Every finding on record at Harborview Rehabilitation and Care Center at Lansd

Based on observation, interview, and record review, the facility failed to ensure meals were served and maintained under sanitary conditions for one of five residents reviewed for nutrition. (Resident R39) Findings include:According to the FDA Food Code (2017), Section 3-501.19, Time/Temperature Control for Safety (TCS) foods, such as milk, meat, and cooked vegetables, must be consumed, served, or discarded Whitin a maximum of 4 hours when held without temperature control. In addition, CDC and USDA further recommend discarding perishable foods left at room temperatures beyond 2 hours. On August 18, 2025, at 2:01 p.m. and 2:45 p.m., observations revealed Resident R39's lunch tray remained at the bedside with food and beverages still present, including meatloaf, potatoes, cauliflower, and milk more than two and a half hours after service. The interview conducted on August 18, 2025, at 2:50 p.m. with Licensed Practical Nurse, Employee E30, confirmed that the lunch meal had been delivered between 11:30 a.m. and 12:00 p.m. that day. On August 19, 2025, at 12:24 p.m., resident R39 was observed asleep with a meal tray still at bedside containing fish, collard greens, and sweet potatoes. Follow-up observations at 2:15 p.m. revealed the meal tray was still at bedside. The interview conducted on August 18, 2025, at 2:17 p.m. with Licensed Practical Nurse, Employee E30, confirmed that the lunch meal had been delivered between 11:30 a.m. and 12:00 p.m. that day. On August 20, 2025, at 11:22 a.m. Resident R39's breakfast tray was observed at the bedside containing milk, oatmeal, cereal, a cookie, more than 3 hours after delivery. The interview conducted on August 20, 2025, at 11:29 a.m. with Licensed Practical Nurse, Employee E30, confirmed that the meal had been delivered between 7:30 a.m. and 8:00 a.m. that morning. During an interview with the Facility Administrator and Director of Nursing, on August 21, 2025, at 2:00 p.m. it was acknowledged that meal trays were not consistently removed in a timely manner. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility documentation and staff interviews, it was determined that the facility failed to include the needs of its bariatric resident population in the facility assessment, which is required to ensure the facility has the necessary resources to provide person-centered care.Findings include: Review of the facility census dated August 18, 2025, revealed a total resident census of 117. Documentation provided to the surveyor by the facility included a list identifying 10 residents currently residing in the facility with a diagnosis of morbid obesity requiring bariatric-specific equipment. This equipment includes bariatric beds, wheelchairs, mechanical lifts, and other accessories to support safe care delivery.Review of the facility assessment tool, dated August 5, 2025, revealed the assessment failed to include any reference to the bariatric resident population, their care needs, or the specialized equipment, supplies, and staffing resources required to safely care for them. According to the facility's assessment tool, the facility is expected to conduct, document, and annually review a facility-wide assessment, which includes the resident population and the resources needed to meet their needs in a person-centered manner.Review of facility policy titled Bariatric Resident Guidelines, dated February 1, 2024, stated it is the policy of the facility to provide a safe environment and appropriate care to bariatric residents, including necessary equipment such as bariatric lifts, beds, gowns, shower chairs, and large BP cuffs. The policy also indicates that bariatric residents require a two-person assist and that staff are to be trained in transfers, mobility, and evacuation preparedness.Interview with Nursing Home Administrator (NHA), Employee E1 on August 20, 2025, Employee E1 confirmed that the facility had obtained bariatric equipment on an as needed basis. However, the NHA acknowledged that the facility had not evaluated or included the staffing needs, care planning considerations, or resource requirements specific to the bariatric population in the facility's most recent assessment. 28 Pa. Code 201.14(j) Responsibility of licensee 28 Pa. Code 201.20(a)(6) Staff Development

Based on reviews of staff training and competency sets for nurse aides, reviews of the facility assessment and interviews with staff, it was determined that the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for 16 nursing assistants employed since the last review period. (Employees E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, E24, E25, E26, E27, E28, and E29) Findings Include:Record review of staff training files revealed that Nurse Aides Employees E14, E15, E16, E17, E18, E19, E20, E21, E22, E23, E24, E25, E26, E27, E28, and E29, were employed by the facility since the last review period on November 12, 2024, and had not completed the required 12 hours of annual nursing- related in-service training based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techniques, emergency preparedness, resident rights, cultural competency). During the interview on August 21, 2025, at 12:46 p.m. the facility Director of Nursing confirmed the above findings and stated that the facility had not ensured the completion of the annual required in-service training for these nursing assistants. 28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures

Based on observation, and staff interview, it was determined that the facility failed to ensure that all residents at the lunch table were provided their meals at the same time and failed to ensure resident's dignity on one of five dining rooms observed. (First Floor) Findings include:Observation on August 19, 2025, at 11:33 a.m., during lunch service in the first-floor dining room, three residents were observed seated at one table. Two of the residents had received their meals and were actively eating. Resident R70 was seated at the same table, with the meal tray placed in the center of the table, out of the resident's reach. Continued observation at 11:55 a.m. revealed the same three residents at the table. The two residents who had previously received their meals had finished eating. Resident 70 remained without the lunch meal, and the tray was still observed in the center of the table, untouched. Review of Resident R70's meal ticket indicated that the lunch meal consisted of fish, potatoes, collard and greens. Review of Resident R70's current care plan listed dietary requirements including mechanical soft solids and thin liquids. Tray notes indicated aspiration precautions and that the resident required one-on-one assistance with feeding. Interview with the Food Service Manager, Employee E19 confirmed that Resident R70 had not yet been served because she's a feeder, meaning she required assistance with eating. The use of the term feeder was made in the presence of staff and other residents.Interview with the Nursing Home Administrator (NHA), Employee E1 during the observation confirmed that Resident R70 had not yet received assistance with dining. Employee E1 subsequently directed a staff member to assist the resident. 28 Pa. Code 211.6(a) Dietary Services28 Pa. Code 201.29(4) Resident Rights

Based on a review of clinical records, review of facility documentation, and staff interview, it was determined that facility failed to timely provide notices of Medicare non coverage (payment) for two out of six residents reviewed (Residents R126, R31).Findings Include: A review of the form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end.Review of facility documentation revealed Medicare services ended for Resident R126 on April 2, 2025; Medicare services ended for Resident R31 on April 30, 2025. Resident R126 was discharged to another facility and Resident R31 remained in facility. Review of the Notices of Medicare Non-Coverage (form CMS-10123) provided for Residents R126 and R31 revealed the facility failed to provide the required form timely. The facility did not provide form CMS-10123 at least two calendar days before Medicare covered services ended.Interview on August 20, 2025, at 10:15 a.m. with Social Services, Employee E13, confirmed the NOMNC was not provided timely for Resident R126 and R31. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on observations, interview with residents and staff and interview conducted during resident group meeting, it was determined that the facility failed to provide a clean, comfortable, homelike environment for one of 25 residents reviewed (Residents R56). The facility failed to provide a locked drawer for personal belongings for twelve of twelve residents reviewed (Residents R56, R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19).Findings include:On April 18, 2025, at 10:25 am observation in room [ROOM NUMBER] had significant dirt around the baseboards and floor visibly soiled. Further observation in room [ROOM NUMBER], revealed a hole in wall near outlet.Interview with Employee E1, Nursing Home Administrator on August 19, 2025, at 12:00pm confirmed findings of soiled floor, significant dirt and hole in wall of room [ROOM NUMBER].Interview on August 18, 2025 at 10:30am with Resident R56 in room [ROOM NUMBER] revealed that resident hides belongings in room to prevent losing them or someone taking them while she is at activities. Further interview revealed that Resident R56 did not have a locking drawer to feel comfortable leaving personal belongings in her room while she was not there.On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (Residents R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19) who reported that they do not have a locked drawer to store and keep safe personal belongings.Interview with Employee E4, Maintenance Director on August 19, 2025, at 12:30pm stated that residents must request a locking drawer on admission, they are not provided with them automatically. Further, Employee E4 confirmed above listed residents do not have locking drawer.28 Pa. Code 201.18(b)(1) Management

Based on a resident group interview, tour of the facility and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents for anonymous submission on two of three nursing units (2nd floor and 3rd floor nursing units). Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (Residents R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19) who reported residents were unaware of where the grievance forms were located. The residents were unaware of location of grievance/concern submission boxes to submit an anonymous grievance.On August 19, 2025, at 11:40 a.m., a facility tour was conducted with the Nursing Home Administrator, Employee E1. During the tour, it was confirmed that grievance forms were not available on the second and third floor nursing units. Nurses at the nursing station indicated that grievance forms are available upon request behind the nursing station.Interview with Nursing Home Administrator, Employee E1 on August 19, 2025, confirmed no forms available on the second or third floor for residents to submit anonymous grievances and no grievance/ concern submission boxes available second or third floor nursing units. Further interview revealed Residents with wander guards or inability to leave nursing unit would have to provide grievance to staff member who can drop the grievance in the box on the 1st floor or they can give their grievance to administrator.28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)Resident rights

