Every finding on record at Greenwood Center for Nursing and Rehab

Based on observations, clinical record review, review of facility policies and investigative documentation, video surveillance, and resident and staff interviews, it was determined the facility failed to provide adequate supervision and implement effective interventions to prevent two of 10 residents reviewed (Residents 1 and 2), who were identified as being at risk for elopement, from exiting the facility without staff knowledge or supervision.Findings include: A review of the facility policy titled Elopement, last reviewed January 28, 2026, revealed the facility's policy is to provide residents with a safe and secure environment and to proactively prevent resident elopement (when a resident leaves the facility or a designated safe area without staff knowledge or authorization). The policy directs staff to evaluate residents for elopement risk upon admission, readmission, quarterly, and following a significant change in condition. The policy required staff to assess residents with a history of substance use disorder, develop individualized care plan interventions to reduce the risk of elopement, redirect residents who attempt to leave the facility without supervision, and maintain a current photograph of each resident identified as being at risk for elopement. Observation of the facility's main entrance revealed two interior doors leading to the exit area. One interior door opened into an enclosed vestibule (an enclosed area between the interior and exterior entrance doors), and the second door provided access to the outside. Neither interior door was routinely locked from inside the building. During weekday daytime hours, a clerical employee was stationed in an office adjacent to the entrance and had a direct line of sight to the main hallway and entrance doors from 8:30 AM until 2:00 PM. The entrance was not routinely monitored by an employee stationed in this area after 2:00 PM on weekdays or during weekends. Observation revealed the exterior entrance operated through an electronic access system. Between 8:00 AM and 4:30 PM, individuals entering the facility from outside could access the entrance without staff assistance. After 4:30 PM, individuals seeking entry were required to activate an exterior call button that alerted staff inside the facility, who could remotely unlock the exterior entrance door. From inside the facility, the entrance permitted residents to exit unless the electronic elopement-prevention system was activated by a resident's electronic device. The facility utilized an electronic Wander Guard system to assist in preventing elopement. Residents identified as being at risk for elopement wore an electronic device attached to the resident or the resident's mobility equipment, such as a wheelchair or walker. When a functioning electronic device approached a monitored exit, the system was designed to lock the interior exit door, activate an audible alarm at the doorway, and illuminate a red indicator light above the door. A review of facility records dated August 11, 2026, revealed the facility had identified 20 residents as being at risk for elopement, including Resident 1 and Resident 2. These residents relied on the facility's elopement prevention system and staff supervision to prevent unauthorized exit from the building. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include diabetes mellitus (sugar builds up in the bloodstream) and adjustment disorder with depressed mood (happens when a person has deep sadness, crying, or hopelessness after a major life stressor). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2026, revealed Resident 1 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 indicates significant thinking or memory challenges that could impact daily life).A review of Resident 1's care plan initiated May 3, 2026, identified a history of recurrence of substance use and withdrawal symptoms (physical or emotional symptoms that may occur after reducing or stopping the use of certain substances). Interventions included providing relaxation techniques, referral to mental health services, and identifying Resident 1's goals for the stay. A separate care plan initiated May 20, 2026, identified Resident 1 as being at risk for elopement and associated injury related to exit-seeking behavior. Interventions included informing reception and other staff of the resident's elopement risk, offering outside time on the back porch, and providing diversional activities when the resident searched for an exit. On June 30, 2026, the facility revised the care plan to include hourly checks from 4:00 PM until bedtime on business days and hourly checks from 7:00 AM until bedtime on weekends and holidays. A review of the clinical record revealed Resident 1 demonstrated a persistent and escalating pattern of exit seeking behaviors beginning in March 2026. Documentation consistently showed Resident 1 repeatedly expressed the intent to leave the facility, packed personal belongings in preparation for leaving, requested housing information, remained focused on returning home, and was frequently unable to be redirected by staff despite repeated interventions. A nursing progress note dated June 22, 2026, at 2:23 PM documented that the Wander Guard alarm sounded when Resident 1 was at the front door attempting to open it and stating, I need to go to work. Staff redirected Resident 1 to the nursing unit. The facility subsequently initiated safety checks every 15 minutes. A nursing progress note dated June 22, 2026, at 10:59 PM documented that Resident 1 traveled down the hallway to the front door and attempted to exit, she was redirected to coloring activities and the resident stated No one told me I couldn't go outside, my husband takes me out there all the time. The note documented Resident 1 was placed in bed at 5:15PM and no other exit seeking was observed. A nursing progress note dated June 23, 2026, at 11:54 AM documented that Resident 1 continued to receive safety checks every 15 minutes and was observed near the front door but did not make any attempts to go outside. A psychology note dated June 24, 2026, documented that Resident 1 reported attempting to leave the facility because of an ongoing desire to return home. A nursing progress note dated June 28, 2026, at 6:26 PM documented that Resident 1 wanted to go outside and was found at the facility's front door. Staff accompanied Resident 1 outside for fresh air and the resident was satisfied. On July 2, 2026, the facility decreased Resident 1's monitoring from every 15 minutes to every 30 minutes after staff documented that the resident had been stable and was not demonstrating exit-seeking behavior during the 15-minute checks, despite previous documentation of the resident attempting to leave the facility, documented statements of her wanting to go home, and documentation of frequent wandering. A progress note dated July 8, 2026, at 12:30 PM documented that Resident 1 was again observed at the facility's front door. Activity staff accompanied Resident 1 outside. A progress note dated July 8, 2026, at 6:26 PM documented that Resident 1 attempted to exit the building while stating, I am going home. Staff redirected Resident 1. A progress note dated July 9, 2026, at 2:08 PM documented that the facility resumed safety checks every 15 minutes because Resident 1 demonstrated an increase in exit-seeking behavior. The clinical record revealed Resident 1 remained on safety checks every 15 minutes through August 9, 2026. Resident 1's care plan was again updated on July 14, 2026, to 1:1 supervision, and when wandering ask Resident 1 what she is looking for and accommodate as able. A review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease (a common brain disorder that slowly gets worse over time), and dementia without behavioral disturbances (a decline in mental ability severe enough to interfere with daily life, including loss of memory, language, and problem-solving skills). A review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident 2 was severely cognitively impaired with a BIMS score of 5, a score of 5 indicates significant thinking or memory challenges that could impact daily life. A review of Resident 2's care plan identified Resident 2 as being at risk for elopement and associated injury related to exit-seeking behavior. Interventions included providing one-to-one supervision as needed, maintaining door alarms, providing individual interaction, redirecting the resident from exits based upon behavior, taking the resident for daily walks, and providing opportunities to go outside when weather permitted. A review of Resident 2's progress notes revealed the facility initiated safety checks every 15 minutes on July 10, 2026. The clinical record revealed no documented increase in exit seeking behavior after the initiation of every 15-minute checks. An interview with Employee 1 Nurse Aide (NA) on August 12, 2026, at 10:31 AM revealed Employee 1 was outside on a break and was returning to the facility through the front entrance when she observed Resident 1 traveling in her wheelchair through the entrance with Resident 2 following behind her. Employee 1 stated Resident 1 reached the sidewalk immediately outside the facility; however, she stated Resident 2 did not exit the building and remained within the front vestibule. Employee 1 stated she redirected the residents back into the facility. Employee 1 further stated that the Wander Guard alarm was sounding at the time of the occurrence; however, a visitor entering the facility was holding the entrance door open. On August 12, 2026, at 1:00 PM, in the presence of the Nursing Home Administrator and Director of Nursing, the surveyor reviewed facility video surveillance from August 9, 2026. The video surveillance revealed that at 10:31 AM, Employee 1 NA exited the building and walked toward the parking area and out of view of the camera. At 10:39 AM, a visitor entered the facility and held the entrance door open while Resident 1, followed by Resident 2, traveled through the vestibule and exited the building. Contrary to Employee 1's statement that Resident 2 remained inside the vestibule, the video surveillance showed both Resident 1 and Resident 2 completely outside the building on the sidewalk near a bench located in front of the facility. Employee 1 subsequently approached the residents at 10:40AM, entered the vestibule to silence the Wander Guard alarm, and then remained outside with the residents. During an interview on August 12, 2026, at 10:00 AM, the Director of Nursing stated that the facility did not investigate the occurrence because the Director of Nursing believed the residents had not actually exited the facility. During a subsequent interview on August 12, 2026, at 1:15 PM, after reviewing the video surveillance with the surveyor, the Director of Nursing acknowledged that the surveillance showed both residents completely outside the building. During a telephone interview on August 12, 2026, at 11:34 AM, Employee 2, a Registered Nurse Supervisor, stated that Employee 1 informed her of Residents 1 and 2 exiting through the facility's front entrance. Employee 2 stated that she immediately notified the Director of Nursing and was instructed to discontinue the 15-minute checks and station Employee 1 NA at the front entrance to prevent residents from exiting the facility. Based on clinical record review, video surveillance, and staff and administrative interviews, the facility identified Residents 1 and 2 as being at risk for elopement and implemented interventions intended to reduce their risk of exiting the facility without staff knowledge or supervision. These interventions included the use of an electronic Wander Guard device, scheduled safety checks, redirection from exits, and opportunities for supervised time outside. Resident 1 had also demonstrated repeated exit-seeking behavior, including approaching the front entrance, attempting to exit the facility, and expressing a desire to leave. Despite the identified elopement risks and interventions implemented, the facility failed to ensure that the supervision and interventions in place were effective to prevent Residents 1 and 2 from exiting the facility without staff knowledge or supervision. On August 9, 2026, while a visitor held the entrance door open, Residents 1 and 2 traveled through the vestibule and exited the building without staff knowledge or supervision. Video surveillance confirmed both residents were outside the building on the sidewalk near the facility's front entrance before a staff member encountered them.The facility failed to evaluate and modify the supervision and interventions in place to effectively address the identified elopement risks and prevent Residents 1 and 2 from exiting the facility without staff knowledge or supervision. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on observations, review of clinical records, facility policies, facility investigative documentation, video surveillance, and resident and staff interviews, it was determined that the facility failed to ensure the environment remained as free of accident hazards as possible by failing to provide adequate supervision and implement effective interventions to prevent an avoidable elopement for one of 12 residents reviewed (Resident CR1). This deficient practice placed Resident CR1 and other residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, & 12) identified by the facility as being at risk for elopement in Immediate Jeopardy due to the likelihood of serious injury, serious harm, impairment, or death.Findings include: A review of the facility policy titled Elopement, last reviewed January 28, 2026, revealed the facility's policy is to provide residents with a safe and secure environment and to proactively prevent resident elopement (when a resident leaves the facility or a designated safe area without staff knowledge or authorization). The policy directs staff to evaluate residents for elopement risk upon admission, readmission, quarterly, and following a significant change in condition. The policy required staff to assess residents with a history of substance use disorder, develop individualized care plan interventions to reduce the risk of elopement, redirect residents who attempt to leave the facility without supervision, and maintain a current photograph of each resident identified as being at risk for elopement. Observation of the facility's main entrance revealed two interior doors leading to the exit area. One interior door opened into an enclosed vestibule, and the second door opened directly to the outside. Neither interior door was locked from inside the building. During weekday daytime hours, a clerical employee was stationed in an office adjacent to the entrance with a direct line of sight to the main hallway and entrance doors. Observation revealed the exterior entrance operated through an alarmed electronic access system. Between 8:00 AM and 4:30 PM, individuals could enter the building from outside without staff assistance. After 4:30 PM, individuals seeking entry were required to press an exterior call button that signaled staff inside the clinical area to remotely unlock the exterior door. Residents could exit the building from the inside unless an electronic elopement prevention device activated the locking system. The facility utilized an electronic Wander guard system to help prevent elopement. Residents identified as being at risk for elopement wore an electronic device attached to the resident or mobility equipment, such as a wheelchair or walker. When a functioning electronic device approached a monitored exit, the system locked the interior exit door, activated an audible alarm at the doorway, and illuminated a red indicator light above the door. A review of facility records dated June 19, 2026, revealed the facility had identified 12 residents as being at risk for elopement, including Resident 1 through Resident 12 (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). These residents relied on the facility's elopement prevention system and staff supervision to prevent unauthorized exit from the building. A closed clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include diabetes mellitus (sugar builds up in the bloodstream), anxiety (a mental health condition characterized by excessive worry or fear) and psychoactive substance use, in remission (an individual used to use mind-altering drugs or substances in the past). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2026, revealed Resident CR1 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 indicates significant thinking or memory challenges that could impact daily life). A review of Resident CR1's care plan initiated on November 18, 2025, identified a history of substance use disorder with risks for mood or behavioral disturbances, recurrence of substance use, and withdrawal symptoms (physical or emotional symptoms that may occur when an individual stops using certain substances). Interventions included relaxation techniques, referral to mental health services, and identifying Resident CR1's goals for the stay. A separate care plan initiated on November 28, 2025, and revised on June 11, 2026, documented behaviors including taking items that belonged to other residents and attempting to use wheelchairs assigned to other residents. On June 16, 2026, three days before Resident CR1 exited the facility, staff added wanting to go home as a behavioral trigger. Despite identifying this trigger, the facility did not revise the care plan to include additional individualized interventions to address Resident CR1's persistent efforts to leave the facility or the resident's repeated use of mobility devices belonging to other residents. A care plan initiated on March 12, 2026, identified Resident CR1 as being at risk for elopement. Before Resident CR1 exited the facility on June 19, 2026, the care plan interventions remained limited to reorienting the resident, encouraging participation in group activities, redirecting the resident away from exit doors, using the Wander guard system, and checking the Wander guard device each shift. Although the clinical record documented repeated statements over several months that Resident CR1 intended to leave the facility, increasing exit-seeking behaviors, repeated use of wheelchairs that did not belong to the resident, and continued unsuccessful attempts at redirection, the facility did not revise the care plan to implement additional individualized interventions to reduce the resident's risk for elopement. The facility did not revise the elopement care plan until June 19, 2026, after Resident CR1 exited the building without staff knowledge. A review of the clinical record revealed Resident CR1 demonstrated a persistent and escalating pattern of exit seeking behaviors beginning in March 2026. Documentation consistently showed Resident CR1 repeatedly expressed the intent to leave the facility, packed personal belongings in preparation for leaving, requested housing information, remained focused on returning home, and was frequently unable to be redirected by staff despite repeated interventions. A nursing progress note dated March 3, 2026, documented Resident CR1 insisted on leaving the facility. Staff explained facility policies and attempted to redirect the resident without success. Social services documented increased confusion, continued statements about leaving the facility, and determined Resident CR1 lacked the necessary family support and resources for a safe discharge. On the same date, staff completed an Elopement/Wander Risk Evaluation identifying Resident CR1 as being at risk for elopement due to forgetfulness, a short attention span, fear, anxiety, repeated statements about wanting to go home, packing belongings, and remaining near exit doors. The evaluation documented Resident CR1 was independently mobile using a cane, walker, or wheelchair and had a history of substance use disorder. Nursing staff applied a Wander guard device to Resident CR1's wheelchair on March 3, 2026. A physician's order dated March 10, 2026, directed staff to maintain a Wander guard device for Resident CR1 and verify the device's placement and function each shift. Clinical documentation continued to demonstrate Resident CR1's persistent intent to leave the facility. During evaluations completed by the Psychiatric Mental Health Nurse Practitioner on March 15, April 27, May 8, and June 1, 2026, Resident CR1 continued to report wanting to leave the facility. The Psychiatric Mental Health Nurse Practitioner documented ongoing anxiety related to leaving the facility and increased medication on May 8, 2026, because Resident CR1 persistently packed belongings and expressed the intent to leave. Psychology and social services documentation demonstrated the resident's continued exit seeking behaviors. On March 25 and April 22, 2026, Resident CR1 reported plans to return home and stated belongings had been packed in preparation for leaving. On May 5, 2026, Resident CR1 requested information about obtaining an apartment. On June 17, 2026, the psychologist again documented Resident CR1 remained focused on leaving the facility and returning home. The clinical record demonstrated concerns regarding Resident CR1's use of mobility equipment. Progress notes documented that the Wander guard device was missing on May 17, 2026, and staff reapplied a functioning device on May 21, 2026. On June 10, 2026, the occupational therapist documented Resident CR1 was using another resident's wheelchair and expressed dissatisfaction with the facility issued wheelchair. The occupational therapist educated Resident CR1 that the assigned wheelchair contained resident specific safety interventions, including the Wander guard device, a wheelchair cushion, and equipment intended to reduce the risk of injury. Resident CR1 became upset, yelled at staff, and continued to insist the wheelchair was not hers. Nursing administration assisted Resident CR1 back into the assigned wheelchair. On June 11, 2026, the Social Services Director met with Resident CR1 regarding the wheelchair incident. Despite staff intervention, Resident CR1 continued to state an intention to leave the facility and maintained the belief that the assigned wheelchair did not belong to her. Documentation entered by the Director of Nursing on June 17, 2026, revealed Resident CR1 experienced a fall on June 11, 2026, while using a personal wheelchair brought into the facility that did not contain the resident's prescribed safety interventions, including the Wander guard device. Staff subsequently removed the personal wheelchair and reissued the facility wheelchair. A review of the June 2026 electronic treatment administration record (eTAR), an electronic record used to document treatments provided to residents, indicated staff documented verification of the Wander guard device placement and function each shift before the elopement on June 19, 2026. A review of facility investigative documentation completed by the Director of Nursing (DON) on June 19, 2026, revealed Resident CR1 exited the facility without staff knowledge or supervision. According to the investigative documentation, video surveillance showed Resident CR1 holding the exterior entrance door open for an ambulance attendant at 6:35 PM. At 6:37 PM, Resident CR1 independently propelled the wheelchair through the exit, traveled along the sidewalk, and entered the facility parking lot. The investigative documentation revealed that at 6:38 PM, Employee 1, Nurse Aide (NA), observed Resident CR1 in the parking lot while leaving the building for a scheduled break and immediately summoned assistance. At 6:40 PM, Employee 8, Registered Nurse Supervisor (RNS), responded to the parking lot, assisted Resident CR1 back into the facility, notified the Director of Nursing, and initiated continuous one to one observation. On June 30, 2026, at 11:15 AM, the surveyor reviewed the video surveillance in the presence of the Director of Nursing. The video confirmed the facility's investigative findings, and Resident CR1 had a cigarette in her mouth throughout the recording. During an interview conducted on June 30, 2026, at 12:00 PM, the Nursing Home Administrator (NHA), Director of Nursing, and regional consultant were unable to explain how Resident CR1 obtained the cigarette or other smoking materials despite the facility operating as a smoke free facility. During a telephone interview conducted by the surveyor on June 30, 2026, at 11:53 AM, Employee 1, Nurse Aide, stated that on June 19, 2026, while leaving the building for a scheduled break, Employee 1 observed Resident CR1 propelling the wheelchair into the center of the parking lot with a cigarette in the resident's mouth. Employee 1 reported Resident CR1 appeared to be looking for a way to light the cigarette and stated she was looking for her husband. Employee 1 immediately requested assistance from an ambulance attendant returning another resident to the facility, who contacted staff inside the building. Employee 1 stated Resident CR1 frequently expressed the desire to leave the facility, return home, and smoke cigarettes. A written witness statement completed by Employee 1 and included in the facility's investigative documentation confirmed Resident CR1 was using the assigned facility wheelchair at the time of the elopement. The statement documented that the prescribed Wander guard device was not attached to the wheelchair. Employee 1 documented staff searched Resident CR1's room but were unable to locate the missing Wander guard device. Employee 1 also reported asking Resident CR1 where the cigarette had been obtained; however, Resident CR1 did not provide an answer. Although the June 2026 eTAR documented staff verified the Wander Guard device every shift. The facility was unable to determine when the device was removed or how Resident CR1 exited the building without the prescribed electronic device attached to the assigned wheelchair or her person. During a telephone interview conducted on June 30, 2026, at 1:45 PM, Employee 2, the ambulance attendant, stated that on June 19, 2026, the exterior entrance door was unlocked remotely after Employee 2 pressed the entrance call button. As Employee 2 opened the exterior door to assist another resident into the building, Resident CR1 independently exited the facility. Employee 2 stated Resident CR1 had a cigarette in her mouth and initially believed Resident CR1 intended to smoke outside because other residents were observed smoking in designated outdoor areas. Video surveillance confirmed Resident CR1 independently opened the first interior door before exiting through the exterior entrance as Employee 2 entered the building. Additional facility investigative documentation showed Employee 3, Licensed Practical Nurse (LPN), observed the Wander guard device attached to Resident CR1's wheelchair and functioning properly at 3:00 PM on June 19, 2026. Employee 6, Nurse Aide, documented Resident CR1 received the evening meal at 4:40 PM without unusual behaviors. Employee 5, Licensed Practical Nurse, observed Resident CR1 independently propelling the wheelchair to the resident's room at 5:20 PM. Employee 4, Nurse Aide, documented Resident CR1 remained in the room speaking with the roommate at 6:00 PM, and Employee 7, Nurse Aide, documented Resident CR1 continued speaking with the roommate at 6:20 PM. Employee 8 Registered Nurse Supervisor (RNS) provided a statement describing being called to the parking lot at 6:40 PM on June 19, 2026, via a phone call from the ambulance attendant, assisted Resident CR1 back into the facility, contacted the DON and initiated continuous individual observation for Resident CR1. Documentation completed by the Director of Nursing on June 20, 2026, summarized the elopement event, documented placement of a new Wander guard device on Resident CR1's left ankle, and noted plans to transfer Resident CR1 to a secured unit. Facility investigative documentation also included documentation identifying residents who required Wander guard devices on June 19, 2026. The record identified 12 residents as requiring electronic elopement prevention devices. During an interview conducted on June 30, 2026, at 12:30 PM, the Nursing Home Administrator and Director of Nursing confirmed Resident CR1 had a well documented history of wandering into resident rooms, lounges, and vacant rooms, taking items belonging to other residents, and using mobility devices that did not belong to the resident. Based on the clinical record, facility investigative documentation, video surveillance, staff interviews, and administrative interviews, the facility knew Resident CR1 had demonstrated persistent exit seeking behaviors, repeatedly expressed the intent to leave the facility, required an ordered Wander guard device, and had a history of using mobility devices that did not belong to the resident. Despite this knowledge, the facility failed to implement additional individualized interventions as Resident CR1's behaviors escalated, failed to ensure the prescribed Wander guard device remained in place, and failed to prevent Resident CR1 from exiting the facility without staff knowledge or supervision. As a result of the facility's noncompliance, Resident CR1 exited the facility without staff knowledge or supervision and entered the facility parking lot. Despite months of documented exit seeking behaviors, repeated unsuccessful attempts at redirection, repeated use of mobility devices that did not belong to Resident CR1, a previous incident in which the Wanderguard device was missing, and a physician's order requiring continued use of the Wanderguard device, the facility continued to rely primarily on the electronic Wanderguard system and routine redirection. The facility did not implement additional individualized interventions as Resident CR1's behaviors escalated and did not ensure the prescribed Wanderguard device remained in place before Resident CR1 exited the building without staff knowledge or supervision. Because the facility used the same electronic elopement prevention system and staff supervision to protect all residents it had identified as being at risk for elopement, the deficient practice placed Resident CR1 and other similarly situated residents in Immediate Jeopardy because it created a likelihood of serious injury, serious harm, impairment, or death. The survey team notified the facility of the Immediate Jeopardy on June 30, 2026, at 1:25 PM and provided the Immediate Jeopardy template at that time. In response, the facility submitted a written Immediate removal plan on June 30, 2026, at 3:43 PM, and revised plans at 4:37 PM and 5:47 PM. The corrective action plan submitted by the facility included the following measures: 1. Resident CR1 was placed on continuous one-to-one observation until discharge, applying a new Wanderguard device. Elopement evaluations were completed on all residents identified as being at risk for elopement2. Current residents at risk for elopement were reviewed to ensure electronic devices were in place and care plans had appropriate interventions. 3. Residents who have Wanderguards will be checked every hour for placement of the device after 4:30 PM until bedtime. Residents who refuse the Wanderguard device will have documentation of refusal and interdisciplinary team meeting will discuss alternative interventions. 4. Education will be provided to all staff on the elopement policy.5. Audits of corrective actions will be completed daily for seven days, weekly for three weeks, and monthly for two months and reported to the Quality Assurance Performance Improvement department.6. The individual responsible for overall monitoring of the individualized plan of correction is the NHA or designee. On June 30, 2026, at 10:30 AM, in the presence of the Assistant Director of Nursing (ADON), the surveyor verified the placement and function of the Wanderguard devices for the 12 residents the facility had identified as being at risk for elopement. The Assistant Director of Nursing demonstrated the testing process using the facility's electronic testing device, which displayed a green indicator confirming proper device function. At 5:15 PM on June 30, 2026, the facility identified five additional (Resident 13, 14, 15, 16, & 17) residents as being at risk for elopement. Surveyors again observed the Assistant Director of Nursing evaluated the placement and function of the Wanderguard devices. During this verification, the electronic testing device displayed a red indicator showing the Wanderguard devices assigned to Resident 16 and Resident 17 were not functioning properly. The malfunctioning devices were immediately replaced by facility staff. After verification of the facility's corrective actions, including observation of the placement and function of Wanderguard devices for all residents identified as being at risk for elopement, review of resident photographs maintained for elopement identification, staff interviews, verification of staff education, and observation of the facility's elopement prevention processes, the Immediate Jeopardy was determined to have been removed on July 1, 2026, at 12:15 PM. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on observations, review of clinical records, select facility policies, job descriptions, facility-provided documentation, and interviews with residents and staff, it was determined the facility administration failed to effectively use available resources and provide the leadership, oversight, and coordination necessary to ensure residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure effective administrative oversight and implementation of systems to protect residents identified as being at risk for wandering or elopement. As a result, one of twelve residents identified by the facility as being at risk for wandering (Resident CR1) exited the building without staff knowledge or supervision and entered an unsafe environment. This systemic failure placed Resident CR1 and other residents identified as being at risk for wandering or elopement in Immediate Jeopardy due to the likelihood of serious injury, serious harm, impairment, or death.Findings include: A review of the job description for the Nursing Home Administrator (NHA) dated and signed February 27, 2026, indicated the administrator will manage the facility in accordance with policies, procedures, and current federal, state, and local standards, guidelines, and regulations. The job description identified responsibilities that included directing overall facility operations, ensuring the physical environment is maintained, hiring, training, and developing department staff, and ensuring departmental operations comply with applicable regulatory requirements. A review of the Director of Nursing (DON) Services job description, dated and signed November 16, 2023, indicated the DON is responsible for directing nursing services in accordance with current federal, state, and local laws, regulations, and standards. The job description required the DON to collaborate with the Administrator and Medical Director to ensure the highest degree of quality of care for residents, determine staffing necessary to meet resident needs, conduct daily rounds to evaluate nursing services, review nursing documentation, monitor resident care, and assume responsibility for daily facility operations in the absence of the Administrator. The facility failed to ensure administrative systems were effectively implemented and monitored to protect residents identified as being at risk for wandering or elopement. On June 19, 2026, at approximately 6:35 PM. Resident CR1 exited the facility through an exterior door with a cigarette in her mouth without staff knowledge or supervision and entered an unsafe outdoor environment. The resident's ability to leave the building without staff intervention demonstrated that facility systems intended to identify and prevent unauthorized resident exits were not effectively implemented or monitored. Resident CR1 had a documented history of removing safety devices, including the electronic monitoring device intended to activate the facility's exit alarm system, and had repeatedly expressed an intent to leave the facility, smoke, and return home. Despite these known risk factors, administrative oversight did not ensure effective systems were in place to identify when required safety interventions were absent or to prevent the resident from exiting the building without staff awareness. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential administrative duties to monitor departmental operations, identify systemic risks, and ensure the implementation of facility policies to maintain resident safety. This lack of oversight and failure to use available resources to identify and correct system problems resulted in conditions that placed residents in immediate jeopardy. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management.

