Every finding on record at Greenery Center for Rehab and Nursing

Based on a review of facility documents and clinical records, it was determined that the facility failed to implement a restorative nursing program to maintain or improve the ability to perform activities of daily living (ADLs) for one of three residents (Resident R2). Findings include: Review of the Facility Assessment dated 4/14/25, indicated under General Care - Mobility and fall/fall with injury prevention that Restorative Nursing was included at a care or practice provided. Review of the facility document, New Restorative Nursing Program (undated) provided by the facility on 7/31/26, indicated, Patients discharged from therapy services will be provided with appropriate recommendation of a restorative nursing task found in each discipline's specific discharge summary. DOR (Director of Rehabilitation) will provide DON (Director of Nursing) /Designee copies of discharge summaries to be utilized for nursing tasks that will be entered as a physician order, chartable tasks in Point Click Care (electronic medical record software) as well as the individual's care plan. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 6/2/26, included diagnoses of coronary artery disease, (CAD, damage or disease in the heart's major blood vessels) muscle weakness, and history of a stroke. Review of Resident R2's care plan for Mobility, Therapy, Restorative dated 6/12/26, indicated, Pt (patient) to ambulate 150 feet or to tolerate with CGA (contact guard assistance) and quad cane to maintain current function. Review of physician's order dated 6/12/26, discontinued 6/30/26, indicated, RNP (restorative nursing program) Pt to ambulate 150 feet or to tolerate with CGA and quad cane to maintain current function. Review of physician's order dated 6/30/26, indicated, RNP (restorative nursing program) Pt to ambulate 150 feet or to tolerate with CGA and quad cane to maintain current function. RNP to occur 5-7 times a week for a total of 5 minutes. Review of a progress note dated 6/17/26, at 10:38 a.m. indicated, Discussed with resident that since lab work is elevated and she has had an increase in bruising restorative therapy to include walking with staff has been put on hold due to increased fall risk and bleeding that may occur if a fall happens. Review of a progress note dated 6/30/26, at 10:29 a.m. indicated, RNP ambulation to resume as labs have stabilized and returned to a normal level. Review Point of Care Audit Report for July 2026 revealed that charting for the RNP would be completed by day and evening shift, if occurred, for a total of 62 opportunities for RNP charting. Review of the Point of Care Response History indicated that Resident R1 received 15 minutes of restorative ambulation on 7/25/26, and 15 minutes of restorative ambulation on 7/28/26. During a follow-up communication on 8/3/26, at approximately 11:30 a.m. the Nursing Home Administrator was made aware that the facility failed to implement a restorative nursing program to maintain or improve the ability to perform activities of daily living for one of three residents.

Based on facility document review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of thirteen residents (Resident R1).Findings include: Review of the facility document Elopement - Facility Practices dated 1/5/26, indicated, The facility team will assess the environment to identify potential risks associated with elopement. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/22/26, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), coronary artery disease (CAD, damage or disease in the heart's major blood vessels), and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior. Review of Section C: Cognitive Patterns indicated that Resident R1 has severe cognitive impairment. Review of an Elopement Risk Assessment completed on 4/4/26, indicated Resident R1 was at risk for elopement. Review of the physician's order dated 11/8/24, indicated Resident R1 was ordered a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door) to be worn at all times. Review of Resident R1's plan of care for Elopement Risk initiated 10/20/23, included the goal of The resident's safety will be maintained. Review of a progress note dated 7/19/26, at 4:42 p.m. indicated, Informed by CNA (nurse aide) at 155pm that she found resident standing on sidewalk near parking lot. She immediately called resident towards the door and got her to sit on the bench. She was then able to successfully get her to come inside. Once inside, I assessed resident. No injuries found. Resident is non-verbal and unable to tell me why she was outside. Review of a progress note dated 7/19/26, at 6:57 p.m. indicated Resident R1 was seen by the provider and was, being seen today per request of nursing staff after she was found outside of facility. CNA found resident standing on sidewalk outside of facility front doors near parking lot. She was easily redirected back into facility. Patient nonverbal at baseline and unable to provide any details. Patient had a wander guard in place to ankle, and it was functioning. Patient ambulates independently at baseline. Staff has not noted any recent changes in mood, behavior, sleep habits, or level of functioning. Review of facility submitted information dated 7/20/26, indicated that on 7/19/26, at 1:55 p.m. [Resident R1] is non - verbal with the ability to ambulate independently. She was last seen minutes before walking to her room which is in close proximity to the door. She was wearing a blouse and long pants the weather outside was a pleasant summer day with a high of near 81 degrees. She had a wander guard to left ankle. On 7/19/2026 at approx. 1355 (1:55 p.m.) res (resident) was found outside by CNA walking in the parking lot. The alarm was sounding. CNA was able to redirect [Resident R1] to the bench outside and called for additional staff to assist in helping [Resident R1] back into the facility. During an interview on 7/27/26, the Director of Maintenance confirmed the doors, alarms, and Wanderguard system was working appropriately, and had been checked by the vendor on 7/20/26, with no deficiency found. During an observation on 7/27/26, at approximately 1:00 p.m. the surveyor and the Director of Maintenance tested the functionality of the main doors that Resident R1 exited, and found them to be in working order. During an interview on 7/27/26, at approximately 1:10 p.m. the Nursing Home Administrator was asked how the resident was able to exit the building when the alarms sound throughout the building and the Wanderguard system was functioning. The Nursing Home Administrator stated that their investigation concluded that a staff member disarmed the alarm without looking outside to ensure no residents had exited the building. At this time, the Nursing Home Administrator displayed the camera system placed to face the doors to monitor the facility exit. During an interview on 7/27/26, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of 13 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 12 of 21 residents (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116).Findings include: Review of the facility policy Episodic and Narrative Documentation dated 1/6/26, indicated a narrative entry will be made for physician notification. During an interview with the Nursing Home Administrator on 4/8/26, at approximately 10:00 a.m. policies for management of diabetes, hypoglycemia, or hyperglycemia were requested. The NHA confirmed the facility was unable to provide policies. Review of the Facility Assessment last reviewed 4/14/25, indicated the facility will provide care for residents diagnosed with diabetes. Review of the United States Food and Drug Administration prescribing information for basaglar insulin (insulin glargine, a long-acting injectable medication to diabetes) dated 12/2015, indicated basaglar insulin begins to work several hours after administration, the maximum effect of basaglar insulin is approximately 12 hours after administration, and works over 24 hours to lower blood sugar levels. Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/24/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and chronic kidney disease. Review of a physician order dated 1/5/26, indicated that Resident R2 received insulin lispro on a sliding scale. If below 70 (mg/dl) to follow hypoglycemic protocol. If over 400 (mg/dl) to notify the provider. Review of Resident R2's current plan of care for diabetes initiated 11/3/25, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R2's blood sugar record for January 2026, through April 2026, revealed the following blood sugar values failed to have documentation of notification or follow-up: 1/8/26, 8:55 p.m., BS 520, no notes or documentation 1/14/26, 4:57 p.m., BS 508, no notes or documentation 1/14/26, 10:30 p.m., BS 453, no notes or documentation 1/29/26, 10:05 p.m., BS 500, had a note, but no recheck. 3/25/26, 3:54 p.m., BS 421, no notes or documentation Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and CAD. Review of a physician order dated 1/5/26, indicated that Resident R4 received Novolog on a sliding scale and if over 400 (mg/dl) to notify the MD (doctor of medicine). Review of Resident R4's current plan of care for diabetes initiated 3/10/26, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R4's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 3/15/26, 8:30 a.m., BS 483, no notes or documentation Review of the clinical record indicated that Resident R16 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and Congestive Heart Failure (CHF). Review of a physician order dated 1/31/26, through 3/30/26, indicated that Resident R16 was to receive blood sugar checks twice daily. This order did not include parameters for provider notification. Review of a physician order dated 1/24/26, through 2/22/26, indicated that Resident R16 received Tresiba (long-acting insulin) 32 units daily; 2/22/26, through 3/21/26, indicated that Resident R16 received Tresiba 36 units daily. 3/21/26, through 3/21/26, indicated that Resident R16 received Tresiba 40 units daily; 3/30/26, (current order) indicated that Resident R16 received Tresiba 44 units daily. These orders did not include parameters for provider notification. Review of a physician order dated 3/30/26, indicated that Resident R4 received Novolog on a sliding scale and if over 400 (mg/dl) to notify the provider. Review of Resident R16's current plan of care for diabetes initiated 1/19/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R16's blood sugar record for January 2026, through April 2026, revealed the following blood sugar values failed to have documentation of notification or follow-up: 2/6/26, 7:24 p.m., BS 426, no notes or documentation 2/26/26, 7:43 a.m., BS 495, no notes or documentation. Resident left for a leave of absence without reevaluation. 2/27/26, 11:00 p.m., BS 471, no notes or documentation. 2/28/26, 7:42 p.m., BS 459, no notes or documentation 3/2/26, 5:34 p.m., BS 470, no notes or documentation Review of the clinical record indicated that Resident R33 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and CAD. Review of a physician order dated 1/16/26, through 2/23/26, indicated that Resident R33 received insulin lispro on a sliding scale and if under 70 (mg/dl) or over 400 (mg/dl) to notify the provider . Review of Resident R33's current plan of care for diabetes initiated 1/16/26, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R33's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 1/21/26, 1:12 a.m., BS 402, no notes or documentation Review of the clinical record indicated that Resident R37 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and dementia. Review of a physician order dated 6/9/25, through 4/6/26, indicated that Resident R37 received insulin lispro on a sliding scale and if under 70 (mg/dl) or over 400 (mg/dl) to notify the MD. Review of Resident R37's current plan of care for diabetes initiated 4/3/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R37's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 3/12/26, 1:39 p.m., BS 487, no notes or documentation Review of the clinical record indicated that Resident R46 was re-admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and COPD. Review of a physician order dated 9/14/25, and reordered 1/18/26, indicated that Resident R46 received Novolog on a sliding scale and if under 70 (mg/dl) or over 400 (mg/dl) to notify the MD. Review of Resident R46's current plan of care for diabetes initiated 3/13/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R46's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 1/8/26, 8:49 p.m., BS 401, no notes or documentation 1/30/26, 6:36 p.m., BS 429, no notes or documentation 2/2/26, 2:00 p.m., BS 426, no notes or documentation 2/11/26, 12:47 p.m., BS 517, no notes or documentation 2/17/26, 10:06 p.m., BS 402, no notes or documentation 2/26/26, 5:15 p.m., BS 418, no notes or documentation 3/11/26, 12:05 p.m., BS 401, no notes or documentation 3/13/26, 9:57 p.m., BS 414, no notes or documentation 3/20/26, 10:49 a.m., BS 414, no notes or documentation 3/30/26, 9:44 p.m., BS 401, no notes or documentation Review of the clinical record indicated that Resident R47 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and End Stage Renal Disease. Review of a physician order dated 3/15/26, indicated that Resident R47 received insulin lispro on a sliding scale and Call MD if greater than 400 for additional orders! Review of Resident R47's current plan of care for diabetes initiated 3/14/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R47's blood sugar record for March 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 3/19/26, 9:23 p.m., BS 522, no notes or documentation3/20/26, 9:12 a.m., BS 538, no notes or documentation.3/20/26, 1:22 p.m., BS 543, no notes or documentation3/21/26, 2:16 p.m. Progress Note: Meter reading HI (over 600)3/21/26, 5:44 p.m., BS 439, no notes or documentation3/24/26, 6:31 p.m., BS 591, no notes or documentation3/25/26, 12:48 p.m., BS 582, no notes or documentation3/26/26, 10:00 a.m., BS 582, no notes or documentation3/26/26, 1:17 p.m., BS 538, no notes or documentation3/29/26, 11:00 a.m., BS 547, no notes or documentation3/29/26, 2:08 p.m., BS 458, no notes or documentation3/30/26, 9:36 a.m., BS 546, no notes or documentation4/2/26, 8:30 a.m., BS 505, no notes or documentation4/2/26, 5:36 p.m., BS 429, no notes or documentation4/5/26, 10:13 a.m., BS 440, no notes or documentation4/7/26, 8:17 a.m., BS 502, no notes or documentation Review of the clinical record indicated that Resident R56 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and CKD. Review of a physician order dated 1/8/26, indicated that Resident R56 received Admelog on a sliding scale and if under 70 (mg/dl) or over 400 (mg/dl) to notify the MD. Review of Resident R56's current plan of care for diabetes initiated 12/20/23, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R56's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 1/13/26, 10:46 p.m., BS 66, no notes or documentation 1/16/26, 6:00 a.m., BS 69, no notes or documentation 1/25/26, 7:12 p.m., BS 495, no notes or documentation 2/17/26, 6:35 p.m., BS 420, no notes or documentation 3/6/26, 5:48 a.m., BS 57, no notes or documentation4/4/26, 6:11 a.m., BS 55, no notes or documentation Review of the clinical record indicated that Resident R70 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and dementia. Review of a physician order dated 8/18/25, through 3/1/26, indicated Resident R70 will have her blood sugar checked twice per day, on Mondays, Wednesdays, and Fridays. This order did not include parameters for provider notification. Review of a physician order dated 2/24/26, indicated that Resident R70 received Lantus 6 units. This was increased on 3/2/26, to 12 units, and on 3/25/26, to 16 units. These orders did not include parameters for provider notification. Review of Resident R70's current plan of care for diabetes initiated 7/9/25, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R70's blood sugar record for February 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 2/6/26, 7:24 p.m., BS 426, no notes or documentation2/26/26, 7:43 a.m., BS 495, no notes or documentation. 