Based on review of clinical record and interview with staff, it was determined that the facility failed to complete and submit a MDS (Minimum Data Set- a federally required assessment completed at a specific interval) discharge tracking for two of two resident records reviewed. (Resident R121 and Resident R29)Findings: Review of Resident R121's clinical record reveled that Resident R121 was discharge to the hospital on May 11, 2025. Review of the MDS schedule revealed that a discharge MDS was initiated. Review of the discharge MDS revealed that the MDS was completed on May 28, 2025, and submitted on May 28, 2025.Interview with RNAC (Register Nurses Assessment Coordinator), Employee E7 conducted on August 21, 2025, at 11:51AM revealed that Resident R121's discharge MDS should have been completed within 7 days from the start date of May 11, 2025, and should have been submitted with in 7 days after completion. Further Employee E7 confirmed that she completed the MDS late and that she also submitted it late. Review of Resident R29's clinical record reveled that Resident R29 was discharge to the hospital on July 16, 2025. Review of the MDS schedule revealed that a discharge MDS was initiated on July 16, 2025. Review of the discharge MDS revealed that the MDS was completed on August 4, 2025, and submitted on August 5, 2025.Interview with RNAC, Employee E7 conducted on August 21, 2025, at 11:51AM revealed that Resident R29's discharge MDS should have been completed within 7 days from the start date of July 16, 2025, and should have been submitted with in 7 days after completion. Further Employee E7 confirmed that she completed the MDS late and that she also submitted it late. 28 Pa. Code 211.5(d) Medical records. 28 Pa. Code 201.18(e)(2) Management.

Based on clinical record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan related to range of motion and dental needs for one of 25 residents reviewed (Resident R93). Findings include: Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Resident R93's has a current diagnosis of Cervical Disc Disorder with Myelopathy (spinal cord compression), Lumbar Region. Review of Resident R'93s OT (Occupational Therapy) discharge recommendation dated May 29, 2025, revealed a recommendation of Cervical ROM (range of motion). Interview with Director of Rehab, Employee E8, conducted on August 21, 2025, at 9:35 AM, confirmed that Resident R93 was discharged from OT on May 29, 2025, with recommendations for cervical ROM. Interview with Employee E2, Director of Nursing services revealed that the facility did not have a Restorative Nursing Program and that the facility is just starting to develop their Restorative Nursing Program. Further Employee E2 confirmed that there was no documented evidence that the cervical ROM was performed on Resident R93. Further, Employee E2 also confirmed that there was no care plan related to the cervical ROM. Observation on Resident R93 conducted on August 18, 2025, at 12:26AM revealed that Resident R93 was edentulous. Further, Resident R93 was eating breakfast. Interview with Resident R93 conducted at the time of the observation revealed that she has dentures, but it hurts so she does not use it and that she needs new ones. Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE] Review or Resident R93 MDS (Minimum Data Set - a federally required resident assessment completed at a specific interval) section L0200. Dental , B. No natural teeth or tooth fragment(s) (edentulous) was coded NO Review of Resident's current care plan revealed no care plan for dental needs. Interview with RNAC Employee E7 conducted on August 20, 2025, at 12:40PM confirmed that Resident R93 was edentulous and that Resident R93 has full dentures. Further RNAC Employee E7 confirmed that there was no dental care plan related to dentures developed. Further RNAC also revealed that she was not aware that Resident R93 complained of pain related to denture use. Interview with Speech Therapist, Employee E8 confirmed that resident has not been wearing her dentures and that Resident R93 gums her food. Further, Employee E8 also revealed that she has evaluated resident for swallow and that resident was gumming her food. Further interview with RNAC, Employee E7 confirmed that there was no care plan for resident preferences related to not wearing dentures. Further Employee E7 also confirmed that there was no CarePlan for non-compliance related to wearing dentures. Interview with Director of Nursing Employee E2 revealed that they did not have a policy for restorative nursing program. 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, review of clinical records and interview with staff, it was determined that the facility failed to provide services to maintain and prevent further deterioration of functional status for one of 25 residents observed. (Resident R93) Findings include:Review of Resident R93's clinical record revealed that Resident R93 was admitted to the facility on [DATE]. Resident R93's has a current diagnosis of but not limited to Cervical Disc Disorder with Myelopathy (spinal cord compression), Lumbar Region. Review of Resident R's OT (Occupational Therapy) discharge recommendation dated May 29, 2025, revealed a recommendation of Cervical ROM (range of motion). Further review of Resident R93's clinical record revealed that there was no documented evidence that Cervical Range of Motion was provided to Resident R93. Interview with Director of Rehab Employee E8, conducted on August 21, 2025, at 9:35 AM, confirmed that Resident R93 was discharged from OT on May 29, 2025, with recommendations for cervical ROM. Interview with Employee E2 Director of Nursing services revealed that the facility did not have a Restorative Nursing Program and that the facility is just starting to develop their Restorative Nursing Program. Further Employee E2 confirmed that there was no documented evidence that the cervical ROM was performed on Resident R93. 28 Pa. Code 201.29 (d) Resident's rights28 Pa. Code 211.12 (c) Nursing services

Based on observation, clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that a resident preference was honored and to accommodate resident's allergies for two of 25 residents reviewed. (Resident R23 and Resident R39) Findings include: Review of the facility policy titled Dietary Services - Menus and Nutritional Adequacy dated 2/18/2024 revealed that the facility will ensure that all menus are developed and prepared to meet the resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines. Review of Resident R23's quarterly Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated June 9, 2025, revealed that Resident R23 was admitted into the facility on November 21, 2024 with diagnosis of diabetes (chronic medical condition that affects how your body process blood sugar), seizure disorder (a neurological condition characterized by recurrent seizures), anxiety (a feeling or worry, nervousness or unease) and bipolar disorder (a mental health condition characterized by extreme mood swings). Further review of Resident R 23's MDS revealed that this resident had the BIMS (brief interview of mental status) score of fifteen which indicated that Resident R23 cognition was intact. Review of Resident 23's clinical record revealed that this resident has food allergies of strawberries and tree nuts. Review of Residents R23's lunch ticked for August 19, 2025, revealed that Resident R 23 was ordered a regular - consistent carbohydrate diet with thin liquids, with allergies: strawberries, nuts and seeds. Review of the daily menu for the date of August 19, 2025, for the lunch meal was baked fish, sweet potatoes, collard greens and cake with icing. Observation on August 19, 2025, at 11:42am. in the first-floor dining room, revealed Resident R23 was served cake with icing as indicated on the lunch ticket. Resident R23 was observed questioning a staff member who served the cake, what kind of cake it was. The staff member then replied, I don't know. Resident R23 then declined the cake and returned it. Interview with Resident R23 during the observation revealed that he believed the cake contained peanut butter based on the smell. The resident stated, I'm allergic to all nuts. I cannot eat the cake. Interview with Nurse Aide, Employee 10, who served the cake, revealed she was unaware that the cake contained peanut butter. Further observation revealed that no alternative dessert was offered to Resident R23. Interview with the Food Service Manager, Employee E9 confirmed that Resident R23 had a documented allergy to nuts and stated, This resident should not have been served the cake. Employee E9 further explained that all food tickets list allergies and preferences, and kitchen staff are expected to prepare meals accordingly. The cake served that day had been improvised and was not specifically listed on the menu, nor was the change documented. Review of Resident R39's physician diet order dated July 14, 2025, revealed the following restrictions: No beef, no pork, no straws. On August 18, 2025, Resident R39 was observed receiving a lunch tray that included water cup with a straw. On August 20, 2025, at 11:58 a.m. Resident R39 was observed receiving a lunch tray that included pork over rice and water with a straw. Interview with Licensed Practical Nurse, Employee E31, at 11:59 a.m. confirmed the meal was served despite the diet restrictions. 28 Pa. Code 211.6(f) Dietary Services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that call bells were functioning properly for two of 25 residents reviewed. (Resident R73 and Resident 106)Findings include: Review of Resident R73's clinical record revealed that Resident R73 was admitted to the facility on [DATE]. Further review of Resident R73's clinical record revealed that Resident R73 has a diagnosis of Pain in Unspecified Knee, and difficulty walking. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident R73 was in bed wearing a gown. Further observation revealed that Resident R73 was yelling for help. Further observation revealed that the call bell outlet located on the wall left side of Resident R73's bed above his bed side table revealed that two call bell prongs attached to it. Further, one prong did not have a cord and the other prong had a cord cut 3 inches from the prong. Observation conducted on August 18, 2025, at 10:56AM revealed that the Resident R106 was in bed wearing a gown. Further observation revealed that Resident R106 was in bed sleeping.Further observation revealed that the call bell outlet located on the wall left side of Resident R106's bed above his bed side table revealed that two call bell prongs attached to it. Further, one of the prongs did not have a cord and the other cord was on the floor.Interview with second floor Unit manager Employee E30 conducted at the time of the observation confirmed that the call bells for Resident R106 and Resident R73 were non-functional. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(12)(3) Nursing services