Based on observations and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation during the initial tour of the kitchen conducted withe Employee 9 (cook) on January 11, 2026, at 9:44 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Employee 9 (cook) had a thick beard and was in the food preparation area without a beard restraint (effectively keeps facial hair from contacting food). There was a pair of snow boots placed directly on top of an opened box of grease pan liners (disposable pan liners used to reduce scrubbing and prevent food items from sticking to pans) on a bottom shelf in the food preparation area. Three shelves in the reach in refrigerator located next to the tray line were heavily rusted. There were six cases of frozen buns placed directly on the floor in the walk in freezer. Observation of the walk in refrigerator revealed one container of honey thickened cranberry juice, one container of nectar thickened cranberry juice, and one container of nectar thickened orange juice which were not dated when opened. Review of the manufacturer label revealed directions to use within 10 days after opening. Further observation of the walk in refrigerator revealed nine thawed four ounce containers of Mighty Shakes (nutritional beverage) which did not have a thaw date. Review of the manufacturer label revealed directions to use within 14 days after thawing. Interview with Employee 10 (dietary aide) at this time confirmed the food items were not dated. Interview with the consultant dietitian on January 11, 2026, at 1:00 PM confirmed the dietary department was to be maintained in a sanitary manner and that foods should be dated and stored in a manner to prevent potential contamination of food and foodborne illness. 28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services.

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to consistently implement infection prevention and control practices and failed to ensure that reusable medical equipment intended for oral use was stored in a manner that prevented contamination for one of 26 sampled residents (Resident 16). The facility also failed to evaluate infection surveillance data to determine potential contributing factors and identify the need for corrective actions.Findings include: Clinical record review revealed that Resident 16 was admitted to the facility on [DATE], with a diagnosis of cancer of the throat and tracheostomy (surgically created opening in the throat for purposes of breathing). An admission Minimum Data Set assessment dated [DATE], (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 11, 2025, indicated the resident was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status. a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). An observation of Resident 16 conducted on January 11, 2026, at 10:00 a.m., and again on January 12, 2026, at 9:15 a.m., revealed that a Yankauer suction device, (a reusable medical device used to remove saliva and secretions from the mouth), was observed in direct contact with the floor in the resident's room. The floor is considered a non-clean surface, and contact with it increases the risk that bacteria or germs may contaminate an item intended to be placed in the mouth. During both observations, no storage method was observed that would prevent the device from contacting the floor. An interview with Resident 16 conducted on January 11, 2026, revealed that the resident independently uses the Yankauer suction device and reported that there was no designated place to store the device when finished. The resident stated that the device sometimes falls to the floor and that he continues to use it for oral suctioning even after it has contacted the floor. The resident further stated that he attempts to place the device on his abdomen to keep it clean; however, it does not consistently remain there. An interview with the Nursing Home Administrator revealed that staff had not identified or reported concerns regarding storage of the Yankauer suction device prior to surveyor observation and that no preventative solution had been implemented until after surveyor notification. A review of the facility's infection control logs for October, November, and December 2025 revealed documented cases of urinary tract infections (infections that occur when bacteria enter and multiply in the urinary system, including the bladder or kidneys). Review of the infection data revealed that approximately 50 percent of the documented urinary tract infections were caused by Escherichia coli or Proteus mirabilis, which are types of bacteria commonly found in the digestive system and are known to cause urinary tract infections when introduced into the urinary tract through hygiene-related factors. An interview with the Assistant Director of Nursing/Infection Control Preventionist conducted on January 14, 2026, revealed the facility was unable to provide evidence that it evaluated or analyzed the infection data to determine potential contributing factors or trends requiring intervention. This included the absence of documentation demonstrating review of staff hand hygiene practices, glove use between residents, provision of timely incontinence care, performance of perineal care, which is cleaning of the genital and anal areas to reduce the spread of bacteria, or evaluation of toileting practices for residents who were independent. The absence of such evaluation limited the facility's ability to determine whether additional staff education or corrective actions were needed to reduce the recurrence of urinary tract infections. The interview with the Assistant Director of Nursing/Infection Control Preventionist on January 14, 2026, at 1:00 p.m., was unable to provide evidence that the facility evaluated/audited potential causes for the infections specific to E. coli and Proteus mirabilis in relation to the urinary tract infections, such as confirmation that staff were washing their hands upon entering and exiting resident rooms, changing gloves between residents, providing timely incontinence care, and providing adequate perineal care (cleaning genital and anal areas) to determine any potential links that would require staff education to reduce the percentages of occurrence. In addition, if any of these infections were in residents who were independent for toileting, the individual resident practices would need to be evaluated. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(d)(3) (5) Nursing services.