2/27/26, 11:00 p.m., BS 471, no notes or documentation. 2/28/26, 7:42 p.m., BS 459, no notes or documentation3/2/26, 5:34 p.m., BS 470, no notes or documentation Review of the clinical record indicated that Resident R80 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and COPD. Review of a physician order dated 7/14/25, through 2/28/26, indicated Resident R80 will have insulin lispro (8 units plus a sliding scale) before meals and at bedtime every Tuesday, Thursday, Saturday, and Sunday. This order indicated to notify the provider if greater than 400 (mg/dl). Review of a physician order dated 7/15/25, through 2/28/26, indicated Resident R80 will have insulin lispro (8 units plus a sliding scale) before meals and at bedtime every Monday, Wednesday, and Friday. This order indicated to hold the insulin if blood sugar levels was less than 130 (mg/dl) and notify the provider if greater than 400 (mg/dl). Review of a physician order dated 2/28/26, indicated Resident R80 will have insulin lispro on a sliding scale before meals and at bedtime. This order indicated to notify the provider if greater than 400 (mg/dl). Review of Resident R80's current plan of care for diabetes initiated 12/4/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R80's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 1/26/26, 11:07 a.m., BS 404, no notes or documentation1/30/26, 10:25 p.m., BS 454, no notes or documentation2/28/26, 10:17 p.m., BS 438, no notes or documentation3/1/26, 9:11 a.m., BS 430, no notes or documentation3/1/26, 12:02 p.m., BS 430, no notes or documentation Review of the clinical record indicated that Resident R97 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and dementia. Review of a physician order dated 11/19/25, indicated Resident R97 will have Novolog on a sliding scale. This order indicated to notify the provider if greater than 400 (mg/dl). No parameters were included for low blood glucose levels. Review of Resident R97's current plan of care for diabetes initiated 8/26/24, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R97's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 1/9/26, 5:46 a.m., BS 57, no notes or documentation1/14/26, 5:42 a.m., BS 65, no notes or documentation2/20/26, 4:41 p.m., BS 67, no notes or documentation3/7/26, 5:44 a.m., BS 67, no notes or documentation Review of the clinical record indicated that Resident R116 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and heart failure. Review of a physician order dated 3/28/26, indicated Resident R116 will have insulin aspart on a sliding scale. This order indicated to notify the provider if greater than 400 (mg/dl). Review of Resident R116's current plan of care for diabetes initiated 3/31/26, indicated Fasting Serum Blood Sugar/finger stick blood sugar monitoring as ordered by doctor. Review of Resident R116's blood sugar record for January 2026, through April 2026, revealed the following blood sugar value failed to have documentation of notification or follow-up: 3/28/26, 6:33 p.m., BS 405, Supervisor notified, no MD notification documented. 3/2926, 5:35 p.m., BS 450, no notes or documentation4/2/26, 3:46 p.m., BS 535, Supervisor notified, no MD notification documented. During an interview on 4/8/26, at 9:30 a.m. Licensed Practical Nurse (LPN) Employee E8 stated that for blood sugar under 70, they would check for signs and symptoms, check the physician orders, give the resident a snack and recheck the blood sugar to verify its correct, and call the doctor and the supervisor. For blood sugar over 400 they would recheck the blood sugar to verify the results. When prompted they stated they would document in the MAR (medication administration record) and progress notes. During an interview on 4/8/26, at 9:40 a.m. LPN Employee E9 stated that for blood sugar under 70, they would notify the doctor, give a snack, monitor the resident, and recheck the blood sugar in one hour. For blood sugar over 400 they would notify the doctor and get new orders if needed, notify the supervisor and recheck the blood sugar in 20 minutes. When prompted they stated they would document in the progress notes. During an interview on 4/8/26, at 9:45 a.m. LPN Employee E10 stated for blood sugar under 60 they would check the resident's orders, give glucose or a snack and recheck the blood sugar in 20 minutes. For blood sugar over 400 they would call the doctor for new orders, notify the supervisor and recheck the blood sugar in 20 minutes. When prompted they stated they would document in the MAR and progress notes. The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 4/8/26, at 12:03 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. This Immediate Jeopardy began on 1/8/26. On 4/8/26, at 5:32 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The facility was notified of the IJ for F-684 on April 8, 2026 @12:03 PM Resident R 97-The Finger Stick Blood Sugar Results (FSBS) from the following dates 1/9/26, 1/14/26, 2/20/26, 3/7/26 were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R 46- The Finger Stick Blood Sugar Results (FSBS) from the following dates 1/8/26, 1/30/26, 2/2/26, 2/11/26, 2/17/26, 2/17/26, 2/26/26, 3/11/26, 3/13/26, 3/20/26, 3/30/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26.Resident R56- The Finger Stick Blood Sugar Results (FSBS) from the following dates1/13/26, 1/16/26, 1/25/26, 2/17/26, 3/6/26, 4/4/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R70- The Finger Stick Blood Sugar Results (FSBS) from the following dates 2/6/26, 2/26/26, 2/27/26,2/28/26, 3/2/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R16- The Finger Stick Blood Sugar Results (FSBS) from the following dates 2/6/26, 2/26/26, 2/27/26, 2/28/26, 3/2/26 were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Care plan was also reviewed and updated to include a care plan for diabetes. Resident R47- The Finger Stick Blood Sugar Results (FSBS) from the following dates 3/19/26, 3/20/26( times 2) 3/21/26 (times), 3/24/26, 3/25/26, 3/26/26 (times 2)3/29/26 (times 2), 3/30/26, 4/2/26 (times 2), 4/5/26, 4/7/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R37- The Finger Stick Blood Sugar Results (FSBS) from the following dates 3/12/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R2- The Finger Stick Blood Sugar Results (FSBS) from the following dates 1/8/26, 1/14/26 (times 2) 1/29/26, 3/25/26, were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R80- The Finger Stick Blood Sugar Results (FSBS) from the following dates 1/26/26, 1/30/26, 2/28/26, 3/1/26 (times 2) were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident was also seen by the NP on 4/8/26. Resident R33- The Finger Stick Blood Sugar Results (FSBS) from the following dates 1/21/26 were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident R116- The Finger Stick Blood Sugar Results (FSBS) from the following dates 3/8/26, 3/28/26, 3/29/26, 4/2/26 26 were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident R4- The Finger Stick Blood Sugar Results (FSBS) from the following dates 3/15/26 were reported to the Nurse Practitioner (NP) on 4/8/2026. Resident R4 is currently out of the facility at the hospital. This has the potential to affect current diabetic residents who reside in the facility.1) On April 8,2026 at approximately 1:00 PM the NP was notified of the above residents past FSBS and has seen all those residents to verify appropriate orders are in place and updated if indicated for the identified resident. 2) On April 8,2026 the NP began seeing current residents in the facility that may be impacted related to a diabetic emergency to verify appropriate orders are in place and updated if indicated. 3) On April 8, 2026, the MDS nurse reviewed current diabetic residents care plans to verify that a care plan was in place and updated if indicated. This was completed at approximately 3PM. 4) On April 8, 2026, the facility created a new policy titled Managing Hypo and Hyperglycemia. 5) The DON/ADON (Director of Nursing / Assistant Director of Nursing) began immediate education for current nurses including agency nurses on this new protocol. Current nurses, including agency nurses' education will be completed by April 9,2026 This training will continue ongoing for all employees who have not yet received it due to PTO, sick leave, etc., and will also be provided to all new hires. This education on the new policy of Managing Hypo and Hyperglycemia will occur prior to the start of their next shift. No nurse will be allowed to work until Education is completed. 6) The LNHA notified the Medical Director of the IJ on 4/8/2026 at approximately 1:00PM and that the NP was seeing all current diabetic residents today. 7) The facility will have an Ad HOC QAPI meeting with the Medical Director on April 8,2026 to review and discuss the IJ and the Immediate Plan of Correction. 8) Beginning April 9, 2026, the DON/ADON will review all current diabetic residents in the facility FSBS results during daily clinical Morning Meeting M-F to verify that residents FSBS results were recorded and documented and MD/designee notified. Saturday and Sunday results will be reviewed by the weekend Nursing Supervisor. This will be completed 5x for 4 weeks and then the DON/ADON will review a random 15 residents FSBS 3x week for 4 weeks and then a random 5 residents weekly for 3 months and then a random 15 residents monthly ongoing. 9) Beginning April 9,2026, the facility NHA will query 5 random nurses, 3 x week for 4 weeks then weekly x 4 weeks and then monthly for 3 months to verify their knowledge of the protocols for Hypo/Hyperglycemic Management. 10) Results of the audits will be reviewed during QAPI and frequency adjusted based on the results of the audits. 11) Root cause has been completed. The ad hoc committee results of that root cause analysis is that a formalized policy was not in place for the management of Hypo /Hyperglycemia was present. On 4/8/26, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 4/8/26, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 9:30 a.m. on 4/8/26, four of four LPNs on duty were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. On 4/8/26, licensed nursing reeducation was reviewed, revealing its completion. The Immediate Jeopardy was removed on 4/8/26, at 2:08 p.m. when the action plan implementation was verified. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased capillary blood glucose levels, failed to assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for 12 of 21 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of employee files, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian for 25 of 25 days. (March 16, 2026, through April 10,2026) Findings include: Review of the job description Dietary Manager indicated they oversee all food service operations to ensure residents receive nutritious, safe, and appealing meals that must meet clinical and dietary requirements. The key responsibilities included the following: - Manage daily operations of the dietary department.- Work closely with a Registered Dietitian to implement meal plans- Maintain food safety standards.- Hire, train, schedule and supervise dietary staff (cooks, aides, dishwashers)- Ensure food quality, taste, temperature, and presentation meets expectations.- Order food and supplies and maintain inventory During an interview on 4/7/26, at 10:05 a.m. interim Dietary Manager Employee E12 stated she currently does not have her CDM license. She previously held a CDM license but allowed it to lapse after October 2024 after the nursing home she was employed at closed and she decided to pursue a different career path. She also stated the RD only works at the facility on Mondays. Review of employee files indicated the following: - Employee E12 was hired on 1/29/26, as a Graduate Nurse (GN) while she awaited her Registered Nurse State Board test to be completed (scheduled for 4/22/26).