Based on observation and an interview with staff and resident group meeting, it was determined that the facility failed to ensure that the Department of Health Survey results were readily accessible to residents and visitors on three of three nursing units. (1st floor, 2nd floor and 3rd floor nursing units)Findings Include:On August 19, 2025, at 10:30 a.m. a resident group meeting was held with eleven alert and oriented residents (R102, R80, R40, R7, R16, R61, R116, R5, R82, R23, R19 ) who reported that they were not aware of the location where the survey results binder would be located and available to review.Observation on August 19, 2025, at 11:35 a.m. revealed the survey binder was in the main lobby in black unlabeled binder hanging on wall. Further observation with the Nursing Home Administrator, Employee E1 revealed the survey binder did not contain any survey results beyond February 2, 2024 which confirmed that residents do not have access, and it is not readily accessible to residents.Interview on August 19, 2025, at 11:35am with Nursing Home Administrator, Employee E1 confirmed the state survey results were not readily accessible for resident, families, and visitors to review.28 Pa. Code 201.14 (a) Responsibility of licensee

Based on staff interviews, review of facility's policy and the review of clinical records, it was determined that the facility failed to ensure that complete and accurate documentation for two out of eleven residents reviewed (Resident R6 and R7). Findings Include: Review of the facility policy, Behavior Management Program Overview, Overview-The facility promotes the utilization of a behavior intervention and management program based on individual resident/patient needs. Review of Resident R6's clinical record revealed Resident R6 was admitted to the facility on [DATE] with a diagnosis of: Unspecified Dementia, Mood Disorder, and Anxiety Disorder. Review of Resident R7's clinical record revealed Resident R7 was admitted to the facility on [DATE] with a diagnosis of Anxiety Disorder, Depression, Bipolar Disorder. Review of a social services note dated June 16, 2025, documented that the social worker spoke with the resident regarding Resident with BIMS (Brief Interview for Mental Status) score of 13 when tested this morning. She was offered support and validation in her friendship with fellow make resident. Resident made aware that they must meet in common areas and not in room as may be uncomfortable with a male visitor in room. Resident voiced understanding. She was also made aware that if she comfortable with a kiss but nothing further fellow male resident must respect her boundaries. Resident encouraged to update staff immediately if she is feeling uncomfortable or compromised in any way. She will continue to be followed by facility psych services. Staff to monitor and offer on going supports. Review of Resident R7's Minimum Data Set (MDS- assessment of resident's care needs) dated May 21, 2025, revealed that the resident's BIMS (Brief Interview for Mental Status) score of 10 . Review of Resident R6's progress notes from July 1, 2025 revealed social worker note from Employee E3 stating, Resident is slated to transfer to room (105-B) today in the morning for better monitor of relationship with fellow male resident and problematic behavioral patterns; drinking her hygiene products. Resident was updated. Family contacted via phone with message left via voicemail. Awaiting reply. Staff to monitor and offer ongoing supports. The male resident that had been involved with Resident R6 was Resident R7. Further review of the resident's clinical record revealed Resident R7 had a history of inappropriate sexual comments towards both other residents and staff. Interview held with nurse aide, Employee E4 on July 8, 2025 revealed, I was working 7 a.m.-3p.m. shift on July 1st, and I thought it was okay for them to be in relationship as of then. I went to walk into Resident R6's room . and caught them kissing in the room so I told them break it up. I then told [the licensed nurse unit manager Employee E5]. A few days later after completing updated scores we was told they couldn't be alone together and then [Resident R6] was moved. Interview with Resident R6 on July 8, 2025 at 1:38 p.m. revealed the resident did have a close relationship with Resident R7 when she was on the second floor. Resident R6 stated she just recently moved into her current room (first floor) but stated that she was moved down quickly. She stated staff was unsure if Resident R7 was good for her so they moved me down here. When asked if she felt safe around Resident R7, she stated yes. When asked if she had ever held hands or kissed Resident R7 she stated, oh yes, he loved to kiss me all the time, like couples do. Interview with Resident R7 on July 8, 2025 at 1:50 p.m. revealed the resident did state he had a close relationship with Resident R6. He stated that they kissed a few times, in a private room alone and in the library. Review of Resident R6 and Resident R7 progress notes from the last three months show no indication of kissing or touching at any time. 28 Pa Code 211.12(c) Nursing services