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living were provided showers as planned to maintain acceptable standards of personal hygiene for three of 26 residents sampled (Residents 5, 119, and 11).Findings include: A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include fracture of the left femur (thigh bone), fracture of the sixth cervical vertebrae (the sixth bone in the neck), and dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, judgement, language and behavior, caused by brain cell damage). An admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 22, 2025, indicated the resident required substantial/maximal assistance from staff for showering/bathing. The resident was cognitively impaired with a BIMS score of 6 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 0-7 indicates a resident is severely cognitively impaired). A review of Resident 5's task report (an electronic record used to outline and track planned resident-centered nursing tasks) revealed the resident was scheduled to receive showers twice weekly on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. However a review of Resident 5's Documentation Survey Report (reports that capture care-related tasks completed by nurse aides) for December 2025 and January 2026 revealed the resident did not receive any showers since admission to the facility on December 13, 2025, and only received bed baths during that time period. There was no documented evidence that the resident refused showers. There was no documented evidence that the resident preferred bed baths instead of showers. There was no documented evidence that the facility provided showers twice weekly as planned. A review of Resident 119's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include venous insufficiency (condition where leg veins struggle to send blood back to the heart causing swelling, pain, heaviness, cramping, and skin changes) and pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs, making the right side of the heart work harder to pump blood through narrowed or blocked lung vessels). An admission MDS dated [DATE], indicated the resident required moderate assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates a resident is cognitively intact). During an interview conducted on January 11, 2026, at 1:30 PM, Resident 119 reported that staff had not provided or offered a shower since admission. The resident stated a preference for showers over bed baths and reported his hair had not been washed since admission. Observation during the interview revealed the resident's hair appeared oily and unkempt. A review of Resident 119's task report indicated showers were scheduled twice weekly on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. Review of the Documentation Survey Report for January 2026 revealed the resident did not receive any showers since admission and only received bed baths. There was no documented evidence that the resident refused showers. There was no documented evidence that the resident preferred bed baths instead of showers. There was no documented evidence that the facility provided showers twice weekly as planned. A review of Resident 11's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and end stage renal disease (final, permanent stage of chronic kidney disease, where the kidneys can no longer function on their own). An admission MDS dated [DATE], indicated the resident required moderate assistance from staff for showering/bathing. The resident was moderately cognitively impaired with a BIMS score of 10 (a score of 7-12 indicates the resident is moderately cognitively impaired). During an interview conducted on January 11, 2026, at 12:55 PM, Resident 11 stated he only received one shower since admission. He stated, Nobody will give me a shower. I'm so dirty and feel so grimy. Look at my hair, it's so greasy! I ask when I can have a shower and they say tomorrow, tomorrow, tomorrow, but tomorrow never comes. Observation revealed the resident had greasy, disheveled hair and beard. A review of Resident 11's task report indicated showers were scheduled twice weekly on Wednesdays and Saturdays during the 7:00 AM to 3:00 PM shift. Review of Resident 11's Documentation Survey Reports revealed the resident did not receive any showers in December 2025 and only received two sink baths on December 19, 2025, and December 31, 2025. Review of the January 2026 Documentation Survey Report revealed the resident did not receive any showers or bed baths during the month. There was documentation of one shower refusal on December 16, 2025; however, there was no additional evidence of refusal. There was no documented evidence that the resident preferred bed baths instead of showers. There was no documented evidence that the facility provided showers twice weekly as planned. During an interview conducted on January 13, 2026, at 9:40 AM, the Nursing Home Administrator (NHA) acknowledged that residents should have been provided with showers as scheduled. The NHA was unable to explain why showers were not consistently provided. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on a review of clinical records, select facility policies, observations, and staff, resident, and family member interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice. Specifically, the facility failed to ensure licensed nurses accurately administered prescribed medication for one of 26 residents sampled (Resident 5), failed to ensure consistent implementation of a physician-ordered therapeutic positioning device for one of 26 residents sampled (Resident 106), and failed to provide appropriate wound care, treatment, and monitoring for one of 26 residents sampled (Resident 9).Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Administering Medications last reviewed by the facility on January 30, 2025, revealed that medications are administered as prescribed and in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses to include orthostatic hypotension (condition causing dizziness or fainting from a sudden drop in blood pressure upon standing), atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), and supraventricular tachycardia (a type of arrhythmia where the heart beats abnormally fast due to electrical issues causing palpitations, dizziness or chest pain). Review of a physician's order dated December 19, 2025, revealed an order for Midodrine hydrochloride 10 mg, to be given by mouth three times daily for 14 days related to orthostatic hypotension, with instructions to hold the medication for systolic blood pressure greater than 120 mmHg (systolic blood pressure is the top number in the blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood). Review of the Medication Administration Record (MAR) for December 2025 and January 2026 revealed that Midodrine was administered six times outside of the physician ordered parameters, as evidenced by the following documented blood pressure readings at the time of administration:December 22, 2025, at 10:00 AM BP 136/74December 23, 2025, at 10:00 AM BP 125/64December 24, 2025, at 10:00 AM BP 127/70December 24, 2025, at 2:00 PM BP 130/74January 1, 2026, at 10:00 AM BP 124/56January 1, 2026, at 2:00 PM BP 124/56 These administrations occurred despite the physician's explicit hold parameters. During an interview on January 13, 2026, at 9:15 AM, the Nursing Home Administrator acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. A clinical record review revealed Resident 106 was admitted to the facility on [DATE], with diagnosis to include chronic pain syndrome, intervertebral disc degeneration of the lumbar region (breakdown of the spinal discs in the lower back), and muscle weakness. Review of a physician's order dated October 1, 2025, revealed an order for Resident 106 to be positioned out of bed in a Broda chair (a specialized wheelchair designed to support residents with complex positioning needs) with a blue comfy cushion (pressure reducing cushion) and an additional gel cushion placed on top for pressure reduction. Review of Resident 106's care plan, initiated September 19, 2025, identified an activities of daily living (ADL) performance deficit and included interventions to position the resident out of bed in a Broda chair with a blue comfy cushion. An observation conducted on January 12, 2026, at 12:50 PM revealed Resident 106 was seated out of bed in a Broda chair without the ordered blue comfy cushion in place. At the time of observation, a family member reported the blue comfy cushion had not been present on the resident's chair for at least one week. During an interview on January 12, 2026, at 1:30 PM, Employee 7 (Licensed Practical Nurse) confirmed that Resident 106 had a physician's order for the blue comfy cushion and acknowledged that the cushion was not present on the resident's chair at the time of observation. A review of the facility policy titled Skin and Wound Management System, last reviewed by the facility on January 30, 2025, revealed it is the policy of the facility to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided with appropriate treatment to encourage healing and/or skin integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Further review of the facility policy revealed residents with identified skin impairments will have appropriate interventions, treatment, and services implemented to promote healing and impede infection. A clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 13, 2025, revealed that Resident 9 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A progress note dated January 8, 2026, at 3:54 PM, completed by Employee 12 (Physician Assistant), documented Resident 9's complaint of a wound on the right lateral foot, described as a small wound approximately one-fifth of an inch in size, with nursing staff notified. Further review of the clinical record revealed no additional documentation related to assessment, treatment, or monitoring of the right foot wound. During an interview on January 11, 2026, at 11:42 AM, Resident 9 explained that a wound on her right foot has been bothering her. A four-inch by four-inch bandage dated January 8, 2026, was observed covering the top of Resident 9's right foot. She explained that no one has looked at her wound since January 8, 2026. During an interview on January 11, 2026, at 1:30 PM, Employee 11, a Registered Nurse (RN), confirmed the presence of a wound on Resident 9's right foot. The wound is oval in shape, measuring one inch long and half an inch wide, with the center of the wound having a reddish-pink coloration. The skin surrounding the pink area is dry and flaky. No smell or drainage was noted. Employee 11, RN, was unable to provide documented evidence Resident 9 was receiving care or treatment regarding the wound on her right foot. During an interview on January 13, 2026, at 11:25 AM, the Director of Nursing (DON) was unable to provide documented evidence Resident 9 was receiving care or treatment regarding the wound on her right foot. The above information was reviewed with the DON. The facility failed to ensure Resident 9 received treatment, care, and monitoring in accordance with professional standards of practice for an identified wound. 28 Pa. Code 211.5(f)(ii)(ix) Medical records.28 Pa. Code 211.9 (a)(1)(d) Pharmacy services.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, review of clinical records, facility staffing records, and resident and staff interviews, it was determined the facility failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care, for eight out of 26 residents sampled (Residents 53, 76, 104, 87, 5, 119, 11, and 103).Findings include: A review of nurse staffing data from January 7, 2026, through January 13, 2026, revealed the facility failed to meet the state minimum requirement for nurse aides on 14 out of 21 shifts reviewed. During the same time period, the facility failed to meet the state minimum requirement for licensed practical nurses on two out of 21 shifts reviewed. Additionally, review of staffing records revealed the facility failed to meet the state minimum requirement for total direct care nursing hours on two out of seven days reviewed.A clinical record review revealed that Resident 104 was admitted to the facility on [DATE], with diagnoses that include heart failure (a condition that occurs when the heart can't pump enough blood to the body).A review of clinical records revealed Resident 104 was admitted on [DATE], with diagnoses including heart failure (a condition in which the heart is unable to pump enough blood to meet the body's needs). An annual Minimum Data Set (MDS, a federally mandated standardized assessment used to plan resident care) dated December 29, 2025, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS, a standardized tool used to assess cognition; scores of 13-15 indicate intact cognition) score of 15. Physician orders dated January 27, 2025, included tramadol hydrochloride 50 mg (an opioid pain medication) by mouth every 12 hours as needed for severe pain (pain level 8-10), with instructions to attempt non-pharmacological interventions prior to medication administration. During a resident group interview conducted on January 12, 2026, at 10:00 AM, Resident 104 reported experiencing waiting times of one to two hours to receive prescribed as-needed pain medication after notifying staff, which the resident stated occurred repeatedly over the prior month.A clinical record review revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses that include chronic heart failure (a condition that occurs when the heart can't pump enough blood to the body). A quarterly MDS dated [DATE], indicated the resident was cognitively intact with a BIMS score of 14. Physician orders dated May 25, 2025, included tramadol hydrochloride 50 mg by mouth every six hours as needed for severe pain, with required use of non-pharmacological interventions (non-medication approaches used to help relieve pain such as repositioning, relaxation techniques or massage) prior to administration. During the resident group interview on January 12, 2026, Resident 76 reported waiting between ten minutes and three hours to receive as-needed pain medication after notifying staff and stated that she waited over one hour on four occasions in the prior 30 days. A clinical record review revealed Resident 53 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and with bilateral above-knee amputations (surgery to remove the leg above the knee). A quarterly MDS dated [DATE], indicated the resident was cognitively intact with a BIMS score of 15. The resident's care plan identified dependence on staff for toileting and the need for two staff members for transfers (assistance moving from one surface to another, such as bed to wheelchair). Physician orders dated November 26, 2025, included orders to receive acetaminophen oral tablets with directions to give 1000 mg by mouth every eight hours as needed for severe pain. Directions include implementation of non-pharmacological interventions prior to administration and to not administer more than 3000 mg in 24 hours. A physician's order for Resident 53 to receive acetaminophen oral tablets with directions to give 650 mg by mouth every six hours as needed for moderate pain. Directions include implementation of non-pharmacological interventions prior to administration and to not administer more than 3000 mg in 24 hours. A physician's order for Resident 53 to receive acetaminophen oral tablets with directions to give 325 mg by mouth every six hours as needed for mild pain. Directions include implementation of non-pharmacological interventions prior to administration and to not administer more than 3000 mg in 24 hours.During a resident group interview conducted on January 12, 2026, Resident 53 reported experiencing multiple episodes over the prior month in which she waited over one hour to receive pain interventions after notifying staff, which she stated caused her pain to worsen. The resident further reported frequent delays in being assisted out of bed in the morning, despite her stated preference to get out of bed after breakfast. An observation conducted on January 13, 2026, at 10:10 AM revealed Resident 53 remained in bed. At that time, the resident stated she was frustrated because she had not been assisted out of bed since breakfast. During an interview conducted on January 13, 2026, at 10:12 AM, Employee 5, Nurse Aide (NA), assigned to Resident 53, confirmed the resident remained in bed and stated that the resident's preferred time to get out of bed had not been discussed. Employee 5 further indicated that residents with scheduled appointments were prioritized due to assignment size. An observation conducted on January 14, 2026, at 10:00 AM revealed Resident 53 remained in bed. The resident stated that staff had not yet been around to assist her out of bed that morning. During an interview conducted on January 14, 2026, at 10:05 AM, Employee 6, Nurse Aide (NA), confirmed Resident 53 remained in bed and stated that she did not ask the resident her preferred time to get out of bed. Employee 6 further indicated she was assigned to 15 residents and prioritized residents with appointments to get out of bed first. During an interview conducted on January 14, 2026, at 10:10 AM, Employee 7, Licensed Practical Nurse (LPN), indicated there were no residents with appointments in Resident 53's hallway. Employee 7 was unable to explain why Resident 53 remained in bed after 10:00 AM. A clinical record review revealed Resident 87 was admitted to the facility on [DATE], with diagnoses which include congestive heart failure (a condition where the heart cannot pump blood enough blood) and diabetes (chronic condition that happens when blood sugar is too high).A review of a significant change MDS dated [DATE], revealed that Resident 87 is cognitively intact with a BIMS score of 15 (a score of 13 to 15 indicates cognition is intact), incontinent of bladder and bowel, and dependent on staff for toileting and hygiene. An observation conducted on January 12, 2026, at 2:05 PM revealed the resident's call bell was activated Interview with the resident at this time revealed that the resident often waits an extended amount of time (longer than 15 minutes) for her call bell light to be answered. The resident stated that her call bell light was on since 1:20 PM and had not yet been answered. The resident stated that she was incontinent of urine and needed her brief changed. The resident further stated that she watches the clock on the wall in front of her bed to track how long it takes for her call bell light to be answered. At 2:10 PM (a wait time of 50 minutes) Employee 8 (nurse aide) entered the room to provide assistance to Resident 87. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses to include fracture of the left femur (thigh bone), fracture of the sixth cervical vertebrae (the sixth bone in the neck), and dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, judgement, language and behavior, caused by brain cell damage). An admission MDS dated [DATE], indicated the resident required substantial/maximal assistance from staff for showering/bathing. The resident was cognitively impaired with a BIMS score of 6 (a score of 0-7 indicates the resident was severely cognitively impaired).A review of Resident 5's task report (an electronic record used to outline and track planned resident-centered nursing tasks) revealed the resident was scheduled to receive showers twice weekly on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift.A review of Resident 5's Documentation Survey Report (reports that capture care-related tasks completed by nurse aides) for December 2025 and January 2026 revealed the resident did not receive any showers since admission to the facility on December 13, 2025, and only received bed baths during that time.A clinical record review revealed Resident 119 was admitted to the facility on [DATE], with diagnoses to include venous insufficiency (condition where leg veins struggle to send blood back to the heart causing swelling, pain, heaviness, cramping, and skin changes) and pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs, making the right side of the heart work harder to pump blood through narrowed or blocked lung vessels). An admission MDS dated [DATE], indicated the resident required moderate assistance from staff for showering/bathing. The resident was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates the resident is cognitively intact). During an interview on January 11, 2026, the resident reported that no showers had been provided since admission despite scheduled showers twice weekly. Observation revealed the resident's hair appeared oily and unkempt. A review of Resident 119's task report indicated showers were scheduled twice weekly on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. Review of the Documentation Survey Report for January 2026 revealed the resident did not receive any showers since admission and only received bed baths. A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses to include neuromuscular dysfunction of the bladder (a condition in which the nerves and muscles that control bladder function doesn't work together properly. As a result, a person may have trouble storing urine, emptying the bladder, or both) and end stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). An admission MDS dated [DATE], indicated the resident required moderate assistance from staff for showering/bathing. The resident was moderately impaired with a BIMS score of 10 (a score of 7-12 indicates the resident is moderately cognitively impaired). During an interview conducted on January 11, 2026, at 12:55 PM, Resident 11 stated he only received one shower since admission. He stated, Nobody will give me a shower. I'm so dirty and feel so grimy. Look at my hair, it's so greasy! I ask when I can have a shower and they say tomorrow, tomorrow, tomorrow, but tomorrow never comes. Observation revealed the resident had greasy, disheveled hair and beard. Resident 11 also reported that the bandage covering the stoma (small, surgically created opening in the lower abdomen where a tube/catheter is inserted directly into the bladder to drain urine) for his suprapubic catheter (thin tube that drains urine from the bladder through a small opening in the lower abdomen, just above the pubic bone, instead of the urethra (a long fibromuscular tube that serves as the final pathway for urine to exit the body) had not been changed in three days. Resident 11 reported that he waits an excessively long time for his call bell to be answered. He stated I push the call button, and they don't come in for 45 minutes to 1.5 hours. Sometimes I have to go out in my wheelchair to get help. They don't have enough staff. A review of Resident 11's task report indicated showers were scheduled twice weekly on Wednesdays and Saturdays during the 7:00 AM to 3:00 PM shift. Review of Resident 11's Documentation Survey Reports revealed the resident did not receive any showers in December 2025 and only received two sink baths on December 19, 2025, and December 31, 2025. Review of the January 2026 Documentation Survey Report revealed the resident did not receive any showers or bed baths during the month. A review of physician orders dated December 23, 2025, revealed Resident 11 had an order to cleanse the suprapubic catheter site with normal saline solution and apply a dry dressing every day and as needed. Observation of Resident 11's suprapubic catheter insertion site was conducted on January 11, 2026, at 1:24 PM, in the presence of Employee 13, (Licensed Practical Nurse). The observation revealed the dressing covering the suprapubic catheter site was dated January 8, 2026. Employee 13 confirmed the date on the dressing and further confirmed Resident 11 had a physician's order requiring the dressing to be changed daily. A clinical record review revealed Resident 103 was admitted to the facility on [DATE], with diagnosis to include fracture of the left tibia (lower leg) and hypertension (high blood pressure). An admission MDS dated [DATE], indicated the resident was moderately cognitively impaired with a BIMS score of 9. During an interview conducted on January 11, 2026, at 12:00 PM, Resident 103 stated that she frequently waited over 30 minutes for her call bell to be answered. A family member, who was present at the time of the interview, added that the facility is understaffed, especially on weekends and holidays. The family member noted that staff are nice but there aren't enough of them, and they seemed rushed all the time. Yesterday, the girl went on lunch and left my mother on the bed pan for over thirty minutes. During an interview on January 14, 2026, at 11:00 AM, the above information was reviewed with the Nursing Home Administrator (NHA). The facility failed to ensure residents were provided with sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care. Cross refer F 677 F 684 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(6) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c)(d)(1)(4)(5) Nursing services.

Based on observation, review of clinical records, and staff interview, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan to address the identified medical and treatment needs of one out of 26 residents sampled (Resident 5).Findings include:Clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses to include fracture of the left femur (thigh bone), fracture of the sixth cervical vertebrae (the sixth bone in the neck), and dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, judgement, language and behavior, caused by brain cell damage). An observation of Resident 5 conducted on January 11, 2026, at approximately 12:40 PM revealed the resident was wearing a Vista cervical collar, an adjustable neck brace designed to immobilize the cervical spine following injury or surgery. A review of the physician's orders dated December 18, 2025, revealed an active order for Resident 5 to wear a Vista cervical collar at all times except during showering, with instructions to change to a Sierra (peach) cervical collar, a shower-safe cervical collar, during bathing. A review of Resident 5's comprehensive care plan, in effect at the time of the survey, identified an intervention addressing altered musculoskeletal status related to fracture. However, the care plan failed to identify the resident's ordered use of a Vista cervical collar, failed to address the use of an alternate cervical collar during showering, and failed to outline staff responsibilities for monitoring, applying, or ensuring consistent use of the prescribed cervical collars in accordance with physician orders. An interview with the Nursing Home Administrator conducted on January 13, 2026, at approximately 9:30 AM confirmed that the facility failed to ensure Resident 5's comprehensive care plan was developed and implemented in a manner that fully addressed the resident's medical and treatment needs related to cervical spine stabilization.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of clinical records, select facility policies, observations, and staff interviews, it was determined that the facility failed to consistently implement planned measures to prevent the development or worsening of pressure ulcers for one of 26 residents sampled (Resident 27). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists who specialize in the diagnosis, treatment, and care of adults. The largest medical specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility Skin and Wound Management System Policy last reviewed January 30, 2025, indicated it is the policy of the facility to assess residents with wounds and, or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided with appropriate treatment to encourage healing and, or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Preventative intervention will be implemented for residents identified at risk as appropriate, for example beds, wheelchair cushions, nutrition, therapy, etc. An Interdisciplinary Care Plan will be developed, and will identify the contributing risks for breakdown, or the actual skin impairment and the interventions implemented and updated as needed. The Interdisciplinary Care Plan should address (as appropriate) hydration, nutrition, preventative devices, physical activity, as well as positioning requirements, redistribution (techniques to remove pressure and maintain skin integrity), and proper body alignment. A review of the clinical record revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 7, 2025, revealed that Resident 27 was severely cognitively impaired, dependent on staff for mobility and transfers, was non-ambulatory, and at risk for pressure ulcers (localized injury to the skin and underlying tissue, usually over a bony area, caused by prolonged pressure). A review of the resident's current care plan, initially dated January 23, 2025, identified the resident as having the potential for pressure ulcer development related to immobility. Planned interventions included use of a pressure-reduction mattress, transfer out of bed to a Geri Lounger chair (a padded reclining chair with wheels designed for individuals with limited mobility) as tolerated, and an intervention dated September 17, 2025, indicating the use of bilateral heel protectors (devices designed to suspend the heels off the surface to relieve pressure and reduce the risk of skin breakdown) at all times. A physician order dated September 17, 2025, noted an order for bilateral heel protectors to be applied at all times. During observations of Resident 27 on January 11, 2026, at 12:30 PM and again at 1:15 PM, the resident was observed seated in a Geri Lounger chair without the bilateral heel protectors in place. During an additional observation on January 12, 2026, at 2:00 PM, Resident 27 was again observed seated in the Geri Lounger chair without the heel protectors in place. At that time, an interview with Employee 8 (nurse aide) confirmed that the heel protectors were not in place. An interview with the Nursing Home Administrator (NHA) on January 15, 2026, at 10:00 AM confirmed the facility did not consistently implement the planned intervention for heel protectors to prevent pressure ulcers for Resident 27. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility did not demonstrate consistent reassessment and modification of care interventions for one of 26 residents sampled (Resident 72) following the identification of an injury risk during routine care.Findings include: Clinical record review revealed that Resident 72 had a diagnosis of left hemiplegia (paralysis to the left side of the body) and atrophy to the same limb (decreasing size of muscle due to lack of use). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) completed on November 9, 2025, revealed the resident was dependent on staff for moving in bed and dressing and was not interview able, with a BIMS of 10 (Brief Interview for Mental Status, a tool to assess cognitive function a score of 8-10 indicates moderate cognitive impairment). A nurse's progress notes dated December 23, 2025, at 2:00 PM documented the resident was evaluated by a nurse practitioner due to complaints of left shoulder pain, and diagnostic imaging was ordered. A subsequent nurse's note dated December 23, 2025, at 2:57 PM, documented the resident complained of left shoulder pain during the provision of morning care. Nursing documentation dated December 23, 2025, indicated the resident reported left shoulder discomfort during routine care activities. A nurse practitioner evaluation was completed, and diagnostic imaging was ordered to further assess the complaint. Review of facility-provided investigative documentation dated December 26, 2025, indicated that the resident was later identified as having an acute fracture of the distal left humerus (the lower portion of the upper arm bone near the elbow joint). The documentation described that the resident reported pain during assistance with dressing of the affected extremity. A physician progress note dated January 9, 2026, documented that the fracture was consistent with stress occurring during external rotation of the arm (movement in which the arm rotates outward from the body), a motion that can occur during upper-body dressing, particularly in individuals with limited range of motion. During an interview conducted on January 12, 2026, at 12:45 p.m., Employee 4, a nurse aide, described providing routine dressing assistance to Resident 72 on December 23, 2025. The staff member explained that additional difficulty was encountered when dressing the resident's left side due to reduced range of motion and increased stiffness related to the resident's underlying medical conditions. The staff member further indicated they were not aware of any changes to the resident's care approach, dressing technique, or specific safety guidance implemented following the occurrence. An interview with the nursing home administrator (NHA) on January 13, 2026, did not provide evidence that the facility completed a documented reassessment of the resident's dressing needs or implemented modified interventions tailored to the resident's limited mobility and vulnerability to injury following the identification of the fracture. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility-provided documentation, and employee interviews, it was determined that the facility failed to ensure the accuracy and completeness of resident medical records for two of 26 residents sampled (Residents 90 and 102). Findings include: A clinical record review revealed Resident 90 was admitted to the facility on [DATE], with diagnoses that include anoxic brain damage (a serious type of injury characterized by a lack of oxygen to the brain) and chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A clinical record review revealed Resident 102 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 102's clinical record revealed a nursing progress note dated December 21, 2025, at 3:07 PM, completed by Employee 1, Registered Nurse (RN). The note documented that while Resident 102 was in the lounge and yelled help, Resident 90 wheeled over and slapped Resident 102 in the face. The note further documented that the RN separated the residents, completed a nursing assessment (an evaluation of the resident's physical and mental condition), initiated neurological checks (routine monitoring for signs of head or brain injury), provided emotional support, and notified the physician and the resident's emergency contact. A review of Resident 90's clinical record revealed a nursing progress note dated December 21, 2025, at 3:06 PM, also completed by Employee 1, RN. This note documented that Employee 1 observed Residents 90 and 102 in the lounge and then heard a slap. The note did not document Employee 1's direct observation of Resident 90 striking Resident 102. During an interview conducted on January 12, 2026, at 1:25 PM, Employee 1, RN, confirmed that the documentation in Resident 90's clinical record was not accurate. Employee 1 stated that she directly observed Resident 90 slap Resident 102. Employee 1 further stated that documentation involving resident-to-resident altercations is reviewed by the Director of Nursing (DON) or Assistant Director of Nursing, and that she was directed to change her documentation from saw Resident 90 slap Resident 102 to heard a slap so the note would align with information from the facility's internal investigative process. During an interview conducted on January 13, 2026, at 11:25 AM, the Director of Nursing (DON) confirmed that she directed Employee 1, RN, to document that the nurse heard a slap rather than saw Resident 90 slap Resident 102. The DON confirmed that the facility reviews documentation entered into residents' clinical records related to resident-to-resident altercations and acknowledged that the description of the incident differed between Resident 90's and Resident 102's medical records. Based on the above, the facility failed to ensure that resident clinical records accurately and completely reflected the nurse's direct observations of the incident. 28 Pa. Code 211.5 (f)(ii)(iii) Medical records.28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of clinical records, select facility policy, state professional nursing standards, and staff interview, it was determined the facility failed to ensure nursing services were provided in accordance with professional standards of quality by not ensuring licensed nurses accurately administered a prescribed medication within the physician-ordered parameters for one of four sampled residents (Resident 1).Findings include:According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals.The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.Review of the facility policy titled Administering Medications last reviewed by the facility on June 1, 2025, revealed that medications are administered as prescribed and in a safe and timely manner. The policy requires staff to verify medication allergies and obtain vital signs (basic health measurements such as blood pressure, temperature, heart rate, and breathing rate), as applicable, prior to administering medications. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), respiratory failure with hypoxia (not enough oxygen passes from the lungs to the blood, making it difficult to breath), atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow), and hypertension (high blood pressure).A review of the physician's order dated September 26, 2025, directed staff to administer Norvasc (Amlodipine Besylate, a medication used to treat high blood pressure) 10 mg by mouth once daily, and to hold the medication for systolic blood pressure less than 120 millimeters of mercury (mm/Hg). Systolic blood pressure is the top number in a blood pressure reading and reflects the pressure when the heart is actively pumping.Review of the Medication Administration Records for October and November 2025 revealed Norvasc was administered 30 times outside the physician-ordered parameters (outside parameters means the medication was given when the blood pressure reading did not meet the hold instruction).The following blood pressure readings were documented at the time the medication was given:October 1: 100/66 mm/HgOctober 2: 106/60 mm/HgOctober 3: 106/70 mm/HgOctober 4: 105/40 mm/HgOctober 5: 108/62 mm/HgOctober 15: 118/24 mm/HgOctober 18: 107/57 mm/HgOctober 19: 110/64 mm/HgOctober 20: 108/64 mm/HgOctober 21: 110/70 mm/HgOctober 22: 108/66 mm/HgOctober 23: 108/70 mm/HgOctober 24: 108/70 mm/HgOctober 25: 110/68 mm/HgOctober 26: 112/70 mm/HgOctober 27: 110/72 mm/HgOctober 29: 118/70 mm/HgOctober 30: 116/70 mm/HgOctober 31: 118/70 mm/HgNovember 1: 116/70 mm/HgNovember 3: 118/74 mm/HgNovember 4: 116/70 mm/HgNovember 5: 118/68 mm/HgNovember 6: 116/70 mm/HgNovember 8: 118/68 mm/HgNovember 9: 116/70 mm/HgNovember 10: 118/68 mm/HgNovember 11: 118/60 mm/HgNovember 12: 118/64 mm/HgNovember 13: 116/66 mm/HgNovember 14: 118/70 mm/HgThese readings show the medication was administered repeatedly when systolic blood pressure was below the required 120 mm/Hg. During an interview on November 25, 2025, at 12:10 PM the Nursing Home Administrator confirmed that nursing staff failed to follow acceptable standards of nursing practice during medication administration resulting in multiple medication errors. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records, select facility policy, pharmacy records and staff and resident interviews, it was determined that the facility failed to ensure a resident's medication regime was free from significant medication errors for one of four residents reviewed (Resident 2). Findings include: Review of the facility policy titled Administering Medications last reviewed by the facility on June 1, 2025, revealed that medications are administered as prescribed and in a safe and timely manner. The policy required staff to verify medication allergies and obtain vital signs, as applicable, prior to administering medications. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses to include Type 2 Diabetes (a chronic condition in which the body has difficulty controlling blood sugar and using it for energy), congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and nausea and vomiting. The resident's documented allergies and intolerances included: NSAIDs (intolerance, a non-steroidal anti-inflammatory drug, a class of medications used to reduce pain, fever, and swelling),Celecoxib (intolerance, a type of NSAID used for pain and inflammation),Ciprofloxacin (intolerance, an antibiotic used to treat infections ),Codeine (intolerance, an opioid pain medication),Gabapentin (allergy, a medication used for seizures and nerve pain),Meperidine (intolerance, an opioid pain medication ),Ondansetron (allergy, a medication used to prevent nausea and vomiting),Oxycodone (allergy, an opioid pain medication),Prochlorperazine (intolerance, a medication used for nausea and certain mental health symptoms ),Rofecoxib (allergy, a pain and anti-inflammatory medication that is a type of NSAID),Tramadol (intolerance, an opioid-like pain medication), andCompazine (intolerance. brand name for prochlorperazine, used for nausea) An allergy refers to a harmful immune response to a substance. An intolerance refers to an adverse reaction that does not involve the immune system but still causes unwanted effects.A review of the physician's order dated September 26, 2025, revealed an order for Ondansetron HCl oral tablet 4 mg (an anti-nausea and anti-vomiting medication), give 4 mg by mouth every 8 hours as needed for nausea. Despite a documented allergy to Ondansetron, a review of the resident's Medication Administration Records (MARs) for October and November 2025 revealed the resident was administered Ondansetron on October 3, October 7, October 11, October 12, October 15, October 17, and November 3, November 4, November 5, November 16, 2025, for a total of 10 administrations.During an interview on November 25, 2025, at 12:00 PM, Resident 2 stated she was aware she had an allergy to Zofran (brand name for Ondansetron) and reported that when she takes it, it makes me puke. She stated she had previously informed her physician about this effect and was unaware the facility had administered it. She stated, that explains why it didn't work, and I kept feeling sick. A review of the physician's order dated July 4, 2025, revealed an order for Gabapentin 100 mg by mouth at bedtime. Gabapentin is an anti-epileptic medication used to treat seizures and certain types of nerve pain. Despite Gabapentin being listed as an allergy for Resident 2, a review of the September 2025 MAR revealed the resident received the medication daily from September 1 through September 15, 2025, with documentation of refusal beginning on September 16, 2025.The facility was unable to provide documentation showing that the physician justified prescribing or continuing Ondansetron or Gabapentin despite the medications appearing on the resident's allergy list. A review of the consultant pharmacist's monthly recommendations for Resident 2 revealed no documentation indicating that the pharmacist identified the use of the contraindicated medications or recommended discontinuation.During an interview on November 25, 2025, at 11:00 PM, the Nursing Home Administrator acknowledged the facility administered Ondansetron and Gabapentin to Resident 2 despite the documented allergies and acknowledged the facility could not provide evidence of physician justification.28 Pa. Code 211.9(a)(1)(k) Pharmacy services28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of facility's abuse policy, clinical records, and select investigative reports and staff interview it was determined the facility failed to assure that one resident (Resident 2) was free from sexual abuse/harassment perpetrated by another resident (Resident 1) and out of 9 residents sampled.Findings included: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on September 2024, revealed the resident has the right to be free from abuse, neglect, and misappropriation of resident property. Residents must not be subject to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies, family members or legal guardians, or other individuals. Further review defined sexual abuse as non-consensual sexual contact of any type with a resident including sexual harassment, sexual assault. A review of Resident 1's clinical record revealed admission to the facility on April 22, 2024, with diagnoses to include dementia (a group of symptoms affecting memory, thinking and social abilities. The symptoms interfere with a person's daily life). A quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment completed periodically to plan resident care) dated June 5, 2025, indicated the resident was severely cognitively impaired with a BIMS score of 5 (brief interview of mental status to a tool to assess the resident's attention, orientation and ability to register and recall new information 0-7 represents severe cognitive impairment). Facility documentation and behavior progress notes revealed that Resident 1 exhibited sexually inappropriate behaviors prior to the incidents involving Resident 2. A progress note dated February 8, 2025, indicated that Resident 1 attempted to inappropriately grab staff during care. Resident 1's care plan, initiated April 26, 2024, identified sexualized behaviors including making sexual comments and gestures toward staff. Interventions included two-person assistance for all care and a referral to psychiatric services. A review of Resident 2's clinical record revealed admission to the facility on May 23, 2025, with diagnoses including dementia. An admission MDS dated [DATE], documented a BIMS score of 1, also indicating severe cognitive impairment. Resident 2 lacked the mental capacity to consent to sexual contact or activity. A review of facility documentation dated July 4, 2025, revealed that during a scheduled activity, Resident 1 was observed wheeling himself toward Resident 2, who was seated in a chair. Resident 1 then reached out and made contact with Resident 2's chest and groin area. The staff witness, identified as Employee 1 (Activities Aide), provided a written statement on July 4, 2025, at 2:55 p.m., documenting that Resident 1 was seen touching Resident 2's breast and subsequently placing his hand between her legs in the genital area. Staff immediately intervened and separated the residents During an interview with Employee 1 on July 24, 2025, at approximately 11:30 a.m., she stated that during the activity on July 4, 2025, she looked up and saw Resident 1 grab Resident 2 in the breast area. She stated that as she was standing up, she told Resident 1 to stop it and before she could get to them, Resident 1 grabbed Resident 2 in the groin area. Employee 1 stated Resident 2 was upset and crying briefly after the incident. However, this incident was not reported to the Department of Health. In interviews, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated they did not believe the event was reportable, as they did not perceive intent on Resident 1's part. The only intervention implemented was to increase supervision. A second incident occurred on July 14, 2025, during lunch hour in the dining room. Facility documentation revealed that at approximately 11:45 a.m., Resident 1 reached through the back of Resident 2's chair and touched her buttocks. The incident was witnessed by Employee 2 (cook), who provided a written statement and confirmed the contact. Resident 2 expressed discomfort and described Resident 1 as gross. Following this incident, the facility reported the matter to the Department of Health, Adult Protective Services, and local law enforcement. The facility also notified Resident 2's representative. Resident 1 was then placed on one-to-one supervision, and staff were instructed to ensure separation between the two residents. The above findings were reviewed with the NHA during an interview on July 24, 2025, at 1:15 PM, the NHA acknowledged that Resident 1 displayed sexually inappropriate behaviors and was unable to provide evidence the facility ensured that Resident 2 was free from sexual harassment perpetrated by Resident 1 and could provide no evidence the facility had implemented sufficient safeguards to protect Resident 2 from recurring sexual harassment or abuse. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing Services.

