES REDACTED]. Review of an incident report dated May 10, 2017, at 11:16 a.m. revealed Resident 5 ambulating (walking) down 300 hall and staff noted a hematoma above right eye, cause unknown. There was no evidence of an investigation for abuse was done by the facility. During an interview with the Nursing Home Administrator on July 25, 2017, at 3:20 p.m. it was disclosed the incident of unknown origin involving Resident 5 on May 10, 2017, was not investigated. On July 25, 2017, at 3:20 p.m. the immediate action plan was reviewed for compliance. During an interview on July 25, 2017, with the NHA, he was asked who is the abuse coordinator for the facility and he stated, I guess I am the abuse coordinator. Interviews with the staff during the morning of July 26, 2017, regarding abuse questions, revealed only one of six staff interviewed were knowledgeable of who the abuse coordinator was for the facility. The facility stated in their immediate action plan that they would initiate educating the staff on the facility abuse policy at that time. Additionally, an incident of unknown origin on May 10, 2017, was never investigated. Immediate Jeopardy continued. On July 26, 2017, 12:45 p.m. the immediate action plan was reviewed again and the facility did not supply additional information related to the incident of unknown origin that occurred on May 10, 2017. Immediate Jeopardy continued. Staff were interviewed on July 26, 2017, regarding the CSA (facility morning meeting) that was held on July 24, 2017, to ascertain if there was any discussion or plan of action for the incident that occurred on July 23, 2017, with Resident 1. During the interview with RN 3 on July 26, 2017, at 10:05 a.m. she stated that Resident 1's incident that occurred on July 23, 2017, was discussed briefly but the only discussion she recalled was that she had a new skin tear on her right or left arm, I don't remember which arm and that there was no additional information in paper form that was provided. She stated that the NHA was present at the meeting and informed the group, we need to hear more, and ask if there were any statements. RN 3 stated that they discussed getting statements to obtain more information on the event. During the interview with Social Worker 1 on July 26, 2017, at 10:10 a.m. she informed the surveyor that the CSA meeting started around 9:00 a.m. and she was informed that Resident 1 may have experienced a fall. The Social Worker stated that an injury to Resident 1's arm was discussed at the meeting and that they were going to get statements from the staff. Social Worker 1 didn't recall any other detail discussed regarding Resident 1. Social Worker 1 stated she did not know who was assigned to get statements. Social Worker 1 stated that the Nursing Home Administrator (NHA) was present for the meeting. During an interview with the Director of Rehabilitation on July 26, 2017, at 10:16 a.m. she informed the surveyor that the CSA meeting started at 9:30 a.m. and that Resident 1 possibly experienced a fall and that she had a skin tear. There was a discussion regarding the need for more information and that nursing would follow up with obtaining that information. She stated there was a request for a therapy screen on Resident 1. The Director of Rehabilitation stated that the NHA was present at the meeting and said in response to the incident with Resident 1, we have to keep asking why, why, why? During an interview with the NHA on July 26, 2017, at 12:47 p.m. he was asked if there is an expectation to investigate the incident with Resident 1 and the allegation regarding Resident 2 and he stated yes. He also stated that the incident should have been reported immediately to the appropriate state authorities and the police if there was resident to resident assault and an alleged perpetrator. The NHA was also informed that Resident 2 has a single point cane and the surveyors were unable to find a physician order [REDACTED]. On July 27, 2017, at 10:45 education of staff, audits and information related to incident of unknown origin were reviewed and the Immediate Jeopardy was lifted. The facility failed to implement their abuse policy to include identification, protection, investigation, reporting and response to allegations of potential or actual abuse and/or assault and failed to investigate past injuries of unknown origin resulting in head injuries to Resident 1 and Resident 5 and the hospitalization of Resident 1 for altered mental status which placed the residents in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 6/23/17, 10/14/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/23/17, 5/18/17, 10/14/16, 9/16/16. 28 Pa. Code 201.29(a)(d) Resident rights. Previously cited 6/23/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/18/17.

Based on observation, interview and review of resident records, it was determined that the facility failed to promptly implement necessary interventions for one of nine residents who received injuries which resulted in altered mental status requiring hospitalization (Resident 1.) Findings include: Review of Resident 2's clinical record on July 23, 2017, at 6:00 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 2's Quarterly Minimum Data Set assessment (MDS -a periodic assessment of resident needs) dated June 21, 2017, revealed Resident 2's Brief Interview for Mental Status (BIMS - a screening tool to determine cognitive ability) was an 8 which is moderately impaired. Review of Resident 2's plan of care dated September 8, 2016, revealed the resident had behaviors which included hitting during activities, throwing items at others, hitting others during care, and shouting and cursing. Further review of Resident 2's plan of care failed to reveal that he utilized a single point cane for ambulation and failed to mention any past events of utilizing the cane as a weapon. Review of Resident 2's Psychiatric evaluation dated September 26, 2016, revealed Resident 2 informed the evaluator that he doesn't want to be here. I have to go