- On 3/19/26, Employee E12 signed the Dietary Manager job description. During an interview on 4/10/26, at approximately 11:00 a.m. the Nursing Home Administrator (NHA) confirmed the facility was unable to provide a job description for the Registered Dietitian (RD) position and stated the RD is a consultant for the facility so she did not have a job description. The NHA confirmed there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on observations, resident interviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide sufficient dietary staff to perform essential kitchen duties. Findings include: Review of the facility document Meal Service Times, indicated the following meal schedules: Main Dining room:Breakfast 730 - 830 a.m. Lunch 11:30 - 12:30 p.m.Dinner 5:15 pm - 6:15 pm. Cart Service:Breakfast 7:45 a.m. - 8:30 a.m.Lunch 11:45 a.m. - 12:30 p.m.Dinner 5:30 p.m. - 6:15 p.m. Review of Food Committee meeting notes from 1/5/26, indicated concerns related to condiments not being on carts, lack of notice about menu changes, and meal delivery being late due to carts of trays not being distributed when brought to the floor. Review of Food Committee meeting notes from 3/2/26, indicated concerns related to posted menu not being followed, missing items from meal trays, meals being late, food being cold, and running out of food before meal service is complete. During an interview on 4/7/26, at 10:05 a.m. interim Dietary Manager Employee E12 stated the facility did not have enough staff for the kitchen to run efficiently. She stated the Certified Dietary Manager (CDM) walked out of the facility without notice on 3/16/26, and she stepped into the position temporarily on 3/19/26. She held the position of CDM at a different nursing facility that closed in 2024 but let her certification lapse as she pursued another career path. She stated the facility only had a Registered Dietician one day a week, on Mondays. During an interview on 4/7/26, at 11:00 a.m. Resident R59 stated the food is consistently cold, and staff refuse to microwave it for them. During an interview on 4/7/26, at 11:06 a.m. Resident 115 stated if residents want warm food they eat in the dining room, because the meals delivered to his room are always cold and staff refuse to heat it for him. During an interview on 4/7/26, at approximately 11:19 a.m. Resident R98 stated the food tastes bad and is often cold. During an interview on 4/7/26, at 11:23 a.m. Resident R76 stated he eats in the dining room because the food is cold if he eats in his room. During an interview on 4/8/26, at approximately 3:30 p.m. Resident R9 stated that, meals are late and ice cold. During a confidential group interview on 4/8/26, at 2:00 p.m. 14 of 14 residents collectively confirmed that meals are consistently late and cold. During observations on 4/9/26, at 12:07 p.m. tray line was still being assembled in the dining room. At 12:15 p.m. the residents in the dining room began to get their meals. Carts delivery to resident rooms began at 1:15 p.m. During an interview on 4/9/26, at 12:10 p.m. acting Dietary Manager stated lunch was running about 30 minutes behind due to not having enough staff to prepare the meal timely. The menu for the day was roasted turkey, mashed potatoes, carrots, and tapioca pudding. The morning kitchen staff included one [NAME] Employee E15, [NAME] (in training) Employee E17, and Dietary Aide Employee E18. During an interview on 4/10/26. at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide sufficient dietary staff to perform essential kitchen duties. 28 Pa. Code 211.6(b)(c)(d) Dietary Services

Based on a review of facility policy, facility documents, resident interviews, staff interviews and observations, it was determined the facility failed to provide the residents with food and drink that is at a safe and appetizing temperatures for five of 21 residents interviewed (R59, R115, R98, R76 and R9), 14 of 14 residents in a confidential group meeting, two of three resident council minutes reviewed (1/5/26 and 3/2/26), and observations of a test tray (4/9/26).Findings include: Review of facility policy Dietary/ Food Handling reviewed 1/5/26, indicated guidelines for the safe preparation, handling, and storage of perishable food. Temperatures must be maintained at the following (Fahrenheit) settings for the items indicated below: Cold food - 45 degrees or belowFrozen food - 0 (zero) degrees or belowHot food - 140 degrees or aboveReview of the USDA Food Safety Minimal Internal Temperature chart indicated all poultry should reach 165 F to ensure thorough cooking and should be kept at 140 F or higher for holding temperature. During an interview on 4/7/26, at 11:00 a.m. Resident R59 stated the food is consistently cold, and staff refuse to microwave it to heat it up. During an interview on 4/7/26, at 11:06 a.m. Resident 115 stated if residents want warm food they eat in the dining room, because the meals delivered to his room are always cold and staff refuse to heat it for him. During an interview on 4/7/26, at approximately 11:19 a.m. Resident R98 stated the food tastes bad and is often cold. During an interview on 4/7/26, at 11:23 a.m. Resident R76 stated he eats in the dining room because the food is cold if he eats in his room. During an observation on 4/8/26, at 9:28 a.m. breakfast was still being served to the residents on the North Unit. The metal kitchen cart was observed left open between staff removing the trays with five resident trays left in the cart. The back hallway on North Unit was observed to have four resident trays on a cooling rack being used to deliver meals. During an interview on 4/8/26, at 9:30 a.m. Nurse Aid (NA) Employee E5 confirmed the cart doors are left open between trays. During an observation on 4/8/26, at 9:36 a.m. the metal kitchen cart was left open with nine resident trays still inside. During an interview on 4/8/26, at 9:36 a.m. NA Employee E22 stated they were unaware the kitchen carts needed to be closed between removing resident meal trays. During an interview on 4/8/26, at approximately 3:30 p.m. Resident R9 stated that, meals are late and ice cold. During a confidential group interview on 4/8/26, at 2:00 p.m. 14 of 14 residents collectively confirmed that meals are consistently late and cold. During observations on 4/9/26, at 12:07 p.m. tray line was still being assembled in the dining room. At 12:15 p.m. the residents in the dining room began to get their meals. During an observation on 4/9/26, at 1:00 p.m. food temperatures were as follows: -Roasted turkey (sliced and placed in metal tray, no liquid): 99 F -Mashed potatoes: 207 F-Gravy: 162 F-Diced carrots were 159 FDuring an observation on 4/9/26, at 1:15 p.m. revealed lunch trays for cart delivery to the nursing unit began. During an observation on 4/9/26, at 2:35 p.m. a test tray was obtained as the last tray was delivered to the remaining resident. Food temperatures were as follows: -Sliced turkey was 48 F-Mashed potatoes with gravy on top was 55.8 F-Diced carrots: 51 F The food was palatable and smelled savory but was not at an appealing or appetizing temperature. The presentation was in a circular pattern with carrots brightening the plate. During an interview on 4/9/26, at 2:40 p.m. the acting Dietary Manager Employee E12 confirmed the temperatures of the test tray and stated the facility only had one small, insulated food cart, and two metal uninsulated carts for meal tray delivery. During an interview on 4/10/26, at approximately 3:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide the residents with food that is at a safe and appetizing temperature. 28 PA Code: 211.6(b)(c)(d) Dietary services.

Based on review of the facility documents and resident and staff interviews, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that the delivery of care and services was effectively provided to residents. Findings include: Review of the facility's Performance Improvement Program Plan indicated, It is the policy of Greenery Center to continually improve the delivery of health care services by designing, measuring, assessing, improving, and redesigning processes of resident care; thereby improving performance. When processes are will designed, they establish expectations and draw on a variety of information sources. New and/or modified processes should meet the following criteria: a. Be consistent with the organization's mission, vision, values and standards of care. b. Met the needs of the staff and individuals served. c. Must be clinically sound and current d. Must be consistent with sound business practices e. Incorporate available information from other sources about the occurrence of sentinel events.f. Incorporate results of performance improvement activities. During a confidential resident group interview on 4/8/26, at 2:00 p.m. residents expressed concerns that the resident restorative program had been discontinued, and the restorative duties were placed on the nurse aides. The residents in the group confirmed that they are not receiving restorative care. Review of Resident Council minutes dated 2/2/26, revealed concerns expressed by residents that the restorative program had been discontinued. During an interview on 4/10/26, at approximately 11:00 a.m. the Nursing Home Administrator (NHA) confirmed that the facility is currently in the state enforcement process for a lack of nurse aide care, dating back to February 2026. It was confirmed with the NHA that residents, the Resident Council, the local Ombudsman, resident interviews, and facility staffing data all indicated that nurse aide staffing was insufficient to meet the basic resident care needs. When asked if the facility had used its QAPI process and plan to ensure effective delivery of the restorative program to residents, the NHA confirmed that the plan was not utilized. It was then confirmed with the NHA that had the QAPI plan had been utilized it would have revealed that placing additional job duties on nurse aides, when currently the facility is experiencing nurse aide staffing shortages, was not a feasible replacement for the restorative program. During an interview on 4/10/26, at approximately 3:00 p.m. the NHA confirmed that the facility's Quality Assurance Performance Improvement committee failed to ensure that the delivery of care and services was effectively provided to residents. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of facility policy, documentation, and staff interviews it was determined that the facility failed to implement control measures for Legionella within the facility for three of twelve months (February, March, and April 2026). Findings include: Review of the facility policy Legionella Policy and Water Management Plan dated 1/5/26, indicated water testing will be via monthly water temperatures and flushes to ensure water is being maintained and specific actions should be taken for prevention of Legionella and for investigation should a case occur. A review of the water temperature monitoring logs dated February, March, and April 2026 did not include evidence of monthly testing per facility policy. During an interview on 4/10/26 at approximately 1:45 p.m., the interim Maintenance Director, Employee E14 confirmed the facility had no documentation of water testing as per the Legionella Policy for February, March, and April 2026. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of facility documents, resident council minutes, and resident interviews, it was determined that the facility failed to provide services in an atmosphere of dignity and respect for six of twenty residents (Residents R9, R21, R26, R63, R64, and R86) and seven of fourteen confidential group residents (Residents R100, R200, R400, R600, R700, R900, and R901).Findings Include: Review of the facility-provided document, Your Rights and Protections as a Nursing Home Resident indicated:At a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. You have the right to: Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals.Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing homes can't keep you apart from everyone else against your will. If you feel you have been mistreated (abused) or the nursing home isn't meeting your needs (neglect), report this to the nursing home, your family, your local Long-Term Care Ombudsman, or State Survey Agency. Review of a facility-provided letter dated 3/3/26, signed by nine residents, indicated: As residents we are joining together in anticipation of a serious problem at this facility rectified. Each of us has been either neglected, dismissed, or left unattended by aides or employees who are not doing their jobs. The most frustrating reasons include that they are constantly in possession of their cell phones or wearing earbuds and are either talking, eating, watching silly videos, or listening to music when they should be working. Residents are being left in the dining room until 8:30-9pm because aides are sitting in the breakrooms near the nursing stations playing on their phones. There are residents who are not being fed, left lying in dirty briefs and waiting hours to be transferred from their wheelchairs to their beds, aides/employees in the dining room carrying a hot plate in one hand and their cell phone in the other while residents sit at tables waiting and aides vaping in the halls an din the employee bathroom. This has become an enormous problem that is greatly affecting out quality of care and safety. During a resident group interview on 4/8/26, at 2:00p.m. 13 of 14 residents voiced concerns with staff ignoring their care needs. During the group interview, Residents R200 and R700 became tearful. Concerns voiced during Resident Group meeting on 4/8/26, at 2:00 p.m. -They have no intention of taking care of us. 13/14 residents. -Staff turn call lights off, without providing care. 13/14 residents.-Told by administration that We will look into it. 13/14 residents stated this does not happen. -Staff members are using phones while providing care.-All residents who need assistance getting in and out of bed stated they have concerns with not getting staff assistance.-Residents feel dismissed and dehumanized. 13/14 residents.-13/14 residents fear retaliation if they file a complaint. Resident R100:-From the time I was put in my chair, I have had to wait until 10:45 p.m. before they even thought to put me to bed. I rang for a very long time. Nobody attempted to even try.-You don't know if you are going to get back on bed at all.-Told to stay in bed, that I am too much work. -I don't know if anyone even sees me, or if I am invisible. -They don't want to help you.-I was left from 11a to 11 at night. This is too long. My legs were swollen, I was in a lot of pain. -I try to help by being polite, by waiting my turn. But I feel like I'm being completely ignored. -I feel like I'm a table. Just push me in a corner. -I feel like I'm ignored. I say excuse me, hello? I feel like I'm saying stuff, but no one hears. -They say they don't have to time to pull me back up in bed.-It's a 15 to 30 minute wait. Resident R200:-Left on the bed pan through dinner. Staff refused to assist.-On Monday, at 8:30 I pushed my button, and the aide came in, but she was a smart [NAME]. Said she would change me, but wouldn't put me on the bed pan. The she said she would put me on the bed pan and come back in 30-40 minutes. She put me on the bed pan and she didn't come back. Resident R400:-I'm scared. I don't want to be here. -The nurses don't care.