Based on a review of select facility policy, facility investigative reports, clinical records and staff interviews it was determined the facility failed to ensure a complete and accurate investigation into sexual abuse was completed for one resident out of 9 sampled (Resident 2). Findings included: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on September 2024, revealed the resident has the right to be free from abuse, neglect, and misappropriation of resident property. Further review of the facility abuse policy revealed under the area of investigation all reports of resident abuse, neglect, exploitation, misappropriation, shall be promptly reported to local, state and federal agencies as defined by current regulations, and thoroughly investigated by the administrator and or designee. The administrator or his/her designee will provide appropriate agencies or individuals within five working days of the occurrence of the incident. A review of Resident 2's clinical record revealed admission to the facility on May 23, 2025, with diagnoses to include dementia (a group of symptoms affecting memory, thinking and social abilities. The symptoms interfere with a person's daily life). An admission MDS dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 1 (brief interview of mental status to a tool to assess the resident's attention, orientation and ability to register and recall new information 0-7 represents severe cognitive impairment). A review of the facility's investigative documentation dated July 4, 2025, revealed that Employee 1 (Activities Aide) reported observing Resident 1 grab Resident 2's breast and genital area during an activity in the activity room. The investigation summary, completed by the Director of Nursing (DON), referenced input from staff on duty and alert and oriented residents present at the time of the incident; however, no additional written statements or interview documentation from those individuals were included in the investigation file. The only written statement obtained was from Employee 1, which clearly described that she observed Resident 1 grab Resident 2's genital area over her clothing. Further review of the facility's investigative documentation revealed a written conclusion by the Director of Nursing (DON) dated July 4, 2025, which stated: After a full investigation, per reporting guidelines, if both residents are incapable and there is no injury, you do not have to report. At this point, there is no valid proof of any type of inappropriate touching or behaviors that happened. No injuries. Both residents cannot recall what happened. However, this rationale is inconsistent with federal regulatory guidance. Despite the DON's written conclusion, the facility did not document any efforts to interview other staff or alert, and oriented residents present during the incident, nor did it follow up on the eyewitness account from Employee 1, who documented that she observed Resident 1 grab Resident 2's genital area over her clothing. The incident was not reported to the Department of Health. In interviews on July 24, 2025, the DON and Nursing Home Administrator (NHA) stated they did not believe the incident was reportable due to a lack of intent by Resident 1.An interview conducted with the DON and NHA on July 24, 2025, at approximately 1:30 PM, revealed they were unable to provide evidence that the investigation into the potential sexual abuse of Resident 2 was complete or compliant with facility policy and federal reporting requirements. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(5) Nursing Services.

Based on a review of the facility's plan of correction from the survey ending July 24, 2025, the outcome of the activities of the facility's quality assurance committee, a review of clinical records, and staff interviews, it was determined the facility failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies for one of six residents reviewed related to ensuring residents are free from sexual abuse (Resident 3) perpetrated by another resident (Resident 1). Findings include: As a result of the deficiencies cited under the requirements related to ensuring residents are free from sexual abuse during the survey of July 24, 2025, the facility developed a plan of correction to serve as their allegation of compliance, which included a quality assurance monitoring component to ensure that solutions were sustained. This corrective plan was to be completed and functional by August 19, 2025. However, during the survey ending August 28, 2025, continuing deficient facility practice was identified with these same requirements.According to the facility's plan of correction for the deficiency cited on July 24, 2025, relating to ensuring residents are free from sexual abuse, implemented to ensure deficient practice was corrected, included (1) The perpetrator is now 1:1 (level of staff to resident supervision) when out of bed. The recipient of sexual abuse was discharged from the facility. (2) The facility completed a baseline audit of abuse allegations for two weeks, and interventions have been implemented if applicable. (3) Facility educated staff regarding facility abuse policy. The facility will ensure that allegations of abuse will follow a facility policy that includes safeguards to be in place to protect residents from abuse. (4) The Nursing Home Administrator (NHA) or designee will audit the allegation of abuse to ensure facility policy is followed weekly for four weeks and then monthly for two months. (5) Audits will be submitted to the quality assurance performance improvement committee for review.A clinical record review revealed Resident 3 was admitted to the facility on [DATE]. A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with a history of known maladaptive behaviors such as inappropriate sexual comments to staff, touching staff inappropriately, wandering into female residents' rooms, and grabbing residents' wheelchairs. Further clinical record review revealed on August 27, 2025, Resident 1 sexually abused another resident when he was witnessed by facility staff touching Resident 3's genital area over her clothing without consent. A review of QAPI documentation revealed no evidence that the facility's performance improvement plan identified or addressed Resident 1's known maladaptive behaviors as risk factors requiring specific interventions. The QAPI plan focused only on the incident identified during the July 24, 2025, survey, without examining whether systemic failures in supervision, behavioral monitoring, or abuse-prevention interventions contributed to the current event. During an interview on August 28, 2025, at 11:00 AM, the Nursing Home Administrator (NHA) reviewed the concern regarding the August 27, 2025, incident in which Resident 1 was witnessed touching Resident 3 over her clothing without consent. The NHA did not provide documented evidence the facility's internal audits conducted after the July 24, 2025, survey identified Resident 1's history of maladaptive behaviors or that he was included in the audits intended to monitor and prevent recurrence of sexual abuse incidents.Further review revealed no documented evidence the Quality Assurance and Performance Improvement (QAPI) committee evaluated Resident 1's behavioral history, implemented targeted prevention strategies, or monitored the effectiveness of corrective actions beyond the initial audits.As a result, the facility's QAPI activities did not identify or correct the underlying causes of the original deficiency, contributing to the recurrence of resident-to-resident sexual abuse under the same regulatory requirement. Cross Refer to F600 28 Pa. Code 201.18(e)(4) Management.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, medication error reports, and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician's orders and assure that two residents out of eight reviewed were free of significant medication errors (Resident CR1 and Resident 2). Findings include: The Principles of Medication Administration, The Five Rights of Medication Administration indicate that when you are giving medication, regardless of the type of medication, you must always follow the five rights. Each time you administer a medication, you need to be sure to have the: 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right route According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnosis to include Type 2 diabetes (body has trouble controlling blood sugar and using it for energy), and falls with fracture of the let humerus (upper arm). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 4, 2025, revealed the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact). Nurse documentation dated June 1, 2025, at 1:40 PM, revealed that Resident CR1 received Hydralazine 75 mg and Clonidine 0.2 mg (both medications used to treat high blood pressure) in error. RN assessment documented the resident as alert and awake, with clear speech, warm and dry skin, and no signs of distress. Her blood pressure was noted to be 80/52 (low reading). She denied dizziness, chest pain, weakness, nausea, or headache. The resident was transferred back to bed with the assistance of two staff members. Fluids were encouraged, and lower extremities were elevated. A call was placed to the on-call physician, and an order was received to send the resident to the emergency room for evaluation. Emergency medical services were dispatched, and the resident's daughter was notified. A review of the facility's Medication Error report dated June 1, 2025, indicated that Employee 2, a Licensed Practical Nurse, had administered the medications in error. According to the error report and subsequent root cause analysis, the error occurred when Employee 2 was preparing medications for Resident 5 and Resident CR1 approached the nurse requesting a pain pill. Employee 2 placed Resident CR1's pain pill into Resident 5's cup and inadvertently administered Hydralazine and Clonidine to Resident CR1. As a corrective measure, Employee 2 received re-education on the Five Rights of Medication Administration and minimizing distractions during medication pass. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), depression, and fall with fracture of the upper end of the right humerus (upper arm). A quarterly MDS dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 0 (a score of 0-7 equates to severe cognitive impairment). Review of a psychiatry note from Employee 1 (nurse practitioner) dated May 8, 2025, indicated Resident 2's current medication list was as follows: Trazadone 100 mg, give one tablet by mouth at bedtime related to depression; Risperidone 1 mg, give one tablet by mouth at bedtime related to dementia; Duloxetine 30 mg, give 1 capsule by mouth related to depression; Memantine 10 mg, give one tablet by mouth two times a day related to Alzheimer's; and Donepezil 10 mg, give one tablet by mouth at bedtime related to Alzheimer's. Continued review of Employee 1's note recommended a Gradual Dose Reduction (GDR a structured process of slowly reducing a resident's medication dosage over time to evaluate the need for continued use) of Risperidone from 1 mg to 0.75 mg nightly. A physician's order dated May 9, 2025, reflected the change to Risperidone 0.75 mg at bedtime. Review of a physician's order dated May 9, 2025, revealed an order for Risperdal (Risperidone) oral tablet, give 0.75 mg by mouth at bedtime for agitation related to dementia. Continued review of physician orders revealed an order dated December 17, 2024, for Risperidone oral tablet 1 mg, give one tablet by mouth at bedtime related to dementia. A review of facility provided document titled Medication Error dated May 22, 2025, at 12:09 AM indicated a GDR of Risperidone was to be started on May 9, 2025, from 1 mg at bedtime to 0.75 mg at bedtime. The nurse added the new order for 0.75 mg but did not discontinue the 1 mg order. The resident received 1.75 mg of Risperidone from May 9, 2025, until May 22, 2025, when the error was noted. A medication error report dated May 22, 2025, documented that the nurse had entered the new 0.75 mg order into the electronic system but failed to discontinue the existing 1 mg order. As a result, Resident 2 received a combined total of 1.75 mg of Risperidone nightly from May 9, 2025, through May 22, 2025. The root cause analysis identified a transcription error during the medication reconciliation process as the source. Although no adverse effects were noted, corrective actions included staff education on transcribing provider orders, disciplinary action for the responsible nurse, and implementation of 11 PM-7 AM chart checks to verify order accuracy. During an interview with the Nursing Home Administrator (NHA) on June 17, 2025, at approximately 2:00 PM, the NHA confirmed the occurrence of significant medication errors involving both Resident CR1 and Resident 2. The facility failed to ensure residents were free of significant medication errors and failed to ensure that nursing services were provided in accordance with professional standards of practice and physician orders. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.10(c) Resident care policies. \

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to residents and/or their resident representatives prior to a facility-initiated room change for three of eight residents reviewed (Residents CR1, 3, and 4). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. At the time of the survey ending June 17, 2025, all beds in the facility were licensed and dually certified for participation in both the Medicare and Medicaid programs. A review of Resident CR1's clinical record revealed the resident was admitted on [DATE], and initially assigned to a room on the [NAME] wing. On March 1, 2025, the resident's room was changed to a room on the East wing. There was no documented evidence that the resident or the resident's representative was provided with written notice or an explanation for the room change prior to the move. A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], and provided a room on the [NAME] wing. On May 19, 2025, the resident's room was changed to a room on the East wing. During an interview with Resident 3, a cognitively intact resident, on June 17, 2025, at 12:10 PM the resident stated that her room was recently changed. She stated that the facility had not informed her of why her room needed to be changed. She expressed frustration stating, someone came in and told us (pointing to her roommate) that they were going to move us to different room on the other side of the building. She continued I was in that room for over a year, I didn't want to move. I liked it there. Resident 3 stated she was not informed of her right to refuse the room change. She stated that had she been informed of her right to refuse, she would have refused the room change. She also reported the facility did not provide any written notification of the reason for the room change. There was no documentation in Resident 3's clinical record indicating that a written notice or explanation of the room change was provided to the resident or the resident's representative. A review of Resident 4's clinical record revealed the resident was admitted to the facility on [DATE], and was provided a room on the [NAME] wing. On May 19, 2025, the resident's room was changed to a room on the East wing. Continued review of Resident 4's clinical record revealed the resident was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status-a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 8-12 equates to moderate cognitive impairment). There was no documented evidence that written notice, including the reason for the move, was provided to the resident or the resident's representative in advance of the room change. During an interview with the Nursing Home Administrator (NHA) on June 17, 2025, at 11:15 AM the NHA failed to provide documented evidence the facility provided any written explanation of the reasons for the facility-initiated room changes to the residents and/or their representatives. 28 Pa Code 201.29 (a) Resident Rights