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans related to elopement for one of eight residents reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted on [DATE], with diagnoses including, but not limited to, psychosis (a mental health condition characterized by a disconnection from reality, which may involve symptoms such as hallucinations (seeing or hearing things that are not present) and delusions (strongly held false beliefs)) and schizophrenia (a mental health condition that disrupts several different areas of your brain. This condition typically affects your thinking abilities, memories and senses. People with schizophrenia commonly struggle to tell what's real and what isn't. They often have hallucinations and delusions and struggle with disorganized thinking). Further review of Resident R1's clinical record revealed that on April 23, 2025, at approximately 11:00 p.m. Resident R1 was not in his room and a search was started. The local police, administrator, nurse practitioner and guardian were notified. Shortly after, the police notified the facility that the resident was found at a local convenience store and returned to the facility by ambulance with no injuries. Statements from Resident R1 indicated that he left because he was hungry. Interview with Resident R1 on May 15, 2025, at 12:25 p.m. revealed that the resident feels claustrophobic at the facility and that he does not like the food. He also feels like the food makes him sick and that if he has the chance he will likely leave again to get outside and to go and get real food from outside the facility. A review of Resident R1's care plan revealed that the facility failed to developed a care plan related to elopment. Interview with the Administrator and Director of Nursing on May 15, 2025, at 1:15 p.m. confirmed that the care plan was not comprehensive related to elopement and keeping the resident safe from another elopment incident. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, resident and staff interviews, review of facility policies and documentation, it was determined the facility failed to ensure a hot beverage was served at safe temperatures on one of three nursing floors (First Floor). This failure placed 23 of 24 residents on the First Floor in an Immediate Jeopardy situation where the temperature of the hot coffee was 178 degrees Fahrenheit. Further, the failure to ensure that hot beverages were served at safe temperatures resulted in Resident R97 sustaining a burn on the left hip for one of 25 residents reviewed. The facility also failed to properly supervise Resident R9 resulting in actual harm when Resident R9 consumed foods not in accordance with diet orders, experiencing a choking episode, which required the Heimlich maneuver, and developed aspiration pneumonia for one of 25 residents reviewed. (Resident R9). Findings include: Review of facility policy, Hot Liquid Management, dated March 2017, revealed that prior to delivering beverage carts to designated unit, dietary staff temp (take the temperature) to validate it is not > 165 F (Fahrenheit). If temp is > 165 F, allow to cool to 165 F and record temperature on the log. Review of Resident R97's quarterly Minimum Data Set assessment (MDS - an assessment of care needs) dated October 28, 2024, revealed the resident had a BIMS of 15 which indicated that the resident had no cognitive impairments. Continued review of the resident's MDS revealed the resident required set up or clean up for eating (helper sets up or cleans up; resident completes activity). Review of Resident R97's nursing note dated November 11, 2024, at 7:26 p.m. created by Licensed nurse, Employee E21, revealed at 6:30 p.m. the nurse aide reported the resident had a blister on the left hip/buttock area. The nurse aide reported to Licensed nurse, Employee E21 of the resident's coffee spill on the left side of the body at 7:30 a.m. and at that time no blisters were noted. The resident did not complain of pain or discomfort to the area. The blister measured 5.5 centimeters (cm) x 6.5 cm at left hip/buttock area. A new order from the nurse practitioner was obtain for Silvadene BID (twice a day) for 5 days. Interview with Nurse aide, Employee E22, on November 14, 2024, at 11:10 a.m. revealed that she was in Resident R97's room at 6:30 a.m. when the coffee spill incident happened. She stated that the resident had his/her coffee on the over the bed table and was reaching for the cell phone and knocked the coffee over and spilling it onto the bed. She stated that she went and got some paper towels and wiped up the coffee and wiped the resident's left thigh with wet paper towels and noted that it was pink, but not blistered. She said that she then got the nurse (Employee E23) to check on the resident. Employee E22 stated it was later, on her rounds after supper at 6:30 p.m. (she said that she worked a double shift that day) that she noticed the blister on Resident R97's left thigh and she told the nurse (Employee E23) who checked the resident's skin and who requested a second nurse (Employee E21) to write up the incident report. During a follow up interview with Employee E22 on November 26, 2024, she stated that she did not take the temperature of the coffee before serving it and did not know if anyone took the temperature to see if it was safe to serve. Interview with Resident R97 on November 14, 2024, at 1:45 p.m. confirmed the coffee spilled on Monday, November 11, 2024, at breakfast resulted in a blister on the left side of his/her leg which was being treated by nursing with cream and a dressing. Review of facility incident documentation revealed a statement by Nurse aide, Employee E22, dated November 11, 2024, which confirmed the course of events given in her interview. Review of Employee E23's, Registered Nurse, statement revealed at 7:30 a.m., on November 11, 2024, she checked Resident R97's skin and found no redness or blisters and noted the coffee was spilled on the resident's bed sheets. Further review of the November 11, 2024, incident report revealed Resident R97 had a blister attributed to the coffee spill, and the measurements of the blister were 5.5 cm x 6.5 cm (centimeter) at left hip/buttock area. Review of the food temperature log for November 11, 2024, revealed the temperature taken of the coffee in the kitchen was 160 degrees Fahrenheit which was within facility's policy. Observation in the main kitchen on November 15, 2024, at 9:50 a.m. revealed coffee carts for all three floors were set up with hot coffee in carafes. The Food Service Director (FSD), Employee E3, took the temperature of the coffee in the carafe's which was 182.8 degrees. She stated that the coffee had been poured about an hour earlier and would cool down to 165 degrees before being delivered at 11:00 a.m. to the floors. The water dispensed from the coffee urn was 190 degrees. Observation of the lunch meal on November 15, 2024, at 11:00 a.m. on the First floor revealed that the coffee cart was delivered and the dietary aide did not know the temperature of the beverages and he went to get a thermometer. Further observation on November 15, 2024, at 11:15 a.m. revealed nursing aides, Employees E9 and E10, were pouring coffee preparing to serve to residents on the first floor. Surveyor stopped nursing aides until the temperature of the coffee could be taken. The coffee in the carafe was 178 degrees Fahrenheit. Interview conducted at that time with Employees E9 and E10 revealed they were not aware of the facility policy requiring the temperature of the coffee not to exceeded temperature of 165 degrees; they did not know where to find a thermometer to take the temperature. Further interview with Employees E9 and E10 revealed, the nurse aides were not aware of the temperature of the coffee before beginning service to residents on the First floor unit. Interview with the Nursing Home Administrator, on November 15, 2024, at 11:20 a.m. confirmed the coffee was above the facility policy required temperature of 165 degree or less. The Nursing Home Administrator also acknowledged that if the nurse aides were not prevented from serving the coffee, a resident could have received coffee at an unsafe temperature. On November 26, 2024, at 11:35 a.m. an Immediate Jeopardy Template was presented to the Nursing Home Administrator for the facility's failure to ensure that hot beverages were served at safe temperatures by staff who were not aware of the facility policy to ensure hot beverages were served at safe temperatures. The facility submitted a written plan of action on November 26, 2024, at 12:34 p.m. and implemented the plan of action which included: 1. Facility reviewed and updated the hot liquids policy on November 18, 2024. a. Prior to hot liquids leaving Dietary, a temperature will be taken by Dietary staff. b. Before serving to residents a temperature will taken by CNA (nurse aide)/Nurse and be documented. c. If the hot liquid temperature is > 150 degrees, it will not be served and will be cooled down by using ice until the temperature is below 150 degrees. 2. The facility will inservice more than 90% of staff by November 26, 2024 and will be at 100% by November 27, 2024. 3. The facility will do audits to ensure effectiveness of staff in-service using questionnaire and/or on the spot interview and results to be reviewed in QAPI (Quality Assurance Performance Improvement). 4. The facility to audit temperature daily for one week and twice a week for two weeks and weekly for two months and reported and discussed in QAPI. On November 26, 2024, at 3:01 p.m. the action plan was reviewed, observations made on the nursing units to ensure that thermometers were available to take hot beverage temperatures, nursing and dietary staff were interviewed to ensure that in-service training was completed and effective. The Immediate Jeopardy was lifted on November 26, 2024, at 3:01 p.m. Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], with a history of respiratory failure, Dysphagia (difficulty swallowing), Bipolar Disorder (condition which a person has periods of depression and periods of being extremely happy), Parkinsonism (nervous system disorder), Schizophrenia (mental disease characterized by loss of reality). Review of Resident R9's quarterly MDS assessment completed May 15, 2024, revealed the resident was assessed with a BIMS (Brief Interview of Mental Status) of 8, which indicates moderate cognitive impairment. The resident was assessed as requiring set up only with eating. Review of Resident R9's July 2024 physician's orders revealed an order for the resident to receive a mechanical soft diet (diet consisting of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool). Review of R9's care plan initiated February 16, 2017, revealed a problem area related to impaired functional mobility and activities of daily living performance. An intervention developed January 7, 2021, included resident needs supervision to assist of one for eating. Continued review of the resident's care plan revealed Resident is a risk for choking/aspiration (when food or liquid goes into your airway instead of the esophagus) due to diagnosis of dysphagia. Interventions include mechanical soft solids, thin liquid/aspirations precautions. Review of Resident R9's nursing notes dated July 15, 2024, at 4:50 p.m. revealed, Resident had an episode of choking while eating a hoagie with another resident in the dining room requiring the Heimlich maneuver .Resident at baseline is oriented to person, situation only, with confusion and poor safety awareness. Unable to understand and follow (his/her) dietary restrictions independently . LLL (left lower lung) with crackles .No SOB (Shortness of Breath) noted/reported. The resident was re-educated on not eating food offered by other residents. The physician was notified, and an immediate x-ray was ordered. Review of a written statement completed by Licensed nurse, Employee E24, confirmed the nurse was called by the nurse aide for statements of the resident was choking. On observation the resident was choking and had breathing difficulty. An assessment was done by a charge nurse. No food substance was observed in the oral cavity. Food substance was found on the floor. The Resident's face was red and fleshy. Heimlich maneuver (first-aid method for choking) was performed 5 times. Minor gasping observed. As per other staff members the resident was eating a sandwich with the fell ow resident in the dining hall. Review of Resident R9's physician's notes dated July 16, 2024, revealed the resident had a choking episode the prior evening. Chest x-ray result showed aspiration pna (pneumonia- infection of the air sacs in one of both lungs) new order for Levaquin 750 milligrams x 5 days. Further review of facility's investigation report revealed staff education was provided after the incident on July 16, 2024, with topic staff to encourage resident to follow with ordered diets and explain the risk of not following appropriate diet. The facility failed to ensure that Resident R9 was properly supervised in the dining room during the lunch meal resulting in actual harm to Resident R9 who consumed foods not in accordance with diet orders, experienced a choking episode, required the Heimlich maneuver, and developed aspiration pneumonia. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(1)(5) Nursing services 28 Pa Code 211.10(d) Resident care policies