-I kept waiting and waiting, I kept on asking her. They left me sitting in a urine accident. I was all wet. They just walked out the room. For eight hours I sat in poop and piss. I had a rash. They just put the cream on, they don't even wash me properly. Cream on top of cream. -I'm very disappointed.-Everyone is forgetting about me. Resident R600:-I've had to wait an hour, hour and a half. I had to call my mom one time to have her get somebody down there to get me out of the room, they shut the door and nobody could see me or hear me. Resident R 700:-They answer your light and say they will be right with you. But they never come. Resident R900:-Every other word when we met with the Administrator was about profit. It was not about patient care, it was not about us. Resident R901:-They are always on their phones. They were these earbuds, and you think they are talking to you. And they're not. When you are feeding someone, you should communicate with them. -They are not paying attention to what they are supposed to be doing. This is our home, they are supposed to be caring for us. They don't care. During an interview on 4/9/26, at 2:17 p.m. when asked if she felt the facility maintained sufficient staffing to care for the residents, Resident R86 stated, Whenever they come in, they don't help put me on the bedpan. I tell them, but they don't do anything. I call the supervisors and tell them, 'Please, I want someone to come in.' Resident R86 stated that she is not incontinent, but it becomes painful to hold her bladder for extended times, stated that she is not always provided fresh waters, and that call lights take a very long time to be responded to. Resident R86 stated that to the staff, It's a big nothing. I feel very ignored. Resident R86 became tearful during at time. I see staff walking by, but no one comes in. Makes me feel like I'm dying, I'm not worthy. I try to do everything I can do, because I know there's not enough people. I don't say anything bad, but sometimes I feel like I want to. During an interview on 4/10/26, at 10:00 a.m. Resident R9 stated, They don't give a f**k about us. During an interview on 4/10/26, at 10:10 a.m. Resident R64 stated that she is rushed during care, that there weren't washcloths and she had to be cleaned with a pillowcase. Resident R64 stated that she feels like she isn't treated like a human being. During an interview on 4/10/26, at 10:23 a.m. Resident R21 stated, No and Sometimes it takes four to five hours to get help. During an interview on 4/10/26, at 10:25 a.m. Resident R63 stated that she has been left in a soiled brief for a long time, causing skin irritation. During a follow-up interview on 4/10/26, at 1:2 p.m. Resident R86 stated, Last night I had to wait a long time. I get told to wait because they are going to do somebody else, but they don't come back. Resident R86 again became tearful. During an interview on 4/10/26, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide services in an atmosphere of dignity and respect for six of twenty residents and seven of fourteen confidential group residents. 28 Pa. Code 201.29(j) Resident Rights28 Pa. Code 211.10(a)(b)(c)(d) Resident Care Policies28 Pa. Code 211.12(d)(1)(2)(3)(4) Nursing Services

Based on review of facility documents, resident council documents, resident council group interview, resident interview, and staff interview it was determined that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for six out of six months (10/7/25, 11/4/25, 12/2/25, 1/6/26, 2/2/26, 2/4/26, and 3/3/26).Findings include: Review of Resident council minutes dated 10/7/25, 11/4/25, 12/2/25, 1/6/26, 2/2/26, 2/4/26, and 3/3/26 identified resident concerns with inadequate staff response to resident care needs. 11/4/25: Call light response times, lack of licensed nursing response to needs, nurse aides taking breaks together, leaving insufficient staff on the unit to meet needs. 12/2/25: Nurse aides taking breaks together, leaving insufficient staff on the unit to meet needs, late meals, not being assisted out of bed timely. 1/6/26: Call light response times, lack of sufficient staff on the unit to meet needs. 2/2/26: Lack of licensed nursing response to needs. 2/4/26: Call light response times, nurse aides too busy to complete restorative care, staff not checking on residents, residents not assisted from the dining room after evening meal, not being assisted from or to bed timely. 3/3/26: Lack of call light response, call lights shut off without care being provided, nurse aides too busy to complete restorative care. Review of a facility-provided letter dated 3/3/26, signed by nine residents, indicated: As residents we are joining together in anticipation of a serious problem at this facility rectified. Each of us has been either neglected, dismissed, or left unattended by aides or employees who are not doing their jobs. The most frustrating reasons include that they are constantly in possession of their cell phones or wearing earbuds and are either talking, eating, watching silly videos, or listening to music when they should be working. Residents are being left in the dining room until 8:30-9pm because aides are sitting in the breakrooms near the nursing stations playing on their phones. There are residents who are not being fed, left lying in dirty briefs and waiting hours to be transferred from their wheelchairs to their beds, aides/employees in the dining room carrying a hot plate in one hand and their cell phone in the other while residents sit at tables waiting and aides vaping in the halls and in the employee bathroom. This has become an enormous problem that is greatly affecting out quality of care and safety. During a resident group interview on 4/8/26, at 2:00p.m. 13 of 14 residents voiced concerns with the facility administration not resolving their concerns over inadequate staff response to resident care needs. On 4/10/26, the Nursing Home Administrator provided a document completed on 4/10/26, which outlined the facility response to voiced Resident Council Concerns. Nurse aides not getting residents up: It has been explained to both the staff and residents that each department has specific tasks to complete. Specifically with residents on the therapy caseload, they had been made aware that nursing must follow the transfer status of therapy, to help ensure safety of the resident and this is provided to upon completion an assessment within the therapy department. Further review of the document failed to reveal education/instruction to nursing staff to assist residents out of bed timely. Nurse aides sitting in the courtyard for extended times: Staff have been redirected to taking breaks in the assigned breaking areas. Further review of the document failed to reveal that the extended breaks were addressed, only the location. On 4/10/26, evidence of the education and instructions to staff of these and other concerns addressed on this document. By survey end, this information was not provided by the facility. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to respond to concerns from resident council and failed to respond to concerns in a timely manner for six out of six. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(3) Nursing Services

Based on observations and staff interviews, it was determined that the facility failed to provide information regarding how to file a grievance and information on the grievance official on three of three nursing units (South, North, and [NAME] nursing units).During an observation of the North nursing unit on 4/9/26, at approximately 10:00 a.m. a grievance box was noted, with forms. Information on the grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously, and the expected time frame for completion of the grievance review was not provided. During an observation of the South nursing unit on 4/9/26, at approximately 10:05 a.m. a grievance box was noted, with forms. Information on the grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously, and the expected time frame for completion of the grievance review was not provided . During an observation of the [NAME] nursing unit on 4/9/26, at approximately 10:10 a.m. a grievance box was not located. During an observation of the dining area on 4/9/26, at approximately 10:15 a.m. a grievance box was noted, with forms. Information on the grievance official's name and contact information, the right to file grievances orally, in writing, or anonymously, and the expected time frame for completion of the grievance review was not provided. During an observation on 4/9/26, at 12:00 p.m. a bulletin board was observed in the hallway leading to the dialysis area, activities room, and the conference room. The information for the grievance official and information on filing grievances was posted but noted to be posted far above the eyesight of a person seated in a wheelchair. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide information regarding how to file a grievance and information on the grievance official on three of three nursing units. 28 Pa. Code: 201.18(e)(4) Management.

Based on facility policy and clinical record review and staff interview, it was determined that the facility failed to complete a restorative nursing program for four of six residents reviewed for ADLs (activities of daily living) concerns (Residents R24, R31, R78, and R93).Findings include: Review of the facility policy Restorative Nursing Program dated 1/5/26, indicated the facility will safely and effectively improve or maintain the patient's current functional status or to prevent deterioration of current functional status as part of the restorative nursing program. During an interview on 4/9/26 at 3:00 p.m., the Physical Therapy Director Employee E20 revealed that restorative activities are documented on the daily Restorative Nursing Care Flow Record. Clinical record review for Resident R24 revealed a diagnoses list that included stroke and right sided weakness. Review of the current care plan for Resident R24 revealed the resident requires assistance with walking and transferring. An intervention included moderate assistance with all ADLs. Review of the physical therapy Discharge summary dated [DATE], indicated highest practical level achieved. Review of the current Restorative Nursing Programs status indicated Resident R24 walked to dine 100 feet with a wheeled walker with staff supervision. Review of the daily Restorative Nursing Care Flow Record dated January through March 2026 did not include documentation that the restorative task was completed. Clinical record review for Resident R31 revealed a diagnoses list that included Parkinson's disease (a progressive movement disorder of the nervous system). Review of the current care plan for Resident R31 revealed the resident requires assistance with walking. An intervention included supervision with all ADLs. Review of the physical therapy Discharge summary dated [DATE], recommended ambulation with staff and wheeled walker. Review of the current Restorative Nursing Programs status indicated Resident R31 walked to dine 100 feet with a wheeled walker with staff supervision. Review of the daily Restorative Nursing Care Flow Record dated January through March 2026 did not include documentation that the restorative task was completed. Clinical record review for Resident R78 revealed a diagnoses list that included quadriplegia and diabetes. Review of the current care plan for Resident R78 revealed the resident is dependent on staff with all ADLs. Review of the physical therapy Discharge summary dated [DATE], recommended supine/seated exercise program 3X10 reps (three sets of 10 repetitions) to LE (lower extremities). Review of the current Restorative Nursing Programs status indicated Resident R78 requires passive stretching of right elbow to extension as tolerated. Review of the daily Restorative Nursing Care Flow Record dated January through March 2026 did not include documentation that the restorative tasks were completed. Clinical record review for Resident R93 revealed a diagnoses list that included dementia, diabetes, and history of falls. Review of the current care plan for Resident 93 revealed the resident walks at liberty with distant supervision and a wheeled walker. An intervention included supervision assistance with ADLs. Review of the physical therapy Discharge summary dated [DATE], indicated resident is able to walk in hallways with wheeled walker and encourage increased walking to maintain. Review of the current Restorative Nursing Programs status indicated Resident R93 to have AROM (assisted range of motion) to bilateral upper and lower extremities on all planes (side to side, front to back, and rotationally) to tolerance. Review of the daily Restorative Nursing Care Flow Record dated January through March 2026 did not include documentation that the restorative tasks were completed. During an interview on 4/9/26 at 2:05 p.m. Nursing Assistant (NA) Employee E21 revealed restorative nursing was not being completed. During an interview on 4/9/26 at 3:00 p.m. the Physical Therapy Director Employee E20 revealed restorative nursing was not being completed. During an interview on 4/9/26 at 1:45 p.m., The Nursing Home Administrator confirmed the above findings and that the facility failed to complete a restorative nursing program for ADLs concerns for Residents R24, R31, R78, and R93.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to properly monitor weight as ordered for four of six residents (Residents R15, R18, R29, and R33).Findings include: Review of the facility policy, Weight Protocol dated 1/6/26, indicated Residents will be weighed within 24 hours upon admission/re-admission by the CNA (nurse aide). Residents will be weighed weekly for 4 weeks and then monthly ongoing by designated staff. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 2/9/26, included diagnoses chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and a communication deficit. Review of Resident R15's current plan of care, initiated 2/6/26, indicated for the facility to, Monitor wts. (weights) per facility policy/approach. Review of a physician's order dated 2/4/26, indicated, Weekly weights x 4 weeks then monthly. Review of Resident R15's weight record for February 2026, failed to include a weight evaluation on 2/11/26, through discharge on [DATE] (discharge to hospital). Review of a physician's order dated 2/25/26, indicated, Weekly weights x 4 weeks then monthly. Review of Resident R15's weight record for March 2026, and April 2026, failed to reveal a weight recorded after 3/3/26, with no refusals of monitoring documented. Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE]. Review of Resident R18's MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Resident R18's current plan of care, initiated 2/6/26, indicated for the facility to, Monitor wts per facility policy/approach. Review of a physician's order dated 3/22/26, indicated, Weekly weights x 4 weeks then monthly. Review of Resident R18's weight record for March 2026, failed to include a weight evaluation after 3/22/26. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's MDS dated [DATE], included diagnoses of heart failure and diabetes. Review of Resident R29's current plan of care, initiated 2/6/26, indicated for the facility to, Monitor wts per facility policy/approach. Review of a physician's order dated 2/12/26, indicated, Weekly weights x 4 weeks then monthly. Review of Resident R29's weight record for February 2026 through April 2026, revealed weight evaluations on 3/3/26 (338 pounds) and 3/5/26 (336 pounds). Per surveyor request, a weight assessment was completed on 4/10/26, which indicated 285 pounds, a change of 51 pounds in 36 days. Review of the clinical record indicated Resident R33 was admitted to the facility on [DATE]. Review of Resident R33's MDS dated [DATE], included diagnoses of heart failure and kidney disease. Review of Resident R33's current plan of care, initiated 1/16/26, indicated for the facility to, Monitor wts per facility policy/approach. Review of a physician's order dated 3/4/26, indicated, Weekly weights x 4 weeks then monthly. Review of Resident R33's weight record for February 2026 through April 2026, failed to reveal weights captured after 2/1/26. Per surveyor request, a weight assessment was completed on 4/10/26, which indicated 199 pounds, a change of approximately 15 pounds in two months. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to properly monitor weight as ordered for four of six residents. 28 Pa. Code: 211.6(b) Dietary services.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, resident observations and interviews, Resident Council minutes, confidential resident group interview, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eleven of twenty residents (Resident R21, R26, R56, R63, R64, R86, R117, R118, R119, R120, R121), seven of fourteen confidential group residents (Residents R100, R200, R400, R500, R600, R700, and R900), and for five of six Resident Council monthly meetings (October 2025, November2025, December 2025, and February 2026 and March 2026).Findings Include: Review of the Facility Assessment dated 4/14/25, indicated that the facility will follow state required staffing ratios to meet resident to aide/nurse ppd (per patient day) and would provide care for -Activities of Daily Living: (Bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself).-Mobility and fall/fall with injury prevention: Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself.-Bowel/bladder: Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. During an interview on 4/9/26, at 2:17 p.m. when asked if she felt the facility maintained sufficient staffing to care for the residents, Resident R86 stated, Whenever they come in, they don't help put me on the bedpan. I tell them, but they don't do anything. I call the supervisors and tell them, 'Please, I want someone to come in.' Resident R86 stated that she is not incontinent, but it becomes painful to hold her bladder for extended times, stated that she is not always provided fresh waters, and that call lights take a very long time to be responded to. During an interview on 4/10/26, at 9:30 a.m. Resident R23 stated she often must leave her room to get staff to assist her roommate (Resident R10). During an interview and observation on 4/10/26, at 10:10 a.m. Resident R64 stated there's not enough staff, she feels her care is rushed, and that meals are often late. Resident R64 was noted to have greasy appearing skin and an unclean face. During an interview on 4/10/26, at 10:16 a.m. when asked if he felt if the facility maintained sufficient staffing to care for the residents, Resident R56 stated No, not at all. Resident R56 stated call light response times are long. During an interview on 4/10/26, at 10:23 a.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R21 stated, No and Sometimes it takes four to five hours to get help. During an interview on 4/10/26, at 10:25 a.m. when asked if she thought the facility maintained sufficient staffing to care for residents, Resident R63 stated, Sometimes the call lights can be long. When asked, Resident R63 confirmed that she has been left in a soiled brief for a long time, causing skin irritation. During a follow-up interview on 4/10/26, at 1:2 p.m. Resident R86 stated, Lat night I had to wait a long time. I get told to wait because they are going to do somebody else, but they don't come back. Review of Resident Council minutes from 10/7/25: Call light response. 11/4/25: Staff not being present on the floor to provide care, not getting residents out of bed. 12/2/25: Staff not responding to call lights unless it is their section, lack of call light response on evening shift. 2/4/26: Staff not getting residents out of bed, left in the dining room after meals, waiting a long time to be assisted to bed. 3/3/26: Call lights being shut off, care not provided. During a confidential resident group interview on 4/8/26, at 2:00 p.m. the following concerns were voiced:-They have no intention of taking care of us. 13/14 residents. -Staff turn call lights off, without providing care. 13/14 residents.-All residents who need assistance getting in and out of bed stated they have concerns with not getting staff assistance. Resident R100: -From the time I was put in my chair, I have had to wait until 10:45 p.m. before they even thought to put me to bed. I rang for a very long time. Nobody attempted to even try.-You don't know if you are going to get back on bed at all.-Told to stay in bed, that I am too much work. -They are short-staffed. -They don't want to help you.-I was left from 11a to 11 at night. This is too long. My legs were swollen, I was in a lot of pain. -I try to help by being polite, by waiting my turn. But I feel like I'm being completely ignored. -They say they don't have to time to pull me back up in bed.-It's a 15 to 30 minute wait. Resident R200:-Left on the bed pan through dinner. Staff refused to assist.-On Monday (4/6/25), at 8:30 I pushed my button, and the aide came in, but she was a smart [NAME]. Said she would change me, but wouldn't put me on the bed pan. The she said she would put me on the bed pan and come back in 30-40 minutes. She put me on the bed pan and she didn't come back. -My roommate doesn't get changed for 4 to 5 hours. Resident R400-They are way understaffed. -I kept waiting and waiting, I kept on asking her. They left me sitting a urine accident. I was all wet. They just walked out the room. For eight hours I sat in poop and piss. I had a rash. They just put the cream on, they don't even wash me properly. Cream on top of cream. Resident R500-There's not enough staff on the weekends, particularly 11p to 7a. Resident R600-Biggest concern is not enough people and staff not answering call lights.-I've had to wait an hour, hour and a half. I had to call my mom one time to have her get somebody down there to get me out of the room, they shut the door and nobody could see me or hear me. Resident R700-One night there was only two on my floor. -They answer your light and say they will be right with you. But they never come.-The nurses say they have so many patients they need to get to. Resident R900-The staff loaf around. The aide keeps disappearing when it's time to pass out trays. -11-7 is the worst times, and the weekends. The call light wait times are so long. Review of a grievance on Resident R118's behalf on 10/1/25, stated, Family concerned not receiving appropriate oral care, am and pm hygiene - bed linens not being changed and not out of bed. Review of a grievance on Resident R117's behalf on 10/7/25, stated, Family in to visit. Resident was up in chair however her nails were in poor condition, feces under nails. Pad on bed was soiled/urine/feces. Review of a grievance submitted by Resident R86 on 12/20/25, stated, Stated she is not getting the care she needs. Review of a grievance on Resident R119's behalf on 12/22/25, stated, Concerned for her mom and roommate (Resident R120) not being set up for meals in bed. Review of a grievance submitted by Resident R86 on 12/23/25, included concerns relating to long call light response times and not being assisted out of bed. Review of a grievance on Resident R121's behalf on 1/5/26, stated, Resident's wife reported aide told resident to use brief and not urinal. Review of a grievance submitted by Resident R78 on 2/12/26, included concerns relating to not receiving showers and not being assisted to bed until midnight. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents, seven of 14 confidential group residents, and for five of six Resident Council monthly meetings. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of facility documents and staff interview, it was determined that the facility failed to complete annual performance evaluations for five of five nurse aides (Employees E2, E3, E4, E5, and E6).Finding include: During an interview on 4/10/26, at approximately 10:00 a.m. Human Resources Director Employee E1 confirmed that the facility did not complete performance reviews for Employees E2, E3, E4, E5, and E6. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for five of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(a)(b)(c)(d) Staff Development.28 Pa. Code: 211.12(c)(d)(1)(2)(5) Nursing Services.

Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. This failure resulted in immediate jeopardy for 12 of 21 residents (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated, The Nursing Home Administrator (NHA) is responsible for the overall leadership, management, and operation of The Greenery Center for Rehab and Nursing. This role ensures the delivery of high-quality short-term rehabilitation and long-term care services while maintaining compliance with all federal, state (Pennsylvania), and local regulations. The NHA promotes a resident centered environment focused on clinical excellence, safety, and compass. Review of the facility-provided Director of Nursing (DON) job description indicated, The Director of Nursing (DON) is responsible for the overall clinical leadership and management of nursing services at The Greenery Center for Rehab and Nursing. This role ensures the delivery of high-quality, resident-centered care in both short-term rehabilitation and long-term care settings, while maintaining full compliance with Pennsylvania Department of Health and CMS regulations. Based on findings identified in this report, the facility failed to ensure that physicians or other advanced practice providers were notified of capillary blood glucose levels beyond the parameters set in the physicians' orders. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 4/10/26, at approximately 3:00 p.m. the NHA and current DON confirmed that facility administration failed effectively manage the facility to ensure provider notification of changes in condition. This failure created an Immediate Jeopardy situation for 12 of 21 residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of select facility policies and procedures, current Centers for Disease Control (CDC) guidelines, clinical record review, and staff interview, it was determined that the facility failed to document each resident was offered a Covid 19 immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for four of five residents reviewed for immunizations (Residents R20, R24, R31, and R98).Findings include: A review of facility policies, Covid Protocols Post PHE, dated 1/5/26, indicated vaccines are administered in accordance with Centers for Disease Control and Prevention (CDC) recommendations. All residents are encouraged to remain up to date with all recommended Covid 19 vaccine doses. Staff and residents will be educated on the risks/benefits of the Covid vaccination and will be offered the vaccination. A review of the clinical record indicated Resident R20 was admitted to the facility on [DATE], with diagnoses that included COPD (chronic obstructive lung disorder). A review of the Resident Influenza/Pneumococcal/Covid-19 Consent Declination dated 10/8/25 did not include evidence that the resident was offered the Covid-19 vaccine. A review of the clinical record Immunizations documentation on 4/10/26 at 11:00 a.m., did not include information that the Covid-19 vaccines were offered or declined. A review of the clinical record indicated Resident R24 was admitted to the facility on [DATE], with diagnoses that included stroke. A review of the Resident Influenza/Pneumococcal/Covid-19 Consent Declination dated 10/2/25 did not include evidence that the resident was offered the Covid-19 vaccine. A review of the clinical record Immunizations documentation on 4/10/26 at 11:00 a.m., did not include information that the Covid-19 vaccines were offered or declined. A review of the clinical record indicated Resident R31 was admitted to the facility on [DATE], with diagnoses that included Parkinson's (a progressive movement disorder of the nervous system) and bipolar disorder. A review of the Resident Influenza/Pneumococcal/Covid-19 Consent Declination dated 10/14/25 did not include evidence that the resident was offered the Covid-19 vaccine. A review of the clinical record Immunizations documentation on 4/10/26 at 11:00 a.m., did not include information that the Covid-19 vaccines were offered or declined. A review of the clinical record indicated Resident R98 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, and diabetes. A review of the Resident Influenza/Pneumococcal/Covid-19 Consent Declination dated 10/8/25 did not include evidence that the resident was offered the Covid-19 vaccine. A review of the clinical record Immunizations documentation on 4/10/26 at 11:00 a.m., did not include information that the Covid-19 vaccines were offered or declined. During an interview on 4/10/26 at 11:00 a.m., the Infection Control Preventionist (ICP) Employee E13 confirmed the above findings, and that the facility failed to document each resident was offered a Covid-19 vaccine and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations, for Residents R20, R24, R31, and R98.