Based on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfer notces for residents to a representative of the Office of the State Ombudsman for three out of 12 residents reviewed (Residents 1, 23, and 90). Findings include: A review of the clinical record revealed that Resident 1 was transferred to the hospital on February 10, 2025, and was readmitted to the facility on [DATE], Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. A review of the clinical record revealed that Resident 23 was transferred to the hospital on November 5, 2024, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. A review of the clinical record revealed that Resident 90 was transferred to the hospital on January 21, 2025, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the administrator on April 15, 2025, at approximately 10:00 AM confirmed there was no documented evidence that copies of facility-initiated transfer notices for Residents 1, 23, and 90 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The administrator further confirmed there was no evidence that copies were sent to a representative of the Office of the State Long-Term Care Ombudsman during the months of January 2025 (for facility-initiated transfers in the month of December 2024) and February 2025 (for facility-initiated transfers in the month of January 2025). 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on review of clinical records and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed staff properly evaluated and provided nursing care for one resident (Resident CR1) out of 5 residents reviewed. Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnosis to include, COVID-19 positive, cognitive communication deficit (A cognitive communication deficit is a communication difficulty caused by a cognitive impairment) and acute kidney failure. An admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE] revealed that Resident CR1 had a BIMS score of 12 (a score of 8 to 12 indicates moderate cognitive impairment) and required staff assistance for activities of daily living. A review of physician's orders dated [DATE] indicated the resident was ordered to have vital signs ( measurements of the body's most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) taken every shift. A review of admission nursing documentation dated [DATE], at 7:30 PM indicated Resident CR1 arrived at facility from a hospital stay. While at the hospital he was diagnosed with Covid 19 after having increased weakness and fatigue at home. The resident was placed on the facility's designated COVID-19 isolation hallway. Resident CR1 was the only COVID-19 positive resident in the facility at the time of his admission and was housed in this hallway unit. The residents door as well as the hallway exit doors were kept closed at all times. A review of a nursing assessment completed on [DATE], revealed the resident's vital signs were stable. The resident was noted to have diminished lung sounds but did not complain of any shortness of breath at that time. The facility's certified registered nurse practitioner (CRNP) examined the resident on [DATE], at 10:16 AM. The CRNP noted at the time of the assessment, the resident had a mild productive cough, denied increased shortness of breath, had bilateral rales (an abnormal lung sound), and was exhibiting diarrhea. It was documented the resident was not in any acute distress. A review of nursing documentation, contained in the clinical record, dated [DATE], at 8:26 AM revealed the resident's condition had deteriorated. The resident's daughter notified nursing the resident was having trouble breathing. Facility staff were unable to obtain an oxygen saturation level (blood oxygen saturation level which is the amount of oxygen circulating in the blood. A normal resting pulse oximetry reading for oxygen saturation is between 95% and 100%. This shows that blood has an appropriate amount of oxygen. If oxygen saturation level drops below 95%, it may suggest a potential issue with the lung or heart function. Levels below 92% are considered low and may require medical attention. Seek immediate medical attention for a reading of 88% or lower) using pulse ox (a small, electronic device that measures the amount of oxygen in your blood) on each finger with multiple attempts. The resident was noted to be using accessory muscles (muscles that are not primarily responsible for respiration but can assist in the act of breathing when there is increased demand, or when the primary muscles of respiration are not sufficient to achieve adequate gas exchange) while breathing. The resident stated he was having difficulty breathing at that time. Nursing contacted the CRNP via telephone, and new orders were received for oxygen, 5 L/min via nasal cannula to keep the resident's oxygen level at 90% or above and Ipratropium-Albuterol Solution (respiratory treatment) 0XXX,d+[DATE].5 (3)MG/3ML,3 ml inhale orally via nebulizer every 6 hours for shortness of breath/Wheezing for 5 Days. Nursing documentation indicated they continued to be unable to obtain pulse oximetry levels. A review of the clinical record revealed the nurse practitioner failed to examine or evaluate the resident after the resident had a change in condition and was experiencing difficulty breathing and had an unobtainable oxygen saturation level. A review of nursing documentation dated [DATE], at 12:54 PM indicated that Resident CR1 complained of difficulty breathing and was using his accessory muscles to assist with breathing. The facility staff at that time were unable to get pulse oximetry reading with multiple attempts on all fingers. A review of the resident's July Medication Administration Record (MAR) revealed on [DATE], Resident CR1 received a nebulizer treatment at 12:00 PM over three hours from when his symptoms of shortness of breath initially began. A review of nursing documentation revealed that the treatment was given after the CRNP's order was documented as received on [DATE], at 12:54 P.M. There was no documented evidence the facility staff had provided any further assessments or follow up vital signs after the resident had difficulty breathing and unobtainable oxygen level. The facility failed to document the resident's condition to show if the resident was improving or declining or if the CRNP's orders were effective. An interview with the NHA [DATE], at 2:00 PM indicated the CRNP was in the facility on [DATE], at 10:30 AM but failed to assess the resident. A review of nursing documentation dated [DATE], 5:38 PM indicated the resident's daughter ran to the nurse's station at 4:50 PM and stated, I think my father stopped breathing! The nurse immediately ran to room to check the resident after instructing nurse aide to get another nurse immediately. The CPR cart was brought into the room. Staff were unable to detect a pulse. The resident's breathing ceased. The AED (automated external defibrillator, a portable device used to treat a person whose heart has suddenly stopped working) initiated and started by nursing staff. EMS(emergency medical services personal) was called by nursing staff and and facility staff were instructed to begin CPR. CPR was started by the facility staff. EMS arrived within 5 minutes and took over CPR. The Physician was in the facility and called into the room. CPR was not effective, and the resident expired on [DATE], at 5:00 PM. There was no evidence at the time of the survey that staff timely responded to this resident's immediate medical needs. During an interview [DATE], at 2:00 PM, the Nursing Home Administrator and the Director of Nursing confirmed that Resident CR1 was not timely assessed after a change in condition. She confirmed the nurse practitioner and the Physician could not see the resident in the same 24 hour period for payment purposes. Only one practitioner would get paid for the visit therefore delaying treatment. 28 Pa Code 211.2(d)(3) Medical Director 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services.

Based on a review of clinical records and select investigation reports and staff interview, it was determined that the facility failed to implement effective safety interventions including necessary staff supervision of resident with known behaviors that increased the resident's risk for falls to prevent a fall with serious injury, a fractured hip, to one resident out of four sampled (Resident 27). Findings include: Clinical record revealed that Resident 27 was admitted to the facility on [DATE], with diagnoses of dementia, protein calorie malnutrition and a history of falls with fracture at home. An admission Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 11, 2023, revealed that the resident was cognitively intact with a BIMS score of 13 and required staff assistance with activities of daily living. The resident's care plan dated June 8, 2023, indicated that the resident was at risk for falls with planned interventions to anticipate and meet the resident's needs, place the resident's call bell in reach and apply non-skid socks Nursing documentation July 18, 2023 12:16 PM revealed that staff observed Resident 27 walking up and down the hallway and wandering with no purpose. When staff asked, the resident stated he didn't know where he was and was looking for his room. Nursing noted that an elopement risk was completed and a Wanderguard placed on the resident's left wrist. A physician order dated July 19, 2023 at 4:06 PM was noted for the resident to ambulate independently in the facility with rollator walker. On July 20, 2023 an LPN was across the hall from Resident 27's room and heard a noise in Resident 27's room. The LPN responded and found the resident sitting upright on the resident's buttock with his back to the bed. The resident's walker was upright in front of the resident and his legs were stretched out in front of him. He was wearing non-skid socks with good traction. LPN and therapist assisted resident into a wheelchair and the RN completed a full assessment with no visible injuries noted. The resident stated that he got up to go into the bathroom and became dizzy on changing positioning. The resident stated that he bumped the posterior aspect of his head on the bed. Neuro Checks initiated. Therapy screen sent. A behavior note dated July 30, 2023 1:33 PM indicated that Resident 27 was confused all morning, wandering in and out of his room, and wanting to go to Summit Hill, thinking people are in his room moving his things around. When the nurse was administering medications, the resident asked the nurse about the FBI agents in hallway and their investigation. Staff found the door to the resident's room closed numerous times. A behavior note July 31, 2023 04:40 AM noted that the resident continues with confusion and increased behaviors. banging on back door. waiting for police. Redirected out of other residents' rooms. Calming conversation offered. refused to get ready for bed. attempted to assist refused said his daughter was coming with the police. A nurse's note dated July 31, 2023 11:24 AM indicated that Resident 27 was standing at the nurse's desk. The nurse was talking on the phone, looked back and heard a loud bang resident fell backward hitting his head on treatment cart garbage can. The resident stated he felt dizzy. The RN was notified and assessed. The physician was notified and ordered stat labs and a urine collected for tests. Nurses notes stated that staff were unable to collect the sample for the labs due to the resident's behavior. A late entry health status note dated July 31, 2023 2:12 PM from about 11 AM until 1 PM indicated that the resident was at nurse's station in a wheelchair for staff observation. He was given a bible to read and drinks for diversion. No behaviors were noted at that time. Around 1:30 PM, the resident was in room after visiting with family. He was seated in a wheelchair, and brought out to nurse's station for close observation. The resident wheeled himself back down to his room numerous times, stating he wanted to sit in his room. A review of a facility investigation report dated July 31, 2023 at 9 PM. revealed that staff heard a loud crash and heard help me coming from Resident 27's room. Resident 27 was found lying on the floor on his left side with the bedside table knocked over and the resident lying over the top of the table leg. He was not wearing non-skid socks, which the resident had removed and tucked under the corner of his mattress. Resident 27 had spilled melted ice cream under him as well as garbage bags scattered everywhere that he was ripping apart when found. Nursing assessment of the resident found that a bruised area to the left side of his head, 1 cm x 1 cm abrasion to the bottom of his left rib cage. He was assisted via mechanical lift to his bed and the resident complained of pain during lifting his left leg. The physician was notified and ordered that the resident be sent to the hospital for evaluation. A review of hospital documentation dated July 31, 2023 at 11:33 P.M. revealed that the resident had sustained an intertrochanteric fracture of the left hip. Resident 27 had surgery to repair the fractured hip. He was readmitted to the facility on [DATE]. The facility was aware of the resident's restless behaviors, falls related to reported episodes of dizziness, increased confusion and lack of safety awareness, occurring prior to the resident's fall, but failed to provide necessary staff supervision at the level and frequency required to prevent a fall with serious injury. During an interview August 24, 2023 at 1 P.M., the Nursing Home Administrator confirmed that Resident 27 wandered about the facility independently and had displayed increased confusion in the days leading up to the fall with fracture. 28 Pa. Code (d)(5) Nursing services

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of five residents sampled (Resident 1) resulting in serious injury, a fractured arm. Findings include: The facility's policy entitled Abuse Policy dated as reviewed by the facility in September 2022, revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic amputation of the left lower leg, acquired absence of the right leg above the knee, and the need for assistance with personal care An Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated June 15, 2023, indicated that the resident required the assistance of two staff member for transfers. A review of the resident's current plan of care, initially dated May 25, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit related to amputation of both lower extremities. Planned interventions included were that upon admission the resident needed to utilize a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with the assistance of two staff. Subsequently after physical therapy evaluation and treatment, the resident's transfer status was revised and changed to transfers with a sliding board (a device designed for helping those with a physical disability to move from one surface {like bed} to another {like wheelchair}) with the assistance of two staff members on June 9, 2023. A review of physical therapy notes dated June 8, 2023, revealed that a sliding board transfer was completed with a nurse aide present with a moderate assist of two staff members. The resident is a 100 percent assist for board placement and wheelchair setup. Therapy indicated that education was provided to facility staff for sliding board transfers with the assistance of two staff members. Therapy notes dated June 9, 2023, indicated that therapy staff continued education with facility staff with the use of the sliding board with two staff members for transfers. A nursing progress note dated June 12, 2023, at 8:40 PM indicated that Resident 1 was lying on the floor. The entry noted that the resident was an assist of two with a slide board for transfers. A staff member was in the room when the fall had occurred. The resident had been seated in a wheelchair and was transferred to the bed for care to be provided. During transfer the resident fell from the side of the bed. At that time the resident stated she felt that she was slipping so she put her arm out to catch her. The resident expressed severe pain to the right shoulder and nursing noted that the resident's right shoulder appeared asymmetrical to the left shoulder. The resident was transferred to the hospital at that time. A review of a hospital x-ray report dated June 12, 2023, revealed that the resident had an acute humeral neck (bone located at the top of the arm) fracture (break) with impaction (bone is compressed) of the fracture site. A review of the facility's investigation report dated June 12, 2023, revealed Employee 1, a nurse aide, had transferred the resident by herself with the sliding board and the resident slipped off the sliding board and fell to the floor. Employee 1 was disciplined for not following the proper transfer of the resident resulting in injury. A review of a witness statement from Employee 1 dated June 13, 2023, at 10:30 AM revealed that Employee 1 was providing care to the resident and utilized her sliding board to transfer her back to bed. As the transfer was almost complete the resident slid off the sliding board on to the floor. An interview with the Nursing Home Administrator on June 29, 2023, at approximately 10:00 AM revealed that Employee 1 knew she was to use two people when transferring Resident 1 with the sliding board. The NHA stated that therapy had educated the nursing staff on using the slide board with two staff assistance in the days prior to the resident's fall. A telephone interview with Employee 1 on June 29, 2023, at 11:40 AM revealed that Employee 1 confirmed that she knew the resident was supposed to be an assist of two staff for transfers. Employee 1 stated I made a mistake and transferred the resident myself. Employee 1 further stated I should have used two people, but I just didn't. There is no reason. It's my fault. An interview with the Nursing Home Administrator and Director of Nursing on June 29, 2023, at approximately 1:30 PM confirmed the facility failed to ensure that Resident 1 received the services necessary to avoid physical harm. The NHA and DON confirmed that Employee 1 was aware that the resident's transfer was to performed with two people but neglected to assure the presence of a second person and performed the transfer by herself resulting in the resident's fall and serious injury during transfer. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing Services