home. and Get along with roommate, but annoyed by other residents rattling my door and approaching me. Further review of the clinical record revealed that on October 1, 2016, Resident 2 had an altercation with Resident 9 and struck Resident 9 with his cane. This altercation did not result in any injury. Resident 2 was placed on every 15 minute checks and behavior log and a request for re-evaluation via psych consult. Review of the clinical record dated October 3, 2016, revealed that Resident 2 stated in an interview with the social worker that he will defend himself if necessary. Further review of Resident 2's plan of care failed to reveal that he utilized a single point cane for ambulation and failed to mention any past events of utilizing the cane as a weapon. Review of Resident 1's Quarterly Minimum Data Set assessment (MDS -a periodic assessment of resident needs) dated May 16, 2017, revealed Resident 1 was unable to complete the Brief Interview for Mental Status (BIMS - a screening tool to determine cognitive ability) and that her cognitive skills for daily decision making were severely impaired. Review of an incident report dated July 23, 2017, at approximately 7:00 p.m. revealed that Licensed Practical Nurse (LPN) 1 noticed Resident 1 walking in the hallway with a skin tear near her right elbow and a bruise on her head and that there were no witnesses to these injuries. Further review of the clinical record revealed that on July 23, 2017 at 7:00 p.m. Registered Nurse (RN)1 was called to assess Resident 1 and upon entering the unit she observed Resident 1 sitting on a chair in the Dining Room. A skin tear was present on Resident 1's right forearm. The progress note also revealed there were two hematomas (a solid swelling of clotted blood within the tissues) on the top of her scalp. Review of a clinical record for Resident 1 dated July 24, 2017, at 2:03 p.m. revealed the following documentation by Registered Nurse (RN) 2, in an assessment related to the report of 3 hematomas to the right side and top of head, as well as injury to resident's right hand. Vital Signs were Blood Pressure 100/56. Heart Rate 101 and Respiratory Rate 16 and oxygen saturation 89% on room air. It was also reported, Resident 1 lying in bed, alert to movement and pain but lethargic. Per regular staff and agency LPN 2, resident was not her self today. Resident 1 was reported to be laying down all day. In morning report the staff were advised that Resident 1 was assisted to bed at 5:00 a.m. that morning and reported that Resident 1 was not up or walking around like her usual self all day or since then. RN 2 assessed the 3 hematomas on Resident 1's head (two on the right side and one on the top). The 3 hematomas on the head were new and the skin was intact. Resident 1 was unable to follow simple commands which is her baseline. Pupils were sluggish but reactive, she was much more lethargic than normal. The physician was notified and he gave a new order to send her to the hospital for evaluation. LPN 2 called 911 and called the hospital to give report. The ambulance arrived and they decided to take the resident to a closer hospital. Review of the hospital report dated July 24, 2017, at 3:21 p.m. revealed the hospital accepted resident as a patient with presumed assault. Resident 1 was admitted also due to her reported altered mental status with several bruises in various locations and in various stages of healing and a concern for abuse. A Social Worker was involved in the evaluation of the Resident 1 and it was determined that Resident 1 will not be a safe discharge back to the nursing home and Resident 1 was being admitted to the hospital. During an interview with Nurse Aide 1 on July 24, 2017, at 9:00 p.m. she informed the surveyor that she observed at approximately 7:00 p.m. on July 23, 2017, Resident 1 walked into the Dining Room and she observed 3 hematomas on her head and her right arm actively bleeding. Referring to the hematomas she stated, they were very big and looked like they were ready to burst she stated that she followed the blood trail to Resident 2's room and observed blood all over his bed. NA 1 stated somebody hit her and Resident 4 (Resident 2's roommate) stated he knows Resident 2 did it. NA 1 stated that Resident 2 was wiping up blood from the floor when she arrived to his room. NA 1 asked Resident 2 if he hit Resident 1 and he walked away with his head down and said no. NA 1 stated that she reported abuse (Resident to Resident) to LPN 1 and to RN 1 immediately. During an interview with the Nursing Home Administrator (NHA) on July 24, 2017, at 5:00 p.m. he revealed that Resident 2's cane was removed from Resident 2 and was stored in his office. Observation of the cane revealed the presence of a dried red substance on the rubber point of the cane. During an interview with the NHA on July 24, 2017, at 8:30 p.m. he was asked to provide the investigation for the event that took place on July 23, 2017, at 7:00 p.m. that caused injury to Resident 1. The NHA informed the surveyors that no investigation was initiated. The facility failed to implement interventions and to provide supervision for Resident 1 and Resident 2 resulting in injuries and hospitalization related to altered mental status for Resident 1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 6/23/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/23/17, 10/14/16, 9/16/16. 28 Pa. Code 201.18(b)(3) Management. Previously cited 6/23/17, 10/14/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/23/17, 5/18/17, 10/14/16, 9/16/16. 28 Pa. Code 201.29(a)(d) Resident rights. Previously cited 6/23/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/18/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/23/17, 5/18/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/23/17, 5/25/17, 5/18/17, 3/27/17, 11/17/16, 9/16/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 6/23/17, 5/18/17, 3/27/17, 9/16/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/23/17, 5/18/17, 11/17/16, 9/16/16.