Based on review of facility documents, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for five of five nurse aides (Employees E2, E3, E4, E5, and E6).Finding include: Review of the Facility Assessment last reviewed 4/15/25, indicated the facility follows all state and federal guidelines for staffing education. Review of the facility provided, Nursing Assistant In-Service Hours document indicated that Nurse Aide (NA) Employees E2, E3, 14, and E5, E6 had the following education: Nurse Aide (NA) Employee E2 had a hire date of 3/7/86, with 2.00 hours in-service education between 3/7/25, and 3/7/26.NA Employee E3 had a hire date of 3/6/20, with 2.00 hours in-service education between 3/6/25, and 3/6/26.NA Employee E4 had a hire date of 9/30/91, with 4.00 hours in-service education between 9/30/24, and 9/30/25.NA Employee E5 had a hire date of 12/21/00, with 4.00 hours in-service education between 12/21/24, and 12/21/25.NA Employee E5 had a hire date of 1/22/24, with 4.00 hours in-service education between 1/22/25, and 1/22/26. No additional documentation of hours were provided to the survey team, as requested, by the end of the survey. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for five of five nurse aides. 28 Pa. Code: 201.14(a) Responsibility of Licensee.28 Pa. Code: 201.20(c) Staff Development.28 Pa. Code: 211.12(c)(d)(1)(2)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters waste, salt and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of five residents reviewed (Resident R1).Findings include: Review of the facility policy Dialysis Management reviewed 1/5/26, indicated the facility has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents regardless of if the procedure is performed at the dialysis center. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included sepsis (overwhelming and life-threatening response to infection that causes organ failure), dependence on renal (kidney) dialysis, and diabetes. Review of the Minimum Data Set (MDS - periodic assessment of care needs) date 1/27/26, indicated the diagnoses remain current. Review of a physician's order dated 1/22/26, indicated Resident R6 was to receive dialysis three days a week on Monday, Wednesday, and Friday. Review of a care plan dated 1/22/26, indicated the following interventions:- Monitor pre and post dialysis weights.- Encourage the resident to go for the scheduled dialysis appointments.- Monitor vital signs as needed/ordered. Notify doctor of significant abnormalities. Review of the dialysis communication forms from January 2026 through April 2026, revealed 12 communication forms out of 16 not completed by the nursing facility pre-dialysis on 1/27/26, 2/2/26, 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26, 2/18/26, 2/20/26, 2/25/26, 3/21/26, and 3/23/26; and 16 possible missing communication sheets on dialysis days 2/16/26, 2/23/26, 2/27/26, 3/2/26, 3/6/26, 3/9/26, 3/11/26, 3/13/26, 3/16/26, 3/18/26, 3/25/26, 3/27/26, 4/1/26, 4/3/26, and 4/6/26. During an interview on 4/10/26, at 9:00 a.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E11 confirmed the facility failed to ensure the dialysis communication form was completed pre and post treatment between the facility and dialysis center and confirmed the missing dialysis sheets were not available at the facility. During an interview on 4/10/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure dialysis communication sheets were completed prior to dialysis treatment. 28 Pa Code: 211.10(c)(d) Resident care policies.28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, observations and staff interview, it was determined that the facility failed to make certain that out of date medications were discarded in one of three medication rooms (North Unit medication room) and failed to properly secure a treatment cart on one of two nursing units (South Unit). Findings include: Review of the facility policy Medication Storage in the Facility, dated [DATE], indicated medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Also, Outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory. During an observation of the North Unit medication room on [DATE], at 1:40 p.m. revealed:(7) Blood collection tubes with an expiration date of [DATE].(15) Blood collection tubes with an expiration date of [DATE].(7) Blood collection tubes with an expiration date of [DATE].(1) Anaerobic blood culture bottle with an expiration date of [DATE].(1) Aerobic blood culture bottle with an expiration date of [DATE].(4) glycerin swab sticks with an expiration date of 1/2026.(62) hydrocortisone packets with an expiration date of 10/2025.(2) hydrocolloid dressings with an expiration date of 07/2024.(3) foam dressings with an expiration date of [DATE].(3) Huber needle sets with an expiration date of [DATE].(1) Silicone contact layer with an expiration date of [DATE]. During an interview on [DATE], at approximately 1:55 p.m. Licensed Practical Nurse Employee E7 confirmed the above items were expired. During an observation on [DATE], at 9:45 a.m. a treatment cart was unsecured inside the supply room with the door propped open. The treatment cart contained two bottles of peroxide, one bottle of rubbing alcohol, seven bottles of resident specific ammonium lactate 12 % (lotion used to treat dry, scaly skin conditions), and seven tubes of triamcinolone acetonide (cream used to reduce inflammation, itching, and redness, or joint pain), and various bandages and gauze. During an interview on the same date and time, Registered Nurse Assessment Coordinator (RNAC) Employee E11 confirmed the treatment cart should be secured when unattended, and the door to the supply room should not be propped open. During an interview on [DATE], at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that out-of-date medications were discarded in one of three medication rooms and failed to properly secure a treatment cart inside a propped door. 28 Pa. Code: S211.9(a)(1)(k) Pharmacy services.28 Pa. Code: S211.12(d)(1)(5) Nursing services.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision which resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of 15 residents who were identified as high risk for elopement (Resident R1). The facility also failed to make certain that four of 15 residents had appropriate data including pictures and identification of risk for elopement available to staff for review (Resident R2, R3, R4 and R5). Findings include: Review of the facility Wandering and Elopements policy last reviewed 8/9/24, indicated that the facility will identify residents who are at risk of unsafe wandering and exit seeking behavior and develop individualized prevention and management interventions based on assessment. The facility procedure includes the assessment of potential risk factors such as exit doors and the door alarms and wander control systems are to be maintained in working order. The facility is to maintain a current list of names and photographs of residents identified to be at risk for elopement and monitor the whereabouts of the at risk residents. Residents identified as at risk have a monitoring bracelet and an order identifying where the monitor is placed and that it is to be checked every shift for placement and functioning and documented on the Medication Administration Record/Treatment Administration Record (MAR/TAR). The resident's plan of care is reviewed and revised as needed. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's admission record indicated she was originally admitted on [DATE], with a re-admitted [DATE]. Review of Resident R1's Minimum Data Set assessment (MDS -a periodic assessment of resident care needs) dated 1/13/25, included diagnoses of dementia (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), anxiety disorder, Stage 3 kidney disease with urinary retention. Review of Section C0500-BIMS screening indicated a score of 2, which indicated Resident R1 was not alert and oriented, and had severe cognitive impairment. Review of the clinical record indicated Resident R1 had a recent hospitalization due to a fall at home requiring admission to the facility. Review of Resident R1's admission Elopement Risk Assessment completed on 1/9/25, indicated that Resident R1 was cognitively impaired with poor decision making skills, exhibited wandering behaviors and wandering is likely to affect herself and others and the elopement score was 4, which indicated she exhibited wandering behaviors and was at risk for elopement. Review of a progress note dated 1/9/25, at 12:10 p.m., Licensed Practical Nurse (LPN) Employee E1 documented Resident R1 wandering in the hallways and into other resident rooms and placed a Wanderguard (electronic monitoring bracelet) on Resident R1's right ankle and notified the family. Review of a progress note dated 1/9/25, at 12:28 p.m. (the same day, not less than a half hour later), LPN Employee E1 documented that Resident R1 was not exhibiting exit seeking behaviors, so the Wanderguard was removed, and staff were to monitor her. Documentation in the clinical record did not include any interventions of the monitoring completed by staff. During an interview on 1/29/25, at 11:17 a.m., the Director of Nursing (DON) stated, I told the LPN to remove the Wanderguard as the resident was not exhibiting exit seeking behaviors. Review of facility submitted documentation dated 1/11/25, indicated on Saturday, 1/11/25, at approximately 7:15 a.m., Resident R1 was observed by staff outside of the building walking on the sidewalk in front of the building near the parking lot of the facility. The weather that day was sunny and cold at 26 degrees Farenheit. A staff member who was coming in found her and immediately walked her back into the building. There were no injuries and when asked Resident R1 did not respond to where she was going. Resident R1 was last seen at approximately 7:10 a.m., inside the facility in the cafeteria waiting for breakfast. Review of LPN Employee E1's witness statement dated 1/11/25, indicated that Resident R1 was standing near the breakroom near the main entrance and LPN Employee E2 walked her into the cafeteria and sat her in a stationary chair. LPN Employee E1 notified cafeteria staff and the other staff in the cafeteria. At approximately 7:15 a.m., LPN Employee E1 was in report and overheard a nurse aide state that Resident R1 was outside and had been brought back into the building. During an interview on 1/28/25, at 3:26 p.m., LPN Employee E1 stated that she remembered her statement during the investigation and that the resident wandered all over the place in all the halls and into other resident rooms. On the date of the elopement, LPN Employee E1 stated that she had to walk Resident R1 from the entrance area to the cafeteria where she had last seen her. Review of Agency LPN Employee E2's statement dated 1/11/25, indicated that when she came in Resident R1 was walking out of the double front doors and LPN Employee E2 met her and asked where she was going. Resident R1 did not respond and LPN Employee E2 walked Resident R1 back inside. LPN Employee E2 got a nurse aide's attention and the nurse aide returned Resident R1 to the nurses station and the Registered Nurse Supervisor was made aware. During a phone interview on 1/28/25, at 3:30 p.m., LPN Employee E2 stated she remembered what happened and stated she was running late getting to the facility and Resident R1 was in a sweatsuit with slippers on. LPN Employee E2 stated there was no staff at the front desk and she is unsure what could have happened had she not come in when she did. Review of Resident R1's clinical record after the elopement on 1/11/25, included a complete full body assessment immediately after the incident. Resident R1 had an elopement bracelet placed and her plan of care was updated. During an observation on 1/28/25, at 8:53 a.m., the Wanderguard alarm was tested which locked when near the front door, however, the Maintenance Director Employee E4 demonstrated that the doors break away to open if pushed. During an interview on 1/28/25, at 8:55 a.m., Restorative Aide / Front Desk staff Employee E3 stated that there are no staff posted at the front desk after hours and on weekends. She stated that the front desk has a Elopement Book with all the resident's identified as an elopement risk listed and their information with a picture to identify them. The book also contains the facility policy and procedures for wandering/elopement risk. During an interview on 1/28/25, at 8:57 a.m., the Nursing Home Administrator confirmed that there is a book left at the front desk and the Director of Nursing has one as well. During an observation on 1/28/25 at 8:59 a.m., Resident R2 approached the doors wearing a Wanderguard, the lock sound was heard but the doors opened which could have allowed Resident R2 to exit. This was attempted three times. Review of clinical record indicated that Resident R2 was admitted to the facility 11/19/21, with diagnoses which included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and falls. Review of an elopement evaluation dated 1/21/25, indicated a 5, at risk for elopement. Review of the Elopement Book did not include Resident R2's information and her picture. Review of the Elopement Book at the front desk which is to include all residents at risk for elopement on a list, their elopement assessment, a picture and personal data and the policies/procedures for elopement: During an observation on 1/28/25, at 9:04 a.m., Resident R3 approached the front entrance doors with the door lock sounding and alarm sounding. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease and falls. Review of an elopement evaluation dated 12/25/24, indicated a 3, at risk for elopement. Review of the Elopement Book at the front desk did not include a picture to identify Resident R3. During an observation on 1/28/25, at 9:10 a.m., Resident R4 approached the front entrance doors with the door lock sounding and alarm sounding. Review of the Elopement Book at the front desk did not include a picture, an elopement risk assessment, or personal data to identify Resident R4. During an observation on 1/28/25, at 9:17 a.m., Resident R5 approached the front entrance doors with the door lock sounding and alarm sounding. Review of the clinical record indicated that Resident R5 was admitted to the facility on [DATE], with diagnoses which included dementia and difficulty walking. Review of an elopement evaluation dated 11/16/24, indicated a 3, at risk for elopement. Review of the Elopement Book at the front desk did not include Resident R5 listed as at risk, but did include a picture, assessment and personal data. During an interview on 1/28/25, at 11:50 a.m., the Nursing Home Administrator and the DON confirmed that Resident R1 was identified as a wander risk on 1/9/25, confirmed that the facility relied on the Wanderguard system to provide elopement supervision, although the front doors are not always monitored after hours and on the weekend, and will release if pushed. On 1/28/25, NHA and the DON were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 1/11/25, and facility staff were provided an Immediate Jeopardy template at 11:53 a.m., and a corrective action plan was requested. On 1/28/25, at 3:53 p.m. an immediate action plan was received and accepted which included the following interventions: 1. Resident R1 had been discharged . 2. Elopement reassessments of all residents currently identified as elopement risk by 1/29/25. 3. Complete whole house education with all staff on elopement policy/procedure, the elopement binder, and appropriate supervision by 1/29/25. 4. The door vendor was onsite 1/28/25, to evaluate doors for repairs. 5. All residents upon admission will be evaluated for elopement risk and interventions. The DON will audit two residents weekly for appropriate interventions for four weeks. On 1/29/25 at 2:44 p.m., all residents' assessments for elopement risk were reviewed and found to be completed, and care plans were reviewed and updated if needed. The elopement policy was updated, and documentation verified all current residents' Wanderguard's functioned correctly. During interviews of staff working on 1/29/25, between 12:15 p.m. and 1:50 p.m. staff (27 out of 52 staff persons) confirmed they were trained on the updated elopement policy, what to do during an elopement, the location and purpose of the elopement book at the nurse's station, and appropriate resident supervision. Staff education was verified with dated sign-in sheets and review of all current staff and agency staff utilized in the facility having signed and/or educated over the phone as indicated. The NHA sent out a broad text to the Agency as well indicating any staff that had not been in the facility will have to be educated prior to their shift start. Verification of the facility's Corrective Action Plan revealed all elements of plan were met with all staff signatures and review of education with 27 of 52 staff currently in the building on the date of review which included agency staff. The Immediate Jeopardy was lifted on 1/29/25, at 2:44 p.m. During an interview on 1/28/25, at 10:55 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide adequate supervision resulting in Resident R1's elopement. This failure created an immediate jeopardy situation for Resident R1 and potentially put her at risk of harm or injury. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services.