Based on observations, review of facility policy and interview with staff, it was determined that the facility did not ensure drugs and biologicals were stored according to professional standards of practice for two out of three medication storage rooms observed (2nd floor and 3rd floor unit medication storage rooms) Findings include: Review of facility's policy 'Medication storage in the facility,' indicates that K. Medications requiring 'refrigeration' or 'temperatures between 2C /36F (Fahrenheit) and 8C/46F are kept in a refrigerator with a thermometer to allow temperature monitoring. During observations of the medication cart on November 11, 2024 at 9:30 am, on 2nd floor unit, revealed that the eye drop medication Latanoprost - 0.005%, with instructions to 'refrigerate before opening.' Finding was confirmed that the eye medication was in the medication cart and not rerigerated with Licensed nurse, Employee E18. Further observations of the medication cart on 3rd floor unit, on November 13, 2024 at 10:46 am, revealed the following expired nutritional supplement: Glucerna with carb steady, expiration date November 1st, 2024. Per interview with licensed nurse, Employee E20, the nutritional supplement was going to be given to a Resident R95 but the resident left the nurses station and has not received it yet. Further observations revealed 19 more expired nutritional supplements in unsealed box in medication storage room on 3rd floor unit. Further review of facility' policy indicates that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, and medication storage conditions are monitored on a continual basis and corrective action taken if problems are identified. Observations of medication storage room on November 13, 2024 at 10:20 am, on 2nd floor unit, revealed the following expired medications: Vitamin B-6 100mg expiration date 10/2023 Diphenhydramine Hcl antihistamine 25 mg (allergy relief) Reguloid (dietary fiber supplement) expiration date 11/9/2023 Bisacodyl suppository 10mg, expiration date May 31, 2024 Major sore throat spray, expiration date July 2024 Zinc Sulfate 220mg, expiration date 9/8/24 The findings were confirmed with Unit manager, Employee E19. Further observations of medication storage room on 3rd floor unit, on November 13, 2024 at 10:46 am, revealed the following expired medications: Mommy's bliss - baby gas relief - Simethicone drops - 20 mg, expiration date 04/2024. Findings were confirmed with licensed nurse, Employee E20. 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.10(c ) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on interviews with residents and staff, review of clinical records, review of monthly resident council minutes and review of facility policy, it was determined that the facility did not ensure prompt efforts were made to resolve residents' grievances and/or concerns elated to, billing clarification, status of the activity van, request for room change and missing items for 11 of 11 residents attending resident council (Residents R10, R12, R16, R17, R38, R52, R66, R79, R90, R91 and R101) and two of 25 resident records reviewed (Resident R26 and R41). Findings include: Review of facility policy titled, Grievance/Concern Management not dated, states, Residents/patients have the right to present concerns on behalf of themselves and /or others to the staff and/or administrator of the facility, to governmental officials or to any other person . these rights also include the right to prompt efforts by the facility to resolve resident concerns. The same policy states, attempts to resolve concern are within 3 business days, and if unresolved within the 3-days it is reported to the Nursing Home Administrator (NHA). The policy further states the Social Service Representative maintains contact with the complainant providing updates and makes entries in the medical record under SS (Social Services) notes regarding the concern and will follow up with the reporter to confirm satisfaction with the outcome and document the resolution in the medical record. Review of clinical records revealed Resident R26 was admitted to the facility in November 2020, alert and oriented with a primary diagnosis of heart failure. Interview with Resident R26 on November 12, 2024, at 11:00 a.m. indicated her husband became a resident at the facility (Resident R80) and both have requested to share a room together. Resident R26 said the Social Worker, Employee E25 is supposed to help me, but she never gets back to me. The last time I spoke with her was at least two weeks ago. She told me there was a lot of work involved moving residents that made me feel that the move won't happen. During the same interview Resident R26 pointed to an orthopedic brace with an attached shoe and indicated the other shoe is missing. The resident stated, The facility wants me to buy new shoes when they're the ones that lost it. I also haven't heard back from the Social Worker for this too! Review of Resident R26's Social Services note from Social Worker, Employee E25 dated July 24, 2024, stated, Resident was made aware that when an appropriate room is available, they will be placed together and to be mindful of RM (roommate) when visiting with each other and to utilize MDR (main dining room) and TV room for visits. Review of Resident R80's clinical records revealed a physician note dated July 24, 2024, stating, While he is at this facility he wants to share a room with his wife. Review of Resident R26's Social Services note dated September 20, 2024, noted Resident was told again that there are currently no semi-private rooms available. Review of Resident R26's Occupational Therapy (OT) notes dated October 22, 2024, indicated Resident R26 was not able to transfer that day due to missing right shoe. OT note dated October 25, 2024, indicated Resident R26 was unable to address transfer goals until they get replacement left shoe, noted Social Worker is looking into another option of obtaining shoes and indicated the resident was going to be moved into bedroom with husband on Monday October 28, 2024. OT note dated November 3, 2024, stated would look into the status of shoes. OT discharge summary dated November 7, 2024, discharge recommendations stated, Resident needs to purchase shoes. On November 14, 2024, at 2:00 p.m. surveyor requested status and/or documentation related to Resident R24's move and missing shoe and the Nursing Home Administrator indicated he was aware and would supply additional documentation but failed to submit. Review of Resident R41's clinical record revealed the resident was admitted to the facility in September 2021 diagnosed with multiple sclerosis (an autoimmune disorder that effects the central nervous system). Interview with Resident R41 on November 12, 2024, at approximately 11:00 a.m. stated, The [Social Worker (SW) Employee E25] said she called my insurance company because I make appointments that aren't covered and I don't show up, so they charge the facility. That's not true because I don't make my appointments, I have the nurses at the front desk make my appointments and never cancel, I have been trying to talk to the SW for at least two weeks because if they (the facility) are being charged I told the SW I want to see those bills. On November 14, 2024, at 2:00 p.m. a request for further documentation received by the Nursing Home Administrator (NHA) revealed an outpatient test done was for Resident R41 on September 27, 2024, with a remaining balance at was not charged to the resident. On November 14, 2024, at 10:00 a.m., during a group meeting with 11 residents, all shared that the facility was not letting them know the status of the activity van. Resident R12 said they have not had the van since March. The NHA keeps telling us, Just two more weeks, just two more weeks. Recently the NHA said it needed a battery but that was weeks ago, it shouldn't take so long!. Review of the last three months of resident council minutes revealed on September 26, 2024, residents inquired about the status of the activity van and the facility documented response was the residents were Informed and updated without any additional specifics. Review of resident council minutes for October noted The resident are wondering when the van is coming back to do outing. Interview with the NHA on November 14, 2024, at 11;00 a.m. indicated the van is still at the shop. The residents don't know this because it is not a regulation, we have a van for activities, but the van might be totaled. It was in an accident, and we might not be able to get it fixed. The NHA indicated needing to wait a few more days to see what happens before saying something to the residents. The facility did not ensure prompt efforts were made to resolve grievances and their concerns 28 Pa. Code 201.29(a)(i) Resident rights

Based on interviews with residents and review of clinical records, it was determined that the facility failed to ensure residents receive proper treatment and care to maintain good foot health in accordance with professional standards of practice for two of 25 residents reviewed (Resident R26 and R41). Findings include: Review of Resident R26's clinical records revealed the resident was admitted to the facility in November 2020, alert and oriented with diagnoses of heart failure and Type II Diabetes (High blood sugar levels can damage nerves in feet, making it harder to sense pain increasing risk of injury). Interview with Resident R26 on November 12, 2024, at 11:00 a.m. with her roommate Resident R41 indicated they have not been seen by the podiatrist. I think they skipped over us. Documentation review of Resident R26's podiatry appointment dated April 19, 2024, noted the resident's toenails were professionally treated to relieve pain due to pressure and should be treated in 60 days due to systemic conditions or sooner if complications should arise. The following appointment dated, July 10, 2024, also indicated the resident should be treated in 60 days. Further review of Resident R26's clinical record revealed no evidence of any further appointments. Review of Resident R41's clinical record revealed the resident was admitted to the facility in September 2021 diagnosed with multiple sclerosis (an autoimmune disorder that effects the central nervous system, symptoms may include numbness and pain in feet). Evidence of Resident R41's podiatry appointment dated April 19, 2024, noted the resident's toenails were professionally treated to relieve pain due to pressure and should be treated in 60 days due to systemic conditions or sooner if complications should arise. The following appointment dated, July 10, 2024, also indicated the resident should be treated in 60 days. Further review of Resident R41's clinical record revealed no evidence of any further appointments. Based on the above documentation received by the Director of Nursing, confirmed on November 15, 2024, at 12:30 p.m., the facility failed to schedule further podiatrist appointments for the above residents. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of facility provided documentation, and interview with staff, it was determined that facility failed to provide sufficient nursing staff to assure resident safety for one of 22 residents reviewed (Resident R9) Findings include: Review of facility's assessment, updated on September 30, 2024, revealed that 40 residents out of approximately 110 residents residing in the facility require special treatment under Behavioral Health Needs. Review of investigation report, dated July 15, 2024, at 8:24 pm, revealed Resident R9 with medical history of Dysphagia (difficulty swallowing), Bipolar Disorder (condition which a person has periods of depression and periods of being extremely happy), Parkinsonism (nervous system disorder), Schizophrenia (mental disease characterized by loss of reality). Review of Resident R9's July 2024 physician's orders revealed an order for the resident to receive a mechanical soft diet (diet consisting of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool). Review of Resident R9's nursing notes dated July 15, 2024, at 4:50 p.m. revealed, Resident had an episode of choking while eating a hoagie with another resident in the dining room requiring the Heimlich maneuver. Review of the facility investigation report related to Resident R9's choking incident revealed that a chest x-ray was ordered, and it was concluded that Resident R9 was diagnosed with aspiration pneumonia and treated with antibiotic Levaquin 750 milligrams for four days. Further review of investigation report revealed a note from Nurse Supervisor, Employee E17, stating that [Resident R9] at baseline is oriented to person, situation only, with confusion and poor safety awareness. Unable to understand and follow her dietary restrictions independently. Review of R9's care plan revealed [Resident R9] is at risk for choking/aspiration due to dysphagia diagnosis, date initiated March 6, 2023. Intervention to supervise, and/or provide assistance to [Resident R9] during meal times, and to monitor for coughing, shortness of breath, choking, labored respiration and congestion, was initiated after the choking incident on July 15, 2024. Interview with licensed nurse, Employee E8, on November 15, 2024 at 11:30 a.m., confirmed that the facility did not have sufficient amount of nursing staff to supervise residents with behavioral health needs resulting in Resident R9 not being properly supervised during the lunch meal on July 15, 2024. Refer to F 689 28 Pa Code 211.12(d)(4) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a)(3) Management