Based on review of clinical records, observations and staff interviews, it was determined that the facility failed to provide the necessary supervision to a resident, resulting in a fall with injury of one of 3 residents reviewed (Resident 5) and it was determined that the facility failed to maintain environment free from accident hazards for residents on six of 9 nursing unit hallways (300, 400, 500, 600, 800 and 900 Hallways). Findings include: Review of Resident 5's clinical record revealed [DIAGNOSES REDACTED]. Review of 5's Admission MDS assessment (Minimum Data Set-a periodic review of resident needs completed on admission, annually or if there was a significant change in condition), dated January 15, 2016, revealed in Section G, Functional Status (ability for resident to perform tasks) G0110 - Activities of Daily Living (ability for resident to perform tasks on a daily basis) regarding transfer status (the ability to move from bed to chair) Resident 5 required limited assistance to perform the task with the physical assist of one staff person. Walking in room or hallway Resident 5 required limited assistance to perform the task with the physical assist of one staff person. Review of Resident 5's Medication Administration Record (MAR- a form used to document date and time a medications were given) on April 4, 5, 6, and 7, 2016, at 8:00 a.m. the medications were not given. On April 5, and April 7, 2016, at 4:00 p.m. and at 8:00 p.m. medications were not given. Review of the progress note completed by Licensed Practical Nurse 3 (LPN 3) for April 5, 2016, at 10:50 p.m. revealed that Resident 1 was very lethargic (being in a state of sleepiness or deep unresponsiveness and inactivity). Review of a progress note dated April 7, 2016, at 9:00 a.m. written by Registered Nurse 1 (RN 1) revealed that according to the Charge Nurse (a nurse in charge of the supervision of a particular unit), Resident 1 had been refusing medications due to complaints of lethargy. Resident 1 stated that her medication makes her too sleepy. The note indicated that the Charge Nurse was to notify the physician. Review of a progress note dated April 7, 2016, at 4:20 p.m. by LPN 4 revealed that the Certified Registered Nurse Practitioner (CRNP) was aware of all refusals. The CRNP was made aware of the resident refusing medications three days after Resident 1 was complaining of the medications made her sleepy. Further review of Resident 5's clinical record revealed that the resident had an unwitnessed fall on April 8, 2016, at 12:00 p.m., resulting in a hematoma (swelling of clotted blood within the tissue caused by a break in a blood vessel) and a two inch laceration (a deep cut or tear in skin or flesh) above the right eye which required five sutures (stitches). Review of Resident 5's, Verification of Investigation, Post fall Analysis/Plan (a facility report completed following a fall investigation) completed on April 8, 2016, at 12:00 p.m. revealed the following: Fall details: loss in strength, Attempting to self transfer. History of falls and impaired safety awareness/judgement. A review of a, Fall Checklist (questions ask of staff during a fall investigation) completed on April 8, 2016, by Nurse Aide 1 (NA 1) indicated that the location of the fall was described as, beside bed I think. When asked to describe th resident's activities before the fall, NA 1 indicated that the resident was in bed saying that she was in pain. and she refused a shower so NA 1 indicated that she gave the resident a full bed bath. There was no evidence that NA 1 notified anyone that Resident 5 was in pain. There was no evidence that the facilty increased supervision of Resident 5 after her reporting being sleepy, with a history of falls and impaired safety awareness/ judgement. Review of facility policy titled, Falls Management Guideline (a policy on the management of falls) revealed that, following a resident's fall: the licensed nurse assessed the resident for injuries, including neurological checks (assessments of a resident's neurological functions and level of consciousness to make sure they aren't impaired after an injury) . Review of facility policy titled, Neurological Checks revealed, Neurological checks shall be performed following an unwitnessed fall or known head injury. Neurological checks should be performed periodically for at least 72 hours. Review of Resident 5's form titled, Neurological Assessment (an evaluation of nerve function, level of consciousness, how eyes react to light, mental status and muscle response) revealed that the neurological checks were completed on April 8, 2016, at 12:00 p.m., 12:15 p.m., 12:30 p.m., 12:45 p.m., 1:15 p.m., and 1:45 p.m. All six of the neurological assessments revealed that Resident 5's right and left pupil (the black circular opening in the center of the iris of the eye, through which light passes to the retina) were both 2 mm (millimeters) in diameter, the right pupil was sluggish (slow moving) when reacting to light and the left pupil was brisk (quick) when reacting to light. All six of Resident 5's neurological assessments also revealed that both the right and left extremities (a limb or appendage of the body) were strong in strength. Review of Resident 5's progress notes revealed a progress note entered by the CRNP on April 8, 2016, at 12:50 p.m. following Resident 5's fall. The progress note revealed that Resident 5's right eye pupil was sluggish (slow moving) to light and the left eye pupil was within normal limits. Hematoma (swelling with blood under the skin) above the right eye surrounding a two inch laceration which continues to moderately bleed. Laceration was closed with five sutures (stitches). The CRNP's note further revealed that Resident 5's hand grasps were equal in strength and Resident 5 was moving all joints (a point where two bones of the skeleton come together usually in a way that allows motion) and extremities. Stat (immediate) labs (laboratory tests), a Chest X-ray and urine culture (test to determine the type of germ in the urine) and sensitivity (test to determine which medication works best to treat the germ) were ordered and the physician was to be notified of the results. A progress note dated April 8, 2016, at 8:32 p.m. by Registered Nurse 2 (RN 2) revealed that the chest X-ray results indicated a LLL (left lower lung) consolidation (firm dense mass) and right lung base atelectasis (collapse). Review of a progress note dated April 9, 2016, at 5:38 a.m. by LPN 5 stated that one day after the fall the left eye was very sluggish in response to light and that the left hand grasp was weak. The Registered Nurse Supervisor and the physician were made aware. The physician directed staff to continue with the neurological checks and to report any abnormal findings. Review of a Registered Nurse assessment progress note dated April 9, 2016, at 7:31 a.m. revealed neurological checks were within normal limits. Review of Resident 5's Registered Nurse assessment progress note dated April 9, 2016 at 11:00 a.m. revealed a change in the resident's condition. Resident 5's pupils were now unequal. The right pupil increased in size to 3 mm and the left pupil measured at 2 mm and both pupils were sluggish. The progress note also revealed that Resident 5 had notable weakness in the left upper extremity. Further review of Resident 5's progress notes dated April 9, 2016, at 3:38 p.m. revealed that the physician was made aware of the change in resident's condition but there were no new orders or interventions put into