Based on review of facility policies, clinical records and facility documents, and resident and staff interviews, it was determined that the facility failed to make certain that each resident's environment remained free of accident hazards regarding the facility's failure to accurately assess four of 14 residents who smoke (Resident R26, R31, R71 and R288) and failed to secure smoking materials for one of 4 residents (Resident R288) who ignited a trash can on two separate occasions, which placed the residents at a high risk for injury resulting in an Immediate Jeopardy situation. Findings included: Review of the facility policy Resident Smoking dated 6/28/19, indicated that residents will be permitted to smoke in designated areas on the outside of the facility, located in the enclosed courtyard, outside the main dining room. At no time will smoking be permitted inside the facility. Residents will be evaluated to determine whether they can safely smoke independently. If a resident is not able to smoke safely independently, they must have supervision of family or staff at set smoking times. Residents that cannot smoke independently must have their smoking items kept secured at the nurses' station. No resident is permitted to supervise another resident or give another resident smoking items. Review of the facility admission packet provided to all residents on admission indicated in the Smoking Policy section, that all residents are prohibited from keeping any smoking material in their rooms or on their person. Review of the facility policy Resident Incident/Injury Investigation Protocol dated 6/28/19, indicated that should a resident be involved in an incident/accident, an investigation will be started by the nurse on the shift. The shift supervisor will notify the physician and document in the clinical record shall include new interventions and following up with MD and notifying responsible party. Review of the clinical record indicated that Resident R288 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Clinical Record for Resident R288 revealed the following progress notes: -dated 9/9/19, at 5:30 a.m. Licensed Practical Nurse (LPN) documented, Resident coughing, refused cough medication, out to courtyard to smoke. -dated 9/18/19, at 2:19 a.m. LPN documented, strong smell of smoke in the hall, when investigated found coming from this room, resident sitting on bedside, at first denied smoking in room, but after inquiring several times resident admitted that he did wake up and light a cigarette but realized where he was and immediately threw it in trash and dumped soda pop on it, bag removed from room with cigarette in it, resident refused to give lighter or smoking material to this nurse, supervisor notified, resident up and out to courtyard at this time. -dated 9/20/19, at 12:30 a.m. LPN documented, Strong odor of smoke detected in the hall, when investigated found partially smoked cigarette on the bedside table and smoldering tissues in the trash can beside bed, resident began snoring very loudly when nurse called name, refusing to acknowledge that this nurse and CNA are in room, trash liner taken from room as well as used cigarette, doused liner with water, called supervisor to room, resident continues to ignore staff when speaking to him, explained to resident that at this time he will need to obtain cigarettes from supervisor due to unsafe to have with him and that the two open packs on the table were being taken and put in the supervisors office, resident again not acknowledging that staff in room and snoring louder. -dated 9/20/19, 4:06 a.m. LPN documented, Resident in the hall yelling, Resident said police were called because staff took his smoking materials. Resident was reeducated on the incident of the trash liner being lit on fire. Resident was told for safety reasons that smoking materials were in supervisor's office. -dated 9/20/19, 4:38 a.m. LPN documented, Per supervisor smoking material returned to resident. -dated 9/20/19, LPN documented, Resident angry about floor nurse taking cigarettes. These were returned to him. Resident counseled about smoking in his room but was not listening. Was screaming that he/she did not have to talk. During an observation on 9/24/19, at 2:08 p.m. Resident R288 was at the West Unit nurses' station with a lighter and cigarettes. During observations on 9/24/19, at 2:09 p.m. and on 9/25/19, at 7:55 a.m. Resident R288 was seen walking through out the facility, unsupervised with a lighter and cigarettes. During an observation on 9/24/19, at 2:18 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R288 was in the courtyard with his smoking materials unsupervised. Review of the clinical record did not include an assessment to determine Resident R288's ability to smoke safely. Review of the Admission Nursing Data Collection Tool dated 8/21/19, revealed that Resident R288 was not oriented to facility's smoking policy. Review of Resident R288's (MONTH) 2019, recapitulation orders did not include a physician order to smoke. Review of Resident R288's plan of care dated 9/20/19, indicated that Resident R288 was a smoker and was not safe to independently store smoking supplies, indicated that staff will explain/show where designated smoking areas are located, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times. During an interview on 9/25/19, at 9:48 a.m. the Director of Nursing confirmed that the facility failed to provide Resident R288 with orientation of the facility's smoking policy, failed to assess Resident R288 for safe smoking behaviors or take action after smoking incidents occurred to secure Resident R288's smoking materials, and failed to investigate and develop a plan for safe smoking practice, which created the potential for harm of all residents placing the facility in an Immediate Jeopardy situation. Review of the clinical record indicated that Resident R26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R26's Acute Care Discharge Summary-Social History, indicated that resident smokes cigarettes. Discharge plan indicated that resident required maximum assistance for mobility and will need physical assistance for mobility. Review of Resident R26's (MONTH) 2019 Recapitulation orders did not include a physician's order to smoke. Review of Resident R26's Admission Nursing Data Collection Tool dated 6/24/19, indicated that the facility did not orient resident to facility's smoking policy and the facility failed to identify Resident R26 as a smoker. Review of Resident R26's Smoking Risk Observation dated 8/27/19, indicated that Resident R26 will be a supervised smoker due to inability to hold cigarettes. Staff will assist. Review of Resident R26's care plan dated 8/27/19, indicated that resident is at risk for injury, is to be a supervised smoker, unable to handle cigarettes independently, indicated that staff will explain/show where designated smoking areas are located, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times. During an interview on 9/25/19, at 9:48 a.m. Director of Nursing confirmed that the facility failed to identify Resident R26 as a smoker, assess resident for safe smoking behaviors on admission, provide an orientation of the facility smoking policy,and develop a resident-centered plan of care from admission on 6/24/19, until 8/27/19. Review of the clinical record indicated that Resident R31 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set-Assessment of residents current physical and mental needs) dated 7/4/19, indicated the [DIAGNOSES REDACTED]. Review of Resident R31's history of assessments completed since admission, indicated that the first smoking assessment was not completed until 8/9/19, to determine her ability to smoke safely. Review of the current plan of care dated 8/16/19, indicated Resident R31 now required a smoking apron (fire resistant garment) while smoking. During an interview on 9/24/19, at 9:25 a.m. Resident R31 indicated that she had dropped a cigarette and was not wearing an apron. Review of the clinical record indicated that Resident R71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R71's (MONTH) 2019, recapitulation orders did not include a physician's order to smoke. Review of the Resident Smoking Policy signed by Resident R71 on 8/3/19, indicated that all residents that wish to smoke they will be evaluated to determine if resident can safely smoke independently. Review of Resident R71's Smoking Risk Observation dated 8/4/19, was incomplete. Information related to resident mobility, capability to follow facility safe smoking policy and clinical judgement-resident capable of supervised smoking was not completed. Review of Resident R71's progress note dated 9/11/19, at 2:29 p.m. indicated that resident was out in the courtyard smoking. Review of Resident R71's progress notes dated 9/24/19, at 12:15 p.m. stated, Resident was brought back into the facility from smoking when he was noticed to go unresponsive by a peer. Review of Resident R71's care plan dated 8/3/19, indicated that resident is at risk for injury related to smoking. Resident R71's care plan related to smoking entailed resident will smoke in designated areas without occurrence of injury over next 90 days and the staff will explain/show designated smoking area as needed, perform smoking assessment according to facility policy, and post smoking schedule for resident to refer to facility smoking times. During an interview on 9/25/19, at 9:48 a.m. the DON confirmed that all residents that wish to smoke are to be observed by staff for safe smoking practices, DON confirmed that Resident R71 was not observed or assessed for safety during smoking, which created the potential for an accident and/or injury. On 9/25/19, 2:30 p.m. the Nursing Home Administer and the Director of Nursing were informed of Immediate Jeopardy at the facility and a request for a written Corrective Action Plan. The Corrective Action Plan was accepted on 9/25/19, at 6:26 p.m. and included the following: 1. After the issue was identified resident lighter and cigarettes were removed from possession and now receives from the nurse and returns when complete. Resident R288 had a smoking assessment completed and care plan was updated. 2. Current residents that smoke in the facility were assessed/reassessed for smoking safety by Assistant Director of Nursing (ADON). 3. Care plans were reviewed and revised. Point of Care in Matrix (computer charting system) to notify staff of smoking status and interventions. 4. The facility implemented a new smoking policy that all newly admitted residents will be supervised smoking only at designated smoking times, designated smoking areas, and may not have their smoking materials on their person. 5. Previously identified independent smoking residents will be able to maintain their smoking materials unless when re-assessed according to policy that they are no longer assessed to be able to smoke safely independently or they violate policy. 6. Current residents who smoke will be re-educated by Licensed Nursing Home Administrator on the new policy on 9/25/19. 7. Shift Supervisor is doing 15-minute checks on the designated smoking area's the courtyard and the ambulance entrance. 8. Current staff, included contracted staff, educated on the new policy/protocol beginning on 9/25/19, by the ADON. Staff not available will be educated on their return and newly hired staff will be educated during orientation. 9. Resident smoking assessments will be completed upon admission, quarterly, significant change, annually, and as needed. The shift supervisor or nursing staff member will supervise residents identified as needing assistance. 10. The Medical Director and QAPI Committee has been notified of the alleged Immediate Jeopardy and plan of action and the newly implemented smoking policy. 11. Residents' responsible parties/guardian will be informed of the newly implemented policy by mail. Newly admitted residents/responsible parties will be notified on admission. During observations of the smoking areas (courtyard and ambulance entrance) on 9/27/19, at 6:45 a.m., 7:00 a.m., 7:10 a.m., 8:00 a.m., 8:15 a.m., 8:18 a.m., 9:00 a.m., 9:30 a.m., 9:50 a.m., and 9:55 a.m. Residents R31, R81, R83, and R294 were observed in the courtyard wearing smoking aprons and being supervised by facility staff. There were no observations of Resident R7, who smoked at the ambulance entrance, because the resident had not yet awakened. During interviews on 9/27/19, at 7:15 a.m. and 8:20 a.m. Registered Nurse (RN) Employee E7, RN Employee E8, Nurse Aide (NA) Employee E9, and NA Employee E10 confirmed being educated on the facility smoking policy and were knowledgeable about the new procedure. A review of the documentation received from the facility on 9/27/19, revealed that re-education on the smoking policy was provided to all facility staff, families and residents, and audits were conducted of the smoking areas as per the facility's action plan. The Immediate Jeopardy was lifted on 9/27/19, at 12:45 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/11/17. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 8/11/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/15/18, 8/11/17. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 8/11/17. 28 Pa Code 211.5(f) Clinical records. Previously cited 8/11/17. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 8/11/17. 28 Pa. Code 211.10(b) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 6/25/19, 8/11/17. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/25/19, 8/11/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/11/17.