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 was free from sexual abuse. This failure resulted in an Immediate Jeopardy situation for Resident R1, who was sexually abused by Resident R8 for one of eight residents reviewed. (Resident R1) Findings Include: The facility policy titled, Policy: abuse, Neglect, Mistreatment and Misappropriation of Resident Property, and Exploitation revised October 16, 2018, states, It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion and the taking of pictures/videos with resident consent. The resident will be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medication symptoms. Further, the policy stated, Additionally, resident will be protected from abuse, neglect, and harm while they are residing at the facility. In accordance with the facility's Zero Tolerance, no abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. Review of the July 2022, physician orders revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), hyperlipidemia (the blood has too many lipids (or fats), such as cholesterol and triglycerides), and altered mental status (a change in mental function). Review of the Resident R1's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 13, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 99, which indicated that the resident was significantly congnitively impaired. The staff interview was completed and the resident was assessed with short and long term memory problems. Review of Resident R8's September 2023, physician orders revealed Resident R8 was admitted to the facility on [DATE], with diagnoses of dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), bi-polar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behaviour), schizophrenia ((a serious mental illness that affects how a person thinks, feels, and behaves), violent behavior, and conduct disorder (Aggression toward people and/or animals. Destruction of property. Deceiving, lying or stealing). Review of Resident R8's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 20, 2023, revealed that Resident R8 had a BIMS (Brief Interview of Mental Status) of 7 revealing that he was severely cognitively impaired. Review of Resident R8's nursing note from September 21, 2023, revealed, Note Text: Resident offered shower this shift. Resident refused shower at first and spoke inappropriately to aide offering shower. Resident then gathered cloths and toiletries for shower and received a shower. Review of social service progress note from September 21, 2023, revealed, Note Text: SS//This SW (Social Worker) and DON placed phones call to RP (Responsible Party) to update on status. RP was reassured that all meds are in place and staff will continue to monitor. RP stated she had called resident and spoke with him about his med regimen and facility concerns with his negative behaviors exhibited. RP stated she will continue to keep in close contact with resident to offer him supports and encourage positive interaction and patience with others. She also stated FM (Family Member) will come to visit with their children as able. RP was made aware that facility will keep her updated and facility hopeful resident's behaviors will improve and he can remain to complete his healing/therapy. RP was made aware that if behaviors do not improve she should be prepared to take him home. RP voiced understanding. Staff to offer ongoing supports. Review of nursing progress note, for Resident R1 on October 3, 2023 reads Note Text: Resident found in her bed in her room with a male resident on top of her. Dr. notified order received to send resident to ER for evaluation Son . notified. Son did not have any questions at this time. Review of hospital discharge paperwork from October 3, 2023 revealed Patient is a [AGE] year old female Korean speaking only who was found with another member of the facility who was found on top of her and both her and the other individual had their pants off. It is not clear if anything actually occurred. Pt is really not able to give much information. Discharge plan Patient Education: Sexual Assault. Additional instructions: Follow up with PCP. A sane exam was not completed because they did not feel it was warranted. The other patient involved should be tested for STD's, HIV, HEP C. Review of Resident R1's weekly skin check from October 9, 2023 revealed Resident's bruise top of the pubic area and has rash on groin area and old rash spot on armpit. Applied powder on. Review of facility grievance form from Resident R9 filed on October 4, 2023, revealed statement of concern: Resident feel threatened, uncomfortable by ongoing graphic sexual remarks made to resident about staff, residents, what he had done with female resident. Resident R8 was trying to get Resident R9 to cut off his wander guard with a butter knife so he can go downstairs and have sex with her again. Interview with the Director of Nursing, Employee E2 on October 19, 2023, at 9:32 a.m. revealed, On October 3, 2023, I went to go find [Resident R8] to sign a paper and the resident was not in his room. I stated I need to find [Resident R8], asking other staff where he was. At that time I went to find the resident and found [Resident R1's] door closed with the door barricaded shut with furniture. I was able to push the door open and witnessed Resident R8 on top of Resident R1, erect and engaged in sexual intercourse. When I attempted to intervene Resident R8 attempted to hit me and exited the room yelling and screaming. Interview with Employee E4 on October 19, 2023, at 10:03 a.m. revealed when working with Resident R8 he would make sexual comments and grabbed my neck once. Employee E4 stated she would address by talking to him and trying to redirect him which didn't work. Employee E4 stated Resident R8 would also curse and ask inappropriate questions. Interview with Licensed nurse, Supervisor, Employee E5 on October 19, 2023, at 10:31 a.m. revealed that she completed Resident R8's admission and stated from the day he came in was agitated, violent verbally and physically towards staff, making inappropriate comments. Interview revealed that the resident was not able to be re-directed easily and would often become more agitated with re-direction stating what are you gonna do about it. Employee E5 stated, He kept saying he was going to f--- people. Employee E5 revealed that Resident R1 had a bruise on her pelvic area after the incident occurred on October 3, 2023. Interview held with the Director of Nursing, Employee E2 on October 19, 2023, at approximately 12:30 p.m. revealed the facility staff were aware of Resident R8's inappropriate behavior. Review of facility documentation revealed a witness statement from October 19, 2023, by Employee E4 I was assigned to care for Resident R8 for multiple shifts. Resident R8 was verbally abusive, cursed at staff members often, made sexual advances towards me often, requiring constant redirection. Resident R8 physically put his hands around the back of my neck, making sexual comments. Resident R8 would stare at myself and female staff for long periods of time, making inappropriate comments. Resident did not respond to re-direction. Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 32 I This therapist treated Resident R8 on multiple occasions. During every treatment, he would make sexual comments and facial gestures stating, I want to lick your p---. I'm really good at licking vaginas, let me love you, etc. Resident R8 not receptive to multiple redirecting. Resident R8 attempted to sneak up on this therapist deliberately when no one was watching and attempted to grab this therapist's wrist while stating inappropriate comments. Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 21, Resident R8 stated multiple times during therapy sessions, I want to lick your p--- with obscene gestures accompanying this. Resident R8 also bringing up sex or sex related topics- attempted to redirect however unsuccessful with this therapist ending sessions early due to behaviors. Review of facility documentation revealed a witness statement from October 19, 2023, by physical therapist assistant Employee 33, Treated Resident R8 for PT multiple times, patient difficult to redirect, making comments such as very nice body, makes culo look nice. Resident R8 would often encourage therapist to walk in front of him to stare at therapist's back-side. Resident R8 would constantly ask therapist if they were in a relationship married despite cues of re-direction. Review of facility documentation revealed a witness statement from October 20, 2023, by physical therapist Employee 32 This therapist received a phone call on October 3, 2023 to translate for Resident R1. This therapist asked Resident R1 what happened in Korean. Resident R1 stated, This guy came into my room and want to have sex with me. This therapist asked Resident R1 if she wanted to have sex with this patient and Resident R1 reported no. Resident R1 then reported she was ok. Review of Resident R8's entire clinical record, failed to reveal documentation regarding inappropriate sexual behavior and sexual comments made to residents and staff. The facility failed to ensure that Resident R1 was free from sexual abuse by Resident R8. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on October 19, 2023, at 1:38 p.m. for failure to protect a female resident (Resident R1 ) who had a cognitive impairment and a language barrier from sexual abuse from a male resident (Resident R8). It was witnessed that the male resident made unwanted sexual contact on a female resident with a cognition impairment. The Immediate Jeopardy template was provided to the Nursing Home Administrator on October 19, 2023, at 1:45 p.m. and an Immediate action plan was requested. On October 19, 2023, at 6:19 p.m. the facility provided the following corrective action plan. 1. Staff Education on identifying by staff deveopment coordinator regarding the updated abuse policy will be immediately intiated with goal of 80% by 10/20/2023 and continue with each employee before next scheduled shift if unable to be reached by 10/21/23 2. Facility will immediately start bodychecks on all residents in the facility to find out any signs of sexual abuse and will cover all residents within 10/20/2023. 3. Facility will immediately update current abuse policy regarding resident-to-resident nonconsensual sex and inappropriate behavior on 10/19/2023. 4. Facility will start to conduct monthly audits from 10/19/2023 of resident electronic medical records immediately regarding any sexually inappropriate behaviors. 5. Facility will continue to read all resident rights loudly to residents in all resident council meetings regarding sexual abuse. 6. Facility will immediately review care plans from 10/19/2923 of all residents weekly for sexually inappropriate behaviors. 7. All education and training information will be provided and discussed in the QAPI meeting. The implementation of the action plan was verified on October 20, 2023. Interviews conducted with facility staff on October 20, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident sexual abuse, recognizing the signs of sexually inappropriate behavior, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse. The Immediate Jeopardy was lifted on October 20, 2023, at 3:55 p.m. Refer to F656 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to develop a plan of care for a resident who exhibited sexual behaviors (Resident R8). This failure resulted in Resident R8 sexually abusing Resident R1 and placing Resident R1 in an Immediate Jeopardy situation, for one of eight residents reviewed. (Resident R1) Findings Include: Review of the July 2022's physician orders revealed Resident R1 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) , hyperlipidemia (the blood has too many lipids (or fats), such as cholesterol and triglycerides), and altered mental status (a change in mental function). Review of the Resident R1's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 13, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 99, which indicated that the resident was significantly impaired. Review of Resident R8's September 2023, physician orders revealed Resident R8 was admitted to the facility on [DATE], with diagnoses of diagnosis of dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), bi-polar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), schizophrenia ((a serious mental illness that affects how a person thinks, feels, and behaves), violent behavior, and conduct disorder (Aggression toward people and/or animals. Destruction of property. Deceiving, lying or stealing). Review of Resident R8's admission Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 20, 2023, revealed that Resident R8 had a BIMS (Brief Interview of Mental Status) of 7 revealing that he was severely cognitively impaired. Review of nursing progress note, for Resident R1 on October 3, 2023, noted Note Text: Resident found in her bed in her room with a male resident on top of her. Dr. notified order received to send resident to ER for evaluation Son . notified. Son did not have any questions at this time. Review of facility grievance form from Resident R9 filed on October 4, 2023, revealed statement of concern: Resident feel threatened, uncomfortable by ongoing graphic sexual remarks made to resident about staff, residents, what he had done with female resident. Resident R8 was trying to get Resident R9 to cut off his wander guard with a butter knife so he can go downstairs and have sex with her again. Interview with the Director of Nursing, Employee E2 on October 19, 2023, at 9:32 a.m. revealed, On October 3, 2023, I went to go find Resident R8 to sign a paper and the resident was not in his room. I stated I need to find Resident R8, asking other staff where he was. At that time I went to find the resident and found resident R1's door closed with the door barricaded shut with furniture. I was able to push the door open and witnessed Resident R8 on top of Resident R1, erect and engaged in sexual intercourse. When I attempted to intervene Resident R8 attempted to hit me and exited the room yelling and screaming. Interview with Licensed nurse, Employee E4 on October 19, 2023, at 10:03 a.m. revealed when working with Resident R8 he would make sexual comments and grabbed my neck once. Employee E4 stated she would address by talking to him and trying to redirect him which didn't work. Employee E4 stated Resident R8 would also curse and ask inappropriate questions. Interview with Licensed nurse, Supervisor, Employee E5 on October 19, 2023, at 10:31 a.m. revealed that she completed Resident R8's admission and stated from the day he came in was agitated, violent verbally and physically towards staff, making inappropriate comments. Interview revealed that the resident was not able to be re-directed easily and would often become more agitated with re-direction stating what are you gonna do about it. Employee E5 stated, He kept saying he was going to f--- people. Employee E5 revealed that Resident R1 had a bruise on her pelvic area after the incident occurred on October 3, 2023. Review of facility documentation revealed a witness statement from October 19, 2023, by Employee E4 I was assigned to care for Resident R8 for multiple shifts. Resident R8 was verbally abusive, cursed at staff members often, made sexual advances towards me often, requiring constant redirection. Resident R8 physically put his hands around the back of my neck, making sexual comments. Resident R8 would stare at myself and female staff for long periods of time, making inappropriate comments. Resident did not respond to re-direction. Review of facility documentation revealed a witness statement from October 19, 2023, by Employee 32 I This therapist treated Resident R8 on multiple occasions. During every treatment, he would make sexual comments and facial gestures stating, I want to lick your p---. I'm really good at licking vaginas, let me love you, etc. Resident R8 not receptive to multiple redirecting. Resident R8 attempted to sneak up on this therapist deliberately when no one was watching and attempted to grab this therapist's wrist while stating inappropriate comments. Review of facility documentation revealed a witness statement from October 19, 2023, by speech therapist Employee 21, Resident R8 stated multiple times during therapy sessions, I want to lick your p--- with obscene gestures accompanying this. Resident R8 also bringing up sex or sex related topics- attempted to redirect however unsuccessful with this therapist ending sessions early due to behaviors. Review of facility documentation revealed a witness statement from October 19, 2023, by physical therapist assistant Employee 33, Treated Resident R8 for PT multiple times, patient difficult to redirect, making comments such as very nice body, makes culo look nice. Resident R8 would often encourage therapist to walk in front of him to stare at therapist's back-side. Resident R8 would constantly ask therapist if they were in a relationship married despite cues of re-direction. Review of facility documentation revealed a witness statement from October 20, 2023, by physical therapist Employee 32 This therapist received a phone call on October 3, 2023 to translate for Resident R1. This therapist asked Resident R1 what happened in Korean. Resident R1 stated, This guy came into my room and want to have sex with me. This therapist asked Resident R1 if she wanted to have sex with this patient and Resident R1 reported no. Resident R1 reported she was ok. Interview held with the Director of Nursing, Employee E2 on October 19, 2023, at approximately 12:30 p.m. revealed the facility staff were aware of Resident R8's inappropriate behavior. Review of Resident R8's care plan dated September 16, 2023, revealed that there was no care plan and interventions developed related to Resident R8's inappropriate sexual behaviors and sexual verbal overtures toward staff and residents displayed since admission. During an interview with the Nursing Home Administrator, Employee E1, and the Director of Nursing, Employee E2, on October 19, 2023, at 11:52 a.m. and a review of the care plan for Resident R8, was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate sexual behaviors for Resident R8. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on October 19, 2023, at 1:38 p.m. for failure to ensure that a plan of care was developed to address Resident R8's inappropriate sexual behaviors, resulting in Resident R8 sexually abusing Resident R1. The Immediate Jeopardy template was provided to the Nursing Home Administrator on October 19, 2023, at 1:45 p.m. and an Immediate action plan was requested. On October 19, 2023, at 6:19 p.m. the facility provided the following corrective action plan. 1. Facility will immediately start auditing all residents regarding any type of sexual abuse and finish the audit on 10/19/23. 2. Staff education on identifying residents with sexually promiscuous behavior will be immediately initiated with a goal of 80% by 10/21/2023 and continue with each employee before next scheduled shift if unable to be reached by 10/23/2023. 3. Facility will update current resident to resident nonconsensual sex policy and will finish update on 10/19/2023. 4. After the incident following actions has been taken: Female Resident: On 10/03/2023, called an interpreter to talk with the resident and provided a safe environment and done immediate body check. Contacted family members regarding the incident. Reported incident to county, DOH and AOA. Informed medical director. Contacted 911 and got police support. Sent the resident for a medical exam. Kept close supervision and monitoring. Male Resident: On 10/03/2023, male resident was taken back to a different floor and put on wander guard and put on 1 to 1 supervision. Contacted POA regarding the incident. Reported incident to the county, DOH and AOA. Informed medical director. Contacted 911 and got police support. Immediate paperwork sent to the county to get 302. 5. Staff training on identifying residents with sexual inappropriate behavior will be immediately initiated with a goal of 80% by 10/23/2023 and continue with each employee before the next scheduled shift if unable to be reached by 10/23/2023. 6. All education and training information will be provided and discussed in QAPI meeting. The implementation of the action plan was verified on October 20, 2023. Interviews conducted with twenty facility staff on October 20, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident sexual abuse, recognizing the signs of sexually inappropriate behavior, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse. The Immediate Jeopardy was lifted on October 20, 2023, at 3:55 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on a review of clinical records, facility documentation, facility policies and procedures and interviews with residents and staff, it was determined that the facility failed to ensure residents were protected from neglect for one of four residents reviewed, resulting in actual harm to one resident (Resident R1) related to a fall from bed and subsequent laceration to the forehead. This deficiency was identified as past non compliance. Findings include: A review of the facility policy title Risk Management: Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for Resident R1 revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's quarterly Minimum Data Set assessment (MDS-periodic assessment of resident's needs) dated May 7, 2020, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 15 indicating the resident was alert and oriented. The MDS also indicated that the resident required extensive assistance of one person with bed mobility and extensive assistance of two people for transfers. Further review of the MDS revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April and May 2020, physician's orders for Resident R1 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care initiated April 17, 2020, revealed an intervention for bed mobility that included Resident has functional limitations related to bed mobility. Resident needs maximum assist with siderails. Review of facility documentation revealed on May 16, 2020, at approximately 2:45 p.m. Resident E1 had a fall during an occupied bed change. Resident, while rolling from the left side to the right side, overextended the perimeter of the bed and fell from the L (left) side of the bed to the floor. Resident noted with gross bleeding from his head, lacerations noted to the forehead and L side of head. having made contact with his nightstand. VS (vital signs) assessed and were WNL (within normal limits), neuro checks were initiated, resident was alert and able to answer questions appropriately. Pressure applied to areas of bleeding, PA (Physician Assistant) called and ordered for resident to be sent to ER (emergency room ) for evaluation. Resident sent out 911 (Emergency Medical Services). Review of the Director of Nursing interview conducted with Resident R1 during the facility investigation the resident stated that Employee E3, nursing assistant, came in to change his sheets and pull-up (adult brief) as he had an accident and soiled himself. The resident further stated that he first rolled to the right side and Employee E3 took off his brief. He stated that Employee E3 then told him to turn to the left side and when he went to turn he turned too hard and fell off of the bed. The resident stated that the side rail was not in place and that Employee E3 was not there either and that Employee E3 had moved to the right side of the bed to move linen and incontinence product that were moved over to the right side. The resident stated that when he turned to the left side he thought the side rail would be in place and since it was not, he fell to the floor. Review of a statement by Employee E3, nursing assistant, indicated that while providing incontinence care the resident slid off the bed and hit his head. During a follow-up interview with Employee E3 by facility staff, Employee E3 confirmed that the left siderail was not engaged as ordered. The facility proceeded to terminate Employee E3 for neglect at the conclusion of the investigation. Interview with Resident R1 on November 5, 2020, at 11:40 a.m. revealed that the resident confirmed that at the time of the incident on May 16, 2020, Employee E3 did not put the left half side rail up and that he fell from the bed and was injured. Review of Resident R1's nursing notes dated May 16, 2020, at 7:57 p.m. stated that the resident returned from the hospital at 6:45 p.m. with three sutures and five staples to the left forehead and temporal area respectively. Interview with the Director of Nursing, on November 5, 2020, at approximately 2:40 p.m., confirmed the findings related the incident sustained by Resident R1. This deficiency was cited as past non-compliance. The facility immediately initiated an internal investigation into the details of the fall incident sustained by Resident R1 which occurred on May 16, 2021 during the delivery of incontinence care while in bed. The incident was reported to the Department of Health and to appropriate agencies including the local police department. The employee involved was suspended and terminated as of May 19, 2020. The facility conducted staff education related to resident safety during ADLs and reviewed that if an injury occurs and the resident's care plan/Kardex was not being followed it is considered neglect. Staff education was completed June 20, 2020. Resident questionnaires on dignity, respect and freedom from abuse was conducted through May 28, 2020. A monitoring program which included observations, resident transfer status and care plan being followed was conducted through June 17, 2020. The ADL transfer status was reviewed and included in the facility's Quality Assurance and Improvement Program. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18 Management (b)(1) Management 28 Pa. Code 201.18 Management (b)(3) Management 28 Pa. Code 201.29(j) Resident Rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, facility documentation, policies and procedures, observations and interviews with residents and staff, it was determined that the facility failed to ensure that the facility operated and provided services in compliance with professional standards and principles that apply to professionals providing services in the facility. Findings include: Review of the information dated May 10, 2016, submitted by the facility showed that Resident R2 received a hot pack treatment from a Physical Therapy Assistant (PTA) and Resident R2 sustained a burn. Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the physician's orders for the month of May 2016, Resident R2 did not have a physician's order for treatment using moist heat pack (MHP) /hot pack. The physical therapy care plan initiated on April 20, 2016, for the period of April 20, 2016, to May 19, 2016, did not recommend or warrant treatment using MHP/hot pack. During an interview on May 12, 2016 at 1:05 p.m., Resident R2 stated that on May 9, 2016, Resident R2 was given hot pack treatment to the left forearm for pain by a PTA (Physical Therapy Assistant) and the PTA did not monitor Resident R2 during the treatment. During an interview on May 12, 2016 at 1:15 p.m., the Director of Rehab Services, Employee E4, stated that there was no physician's order for the MHP treatment for [REDACTED]. Employee E4 also added that the treatment was done by the PTA solely on the PTA's own decision. During an interview on May 12, 2016 at 1:40 p.m., the Physical Therapist (PT), Employee E5, stated that there was no physician's order for the hot pack treatment for [REDACTED]. Employee E5 became aware of it only when the PTA told Employee E5 that the PTA was putting a note into Resident R2's Physical Therapy Plan of Care about Resident R2's incident. The Practice of Physical Therapy as defined in section 5 of Act 92 of 2001 relating to the practice of physical therapy, stated that, A physical therapist assistant (PTA) while assisting a licensed physical therapist (PT) in the practice of physical therapy shall only perform patient-related physical therapy acts and services that are assigned or delegated by and under the supervision of a licensed physical therapist. Such acts and services of physical therapist shall not include evaluation, testing, interpretation, planning of modification of patient programs. The Addendum to the Outsourcing Therapy Services Agreement between the facility and the therapy company dated July 2012, stated that the facility shall perform all duties and responsibilities required of the facility under applicable law, including, but not limited to, the supervision of the quality of services rendered. The facility failed to ensure that the facility operated and provided services in compliance with accepted professional standards and the principles that apply to professionals providing those services in the facility. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/04/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/06/16 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/06/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 02/26/16, 01/06/16, 11/04/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/26/16, 01/06/16, 11/04/15, 01/30/15