place. During an interview on June 30, 2016, at 2:15 p.m. the DON confirmed that Resident 5's neurological checks were incomplete and should have been done for 72 hours according to the facility's, Neurological Checks. At that time, the DON also revealed an expectation that the neurological checks should have been completed. An observation on June 29, 2016, at 7:35 a.m. revealed that Lab Technician 1 (LT 1) gathered supplies to perform a blood draw and entered a room on the 300 Unit. The room is located in a locked unit where residents who have cognitive impairments reside. The LT 1 left her lab supply cart containing needles, glass tubes for blood collection, tourniquets and a sharps container (plastic container used for disposal of used needles) outside of the room in the hallway when she entered the resident's room, which was not within sight of her or any other staff members. At this time, Resident 10 walked independently out of the room and passed the lab supply cart. Review of the clinical record for Resident 10 revealed a [DIAGNOSES REDACTED]. Review of Resident 10's most recent quarterly Minimum Data Set assessment (a periodic assessment tool) dated March 30, 2016, revealed that his cognitive status was moderately impaired and he ambulates with supervision. During an interview with the Assistant Director of Nursing (ADON) on June 30, 2016, at 10:40 a.m. she stated that the lab technician should have had the lab cart in sight. A second observation made on the 300 Hallway on June 29, 2016 at 8:50 a.m. revealed Resident 9, rummaging through the dirty plates and bowls that were stacked on a bedside table outside of the dining room. Review of the resident's MDS, dated [DATE], revealed a [DIAGNOSES REDACTED]. Observations made on June 29, 2016, at 10:45 a.m. on the 600 Hallway revealed that along the handrail there were 4 wheelchairs, a clean linen cart, a three bin dirty linen cart, a Hoyer lift (a devise that moves a resident from the bed to the chair), a housekeeping cart, a mop bucket, and two metal carts containing tubs for dirty dishes after meals. On June 29, 2016, at 10:46 a.m., on the 500 Hallway, there was a dirty linen cart, a clean linen cart, a Hoyer lift, a vital sign machine (devise used to take the blood pressure and the pulse of the residents), and two medication carts along the hand rail. On June 29, 2016 at 11:15 a.m. on the 900 Hallway along the handrails there were 2 wheelchairs, a clean linen cart, a dirty linen cart and a vital sign machine. On the 800 Hallway on June 29, 2016 at 11:15 a.m., there was a medication cart, a dirty linen cart, a clean linen cart, four wheelchairs and a Hoyer lift. Observations were made on the 500 and 600 Hallway again June 29, 2016 at 1:00 p.m. and 1:15 p.m. and all of the same equipment was in the hallway except the dirty linen carts. Observations on June 30, 2016, at 9:18 a.m. on the 800 Hallway revealed 9 wheelchairs, 2 Hoyer lifts, a vital sign machine, a clean linen and a dirty linen cart. On June 30, 2016 at 9:25 a.m. on the 600 Hallway there was a housekeeping cart, three wheelchairs, a medication cart, a Hoyer lift and a clean linen cart. On June 30, 2016 at 9:20 a.m., on the 400 Hallway, there were 2 wheelchairs, a clean linen cart and a dirty linen cart. During an interview with the ADON on June 30, 2016, at 2:00 p.m. she stated that they do have a place to store equipment when it is not in use. She stated that she would follow up on the storage of wheelchairs in the hallway. During an interview with the Clinical Director on June 30, 2016, at 4:20 p.m. she stated that they do not have a policy specific to storing items in the hallway but provided an environmental safety inspection checklist. The checklist asks, Are isles sufficiently wide to provide ease of movement (any blockage)? The checklist also asks if handrails are provided. Based on numerous observations, the residents were not able to access the handrails in the hallways due to the various items being stored in the hallway against the handrails. 42 CFR 483.25 Quality of Care. Previously cited 10/22/15, 02/18/15, 09/11/14. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 10/22/15, 09/24/15, 04/16/15, 09/11/14. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 04/28/16, 10/22/15, 09/24/15, 09/03/15, 04/16/15, 12/23/14, 09/11/14. 28 Pa. Code 211.12(d)(2) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 04/28/16, 10/22/15, 09/03/15, 09/11/14. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 04/28/16, 10/22/15, 09/24/15, 09/03/15, 04/16/15, 02/18/15, 12/23/14, 9/11/14.

Based on resident and staff interview, and clinical record review, it was determined that the facility failed to provide nutrition to meet the resident's needs for one of 32 residents reviewed (Resident 2) and failed to provide evidence that a resident's insertion site was examined consistently to prevent or resolve possible skin irritation or local infection for one of 32 residents reviewed (Resident 19). Findings include: Review of Resident 2's physician's orders dated October 2015, revealed [DIAGNOSES REDACTED]. The loss of these motor neurons causes the muscles under their control to weaken and waste away, leading to paralysis and eventual death). Additional review of Resident 2's clinical record revealed a physician's order for Enteral Feeding (by means of a tube surgically placed in the stomach) four times per day, 1 can of [MEDICATION NAME] 1.5 (a calorie dense liquid food with a patented fiber blend that provides complete balanced nutrition) via the PEG tube (a percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach it allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus). Review of the Medication Administration Record [REDACTED]. An interview with Resident 2 on October 22, 2015, at approximately 10:15 a.m., who's BIMS (an assessment tool which provides a numerical number for mental status) was a 15 (no impairment), revealed he did not receive his 6:00 p.m. can of [MEDICATION NAME] via the PEG tube on October 21, 2015. Review of the Medication Administration Record [REDACTED]. The nursing progress note dated October 21, 2015, at 6:36 p.m., revealed that RN 3 went to give Resident 2 the prescribed [MEDICATION NAME] at 6:25 p.m., and Resident 2 was not in his room. She was informed by a nurse aide (name not given) that the resident had gone outside with a friend. There was no evidence that RN 3 made any additional attempts to provide Resident 2 with the physician ordered [MEDICATION NAME]. An interview with the Assistant Director of Nursing (ADON) on October 22, 2015, at approximately 2:00 p.m., revealed that on October 21, 2015, the 6:00 p.m., treatment administration of the [MEDICATION NAME] was not documented. Further interview with the ADON revealed an expectation that if Resident 2 was not in his room, he should have been located and given an option to receive his [MEDICATION NAME] feeding and that information would be expected to be documented in the Interdisciplinary Progress Notes. There is no evidence in the clinical record indicating that Resident 2 received his 6:00 p.m., [MEDICATION NAME] feeding on October 21, 2015. Review of the facility policy entitled, Golden Clinical Services for [DEVICE]S (PEG tubes), last revised 2013, revealed, the following individuals may have responsibility for gastrostomy tube ([DEVICE] (PEG tube)) replacement specific to state professional licensing requirements are the Nurse Practioner, the Physician's Assistant and the Physician. The recommendation is not to routinely replace the [DEVICE]s (PEG tubes). Reinsertion of the [DEVICE]s (PEG tubes) should only be done if the tube is accidently removed or becomes dysfunctional, i.e., clogged or leaking. If the surgically-placed [DEVICE] (PEG tube) is in place then the Physician, Physician Assistant or Nurse Practioner may re-insert a replacement [DEVICE] (PEG tube) at their discretion. Licensed staff will not re-insert the [DEVICE] (PEG tube). This policy was the only guidelines provided by the facility related to [DEVICE]s. There were no other policies and procedures provided by the facility relating to the care of [DEVICE]s (PEG tubes). Review of the clinical record for Resident 19 revealed [DIAGNOSES REDACTED]. Resident 19 had the following conditions: [MEDICATION NAME] (artificial opening into the abdominal wall for urine drainage), [MEDICAL CONDITION] (artificial opening into the abdominal wall for small intestine drainage) and a PEG tube (Percutaneous Endoscopic Gastrostomy-flexible feeding tube placed through the abdominal wall and into the stomach for nutrition, fluids and/or medications to be administered, bypassing the mouth and esophagus, also called a [DEVICE]). Review of one of Resident 19's comprehensive MDS dated [DATE], revealed in the category, Nutritional Approach, that Resident 19 is marked as having a feeding tube. There was no evidence provided by the facility regarding when the PEG tube was inserted for Resident 19 or the age of the current PEG tube. Review of Resident 19's physician's orders dated June 24, 2015, revealed that the staff were to cleanse the ([DEVICE]) PEG tube with soap and water and pat dry every shift. Further review of Resident 19's Treatment Administration Record for October 2015, revealed that on October 7, 2015, on the day shift, there were no initials in the provided spaces to indicate that the PEG tube site was cleansed per the physician's order. Interview conducted on October 22, 2015, at 10:00 a.m., with NA 1 (a Nurse Aide) revealed that, she was assigned to Resident 19 and that on October 17, 2015, between 7:00 a.m. and 7:45 a.m., she gave a partial bed bath to the resident and that she did not wash around the resident's PEG tube site. As she was getting the resident ready for lunch around 10:30 a.m., she noticed a maggot roll down the resident's stomach. Resident 19 stated, Maybe this is why my stomach has been burning. An interview conducted on October 22, 2015, at 10:10 a.m., with LPN 6 revealed that she was called to Resident 19's room by NA 1. She lifted the gauze around the PEG tube site and saw crawling objects, tannish in color approximately 1 cm (centimeter) long, around the PEG tube site. LPN 6 revealed that the moving objects were crawling out of the PEG tube insertion site and that she removed more than 10 moving objects. An interview conducted on October 22, 2015, at 10:40 a.m., with RN 1 revealed that she was informed by LPN 6 of bugs on Resident 19. She got gloves, gauze, and saline Q-tips and went to Resident 19's room. She lifted the drainage gauze around the PEG tube and worm-like looking bugs were crawling all around the PEG tube and the surrounding tissue. They were gray, white in color and approximately a half inch long. She removed the bugs on the skin with the saline dampened gauze. She saw more bugs inside the PEG tube insertion site. When the site was sprayed with normal saline the worms came to the surface and were then wiped away. The ADON was at the facility and gave permission to send Resident 19 to the hospital. Review of a progress note dated October 17, 2015, at 11:28 a.m., written by RN 1 (a Registered Nurse) in Resident 19's clinical record revealed that on October 17, 2015, at 11:28 a.m., Resident is alert and oriented (person, place and time) x3. Able to make needs known. Incontinent of bowel and bladder. [MEDICATION NAME] (surgically opening to bladder to drain urine to collection bag) and [MEDICAL CONDITION] (surgical opening for the intestine to drain into a collection bag) drains intact. Double lumen central line (a devise inserted in a vein for the administering of fluids), dressing dry and intact. PEG tube flushed with no difficulties. Serosanguineous (bloody) drainage noted at PEG tube insertion site, redness noted surrounding site, possible infection noted upon assessment. Resident complaints of pain around PEG tube site rating 8 on 0-10 pain scale. Lung sounds clear to auscultation (listening), diminished in BLL (bilateral lower lobes). HR (heart rate) reg (regular). Abdomen soft, non-tender. Contractures (stiffening) of the extremities. Sacral (tail bone area) wound dressing intact. Vital signs stable; BP (blood pressure) 107/68 Pulse: 63 O2: 95% on room air Respirations: 18 even, non-labored Temp (temperature) 96.6 MD (Medical Doctor) notified, advised nursing staff to send resident to hospital. There is no evidence of an assessment of the PEG tube site in the resident's record until October 17, 2015, when there was a progress note written by RN 1. Review of information submitted to the Department of Health indicated that the facility noted that when the nurse aide was providing care to the resident on October 17, 2015, she noticed an object crawling in the PEG tube site. The resident was sent to the emergency room for evaluation on October 17, 2015, and returned to the facility the same day at approximately 6:30 p.m. Review of physician order dated October 17, 2015, at 11:15 a.m., revealed send to ER eval infected peg. The resident was transferred and admitted to the hospital on October 17, 2015, at 11:50 a.m., for evaluation of the PEG tube site. Review of a Progress note written by LPN 6 on October 17, 2015, at 6:38 p.m., revealed Resident 19 returned from the hospital at 6:30 p.m., all of the maggots were removed and a new peg tube was inserted. Review of the, Document Review Report from the hospital dated October 17, 2015, at 1:58 p.m., for Resident 19 revealed that the G tube DSG (dressing) and wound cleansed and found multiple, 'maggot looking' bugs coming out of wound area. Irrigated and collected aprox. ten in sterile (cup). Bugs are still alive. Additional review of the Document Review Report from the hospital indicated that the PEG tube was removed and a new one was inserted. The hospital report indicated that the PEG tube appeared old and neglected and should have been replaced a long time ago. The report also indicated that the surrounding superficial skin around the PEG tube indicated severe neglect of wound care and proper cleaning. During an interview conducted October 22, 2015, at 12:30 p.m., with the Nursing Home Administrator (NHA), the Director of Nursing and the ADON, it was revealed by the NHA that it is his expectation that LPN 6 and RN 1 would accurately and completely document the event with Resident 19 and the worms should not have been crawling out from Resident 19's PEG tube site. The facility failed to provide evidence that the resident's insertion site was examined consistently to prevent or resolve possible skin irritation or local infection causing the resident to require treatment at the hospital. 28 Pa. Code 201.18(b)(1) Management. Previously cited 9/3/15, 2/18/15, 12/23/14, 9/11/14, 7/23/14, 10/10/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/24/15, 9/3/15, 4/16/15, 12/23/14, 9/11/14, 7/23/14, 1/22/14, 10/10/13. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/3/15, 9/11/14, 7/23/14, 1/22/14, 10/10/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/24/15, 9/3/15, 4/16/15, 2/18/15, 12/23/14, 9/11/14, 7/23/14, 1/22/14, 10/10/13.