Based on review of facility policies, clinical records and facility specific documents, observation, and staff interviews, it was determined that the facility failed to evaluate and provide appropriate positioning device(s) to one of two residents in a persistent vegetative state which resulted in actual harm (a burn on the arm) to the resident (Resident R65) . Findings include: The facility policy Resident Rights - Pennsylvania Law dated 6/10/18, and last reviewed by the facility on 7/11/19, indicated that the policies of the facility set forth the rights of the resident which included being treated with consideration, respect, and full recognition of dignity and individuality in care for the necessary personal and social needs. The facility policy Screening, Rehabilitation policy dated 6/10/18, and last reviewed by the facility on 7/11/19, indicated that a resident was referred for a rehabilitation screening for seating and positioning concerns. The face sheet indicated that Resident R65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS-periodic assessment of care needs) dated 9/29/18, included the same [DIAGNOSES REDACTED]. Review of nursing progress notes from 11/28/18 through 12/16/18, revealed multiple occasions that Resident R65 had purposeless movement (movement of body or extremities without voluntary purpose) of arms and fidgeted with sheets and gown. Review of the annual MDS dated [DATE], indicated that Resident R65 continued to have severe cognitive impairment, was totally dependent on at least two staff persons for transfers and bed mobility, and that the resident had impairment of both upper and lower extremities. Review of the care plan dated 12/16/18, indicated that Resident R65 was dependent on facility staff for all positioning needs and that the resident had no safety awareness. Review of the nursing progress notes from 12/17/18, to 1/17/19, revealed several occasions that Resident R65 remained in a vegetative state and continued to have movements of his arms, such as digging hand into the mattress, grabbing, and pinching. Review of ongoing physician orders [REDACTED]. Review of the clinical record indicated that Resident R65 was not evaluated by nursing or the rehabilitation department for positioning needs after the resident exhibited purposeless movements of his upper extremities from 11/28/18 through 1/17/19. Review of a nursing progress note dated 1/18/19, revealed that Resident (R65) was placed in geri-chair and sat outside of window at 11:30 a.m. At 12:15 p.m. resident needed to be repositioned due to arm resting over geri-chair .Assessed left arm resting on baseboard heater [MEDICATION NAME] applied after measurement of 1x2 cm (one by two centimeter) blister observed, surrounding tissue is red. Review of a physician order [REDACTED]. Change daily and as needed. Review of the facility incident investigation dated 1/18/19, indicated that Resident R65 sustained a burn when the resident's left arm was found resting on the heater, staff educated on safety and positioning, and a referral was made to therapy for positioning to prevent hand from sliding off the geri-chair. Review of a nursing progress note dated 1/21/19, at 1:32 p.m. indicated that RN Employee E1 further assessed Resident R65's left arm wound and that blister remains 1x1 cm (one by one centimeter), open skin measures 5x4x0.1 cm (five by four by 0.1 centimeter) wound bed pink. During an observation of Resident R65 on 9/24/19, at 1:05 p.m. there was a reddish colored scar on the resident's left forearm measuring 10 cm in length and 5.8 cm in width. During an interview on 9/24/19, at 1:15 p.m. Licensed Practical Nurse confirmed that Resident R65 had sporadic movements of upper and lower extremities and that prior to the burn on 1/18/19, there were no specific instructions for safety positioning the resident's extremities when the resident was seated in the geri-chair. During an interview on 9/25/19, at 2:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to evaluate and provide appropriate positioning device(s) to Resident R65 which resulted in actual harm (a burn on the arm) to the resident. 42 CFR 483.25 Quality of Care. Previously cited 6/25/19, 8/11/17. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 8/11/17. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 6/25/19, 8/11/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/25/19, 8/11/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/11/17.

Based on review of facility policy, facility documents, clinical records and staff interviews, it was determined that the facility failed to provide care and services associated with a ventilator dependent resident, resulting in actual harm for one of 17 residents reviewed (Resident CR1). Findings include: The facility policy entitled, Ventilator Alarm Equipment Check dated 6/15, indicated the ventilator (device for artificial respiration) alarm and equipment will be checked every shift and intermittent checks will be done when the resident is removed from the ventilator and then returns to mechanical ventilations. Review of the facility face sheet indicated that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the information dated 6/19/15 submitted by the facility, indicated that Resident CR1 was returned to bed and reconnected to the ventilator, after being given a shower by Respiratory Therapist, Employee E1, on 6/18/15 at 7:02 p.m. The Event Report indicated that Respiratory Therapist, Employee E2, responded to a ventilator alarm sounding in the resident's room on 6/18/15 at 7:50 p.m., and found Resident CR1 to be disconnected from the ventilator and without respirations or a pulse. The information submitted by the facility, indicated that the second remote ventilator (unit located in the hall outside the room which is connected to the ventilator system and sounds an additional, louder alarm) for Resident CR1 was not sounding and was found to be turned off. Review of the nurses' notes dated 6/18/15 at 9:38 p.m., indicated that the Registered Nurse (RN) Supervisor, Employee E3, responded to a call for help from Employee E2 and entered the room at 7:59 p.m. During an interview on 7/15/15 at 1:05 p.m., Respiratory Therapy (RT) Director, Employee E4, stated that the ventilator computer printout of function, indicated that the initial ventilator alarm sounded, signaling a problem in Resident CR1's room on 6/18/15 at 7:04 p.m. The printout further indicated that Resident CR1 was disconnected from the ventilator at 7:08 p.m., and had no ventilator support to breathe for a period of 55 minutes. Employee E4 indicated all equipment was checked for malfunction by the contractor on 6/19/15, and that no equipment problem was found with the ventilator or the outside remote alarm unit. During an interview on 7/16/15 at 3:10 p.m., Employee E3, confirmed the events above and stated that Resident CR1 was without heart sounds when she responded at 7:59 p.m. During a phone interview on 7/17/15 at 2:30 p.m., Employee E1 confirmed that the ventilator alarms are able to be heard in the hall and that all the staff are responsible to respond to any alarm detected. The facility staff failed to provide services and respond to a ventilator alarm for a period of 55 minutes, resulting in actual harm to Resident CR1. Refer to F226, F490 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 6/24/15, 9/6/13. 28 Pa. Code: 201.14(b) Responsibility of licensee. 28 Pa Code: 201.18(a) Management. 28 Pa Code: 201.18(b)(1) Management. Previously cited 10/31/14, 9/6/13. 28 Pa Code: 201.18(b)(3) Management. Previously cited 9/6/13. 28 Pa Code: 211.10(a)(d) Resident care policies. 28 Pa. Code: 211.12(c) Nursing services. 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 6/24/15, 10/31/14, 9/6/13. 28 Pa. Code: 211.12(d)(2) Nursing services. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited 12/17/14, 9/6/13. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited 6/24/15, 10/31/14, 12/17/14, 9/6/13.

Based on review of facility policy, facility documents and clinical records and staff interviews, it was determined that the facility failed to complete a thorough investigation of an incident and failed to report an incident of alleged neglect as required for one of 17 residents reviewed (Resident CR1). Findings include: The facility policy entitled, Social Service - Abuse, Neglect and Misappropriation dated 5/01/15, indicated that the facility maintains that all allegations of abuse, neglect, etc. are thoroughly investigated, and if the abuse/neglect involves serious harm, the legal department is contacted prior to beginning an investigation. In addition, the policy stated that, written summaries of interviews with individuals having firsthand knowledge of the incident. Employee/witnesses are not to write out statements. Employees/witnesses will be interviewed by facility designee and the interviewee will record all witness accounts in a document written, dated, and signed by the interviewer. The facility policy entitled, Social Service - Abuse, Neglect and Misappropriation dated 5/01/15, also indicated that the facility conducts an internal investigation through the Legal Department and reports the results to enforcement agencies as prescribed by state law. Review of the facility face sheet indicated that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the information dated 6/19/15, submitted by the facility, indicated that Resident CR1 was returned to bed after being given a shower and reconnected to the ventilator (device for artificial respiration) by Respiratory Therapist (RT), Employee E1, on 6/18/15 at 7:02 p.m. The Event Report indicated that RT Employee E2 responded to a ventilator alarm sounding in the resident's room on 6/18/15 at 7:50 p.m., and found Resident CR1 to be disconnected from the ventilator and without respirations or a pulse. The Event Report indicated that the second remote ventilator alarm (unit located in the hall outside the room which is connected to the ventilator system and sounds an additional, louder alarm) for Resident CR1 was not sounding and was found to be turned off. Review of the information in regards to abuse investigation which was submitted by the facility for the 6/18/15 incident involving Resident CR1, did not include signed statements by staff members on the unit as required. During an onsite visit on 7/16/15, the facility failed to provide signed statements from Employees E1 or E2 as requested. During an interview on 7/16/15 at 3:10 p.m., the Registered Nurse Supervisor, Employee E3, confirmed that she did have Employee E2's signed statement on 6/18/15, and submitted the statements to the Nursing Home Administrator (NHA). During an interview on 7/16/15 at 9:15 a.m., the NHA stated that there were no individual statements written and signed by the employees present during the incident and confirmed that the information submitted by the facility, included the Director of Nursing (DON) summary and interviews of the involved employees which were written and signed by the DON. Review of the investigation submitted to the state agency by the facility, failed to include all statements which were written by the employees involved at the time of the 6/18/15 incident. The facility policy entitled, Social Service - Abuse, Neglect and Misappropriation dated 5/01/15, indicated that the facility's Leadership will provide notification to the proper authorities, and when required, will release of information to those agencies, pursuant to applicable federal and/or state law (F223, F224, F225 and F226). During a phone interview with the Washington County Coroner's Office on 7/17/15 at 9:34 a.m., it was confirmed that the office was not notified of the incident on 6/18/15, involving the death of Resident CR1 as required. Review of the information in regards to abuse reporting which was submitted by the facility on 6/18/15, indicated that the County Adult Protective Services was notified of the incident involving Resident CR1 on 6/24/15 at 3:52 p.m. During a phone interview with County Adult Protective Services on 7/17/15 at 9:20 a.m., it was confirmed that the County Adult Protective Services office was not notified of the incident involving Resident CR1 on 6/18/15, as required by law. Review of the information in regards to abuse reporting which was submitted by the facility on 6/18/15, involving Resident CR1, indicated that the State Adult Protective Services was notified on 6/24/15 at 2:30 p.m. During a phone interview with State Adult Protective Services on 7/22/15 at 2:35 p.m., it was confirmed that the incident on 6/18/15, involving the death of Resident CR1 was not reported to the State Adult Protective Services as required by law. During a phone interview with the North Strabane Township Police on 7/22/15 at 3:34 p.m., it was confirmed that the incident on 6/18/15, involving the death of Resident CR1 was not reported to local law enforcement as required. During an interview on 7/16/15, at 9:30 a.m., the NHA stated the police and coroner were not contacted because there was no need. The NHA also confirmed that the DON entered the information in regards to abuse investigation could not be verified through telephone interviews to various agencies. 28 Pa. Code 201.14(a)Responsibility of the licensee. Previously cited 6/24/15, 9/6/13. 28 Pa Code: 201.18(b)(1) Management. Previously cited 10/31/14, 9/6/13. 28 Pa Code: 201.18(e)(1) Management. Previously cited 6/24/15, 10/31/14, 9/6/13. 28. Pa. code: 207.2(a)Administrator's Responsibility Previously cited 10/31/14, 12/17/14, 9/6/13. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.5(f) Clinical records. Previously cited 6/24/15, 10/31/14. 28 Pa. Code 211.12(a) Nursing services. Previously cited 9/6/13. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/24/15, 10/31/14, 9/6/13. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/17/14, 9/6/13. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/24/15, 10/31/14, 12/17/14, 9/6/13.