Based on interviews with staff and clinical record review, it was determined that the facility failed to implement planned interventions, to include staff assistance with transfers and ambulation as required, to prevent a fall with serious injuries, multiple fractures, for one of five residents reviewed ( Resident CR1). Findings include: A review of the Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of dementia and anxiety The resident's care plan dated November 12, 2018, noted that the resident was at risk for falls related to deconditioning, gait/balance problems and weakness. Planned interventions were to ensure that the resident is wearing non-skid footwear when ambulating and to follow the facility fall protocol. The plan of care also noted that the resident was an elopement risk/wanderer related to impaired safety awareness, dated September 24, 2020. Planned interventions were to identify a pattern of wandering, de-escalate by redirecting or diverting her attention and offer her snacks. Nursing documentation dated January 18, 2021 at 12:43 PM, a Fall Intervention Note, status post fall on January 17, 2021 at 10:49 AM, revealed {resident's name} had a fall resulting in redness and swelling to Right fingers, hand and wrist. Observed sitting on floor in bathroom, back against door frame with pants down around ankles. Non-skid sneakers on. Call bell in reach, but not on at time of incident. When asked about incident resident stated, I don't know. Staff last observed that the resident was in bed sleeping at 1000. Resident independent with transfers. New Interventions: Bowel and Bladder review, need for possible program r/t weakness, Therapy eval to see transfer status is appropriate or if should be changed to assist of 1 rollator walker due to weakness with covid dx, x-ray to R hand from elbow to finger tips, increase fluids. MD and POA aware of all changes. Continue to monitor. Nursing documentation dated January 18, 2021, 8:21 PM revealed X-rays of right hand and wrist were done today. Right hand impression: No definite evidence of acute fracture, significant deformity or soft tissue swelling. Moderate multifocal chronic and [CONDITION(S)] changes particularity involving the first carpometacarpal joint and multiple proximal and distal interphalangeal internally fixed forth metacarpal fracture. A physician order was noted after the resident's fall dated January 26, 2021, to discontinue independent transfers and initiate transfers assist of 1 with rollator walker. A review of the resident's care plan dated April 7, 2021, revealed the problem/need of self care deficit related to intermittent confusion and dementia. The planned interventions identified were that the resident required limited assistance of one for ambulation in room and in the corridor, and assistance of one with the rollator walker for transfers. A fall evaluation completed by the facility dated March 14, 2022, indicated that the resident was at high risk for falls. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 14, 2022, revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) score of 0, indicating that the resident was severly cognitively impaired. The resident required the assisstance of one person for transfers and bed ambulation, utilized a rollator walker and was not steady with ambulation and only able to stabilize with staff assistance. During an interview conducted on June 22, 2022 at approximately 1 PM, the Director of Nursing stated that due to Resident CR1's repeated unsafe transfers and ambulation attempts, a therapy screen was requested and obtained March 24, 2022. A review of a therapy screen dated March 24, 2022, revealed that Resident CR1 was screened by therapy for ambulation status. The resident was a limited assist of one for ambulation with a rollator walker, a history of non-compliance, walking in the hallway at times without the rollator walker present due to cognition limitations/safety/non compliance and BIMs score of 0. Therapy recommend to continue safe ambulation with assistance of one and the rollator walker in the room/hallway at this time. Nursing documentation dated May 27, 2022, at 2:23 PM revealed noted Called to room 243 at 13:30 PM (1:30 PM) to assess {Resident CR1} status post fall. Resident lying on back in her room with legs facing towards window. Resident's head was against wall connecting to resident's closet. Resident's feet were tangled in walker, which was also lying on floor. Moderate amount of blood coming from laceration on forehead (4 cm x 4 cm) as well as, a 10 cm laceration on posterior aspect of head. Wearing shoes with good traction. Environment clear. Cervical neck stabilization provided throughout assessment/intervention/transfers. Lacerations cleansed with normal saline to facilitate better visualization then pressure applied with good effect. VS assessed/stable. Awake and alert to self- at baseline. Responding to verbal stimuli. At baseline, resident only speaks in small phrases and answers occasionally to yes and no questions with clear speech-- this remained the same during assessment. Calm with periods of anxiety exhibited by attempting to strike and kick staff x 4 extremities. Range of motion x 4 extremities at baseline in supine position. Unable to assess strength of hand grasps as resident choose not to complete exercise due to increased anxiety x 3 attempts. No decorticate or decerebrate posturing. Pupils equally round with size of 4 mm. Left pupil noted with brisk reaction and Right pupil reactive but slightly sluggish. Anatomical assessment noted with no deformity to inspection or pain with palpation. Transferred to bed via mechanical lift. Head of bed up to 30 degrees to decrease inter cranial pressure. Multiple staff 1:1 with resident to keep calm, provide emotional support, and assist with cervical neck stabilization and injury treatment. Physician made aware. New order noted to send to emergency room for evaluation and treatment. Call placed to 911 ambulance for transport. A review of nurses notes dated May 27, 2022 at 5:12 PM revealed Call received from RN at the emergency room . Resident CR1 is admitted and is being transferred to a different hospital with a trauma unit with diagnosis of Cervical spine 1 and Cervical spine 2 fractures. A review of an incident/accident report investigation dated May 27, 2022, at 1:29 PM indicated that the resident was found in her room on the floor with her legs tangled in her walker. There was a moderate amount of blood coming from a laceration on her forehead, measuring 4 cm x 4 cm as well as a 10 cm laceration on the posterior aspect of her head. She was wearing shoes with good traction according to the report. The immediate action taken by the facility included an assessment by the licensed nurse, pressure and ice applied to lacerations. The physician and responsible parties notified and the resident was sent to the emergency room for evaluation and treatment A review of a witness statement May 27, 2022, (no time indicated) from Employee 1 (housekeeping) revealed, I walked Resident CR1 back to her room after lunch. Resident was pleasant and her walking was like always. She sat in a chair in her room. I didn't notice anything out of the ordinary. A review of a witness statement May 27, 2022 at 1:30 PM, Employee 2 stated, I was walking down the hallway when I saw a coffee cup go flying into the hallway. I went to go pick it up and that is when I saw Resident CR1 on the floor. The resident's head was up against the wall with blood pouring out. The resident's feet were tangled in her walker. I notified the nurse and I rolled her onto her back. X-rays were ordered and obtained in the emergency room . Results were as follows: -closed, stable burst fracture (a burst fracture is a descriptive term for an injury to the spine in which the vertebral body is severely compressed. They typically occur from severe trauma, such as a motor vehicle accident or a fall from a height. With a great deal of force vertically onto the spine, a vertebra may be crushed) of the first cervical vertebra, -closed, non displaced fracture of the second cervical vertebra, -closed, wedge compression fracture (a compression fracture is a collapse of a vertebra. It may be due to trauma) of Thoracic 5 vertebra and, -an [MEDICATION(S)] hematoma (Accumulation of blood between the dura matter (tough outer membrane covering the brain), and the skull). A review of hospital documentation dated May 27, 2022 revealed Resident CR1 was admitted to the trauma service. Neurosurgery was consulted. Her C/1-C/2's fractures were treated conservatively with a cervical collar. A thoracic X-ray was ordered to evaluate her T/5 vertebral compression fracture. Resident CR1 did not tolerate the X-ray and subsequently was not completed. [MEDICATION(S)] (blood thinning medication) was held due to the [MEDICATION(S)] hematoma. Nursing documentation dated May 30, 2022 at 5:50 PM revealed {Resident CR1}`readmitted at 4:45 PM to room 243D from the hospital. Resident is being readmitted following a fall on May 27, 2022, sent to the emergency department then transferred to an additional hospital for trauma service with a neurosurgery consult. Per records, noted with left sided scalp laceration, with 16 staples. Resident noted with C1 burst fracture and C2 nondisplaced fracture with an [MEDICATION(S)] hematoma, in a VISTA (cervical) collar at all times. Also noted with a T5 compression fracture, no brace or treatment. During an interview June 22, 2022 at 11 AM, Employee 1 (Housekeeping) stated that on May 27, 2022, she noticed Resident CR1 get up out of her seat in the dining room and independently ambulate with her rollator walker out of the dining room. Employee 1 stated that she did not see any nursing staff in that area at that time. Employee 1 stated that she followed behind Resident CR1 from the dining room back into there resident's room. Resident CR1 sat in a chair in her room and placed the walker in front of her. Employee 1 then left the room. Employee 1 (housekeeping) stated that she did not assist Resident CR1 in transfers or ambulation as she was not trained in ambulation or transfer assistance for residents. Employee 1 (housekeeping) then left Resident CR1's room and walked down the hallway. She then saw a coffee cup coming out of the resident's room. Employee 1 (housekeeping) went to Resident CR1's room and saw her on the floor with her feet tangled up in the rollator walker legs. Employee 1 stated that Resident CR1 often ambulated independently in the facility and transferred herself. During an interview June 22, 2022 at 11:15 AM, Employee 3, nurse aide, stated that Resident CR1 often ambulated independently in her room and in the hallway. Employee 3, nurse aide, stated that she was aware that staff should assist Resident CR1 when she is transfering and ambulating. During an interview June 22, 2022 at 11:20 AM, Employee 4 (agency LPN) stated that Resident CR1 had a long history of self transfering and ambulating without staff assistance. She stated that she was also aware that Resident CR1 required the assistance of one staff for ambulation. The interview conducted with Employee 1, housekeeper, during the survey of June 22, 2022, verified that on May 27, 2022 after the lunch meal, Resident CR1 transferred herself out of her chair in the dining room and then self-ambulated down the hallway towards her room without any staff assistance. Employee 1 confirmed that no nursing staff was aware that the resident had left the dining room and was ambulating independently back to her room. The housekeeper (Employee 1) stated that she saw the resident walking by herself and followed behind Resident CR1, as Resident CR1 independently ambulated back to her room. The resident sat down in the chair by herself and positioned the walker directly in front of her, which allowed the resident easy access to continue to transfer and ambulate at will while also posing an accident hazard to the resident as the resident required assistance with transfers and ambulation. Employee 1 verified during interview at the time of the survey of June 22, 2022, that she did not assist the resident's transfer or ambulation in the dining room, corridor or resident's room as the housekeeper was not trained to assist residents in transfers or assistance in ambulation. Employee 1 also confirmed that there was nursing staff was in the dining room to assist this resident back to her room and with the transfers from the chair in the dining room or into the chair in her room, and to safely secure the walker to prevent an accident hazard to the resident, as the resident was shortly thereafter found with her legs tangled in the legs of the walker. Nursing staff interviews at the time of the survey of June 22, 2022, also verified that the nursing staff was aware of the resident's independent transfers and ambulation and repeatedly allowed it, although they acknowledged that the resident required assistance with transfers and ambulation. The resident was assessed to require the assistance of one staff for safe transfers and ambulation with the walker. Staff interviewed during the survey were aware that the resident required the assistance of one staff for transfers and ambulation with the walker, but also acknowledged that the resident frequently transfers herself and ambulates independently in the halls and her room and has done so in the past. The resident's walker also remained readily accessible to the resident when in her room allowing her ambulate independently at will. The facility failed to develop and implement adequate safety measures to promote this resident's safety and prevent falls related to the resident's known history of unassisted transfers and ambulation. The DON (director of nursing) confirmed during interview on June 22, 2022, that the facility staff allowed Resident CR1 to transfer and ambulate independently with the walker and failed to consistently implement the planned intervention of providing one person assistance with transfers and ambulation, and necessary supervision, to prevent this fall with serious injuries. 28 Pa. 28 Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, current CDC (Centers for Disease Control and Prevention) and PAHAN (Pennsylvania Health Alert Network) infection control guidance and infection control consultation documentation, observations and staff interview, it was determined that the facility failed to timely initiate necessary infection control precautions for cohorting residents positive for COVID-19 to prevent the spread of the [CONDITION(S)]-CoV-2 virus to uninfected residents. This failure placed the uninfected residents in immediate jeopardy to their health due to the likelihood of contracting the virus by continuing to reside in the same room as the infected resident and resulted in three residents out of four sampled being infected with COVID-19 (Residents 2, 7, and 10) while residing with COVID positive roommates. Findings include: A review of a facility policy for Monitoring and Testing of Residents and Health Care professionals updated by the facility December 28, 2021 revealed that the purpose of this policy is to reduce the risk of [CONDITION(S)]-CoV-2, otherwise known as COVID-19 and Corona Virus. The virus causes health complications for patients/residents and employees. The company is committed to help prevent the unnecessary spread of the virus between employees, patients and families. This is accomplished through the requirement that all health care personnel follow recommended infection control procedures as defined by the CDC and Pa Department of Health. According to the facility policy, the facility will identify space in the facility that could be dedicated to monitor and care for residents with confirmed [CONDITION(S)]-CoV-2 infection. Determine the location of the COVID-19 care unit and create a staffing plan. The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. This could be a dedicated floor, unit or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with [CONDITION(S)]-C0V-2 infection. Ideally, a resident with suspected or confirmed [CONDITION(S)]-Co-V-2 infection should be moved to a single-person room with a personal bathroom. A review of a Pennsylvania Department of Health 2021-PAHAN-610-12-01 UPD dated December 1, 2021, subject: UPDATE: Response to an outbreak and residents with exposure to COVID-19 for Long Term Care Facilities ( This HAN provides guidance on response to exposure and outbreaks of COVID-19. The guidance applies to skilled nursing facilities (SNF's), personal care homes, assisted living facilities and intermediate care facilities). Key definitions referenced in the PAHAN included a close contact: someone who is within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, during their infectious period. The infectious period begins from 2 days before illness onset or for asymptomatic (without symptoms) patients, 2 days prior to specimen collection date of the positive test. Source control definition: Use of well fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing or coughing. Isolation for residents: The term isolation refers to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, health care professionals or visitors. Isolation in long term care facility residents includes: the use of standard and transmission based precautions for COVID-19 and provide a private room with a private bathroom or with another resident with laboratory-confirmed COVID-19, preferably in a COVID Care Unit and restrict the resident to their room with the door closed. (In some circumstances keeping the door closed may pose resident safety risks and the door might need to remain open. If the doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway) An outbreak is defined as one or more COVID-19 cases in a facility. If residents develop signs and symptoms of COVID-19 perform [CONDITION(S)] testing, implement isolation while tests are pending and place unvaccinated roommate(s) under quarantine immediately. Do not place a person with suspected COVID-19 into a COVID care unit prior to confirmation of infection by positive test result. Managing Residents with exposure: to include the use of standard and transmission-based precautions for COVID-19 and maintain source control at all times while around others; and be placed in a single- room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter-in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2 infection; and restrict the resident to their room; and Quarantine for residents should extend 14 days from the date of last exposure, regardless of the results of testing, unless the resident should become symptomatic or positive for [CONDITION(S)]-CoV-2 during that period. Unvaccinated residents should be placed in quarantine for 14 days. Fully vaccinated residents and [CONDITION(S)] CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by health care professionals using full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-Co-V-2 infection, are moderately to severely immunocompromised. Limited circumstances where units or facilities might be considered zones. For COVID-care units (RED zone), for admission units designated for unvaccinated residents (yellow zone) -a unit-based or facility-wide approach to outbreak response where all residents are undergoing quarantine (yellow zone) because none are fully vaccinated, or the facility has been advised to do so to respond to an outbreak with ongoing transmission. A review of a current facility policy for Coronavirus Disease (COVID-19) Prevention and Control, revised March 2021 revealed that the response to the current outbreak of coronavirus disease is based on the most current recommendations from health policy officials, state agencies and the federal government. Infection prevention and control measures are based on established guidelines governing all communicable diseases. Residents with suspected or confirmed COVID-19 infection are placed in a separate room or cohorted with other residents with the same infection status. Residents who cannot be treated adequately or safely separated from other residents will be transferred. The facility has a licensed and certified bed capacity of 150 beds. At the time of the survey of January 27, 2022, the facility's census was 73 residents. Observations conducted during a tour of the facility on January 27, 2022, along with a review of a facility floor map of resident rooms, revealed that at the time of the survey resident rooms 167 through 205, the west wing of the facility, was not occupied. The east wing of the facility included resident rooms 206 through 237. At the time of the survey, resident rooms 229, 232 and 242 comprised the facility's designated RED zone(COVID-19 positive) isolation rooms. At the time of the survey, all other resident rooms on the East wing of the facility were designated as green (negative for COVID-19 and not under observation or quarantine for potential exposure). Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3, was fully vaccinated for COVID-19 as of February 19, 2021. An annual MDS Assessment (Minimum Data Set Assessment - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 12, 2021 revealed that Resident 3 was severely cognitively impaired and required maximum assistance with activities of daily living. Resident 3 resided in in room [ROOM NUMBER] W, a designated red room, with Resident 4. A review of the clinical record revealed that Resident 4 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an annual MDS assessment dated [DATE], revealed Resident 4 was cognitively intact and required minimal assistance with activities of daily living. A review of facility documention revealed that Resident 3 tested positive for COVID-19 on January 18, 2022, and had displayed symptoms of an occasional, wet-non productive cough. At the time Resident 3 tested positive the resident resided in room [ROOM NUMBER], a Red isolation room. Resident 4 and Resident 3 continued to reside in this same room together following Resident 3's positive test result for COVID-19, on January 18, 2022. Nursing documentation dated January 21, 2022 revealed that Resident 4 tested negative for COVID-19. The facility failed to promptly to isolate Resident 3, a resident with a symptomatic COVID-19 infection, to prevent potential transmission to Resident 4 according to current infection control guidance and facility policy. Resident 3 and Resident 4 resided in resident room [ROOM NUMBER] prior to, and subsequent to, Resident 3' s' COVID-19 positive test, on January 18, 2022. Resident 4, a COVID negative resident was exposed to Resident 3, a symptomatic COVID positive prior to Resident 3 testing positive and after the resident tested positive. The residents remained roommates and continued to reside in the quarantined (RED) isolation room at the time of the survey of January 27, 2022. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was fully vaccinated for COVID-19 as of February 23, 2021 . A significant change MDS assessment dated [DATE], indicated that Resident 1 was cognitively intact and required maximum assistance of staff for activities of daily living. Nursing documentation January 18, 2022, at 12:39 PM indicated that Resident 1 had a dry, non productive cough and congestion. A review of facility documentation revealed that Resident 1 tested positive for COVID-19 on January 18, 2022. Resident 1 resided in room [ROOM NUMBER]D, a designated RED isolation room, at that time with Resident 2. Clinical record review revealed Resident 2 was admitted to the facility on [DATE]. and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 was fully vaccinated for COVID-19 as of February 19, 2021. A quarterly MDS assessment dated [DATE], revealed that Resident 2 was cognitively intact and independent with ADLs (activities of daily living). Following Resident 1's positive COVID-19 test, the resident was not isolated and continued to reside in the same room with Resident 2. A review of facility documentation revealed that Resident 2 tested negative for COVID-19 with rapid testing on January 21, 24 and 26, 2022. Nursing documentation dated January 24, 2022, at 10:11 PM indicated that Resident 2 was assessed- Occasional, infrequent dry cough noted. Lung sounds clear upon auscultation. Afebrile. No other complaints. Nursing documentation dated January 26, 2022 at 11:44 AM revealed that Resident 2 had lingering infrequent dry cough persists. Lungs clear to auscultation. Denies sore throat, shortness of breath, chest pain. Fluids encouraged/accepted. Rapid Covid Nasal Swab test performed with (-) (negative) result noted. PCR (polymerase chain reaction. It's a test to detect genetic material from a specific organism, such as the COVID-19 virus) Covid-19 Nasopharyngeal (the upper part of the throat {pharynx} that lies behind the nose) swab test performed. Specimen sent to lab. Tolerated both procedures well without complaints. New order noted per MD: Initiate Covid Precautions: wear N95 mask, gown, gloves, eye protection. A review of a COVID-19 PCR test result dated January 26, 2022, revealed that Resident 2 tested COVID-19 positive. Resident 1 and Resident 2 resided in room [ROOM NUMBER] at the time of Resident 1's COVID-19 positive test on January 18, 2022. Resident 2 was exposed to Resident 1 for at least 8 days prior to Resident 2's COVID positive result on January 26, 2022. A review of the clinical record of Resident 9 revealed admission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] revealed Resident 9 was cognitively intact and independent with most ADLs. A review of nursing documentation dated January 12, 2022, at 12:39 PM revealed that Resident 9 had a Rapid Covid-19 swab performed with +Positive result noted. Increased fatigue noted otherwise free of s/sx respiratory or GI distress. Covid Precautions: wear N95, gown, gloves, eye protection. Resident & RP (responsible party) aware. Nursing documentation dated January 12, 2022 at 2:39 PM, Resident 9 was noted with new sudden onset disorientation and behavioral disruption of mood. Nursing noted that Patient upset he was covid-19 positive and roommate (Resident 10) was still in room. Patient proceeded to walk around building to closed down unit of west wing and look for the boss (nursing home administrator) to yell at her about a situation he refused to speak to the LPN about. After the patient found the Administrator (NHA) in a meeting he proceeded to sit up front in the front of the office and wait to speak to his daughter regarding someone trying to steal his blood. Multiple attempts made to reorient patient to situation and place, but patient continued to choose to believe someone was out to get him. When this nurse left shift patient continue to choose to sit up in front office await return call from daughter. Nursing documentation dated January 12, 2022, 6:40 PM revealed that Resident 9 complains of being unable to get out of chair. stated I felt dizzy & my body hurts. vital signs within normal limits. glucose 127, spo2 (oxygen saturation level-amount of oxygen in the blood) 94 on room air, heart rate 58, blood pressure 152/63, lung sound clear bilaterally. Able to squeeze hands equally. patient currently positive for COVID-19. resident assisted to lay in bed comfortably. Tylenol provided for pain. will continue to monitor. Clinical record review revealed that Resident 10, Resident 9's roommate, was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE], revealed that Resident 10 was moderately, cognitively impaired and was independent for ADLs. Nursing documentation dated January 15, 2022 at 11:20 AM Per LPN (Licensed practical nurse), positive cough/congestion. Rapid Nasal Covid swab positive results. Covid Precautions initiated as follows: wear N95, gown, gloves, eye protection. CRNP made aware: Continue PRN cough drops and cough medicine as ordered. Resident 9 and Resident 10 resided in room [ROOM NUMBER] at the time of Resident 9 COVID-19 positive test on January 12, 2022. Resident 10 was exposed to Resident 9 for at least 3 days prior to Resident 10's subsequent COVID positive result on January 15, 2022. The facility failed to timely isolate Resident 9 to prevent Resident 10 from being infected with COVID-19. Clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE], revealed Resident 6 was severely, cognitively impaired and required extensive assistance with ADLs. Nursing documentation dated January 12, 2022, at 12:37 PM revealed that Resident 6's Vital signs stable, hoarse voice and sore throat. Rapid Covid-19 swab performed with Positive result noted Covid Precautions: wear N95, gown, gloves, eye protection. Resident 6 was identified as positive for COVID-19 on January 12, 2022, but was not isolated from the resident's roommate, Resident 7 at that time. Clinical record review revealed that Resident 7, Resident 6's roommate, was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS assessment dated [DATE], revealed Resident 7 to be severely cognitively impaired and required maximum assistance with ADLs. Nursing documentation dated January 21, 2022, at 3:03 PM indicated that Resident 7 had nasal congestion/hoarse throat. Denies sore throat. Rapid Nasal Covid-19 Swab noted with positive results. Covid Precautions as ordered. Resident 6 and Resident 7 resided in room [ROOM NUMBER] at the time of Resident 6's COVID-19 positive result January 12, 2021. Resident 7 was exposed to Resident 6 for 9 days prior to Resident 7's COVID positive result on January 21, 2022. An interview conducted on January 26, 2022, at 1 PM with the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not isolate COVID positive residents and continued the practice of housing COVID positive and negative residents in the same room. The DON and NHA stated that the practice of allowing residents to shelter in place upon a positive COVID-19 test result was approved by the infection control consultants, contracted by the PA Department of Health, during their recent visit to the facililty on January 24, 2022. However, in response to surveyor inquiry, information was provided to the State Survey Agency by the infection control consultant, contracted by the PA Department of Health, to assist long term care facilities with COVID-19 mitigation efforts. This information dated January 27, 2022, revealed that The co-horting of COVID positive residents and COVID negative residents together, regardless of vaccination status, is not consistent with current guidance as per 2021 - PAHAN - 597 - 09-21-UPD. Our team would not make this recommendation. If a resident is confirmed COVID positive we would recommend placement in a single person room with closed door and dedicated bathroom if possible. The contracted infection control consultant explained that their during their visit to the facility, on January 24, 2022, the facility had an empty wing to move COVID positive residents; however, their corporate office declined to do so. At the time of the visit, our team found residents COVID positive and negative mingled together for 5-7 days past the initial positive test date. The corporate decision to NOT move the residents at the time they tested COVID positive was reportedly based on staffing. The ADON was out when this decision was made; therefore, upon her return she was surprised to learn that the team at the facility did not move the residents who tested COVID positive to a private room. At the point at which our team visited this facility, at least 7 days had passed from the initial resident COVID positive date. At that point, our team felt that moving these residents would be more disruptive and provide additional unnecessary risk to the rest of the population at the facility. The decision point to NOT move the residents to a Red zone at the time they tested COVID positive was made well before our team arrived. Further interview with the NHA and DON on January 27, 2022, at 2 PM confirmed that the facility did not want to relocate residents to the empty wing for the purpose of cohorting and/or isolating COVID-19 positive residents for staffing reasons. The NHA and DON verified that the facility chose to allow the residents positive for COVID-19 to remain in the same room with residents who were negative for COVID-19. The facility decided to allow the residents to shelter in place instead of moving them to the vacant wing or rooms within the facility that were available at that time because of staffing considerations. As result of the facility's failure to promptly isolate residents positive for COVID-19, immediate jeopardy to the health and safety of residents was identified at 2:42 PM on January 27, 2027. The immediate jeopardy template was provided to the facility on [DATE], at 3:20 PM. The facility's corrective action plan was as follows: -Resident 4, that was residing with a COVID-19 positive resident, was immediately moved to room [ROOM NUMBER]. This room change was completed as of 1/27/2022. -The practice of sheltering in place will be discontinued effective immediately and will not be used moving forward. Any residents testing positive will be relocated immediately to protect the resident. There are currently no residents who have tested positive who are residing with residents who have tested negative. -Education was provided to NHA, DON, ADON/IP Nurse, and RN Supervisor on 1/27/2022 on the need/rationale for immediate room changes to keep Covid negative and positive residents safely apart The facility's corrective action plan was completed on January 27, 2022, at 5:15 PM and the immediate jeopardy was removed. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18 (b)(1)(d)(e)(1)(2)(3) Management