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development and promote optimal healing for two of 30 residents reviewed (Residents 7 and 9) Findings include: Review of the clinical record revealed that Resident 9 was admitted to the facility in March 2010 following a [MEDICAL CONDITION] (stroke) with [MEDICAL CONDITION] (inability to move one side of the body). Review of the care plan revealed Resident 9 had a potential for skin breakdown related to needing assistance with bed mobility, incontinence (involuntary excretion of bowel and or bladder contents), and preferring to stay in bed most of the time. Interventions included weekly skin checks, heel protectors (soft boot used to minimize pressure/friction), and turning and repositioning. Review of the Weekly Skin Check form revealed there were no new open areas identified during a staff weekly skin check on September 6, 2013. A staff observation made on September 20, 2013, revealed a new Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) pressure ulcer (an area of skin that breaks down) to the left heel. According to the weekly skin check form, Resident 9's skin should have been checked on September 13, 2013, but there was no documentation of Resident 9's skin being checked for the week of September 13, 2013. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Orders dated August 18, 2010, and current at the time of survey revealed to keep heels off the mattress, use heel protectors while in bed and to check every shift. Orders dated September 21, 2013, revealed bilateral (on both sides) heel protectors to be worn at all times and float heels while in bed. Review of the Treatment Administration Record (TAR~a documentation tool to record care given) revealed the heel protectors were not documented as checked on 15 shifts in August 2013, and keeping the heels off the mattress, was not documented for 13 shifts in August 2013. Review of the nursing notes revealed, "no heel protectors" on August 1, 24, and 29. In September 2013, keeping the heels off mattress was not documented on 20 shifts, turning and repositioning was not documented on 23 shifts, and bilateral heel protectors at all times and float heels while in bed was not documented on 12 shifts. Review of nursing's notes revealed the heel protectors "missing" on September 3, 2013. During an interview on October 8, 2013, at 10:00 a.m., the Director of Nursing stated the documentation was poor regarding turning and repositioning and use of heel protectors. She acknowledged there was no evidence of a skin observation between September 6, 2013 and September 20, 2013. Clinical record review revealed that Resident 7 was readmitted to the facility on [DATE], with an area on the right buttock (either of the two soft parts of the body below the back that support the body when sitting) identified as a 4 centimeter by 3 centimeter abrasion (an injury caused by something that rubs or scrapes against the skin). A treatment was ordered for the area to be done. The next documented assessment of the area was on August 12, 2013, and the area was described as a 4 centimeter by 3 centimeter superficial (occurring at or on the surface) area. The next documented assessment of the wound was on September 25, 2013, (44 days later) and the area is described as a Stage III pressure ulcer (an injury to the skin and underlying tissue that extends into the tissue beneath the skin, forming a small crater) and was measuring 9.4 centimeters by 3.8 centimeters with a depth of 0.1 centimeter. There was no documentation that the daily treatment was done on 21 of 45 days between August 9, 2013 and September 25, 2013. Review of the "Skin Integrity Guidelines" reviewed on August 22, 2013, indicates that the "Licensed nurse to document weekly on all wounds using the "Wound Evaluation Flow Sheet". There was no documentation of the weekly wound assessment from August 12, 2013 until September 25, 2013, a six week period during which time the area on the sacrum (triangular bone at the base of the spine)/right buttock deteriorated from superficial to a Stage III pressure ulcer. In an interview on October 8, 2013 at 1:30 p.m., the Director of Nursing Services confirmed that assessments should have been done and documented weekly. It is also confirmed that there is no evidence that the daily treatment to the area was being done as ordered. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record review and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 3 residents sampled (Resident 1). Findings include: Review of the clinical record, revealed that Resident 1 was admitted to the facility in August 2008, with [DIAGNOSES REDACTED]. The resident resides on the facility's locked unit, which houses residents who have been diagnosed with [REDACTED]. Review of the care plans for Resident 1 revealed a previous care plan for risk of elopement dated February 2011 through September 2012, at which time it was discontinued. Further review indicated on April 12, 2013, the elopement care plan was reinstituted and was current as of the date of this survey. Handwritten notes on the printed care plan dated April 16 (no year given), revealed that the resident was "found off the unit." Interventions noted on the original care plan for elopement indicated that the alarm systems throughout the facility should be on at all times, unless the exit is down for maintenance at which time the exit will be under visual supervision until rearmed. Review of the clinical record revealed that Resident 1 had falls on October 20, 2012, December 21, 2012, February, 25, 2013, March 8, 2013, and April 12, 2013. Review of the Fall Report for February 25, 2013, revealed that the immediate intervention was to, "keep resident in supervised area during change of shift". Review of the care plan revealed that the intervention to, "keep resident in view of staff at high risk times" was added to the care plan on February 26, 2013. Review of nursing notes dated April 12, 2013, revealed that at approximately 3:00 p.m., another resident reported to the nurse that there was a resident lying on the floor outside her window. Review of the investigation notes revealed that Resident 1 was found outside, face down, bleeding from face. The nursing assessment revealed