Based on a review of clinical records, facility documentation, policies and procedures, observations and interview with residents and staff, it was determined that the facility failed to ensure that trained and qualified staff performed therapy according to the norms related to the Practice of Physical Therapy as defined in section 5 of Act 92 of 2001 and according to physician's orders, which resulted in a burn injury from a hot pack that was applied to one resident (Resident R2) resulting in actual harm to the resident. Findings include: Review of information dated May 10, 2016, submitted by the facility indicated that Resident R2 received a hot pack treatment from a Physical Therapy Assistant (PTA) and sustained a burn on May 9, 2016. Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders for Resident R2 for the month of May 2016, showed that Resident R2 did not have a physician's order for treatment using moist heat pack (MHP)/hot pack. Review of the physical therapy care plan for improving Resident R2's functional capacity related to bed mobility, transfer, and ambulation, initiated on April 20, 2016, for the period of April 20, 2016, to May 19, 2016, did not recommend or warrant treatment using MHP/hot pack. During an interview on May 12, 2016 at 1:05 p.m., Resident R2 stated that on May 9, 2016, Resident R2 was given the hot pack treatment to the left forearm for pain by a PTA in the Physical Therapy Room. Resident R2 stated that the PTA put the hot pack on the left arm and returned after about fifteen to twenty minutes or so and returned only to take it off. Resident R2 stated that the PTA did not return during the treatment to monitor or assess the treatment. Resident R2 stated that when the hot pack was taken off, the left forearm was red. Resident R2 added that the PTA took her to the nursing station and the nurses took care of the burn on her left forearm. During an interview with the Clinical Educator/Registered Nurse, Employee E3, on May 12, 2016 at 11:20 a.m., Employee E3 stated that when Employee E3 saw Resident R2 pursuant to the hot pack treatment, the top layer of the skin was peeled off. A late entry nursing note dated May 9, 2016 entered at 1:00 p.m., showed that the wound on the left forearm measured 5.7 cm (centimeters) x 4.0 cm and that it was very red with the top layer of skin peeling. A physician's note dated May 9, 2016, indicated that Resident R2 was seen by a Certified Registered Nurse Practitioner (CRNP) and the note revealed that the patient complained of blistering of the skin from the burn. The CRNP classified the wound as a second degree burn (damage that extends beyond the top layer of skin. This type of burn causes the skin to blister and becomes extremely red and sore). The wound care note dated May 11, 2016, by the Wound Nurse, revealed that the left forearm wound measured 5.3 cm x 3.0 cm and greater than 0.1 cm deep and the top layer of skin was completely off. A physician's note dated May 11, 2016, revealed that the attending physician examined Resident R2 and mentioned the wound as a second degree burn. The note revealed that Resident R2's left upper forearm had an area of 2 cm X 3.4 cm of blister. The policy of the therapy company (contracted physical therapy provider for the facility) revised on December 26, 2012, on clinical practice guidelines on application of hot packs stated that, Clinicians will identify appropriate patients for hot pack treatment. The policy did not define what professionals come under the term clinician. The Practice of Physical Therapy as defined in section 5 of Act 92 of 2001 stated that, A physical therapist assistant while assisting a licensed physical therapist in the practice of physical therapy shall only perform patient-related physical therapy acts and services that are assigned or delegated by and under the supervision of a licensed physical therapist. Such acts and services of physical therapist shall not include evaluation, testing, interpretation, planning or modification of patient programs. During an interview on May 12, 2016 at 1:15 p.m., the Director of Rehab Services, Employee E4, stated that there was no physician's order for the MHP treatment for [REDACTED]. Employee E4 also added that the treatment was done by the PTA on the PTA's own decision. During an interview on May 12, 2016 at 1:40 p.m., the Physical Therapist (PT), Employee E5, stated that there was no physician's order for the MHP treatment for [REDACTED]. Employee E5 became aware of this burn only when the PTA told Employee E5 that the PTA was documenting a note in Resident R2's Physical Therapy Plan of Care. During an interview on May 12, 2016 at 4:25 p.m., with the Nursing Home Administrator (NHA) and the Director of Nursing, the NHA stated that the facility was still investigating the incident. The facility failed to provide proper supervision to ensure the resident's safety when a physical therapy aide acted outside their authority or practice and applied a hot pack that resulted in a burn to the resident. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 01/06/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/04/15 28 Pa. Code 201.18(b)(1) Management Previously cited 01/06/16 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/06/16. 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 02/26/16, 01/06/16, 11/04/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/26/16, 01/06/16, 11/04/15, 01/30/15