Based on review of clinical records, information submitted by the facility and select incident reports, observations and resident and staff interviews it was determined that the facility failed to provide necessary staff assistance and supervision at meals, consistently follow physician orders for positioning and utilize the most effective safety device during transfer to prevent accidents, including falls with injuries for two residents, a fractured rib for one resident and a fractured arm for one resident, and [CONDITION(S)] sustained by one resident out of 20 sampled residents (Resident 49, 5, 140). Findings include: A review of resident 49's clinical record revealed admission on May 7, 2021, with diagnoses to include a left leg amputation (missing limb) above the knee. A review of a significant change MDS Assessment (Minimum Date Set Assessment is a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 19, 2021, indicated the resident required the assistance of two staff for all activities of daily living. The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. A review of an Occupational Therapy (OT) note dated August 17, 2021, revealed that OT received a screen request from nursing regarding the resident's out of bed positioning in her current 22 inch wheelchair. The screen indicating that the resident was sleeping frequently in the chair with head hyperextended and resident sliding from the chair, requiring staff to boost her frequently. OT provided the resident with a tilt-n-space wheelchair with extra thick cushion. The positioning devices to be in upright position for all meals, tilt all other times The note also indicates that OT provided education and training to several NA's, LPN's, and RN's on first shift. Staff demonstration with verbal understanding. A physician order dated August 17, 2021, was noted for an out of bed tilt-n-space wheelchair with lateral supports along the leg and right hips, a foot buddy (a cushion that controls flexion contracture of the legs) on elevated legs rests and small pillow behind the resident's head. The chair was to be positioned upright for all meals only and at a tilt at all other times. An incident/accident report dated October 2, 2021 at 9:15 AM, revealed that the resident had an unwitnessed fall in her room while seated in the tilt-n-space wheelchair. A nickel size ecchymotic (bruised) hematoma (a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury) was noted to the left temporal region (the are of the head just behind the temples) with moderate amount of bleeding. The resident was sent to the hospital for evaluation and treatment. X-ray results dated October 2, 2021, revealed a non-displaced fracture to the left posterior lateral third rib. A review of a written statement provided by Employee 3 (nurse aide) regarding the resident's fall indicated that she heard a loud bang and heard a yell for help. Resident 49 was found on the floor, face down and she appeared to be bleeding from her forehead. A review of a written statement by Employee 4 (nurse aide) stated that prior to the resident's fall she had transported resident from the dining room back to her room. Employee 4 indicated that she was unaware of the resident's specific care needs and that she was not assigned to the resident that day. A physician order was noted October 2, 2021, for [MEDICATION(S)] (combination of acetaminophen and [MEDICATION(S)]. [MEDICATION(S)] is an opioid pain medication) tablet 5-325 mg one every 6 hours as needed for left rib pain. A review of the resident's October 2021, Medication Administration Record (MAR) revealed that the resident was medicated with [MEDICATION(S)] medication 21 times from October 2, 2021, through October 16, 2021. The resident also had a physician order current for October 2021, for [MEDICATION(S)] ([MEDICATION(S)], a pain medicine similar to an opioid) 50 mg 1 every 12 hours for pain. A review of the October 2021 MAR revealed that the resident received [MEDICATION(S)] eight times from October 2, 2021, through October 16, 2021. Eight doses of those doses of [MEDICATION(S)] administered during October 2021 were administered on the same days that the resident also received [MEDICATION(S)] for management of left rib pain. During an interview with the Nursing Home Administrator (NHA) on October 21, 2021, at 10:55 AM, the NHA stated the nurse aide who had returned the resident to her room from the dining room after breakfast, was not aware that the resident's chair needed to be adjusted into a tilt position after meals. The NHA stated that at the time of the survey ending October 22, 2021, only Resident 49 was using a tilt-n-space chair in the facility. A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses to include [CONDITION(S)] (stroke) with left [CONDITION(S)] (is the paralysis of limbs on the left side of the body), dysphagia (difficulty swallowing), [CONDITION(S)], and muscle weakness with difficulty walking. A review of a significant change Minimum Data Set assessment dated [DATE], revealed that Resident 5 was cognitively intact and required extensive assistance of two plus persons physical assist for toileting, dressing, and bed mobility. The resident was totally dependent for transfers with two plus persons assistance and not steady during surface-to-surface transfers. The resident's plan of care, October 2, 2020, indicated that Resident 5 had ADL (activities of daily living) deficits related to impaired balance related to [CONDITION(S)] with [CONDITION(S)] and required the use of a mechanical lift with the assistance of two persons for transfers. A review of information submitted by the facility dated October 2, 2021, at 9:15 AM, revealed that Resident 5 had a fall during transfer with a mechanical lift. According to the nurse aides, while transferring Resident 5 utilizing a split-sling lift pad, the resident slipped out of the sling and fell to the floor. The resident was lying supine (means lying horizontally with the face and torso facing up) next to door side of bed. The nurse aides reported that they gently broke the fall and the resident did not hit her head. The facility noted that the mechanical lift was assessed and was working properly and the split-sling lift pad was assessed with no abnormalities noted. However, the facility identified that the lift pad used was observed to be the inappropriate size. After the fall, the Resident 5 had complaints of breakthrough left shoulder pain and the physician ordered x-rays of the left shoulder, left clavicle (or collarbone), and left scapula (shoulder blade or wing bone). Review of x-ray results dated October 2, 2021, at 2:31 PM, revealed that Resident 5 sustained an acute displaced fracture of the left humeral neck (the humerus is a long bone in the arm that runs from the shoulder to the elbow and the humeral neck is the ball-like head of the humerus). Resident 5 was sent to the hospital to be evaluated. Review of hospital records dated October 2, 2021, indicated that Resident 5 sustained a 3-foot fall out of the Hoyer lift and was diagnosed with a comminuted left proximal humeral fracture (is a fracture where the bones are broken in several fragments and are not aligned that can be caused by trauma). Post fall with fracture that occurred October 2, 2021, Resident 5 had complained of severe pain at levels of 10 (on a scale of 1-10, with 10 being the most severe) for 10 days after the fall. An Employee Witness Statement received from the nurse aides providing care to the resident on October 2, 2021, revealed that Employee 1, a nurse aide, stated that on October 2, 2021, they (nurse aides - Employee 1 and Employee 2) were getting Resident 5 out of bed and found a blue trimmed lift pad on the resident's chair and placed it under her. Employee 1's statement indicated that while the resident was sitting in the Hoyer lift [is an assistive medical device that is a portable patient floor lift which typically uses electric, hydraulic, or battery power, and specialized sling-style pads that slide under the user's body to securely and comfortably transfer an individual requiring 90% - 100% assistance to move from a bed to a wheelchair, toilet, or chair] the resident was leaning to the left side, and the resident started to slide out of the sling. Employee 1 indicated that they (nurse aides) tried to stop her from falling and broke her fall. The Employee Witness Statement received from Employee 2, nurse aide, dated October 2, 2021, at 9:15 AM, indicated that she assisted Employee 1 with getting Resident 5 out of bed with the Hoyer lift. Employee 2 indicated that while transferring the resident, Resident 5 slipped out of the sling and they gently broke her fall and lowered her to the ground. Employee 2 noted that the Hoyer was set up correctly and all the proper precautions were taken. Interview with Resident 5 on October 21, 2021, at 9:30 AM, indicated that while she was being lifted in the Hoyer lift, the nurse aides (Employee 1 and Employee 2) were lifting her up and at the same time began to move the lift over to her chair. During the transfer, Resident 5 stated that they (nurse aides) performed the transfer quickly and the resident stated that she told the nurse aides that she was sliding from the pad. Resident 5 stated the next thing I knew, I was on the floor. The resident stated when the nurse aides realized that she was falling, they attempted to break her fall and protected her head. Resident 5 stated that since the fall she doesn't want to get out of bed (OOB) because she is afraid of the Hoyer lift. The resident also stated that her left arm hurts. She stated that she had limited function to her left side due to a previous stroke, but after her fall has to keep her left arm in a sling to keep the fracture in place. Interview with Employee 1 on October 21, 2021, at 1:35 PM, revealed that she operated the Hoyer lift and during Resident 5's transfer and fall. Employee 1 stated that she heard the sling clip snap and then noticed that the resident was leaning. Employee 1 reported that she heard the resident say that she was slipping and that the resident slid from the sling onto the floor. The employee stated that the transfer happened quickly. Employee 1 also stated that if they (nurse aides) kept the resident over her bed until fully elevated, instead of moving the Hoyer while the lift was still elevating the resident, the resident may have landed on her bed instead of on the hard floor when she fell . Interview with Employee 2 on October 21, 2021 at 1:25 PM, revealed she had never been assigned to Resident 5 prior to that date and was just assisting Employee 1 with the transfer and was not actually operating the lift. Employee 2 stated that the blue sling lift pad was already in place when she arrived to assist, but she was sure that it was the correct lift pad because the trim was blue. Interview with the director of nursing (DON) on October 21, 2021, at 10:30 AM, during observation of the Hoyer lift pad used in Resident 5's transfer revealed that the DON stated that the blue trimmed Hoyer lift pad used at time of the incident was an older Hoyer lift pad, but was considered the correct pad to use based on the resident's weight. However, the DON stated that the newer blue trimmed lift pads came with a newer lift purchased by the facility. The DON compared the differences between the new blue trimmed Hoyer lift pad and the older blue trimmed Hoyer pad. She stated that both were considered safe for bariatric residents, although the new blue trimmed Hoyer pads are larger and have safety locks on the clips that get attached to the lift. The older blue trimmed Hoyer pad was observed and appeared to be smaller in size and did not have a safety clip to prevent it from slipping out of place when compared with the new lift pads. Additionally, the DON reported that the NAs that were involved in the incident, saw that the Hoyer pad that was on the resident's chair was trimmed in blue and used it because it was the appropriate color coded pad per the manufacturer's recommendations for use. During interview on October 22, 2021, at 11:45 AM, the DON stated that the old blue trimmed Hoyer lift pad should have been taken out of use when the new lift pads were obtained because the new pads were larger size and had the enhanced safety feature on the sling clip. The facility failed to ensure that the safest equipment was used, which resulted in Resident 5 fall with fracture and pain. A review of the clinical record of Resident 140 revealed admission to the facility on [DATE], with diagnoses which include unspecified dementia without behaviors, [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (weakness of one side of the body) of his non dominant, left side, dysphagia (difficulty swallowing) and diabetes mellitus. A review of an admission MDS assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS of 3 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment). The resident required extensive assistance with two persons for bed mobility, transfers, and dressing and extensive assistance of one person for feeding. A review of facility report dated October 18, 2021 at 11:52 AM indicated that the resident was in the dining room awaiting to be assisted with lunch when he spilled thickened coffee on himself and sustained minor [CONDITION(S)] to his right forearm (reddened ares measuring 28 cm x 10 cm) and abdomen (15 cm x 10 cm). A statement written by Employee 6, a nurse aide, indicated that she placed the resident's lunch meal tray in front of the resident and out of his reach. She stated she then continued to serve other residents their lunch trays. A statement from Employee 7, a nurse aide, revealed that after finishing passing trays to all residents in the dining room she noticed that Resident 140 was not being assisted with feeding by anyone. She stated when she approached him to assist him with his lunch, she noticed he had thickened coffee spilled on him. She stated she asked him if he got burned and he stated yes. Nursing documentation dated October 18, 2021, at 12:14 PM by Employee 8, RN (Registered Nurse) indicated that the Charge Nurse/LPN requested that she come to west wing to the resident's room to assess Resident 140's skin. Employee 8 stated Resident 140's right forearm had areas of reddened skin, 28 cm by 10 cm red area, and the right side of his abdomen had a 15 cm by 10 cm area. Documentation dated October 19, 2021 at 4:15 PM, indicated the resident's son stated his father did not usually drink coffee or teas and the resident's son would prefer the facility not to serve him hot beverages. An observation of the resident's [CONDITION(S)] on October 21, 2021 at 8:45 AM revealed multiple red areas on the resident's right abdomen. The resident's skin was intact with no blisters. Observation of his right anterior forearm revealed a large reddened area with [MEDICATION(S)] cream present over an area which appeared to be a blister that had opened/healing. The resident's right antecubital area also had healing reddened areas without blisters. Interview with the director of nursing (DON) on October 21, 2021 at 2:00 PM revealed that the facility failed to sufficient supervise the resident and provide the necessary feeding assistance with meals to prevent this resident's burn injuries. 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services

Based on a review of clinical records and resident and staff interviews it was determined that the facility failed to implement sufficient measures to prevent development and worsening of pressure ulcer/injury for one resident out of one sampled resident (Resident 70). Findings included: During interview with Resident 70 on (MONTH) 26, 2019, at 10:04 a.m. a visible dressing was observed on the resident's right foot. Resident 70 stated that she had a pressure sore on her foot, which was acquired at the facility from a brace after she broke her leg in (MONTH) 2019. A review of the clinical record revealed Resident 70 had diagnoses, which included type II diabetes mellitus with diabetic [MEDICAL CONDITION], muscle weakness and end stage [MEDICAL CONDITION]. An annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated (MONTH) 21, (YEAR), revealed that the resident was cognitively intact, with a BIMS score of 15 (brief interview for mental status- a tool to assess cognitive function; a score of 13-15 equates to being cognitively intact). The resident required extensive assistance with activities of daily living, had pressure ulcers and was identified at risk for pressure ulcers. Review of clinical records revealed Resident 70 returned from [MEDICAL TREATMENT] on (MONTH) 8, 2019, with complaints of pain in right leg. Subsequently an x-ray was ordered, which identified a suspected un-displaced fracture of her right ankle. Review of the resident's care plan, initiated (MONTH) 14, 2019, revealed that the resident was weight bearing as tolerated and no restriction in cam boot, may take off for range of motion and physical therapy. It was noted that the resident can sleep without cam boot at night. There was not a physician's orders [REDACTED]. There was not an identified physician's orders [REDACTED]. Review of clinical record revealed a physician's orders [REDACTED]. A physician's orders [REDACTED]. Further review of the clinical record revealed that on (MONTH) 10, 2019, at the end of the 3:00 p.m. to 11 p.m. shift skin discoloration was noted on Resident 70's right heel. Review of the resident's care plan in place at that time revealed that the care plan did not identify measures to prevent the development of a pressure sore related to the use of the medical device/ temporary brace application until after the pressure area was identified. Review of skin integrity evaluation from the wound nurse (Employee 11, Licensed Practical Nurse) dated (MONTH) 11, 2019, revealed that this LPN measured and staged the area on the right heel as 2 centimeters (cm) x 2 centimeters (cm), deep tissue injury, intact and deep purple in color, no depth or drainage and surrounding skin was identified as healthy. Review of the skin integrity evaluation from Employee 11 dated (MONTH) 15, 2019, revealed that the pressure sore on the resident's right heel was 2 cm x 2 cm, deep tissue injury, intact and deep purple in color again, no depth or drainage and surrounding skin was identified as healthy. The skin integrity evaluation by the wound nurse dated (MONTH) 18, 2019, revealed that the pressure area on the resident's heel was 1.9 cm x 2 cm, deep tissue injury, intact and deep purple in color, no depth or drainage and surrounding skin was identified as healthy. Review of a consultation dated (MONTH) 22, 2019 from an orthopedic physician, revealed that Resident 70 could not be fitted in cam boot initially and placed in a splint on (MONTH) 25, 2019. Resident 70 presented to the orthopedic physician with a dressing on right heel as indicated in his consult. Further review revealed the orthopedic physician recommended wound care clinic for Resident 70 after conducting his assessment of the resident's pressure wound. Review of a VOHRA wound physicians (specialty physician for wound evaluation and management) dated (MONTH) 25, 2019, revealed that the area on the right heel had increased in size and was now 4 cm x 6 cm x 0.1 cm, deep tissue injury within and around the wound, with moderate amount of serous exudate. Treatment recommendations provided by the wound physicians was to apply skin prep three times per week for 30 days as a primary dressing and foam with boarder to be applied three times per week for 30 days as a secondary dressing. Review of the treatment administration record revealed an order dated (MONTH) 27, 2019, to apply skin prep three times per week and a dry protective dressing was also ordered. The foam with boarder, as recommended by the wound physician, was not ordered Interview with the Employee #11 (LPN wound nurse), (MONTH) 28, 2019 at approximately 12:30 p.m. revealed she has been the wound nurse for 3 years and independently performs assessments, stages, and measures pressure areas. Employee 11 stated that she performs the wound evaluations in the facility weekly alone until VOHRA is consulted, then she reviews wounds with the wound care physician. The employee was asked about the the discrepancies of resident care plans and physician's orders [REDACTED]. Employee 11 stated that she does not recall Resident 70 having a temporary brace. She only recalls an ace wrap prior to the cam boot. Additionally, Employee 11 stated that she considers a dry dressing and a foam dressing to be the same. Employee 11 confirmed that the resident's pressure sore had declined in condition from the time of her evaluation dated (MONTH) 18, 2019, to VOHRA wound physician's assessment on (MONTH) 25, 2019. Interview with the Director of Nursing on (MONTH) 28, 2019 at approximately 1:30 p.m , indicated she was unaware of a temporary splint and only recalls ace bandages in place prior to obtaining the CAM boot. The facility was unable to provide evidence of accurate and consistent monitoring of the resident's skin integrity related to the use of any therapeutic devices to the resident's lower extremity related to the resident's fracture ankle (MONTH) 8, 2019, to prevent development of a pressure sore. The facility further failed to ensure that the resident received necessary treatment to promote healing and prevent worsening of the resident's pressure injury. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services previously cited 7/27/18 28 Pa. Code 211.5(f)(g)(h) Clinical Records previously cited 7/27/18

Based on observation, a review of clinical records, select facility investigation reports, select facility policy and family and staff interviews it was determined the facility failed to provide necessary staff supervision and implement effective interventions to prevent a fall for a resident identified as a fall risk with exit seeking behavior, which resulted in a [MEDICAL CONDITION] and tibia of the right leg for one resident out of one sampled (Resident 38) and further failed to implement supervisory and periodic smoking assessments to ensure safe smoking for one resident of two sampled (Resident 72). Findings include: During an interview with Resident 38's family conducted on (MONTH) 25, 2019, at approximately 12:16 p.m., the family revealed that the resident was sent to the hospital on (MONTH) 6, 2019, as a result from a fall. The facility informed the resident's family that the resident was trying to exit through the double doors on the unit, which were closed at the time to contain upper respiratory infections on the unit. Resident 38 attempted to open the door and fell . The resident's family confirmed Resident 38 had exit seeking behaviors. A review of the clinical record of Resident 38 revealed admission to the facility on (MONTH) 4, (YEAR), with a [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 22, 2019, revealed that the resident was severely cognitively impaired, with a BIMS score of 5 brief interview for mental status-a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment). The resident required staff assistance for transfers, bed mobility, and ambulation in her room and had a history of [REDACTED]. A review of clinical records revealed that Resident 38 was identified as an Elopement Risk with exit seeking behaviors and had a history of [REDACTED]. Interventions planned to prevent falls included; encourage to participate in activities, redirect with food or fluids during active exit seeking, redirect from exits and supervise as needed. A review of a facility incident investigation dated (MONTH) 6, 2019, revealed that a nurse heard another resident yelling for help by the activity room. Employee 3, Registered Nurse Supervisor, found Resident 38 lying on the floor in the fetal position. The resident could not straighten out her leg. The fall was identified as unwitnessed. Facility staff did not observe the fall, but a witness statement was obtained from Resident 68, who did observe fall. A review of the witness statement completed by Resident 68 indicated that she observed Resident 38 standing and was trying to open the door when she fell . The resident complained of right leg pain, 911 was called and resident was transferred to the hospital. A review of Computed [NAME]ography (combines a series of X-ray images taken from different angles) of right knee revealed that Resident 38 had sustained 1. Acute nondisplaced proximal tibial metaphyseal fracture(fractures that involve the metaphysis(narrow portion of a long bone between the epiphysis(end of long bone) and diaphysis(shaft or central portion of a long bone) of tubular bones) with probable intra articular (is a bone fracture in which the break crosses into the surface of the joint) fracture extension into the region of the tibial spines(specialized ridge of bone in the tibia) and 2. Acute comminuted (is a break or splinter of the bone into more than two fragments) fibular head fracture. A review of Employee 8's, Nurse Aide, witness statement indicated that Resident 38 was confused and was self-transferring all morning (on (MONTH) 6, 2019). Employee 8 indicated that for the resident's safety she placed Resident 38 in her wheelchair and parked her by the nurses' station. Employee 8 explained to the nurse why she put Resident 38 in the wheelchair. Employee 8 indicated that she went to lunch at 10:45 AM and Resident 38 fell at 11:08 AM. Nursing documentation indicated that on (MONTH) 6, 2019, at 10:50 a.m., patient observed to be restless and exit seeking (self-propelling in wheelchair). Redirection form A hall exit door up to front nursing station. One on one distraction, snacks and conversation were offered. Will continue to monitor. The facility identified Resident 38 with increased confusion, restlessness and exit seeking behaviors throughout the morning on (MONTH) 6, 2019, but failed to implement effective safety interventions/sufficient supervision to prevent a fall, which resulted in a [MEDICAL CONDITION] leg. A review of the facility's Smoking Policy, last reviewed (MONTH) 15, 2019, revealed that the designated smoking area is outside to the right of the facility courtyard. A safe smoking assessment will be completed on each resident smoker upon admission, readmission, significant change, quarterly, and annually. When the assessment is completed, each resident will have a completed care plan with appropriate interventions. The resident must be identified through the assessment as independently able to smoke. Staff is not permitted to assist any residents with smoking. Residents who are able to smoke independently must leave all cigarettes, cigars, pipes, lighters, matches, etc., and any other flammable devices at the nurses station. The resident must request them before proceeding to the designated smoking area and return them to the nurses station when completed. A review of the clinical record revealed that Resident 72 had diagnoses, which included diabetes mellitus and depression. Review of a quarterly Minimum Data Set assessment indicated that the resident was cognitively intact. Further review of the clinical record revealed the resident was a smoker. The resident's most recent smoking assessment was completed (MONTH) 8, (YEAR). The resident was determined to be independently able to smoke. Review of the resident's current care plan identified the resident was a smoker, but included no interventions designed to ensure continued safe smoking. A nurses note dated (MONTH) 7, 2019, at 12:58 AM indicated that the resident was smoking a cigarette in the courtyard at this time. The resident was instructed on designated times for smoking according to facility protocol. The resident was aware that cigarettes and lighter are to be kept at nurses station. The resident stated will abide by the rules in the future. Observation on (MONTH) 25, 2019, at 12:00 PM revealed Resident 72 outside smoking in the designated facility smoking area. The posted facility smoking times were between the hours of 9:00 AM-11:00 AM; 1:00 PM -3:00 PM; and 6:00 PM- 8:00PM. Interview with the Administrator on (MONTH) 27, 2019, at approximately 9:30 AM confirmed that Resident 72 does not always adhere to the posted smoking times and smoking procedures designed for safety. The administrator failed to provide documented evidence that periodic safe smoking assessments or a care plan with appropriate interventions to ensure safe smoking were completed for the resident. 483.25 Free of accident hazards/supervision/devices Previously cited 7/27/18 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Previously cited 7/27/18, 3/12/19, 5/29/19 28 Pa. Code 211.10 (d) Resident care policies Previously cited 7/27/18