she had a hematoma (a collection of blood outside of a blood vessel) to the forehead with a small laceration (jagged cut) in the center, an abrasion on the bridge of the nose and a small laceration on the cheek, very close to the left eye. Following the fall, Resident 1 was transferred to the emergency room . The review of the emergency room record dated April 12, 2013, revealed physician assessment notes stating Resident 1 presented with abrasions to forehead and bilateral (both) knees and swelling to left cheek area under the eye. The clinical impression was documented as abrasions post fall, dehydration, and conjunctivitis of the left eye. Review of the facility Fall Report dated April 12, 2103, revealed that the fall was documented as un-witnessed and a summary of the fall stated, "resident completed almost a full circle when she tripped over a raised area on the sidewalk and fell forward hitting her hands, knees, and ultimately her face on the sidewalk". A written statement by Licensed Practical Nurse (LPN) 1 stated that he, "ran back to the office to page for help, while in the office I looked at the alarm panel since neither heard any alarm, the patio switch was in the off position". During an interview on May 15, 2013, at 2:45 p.m., the Unit Director stated that at the time of the fall, Resident 1 was not being supervised, and there was no specific staff assigned to monitor her. She stated that at the time of the fall, the staff were in an activity with residents in the dining room. She stated that there were two LPNs counting medications in the hallway, but at the time of the fall, they had their backs to Resident 1. She stated the fall was un-witnessed and the detailed description summary of the event in the Fall Report was what the staff member assumed happened. She stated that the door alarm was never used, and was unable to explain why LPN 1 wrote in his statement that he checked the alarm panel and it was off. During an interview on May 15, 2013, at approximately 3:30 p.m., the Nursing Home Administrator stated that the doors leading to the outside courtyard were never locked or alarmed, and residents had the ability to go outside as they wished. She stated that there was an alarm on the door but it had not been used since the 1970's because it only alarms inside the nurse's station and therefore is not helpful to staff on the floor. She stated that Resident 1 originally had a care plan for elopement because she did not look like she belonged on the unit and would try to hold the door open for visitors. She stated the care plan was resolved once Resident 1 became accustomed to the unit. She stated that Resident 1 is currently not an elopement risk and should not have a care plan for elopement. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 12/28/12, 10/16/12 28 Pa. Code 201.18(e)(1) Management Previously cited 12/28/12, 10/26/12 28 Pa. Code 211.11(d) Resident care plan Previously cited 10/16/12 28 Pa. Code 211.12(a)(d)(1)(5) Nursing services Previously cited 4/02/12, 10/26/12, 12/28/12

Based on review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of five residents reviewed (Resident R1) was free from any significant medication errors. Findings include: Review of the facility policy for Medication Administration on March 1, 2011, revealed that licensed staff are to note any allergies [REDACTED]. Additionally, the facility policy for Emergency Pharmacy Service and Emergency Kits, revealed that when an emergency or stat medication is needed, the nurse verifies and reviews the prescriber's orders for appropriateness, checks the resident's allergies [REDACTED]. Emergency medications are only administered with a valid prescriber's order. Review of the facility's Red Line Guideline indicates that the Licensed Nurse is to review each Physician's Order Sheet, in the medical record for the identified residents with new orders, to assure the orders are implemented correctly and to check the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident R1's progress notes dated February 8, 2011, at 2:56 p.m., reported a new order for a chest Xray to be done today and to discontinue [MEDICATION NAME] (antibiotic) and start [MEDICATION NAME] 400 milligrams daily for 7 days. Subsequent progress note dated February 9, 2011, at 4:08 p.m. reported that the resident had been given [MEDICATION NAME] at approximately 10:00 a.m., and at 11:00 a.m., began experiencing shortness of breath, severe body-wide itching, complained of her face burning, was restless/anxious, breathing rapidly and complained of her lips becoming numb and her throat 'closing up.' Resident R1 had large red welts on her back, arms, torso, hands and face completely reddened and hot to touch. The physician was present, medications were given to allay the reaction and resident was emergently transferred to the hospital via 911 at 12:05 p.m. and admitted for treatment of [REDACTED]. Review of the facility's investigation of this medication error revealed that: the Physician Assistant who wrote the orders on February 8, 2011, did not identify Resident R1's allergy to [MEDICATION NAME]. She stated that the chart did not have a sticker on the front with the allergy listed. However, Resident R1's clinical record identified her allergy to [MEDICATION NAME] (antibiotic) on the face sheet in the front of her chart, the Medication Administration Record, [REDACTED] Licensed Practical Nurse (LPN) 1 stated that she noted the new order on February 8, 2011, at 2:30 p.m., and faxed it to the pharmacy. She did not check for any allergies [REDACTED]. LPN 3 did not check for allergies [REDACTED]. and on February 9, 2011, at 10:00 a.m., LPN 2 took the medication from the emergency medication box, administered the [MEDICATION NAME] 400 milligrams to Resident R1 and also did not check for allergies [REDACTED]. Interview with the Administrator on March 3, 2011, at 12:45 p.m., revealed that the above-mentioned people should have picked up on Resident R1's allergy. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously Cited 10/21/10, 1/12/11, 1/20/11, 2/1/11 28 Pa. Code: 211.10 (d) Resident Care Policies. Previously Cited 10/21/10, 1/20/11 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services. Previously Cited 10/21/10, 1/20/11 .

Based on observations, review of facility policy, facility documentation, clinical records, and interviews with staff, it was determined that the facility failed to provide a safe environment for one resident (Resident R1). Findings include: Review of facility policy entitled, "Dangerous Temperature Level" dated April 20, 2010, indicated that a dangerous temperature level is any temperature outside the acceptable range for a person's comfort and safety. The facility must be heated between 71-81 degrees Fahrenheit (F). Review of Resident R1's clinical record revealed that the resident was receiving Hospice services due to end stage dementia. The resident's Minimum Data Set (MDS) annual assessment, dated October 20, 2010, indicated that the resident had [DIAGNOSES REDACTED]. The resident's current care plan included that the resident bruised easily, staff should provide limited assistance with feeding, the resident was difficult to understand and be understood, and that the resident resided on the Alzheimer's unit. A review of Resident R1's Verification of Investigation, regarding an incident that occurred on January 14, 2011, at 7:20 p.m., revealed that the resident had been seated in the dining room in a wheelchair close to a heat source; both of the resident's lower legs were pink and hot to touch; and that there were multiple blister formations on both legs. Cool compresses were applied to the resident's legs and Resident R1 was sent to the emergency room . The resident returned to the facility on [DATE], (three days later) following treatment for [REDACTED]. A written statement from Nurse Aide (NA) 1, who was assigned to care for this resident, revealed that she had positioned Resident R1 at the table for supper at about 5:05 p.m., and when she went to lay the resident down in bed at about 7:15 p.m. (some two hours later), the resident's legs were red and hot to the touch. NA 1 went over to where Resident R1 was seated in the dining room and noticed how hot the heat was coming out of the heater, and that it was hotter towards the bottom. Written statement by Registered Nurse (RN) 1 revealed that she checked on Resident R1 on January 14, 2011, at about 8:15 p.m., and noted that the resident's right outer leg, from below the knee to above the ankle, was red with various areas blistering (measured 7.0 centimeters (cm) by 26 cm), and the right outer mid-shin had an ecchymotic (bruise) area (measured 5.0 cm by 10.5 cm) in the middle of the red area, and the resident's left inner leg was red (measured 8.0 cm by 13.0 cm) with various areas blistering. A written statement by RN 2 for January 14, 2011, at 8:30 p.m., described the bruise as a darkened area, and revealed that Resident R1 had no prior bruising, and that the resident was medicated for discomfort. Review of progress notes, dated January 14, 2011, at 10:40 p.m., revealed that Resident R1 was given 650 milligrams (mg) of Tylenol (pain reliever) for pain before the resident was sent to the hospital. Review of hospital records revealed that Resident R1 was received in the emergency room at 10:13 p.m., on January 14, 2011, and admitted to the hospital at 11:09 p.m., with [DIAGNOSES REDACTED]. The hospital record indicated that the, "blisters were present but not weeping, and that the burns extended approximately one and a half of the area of the lower extremities." The hospital records described that Resident R1 was seated close to a heat source for about two hours when the staff noticed the resident's lower extremities had developed [DIAGNOSES REDACTED] (redness) and blisters along with petechiae (small red/purple spots as a result of bleeding under the skin). The area of the burn was the medial (middle) surface of the lower right extremity. On the lower left extremity, it was the lateral (side) surface. The burns approached third degree with exfoliation (peeling or shredding of skin) of skin with tissue damage. Review of the physician's orders [REDACTED]. Observations of Resident R1 on January 20, 2011 (6 days after the injury), at 1:15 p.m., revealed that on the resident's left lower extremity, inner area, there were several small fluid filled blisters, and the surrounding skin was red (measured 13.0 cm by 8.0 cm). On the resident's right lower extremity, outer area, there were also several fluid filled blisters (more than on the left leg), and the surrounding skin was red (measured 26.0 cm by 7.0 cm wide). Observations of the Advanced Alzheimer's Care Unit (AACU) wall heater with the Maintenance Director on January 20, 2011, at 1:00 p.m., revealed that when the heater was turned on (which had been on when Resident R1 was burned) the ambient (air) temperature was 106 degrees Farenheit (F) and at the bottom of the heater, when measured from two feet away. The ambient temperature was 110 degrees F from three feet away. Interview with the Maintenance Director and the Administrator, on January 20, 2011, at 11:27 a.m., revealed that on January 14, 2011, the heater was set on high temperature, it was an old model, from the 1970's, and they had no manual or maintenance instructions for the heater. When set on high, it was 4000 watts (on low, it was 3000 watts). Interviews with the Administrator on January 18, 2011, at approximately 11:00 a.m., and with the Administrator and the Director of Nursing on January 20, 2011, at 1:00 p.m. and 1:58 p.m., revealed that on January 14, 2011, at the time of the incident, Resident R1 was seated in the Advanced Alzheimer's Care Unit (AACU) dining room, at a rectangular table, that was located perpendicular to and flush against a wall that had a heater unit in it. Resident R1's wheelchair was located approximately 2 to 2 1/2 feet, from the vent of the heater unit. The resident had the first seat next to the wall, and the bottom of the vent was directly facing the resident's legs. The resident was wearing a knee-length nightgown, and was fed supper by staff. The Administrator revealed that the heating unit should not have been in the building or on the Alzheimer's Unit. 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/13/09. 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 11/13/09, 10/21/10. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. Previously cited 11/13/09, 8/3/10, 10/21/10, 1/12/11. 28 Pa. Code: 211.10 (d) Resident care policies. Previously cited 10/21/10. 28 Pa. Code: 211.12 (d)(1) Nursing services. Previously cited 11/13/09, 2/23/10, 7/16/10, 8/3/10, 10/21/10, 1/12/11. 28 Pa. Code: 211.12 (d)(5) Nursing services. Previously cited 11/13/09, 2/23/10, 7/16/10, 8/3/10, 10/21/10.