Based on clinical record and Incident/Accident Report review and staff interview, it was determined that the facility failed to consistently provide physician ordered treatment to an existing pressure sore to promote healing and failed to conduct timely evaluation/assessment to identify decline, prevent worsening and the development of additional pressure sores for one of 24 sampled residents (Resident 100). Findings include: Clinical record review revealed that Resident 100 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively impaired, required extensive assistance of at least one staff member for bed mobility, toilet use, dressing and locomotion, was at risk for developing pressure sores and had a history of [REDACTED]. Review of a nurse's note and Incident/Accident Report dated May 17, 2011, at 7:00 a.m., revealed that five newly developed open areas were identified on the resident's left and right buttocks. These pressure sores were in addition to an existing pressure sore on the left buttock/sacral area that was receiving treatment at that time. The review of the May 17, 2011, Wound and Skin Care Weekly Flow Sheet revealed that five newly developed facility acquired Stage II pressure sores were identified by the facility. The pressure areas were noted on the right lower buttock measuring .2 x .3 x .1 centimeters. The right middle buttock pressure sore measured .2 x .3 x .1 centimeters. The right upper buttock pressure sore measured .2 x .3 x .1 centimeters. The left buttock pressure sore buttock measured 1.4 x 1.4 x .1 centimeters. The last pressure sore on the distal sacrum measured .2 x .2 x .1 centimeters. Review of the Incident/Accident Report and interview with the wound nurse on July 12, 2011, at 2:00 p.m., revealed that it was thought that these pressure sores, were the result of improper removal of a physician ordered protective dressing ([MEDICATION NAME] - a thin adhesive dressing to protect open wounds from moisture) covering an existing pressure sore also on the left buttock area. The identified root cause for the pressure sore, as concluded on the Incident/Accident Report, was that staff needed to gently remove the adhesive dressing present on the left buttock/sacral area and that the dressing was not to be removed by pulling " up and away " from the wound but rather "across the wound," which was also stated by the wound nurse during interview on July 12, 2011. The wound nurse confirmed that all five newly acquired pressure sores were located under the [MEDICATION NAME], which was being utilized for the existing pressure sore on the left buttock area. The additional pressure sores were unable to be clearly seen through this dressing and thus the adhesive dressing needed to be removed for timely identification and assessment of the surrounding tissue and healing. Physician orders [REDACTED]. This treatment was to be completed every three days and as needed. Review of the May 2011, Treatment Record and review of the clinical record revealed that the last documented treatment administered to the resident's left buttock/sacral area was on May 10, 2011. Physician orders [REDACTED]. As the result of staff's failure to perform the resident's pressure sore treatment at least every three days as ordered, the facility staff was unaware of the condition of skin covered by the [MEDICATION NAME] for a seven day period. The wound nurse stated that when the last treatment on May 10, 2011, was completed the left buttock/sacral area was noted to be macerated (Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected with bacteria or fungi) and did not look as good as the previous observation of the area on May 8, 2010. The wound nurse indicated that the reason for the maceration and the "wet" appearance was not known. However, a nurse's note dated on May 17, 2011, at 3:30 p.m., revealed that the resident was incontinent of a large amount of urine. There was no evidence that the facility evaluated and timely acted upon the urine incontinence as a source of the maceration and potentially the five additional pressure sores. There was no evidence based on the macerated appearance of the wound on May 10, 2011, that additional measures or alternative treatments were considered to promote wound healing. Interview with the wound care nurse and director of nursing on July 14, 2011, at 10:45 a.m., revealed that they were unaware that the resident's treatment was not performed as ordered and confirmed that the facility had not considered the lack of treatment as a possible cause for the development of the five Stage II pressure sores. It was also confirmed during this interview that if the treatment and assessment of the area was performed as ordered by the physician these pressure areas may have been identified at a lesser stage and preventative measures could have been implemented to prevent development of the Stage II pressure sores. Interview with the nursing home administrator on July 14, 2011, at 10:45 a.m., indicated that the facility was able to identify one staff member (Employee 4, LPN) who did not complete Resident 100's physician treatment as ordered and confirmed that this employee received a disciplinary report. 483.25(c) Pressure sores Previously cited 8/13/10 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services Previously cited 8/13/10 28 Pa. Code 211.10 (a)(c)(d) Resident care policies Previously cited 8/13/10

Based on review of clinical records, select facility policy, Incident/Accident Reports, observation and staff and resident interview, it was determined that the facility failed to prevent the development of avoidable pressure sores for one of nine sampled residents (Resident 62). Findings include: The clinical record review revealed that Resident 62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment (data collection tool completed on a periodic basis to identify resident care needs) dated September 8, 2011, indicated that the resident had minimal cognitive impairment, required extensive assistance of two staff for bed mobility, transfers and hygiene, was occasionally incontinent of bowel and bladder and was at risk for pressure sores. Further review of this MDS assessment revealed that the resident was aware of the correct year and accurately reported the correct month (within five days) and the resident was able to recall previously repeated words after cueing. Review of the facility's "Wound Care Management Policy" reviewed by the facility in August 2011, indicated that the purpose of the Wound Care Management Protocol is to prevent, investigate, treat, manage, and resolve pressure sores. The procedures to be implemented for a resident with increased risk for pressure sore development, with no pressure sores present, is to be repositioned every two hours and the use of a gel foam cushion (a cushion with pressure reducing properties to relieve pressure on the skin while seated) applied to the wheelchair for pressure reduction. A Braden Scale assessment (a tool utilized to predict a resident's risk for pressure sore development) completed on September 6, 2011, indicated that the resident was at high risk for pressure sore development. This assessment tool indicated that the resident often had moist skin from incontinence, spent most of the day seated in a chair and had very limited mobility. A physician's orders [REDACTED]. A care plan dated September 1, 2011, to address the resident's potential risk for skin breakdown, revealed that the resident was to be assisted by staff to reposition every two hours and that pressure relieving/reducing devices were to be utilized as ordered. Review of a nurses' note dated September 11, 2011, at 9:00 p.m., indicated that the resident was noted to have an open yellow slough area (area of dead tissue) on the coccyx measuring 2.2 centimeters by 1.5 centimeters by 0.3 centimeters deep. A second open area was also noted on the right upper buttock measuring 1.5 centimeters by 1.5 centimeters by 0.1 centimeters in depth. Interview with Employee 1, Wound Nurse Registered Nurse (RN), on September 16, 2011, at 9:30 a.m., and review of the Wound and Skin Care Weekly Flow Sheet, revealed that the open area on the resident's coccyx was initially identified as a Stage III open area (full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss). The area on the upper right buttock was identified as a Stage II open area (partial thickness loss of dermis presenting as a shallow open sore with a red or pink wound bed, without slough. May also present as an intact or open blister). Employee 1 confirmed that both of these areas were facility acquired pressure sores, which nurse aides identified on September 11, 2011, at 9:00 p.m. Review of the Incident/Accident Report dated September 11, 2011, at 9:00 p.m., revealed that the last time the resident was provided care, for the changing of a "soiled brief, " was at 7:00 p.m., that same evening. The nurse aide indicated that when the incontinence care was provided to the resident, no skin conditions were noted. Based on this information, two pressure sores (one pressure sore noted to be a Stage III and one pressure sore noted to be a Stage II) had developed on the resident's coccyx and right upper buttock area respectively, within two hours with no indication of any prior skin impairment. Staff statements included with the incident/accident report indicated that proper positioning/assistive devices (such as pressure relieving/reducing devices) were provided to the resident. Interview with Resident 62 on September 16, 2011, at 11:30 a.m., and observation of the resident's room, revealed that the resident had a personal recliner in her room. The resident stated that the chair was brought from home. When asked about the day staff found her skin breakdown (September 11, 2011), the resident stated that she had spent several hours out of bed in her personal recliner that day and that she did not have a pressure relieving/reducing cushion on her personal chair before she developed the pressure sores. The resident further stated that staff did not reposition her while in her personal chair or wheelchair that day and that she had to wait upwards of one hour for staff to assist her with hygiene from incontinent episodes resulting in urine contact with her skin. A review of the nurse aide flow records (document that tracks care and services provided by the nurse aides to their assigned residents) for September 2011, confirmed that there was no pressure relieving/reducing devices on the resident's personal recliner until after pressure sore development (initiated on September 12, 2011.) There was no evidence that the facility implemented physician ordered treatment for [REDACTED]. Review of the September 11, 2011, nurse aide flow records revealed that from 9:00 a.m. thru 7:00 p.m., it was documented that the resident was in a wheelchair and that she repositioned herself without staff assistance. A review of September 2011, care planned interventions, nurse aide flow records and Minimum Data Set assessments indicated that the resident required extensive assistance of one to two staff to be transferred and repositioned and it could not be ascertained how the resident was able to effectively relieve pressure from the coccyx and buttock areas with self repositioning. The facility failed to identify that the physician ordered pressure relieving/reducing chair cushion was in place as ordered. During an interview on September 16, 2011, at 12:30 p.m., the Director of Nursing was unable to state how these pressure sores developed. Cross refer F-520 483.25(c) Pressure sores Previously cited 11/4/09, 6/3/10, 8/13/10, 10/26/10, 7/15/11 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited deficiency 4/28/10, 8/13/10, 10/26/10, 7/15/11 28 Pa. Code 211.10(c) Resident care policies Previously cited deficiency 4/28/10, 7/15/11 28 Pa. Code 211.12(a)(d)(1)(5) Nursing services Previously cited deficiency 9/25/09, 11/4/09, 4/7/10, 4/28/10, 6/3/10, 8/13/10, 10/26/10, 12/22/10, 7/15/11 28 Pa. Code 211.12(d)(3) Nursing services Previously cited deficiency 9/25/09, 4/7/10, 4/28/10, 6/3/10, 8/13/10, 10/26/10, 12/22/10, 7/15/11

Based on review of clinical records, select policy, Incident/Accident Reports, Event Reports, and manufacturer guidelines and observation staff interview, it was determined that the facility failed to ensure that interventions to prevent falls and elopement were consistently implemented for four residents (Resident 124, Resident 100, Resident 46, Resident 26) Findings include: Clinical record review revealed that Resident 124 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, required assistance of two staff members for transfers and locomotion and had a history of [REDACTED]. A nurse's note dated May 13, 2011, at 2:40 p.m., indicated that a new physician order [REDACTED]. A nurse's note dated June 22, 2011, (no time indicated) revealed that the resident was found on the floor in the east television lounge. The resident was noted to complain of left hip pain. The physician was notified and ordered transfer to the hospital. The resident was evaluated at the hospital at this time and was diagnosed with [REDACTED]. Nurses' notes from June 23, 2011, at 7:25 a.m., 10:30 a.m., 2:30 p.m., and 7:45 p.m., revealed that the resident complained of severe left hip pain, which required administration of an oral pain medication (Vicodin, two tablets). A nurse's note dated June 24, 2011, at 12:00 p.m., revealed that the physician was contacted related to the resident's continued complaints of left hip pain and ordered additional evaluation of the left leg. Hospital reports indicated that the resident had a left hip fracture, which required surgical intervention to repair. Review of the completed June 22, 2011, Incident/Accident Report revealed that at 8:20 a.m., staff heard Resident 124 in the television room calling for assistance. Staff responded to the resident and found the resident on the floor on his back next to his chair after an unwitnessed fall. It was noted at the time of the fall that the resident complained of left hip pain. It was also noted that the chair alarm failed to activate and staff were not aware that this resident was involved in unsafe behaviors as there were no staff members present in the television lounge at the time of the fall. Interview with the director of nursing on July 13, 2011, at approximately 1:30 p.m., revealed that the facility determined that the chair alarm on Resident 124's chair failed to activate because staff had the chair alarm flagged (a term used to describe when the battery door on the chair alarm is slid to a position to prevent the alarm from sounding. This technique is used to turn off the alarm and prevent the alarm from sounding when a resident is not using the device. This technique was used by staff as an "off" switch for the alarm). The director of nursing stated indicated that three nursing assistants (Employee 1, Employee 2 and Employee 3) were given written disciplinary action because " walking rounds " (a term used to describe that the off going shift gives report to the on coming shift and these staff members go to each resident on their assignment list and physically look at the resident and assess for the proper functioning of any device being utilized such as alarms) were not completed that morning and are to be done on each shift each day. As a result, Resident 124's alarm functioning was not assessed and was not identified by staff to be " flagged " and not in correct operational status to notify staff of unsafe acts by the resident. Interview with Employee 1(nurse aide) on July 13, 2011, at 2:20 p.m., confirmed that walking rounds were not completed the morning (June 22, 2011) of the resident's fall and that the alarm on Resident 124's chair was not assessed for correct functioning prior to the fall. Employee 1 indicated that she was aware that "walking rounds " had to be done that morning, but indicated that she and the other nurse aides were very busy attending to the resident's needs (answering call bells). Employee 1 stated that her supervisors were not notified of how busy the nurse aides were and that they were having difficulty completing the walking rounds. Employee 1 indicated that "flagging" alarms was a common practice among staff to stop the alarms from continuously sounding when not in use and was unaware of other methods to prevent the sounding of the alarm. Employee 1 stated that Resident 124 displayed daily behavior of attempting to stand unassisted from his bed and chair. Employee 1 relayed that staff is alerted to these unsafe acts by the sounding of the alarm. Review of the facility's "Personal Alarm System Check And Battery Change " Policy and Procedure reviewed by the facility May 25, 2011, revealed that all battery operated personal alarm systems will be checked for proper functioning by direct care staff members per shift. Review of the manufacturer's "Posey company" guidelines for the proper use of the chair alarm used by Resident 124 at the time of the fall, revealed that on the side of the alarm box, there was a button labeled as a "hold" button. This button placed the alarm system in a mode that would prevent the alarm from sounding when not being used and would also provide a visual red light flash that would indicate that the alarm was on hold (not sounding). Once a resident was placed in the chair, the hold mode would automatically convert into a functioning mode which would provide an audible alarm to notify staff of a resident's unsafe acts or behaviors. Based on information provided by the facility and manufacturer's guidelines, there was no evidence that this device which was being effectively utilized by the facility to notify staff of a potential unsafe act. There was no evidence that the facility identified the unsafe practice of " flagging " alarms utilized by staff prior to this incident to ensure proper use of devices. Clinical record review revealed that Resident 100 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired, required two staff members' assistance for walking and locomotion. Review of the clinical record revealed that from January 31, 2011, through June 10, 2011, revealed that the resident had six unwitnessed falls (January 31, 2011, at 12:50 a.m., February 4, 2011, at 12:30 a.m., February 19, 2011, at 10:45 p.m., April 29, 2011, at 1:35 p.m., June 8, 2011, at 2:00 p.m., and June 10, 2011, at 3:05 p.m.) all of which occurred in her room and were not prevented by staff intervention. Upon observation of the location of Resident 100's bedroom, it was noted that this resident's room was approximately 60 feet from the nurses' station. Based on the location of the falls (in the resident's room), there was no indication that the facility implemented appropriate interventions to prevent recurrence of falls or implemented additional measures to allow staff to respond in a more timely manner to prevent the falls. Interview with the director of nursing on July 14, 2011, at 10:45 a.m., was unable to provide evidence that the facility implemented effective interventions to prevent recurrence of falls. Clinical record review revealed that Resident 26 has multiple diagnoses, including but not limited to dementia and a history of a hip fracture. According to his Quarterly MDS assessment dated [DATE], the resident has short/long term memory problems and requires extensive assistance of two persons for bed mobility and transfers. Review of an Incident/Accident report dated May 5, 2011, revealed that the resident was observed on that same date at 11:20 PM on the mat besides his bed in a supine position (lying down with face up). According to statements provided by nurse aides (Employee 5 and 6) as part of the facility's investigation, the resident was observed in bed at 11:15 PM, however, it was noted that he was almost on the floor, so these two nursing employees changed and repositioned the resident that time. When the resident was found on the floor on the mat, it was noted that the bed moved away from the wall since the brakes of the bed were not on, but there was no evidence that the facility had ascertained why the brakes were not on and had planned preventative measures accordingly to prevent similar accidents. This was confirmed in an interview with the Director of Nursing on July 15, 2011 at approximately 11:10 AM. Clinical record review revealed that Resident 46 has multiple [DIAGNOSES REDACTED]. According to a Quarterly MDS Assessment completed on May 31, 2011, the resident has short and long term memory problems, inattention and disorganized thinking. He required extensive assistance with transfers and supervision for locomotion on and off the unit. He has a current physician's orders [REDACTED]. Review of a "WANDERING/ELOPEMENT RISK ASSESSMENT" dated July 17, 2011, revealed that the resident was identified at risk for wandering/elopement and wears a Wanderguard. According to an "INCIDENT/ACCIDENT REPORT" and an Event Report submitted to the State Survey Agency, on August 28, 2010 at 6:00 PM, a visitor approached a Licensed Practical Nurse (Employee 7) and relayed that Resident 46 was found outside of the building sitting in his wheelchair in the grass. (He was found outside of the East side of the building next to a car; the resident resides on the West side of the building). It was also noted that the Wanderguard was checked and had malfunctioned. The 11 PM to 7 AM Registered Nurse is to check the function of all Wanderguards and document on the TAR (Treatment Administration Record) that it is functioning. They are to be replaced every three months. Review of the TAR for August 2010, revealed that on August 5, 2010, the letter "A" was documented (by Employee 8, LPN ) related to the orders to have the Wanderguard changed every three months. A space on August 15, 2010, identified for the Wanderguard to be changed on that same date, was left blank. It was not until August 28, 2010, after the incident, that the Wanderguard was changed. Review of an "EMPLOYEE DISCIPLINARY REPORT" conducted as part of the aforementioned investigation, revealed that the resident was supposed to have the Wanderguard changed on August 15, 2010 on the 11 PM to 7 PM tour of duty. Employee 9, RN failed to sign the TAR for its completion and it was noted that this resulted in the resident's elopement. Interview with the Director of Nursing on July 15, 2011 at approximately 11:15 AM confirmed that the Wanderguard was not changed timely for this resident and that the unchanged Wanderguard did not function properly to alert staff to the resident's elopement. 483.25(h) Accidents Previously cited 08/13/10 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 8/13/10 28 Pa. Code 211.10(d) Resident care policies Previously cited 08/13/10