Based on a closed clinical record review and staff interviews it was determined that the facility failed to accurately assess and to implement adequate fall interventions to prevent a fall with a serious injury/harm for one of three residents reviewed (Resident CL1). Findings include: Review of October 2015 hospital records revealed that Resident CL1 had a ruptured [MEDICAL CONDITION] (bulging wall of an artery that burst) that caused a brain hemorrhage that was repaired May 2015 when the cerebral VP shunt (device/shunt to drain the brain fluid into the abdomen for reabsorption into the blood stream) was surgically placed. This procedure required a craniotomy (surgical removal of the bone of the skull to expose the brain) where a piece to the skull was removed leaving the brain unprotected by the skull in that area of the head. The resident wore a helmet to protect the head at the hospital and was ordered at the facility to be worn when out of bed. Further review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE] at 7:30 p.m. from the hospital after the resident had the [DIAGNOSES REDACTED]. Review of Resident CL1 physician's orders [REDACTED]. Resident CL1 was admitted to the facility and was determined to be at risk for falls and was ordered to have a low bed as the only fall precaution. At 3:56 a.m. on October 17, 2015, seven hours after admission the resident was found face down on the floor with a 12 cm. (centimeter), by 2 cm. deep gash on the top of the head. Review of the facility's fall investigation revealed that the head,where the skull bone was removed, made contact with the dresser causing the the [MEDICAL CONDITION] at the site of the craniotomy. The resident was sent 911 to the hospital. The hospital [DIAGNOSES REDACTED]. The facility failed to implement adequate fall precautions for this resident who was assessed as a fall risk and was missing part of the skull due to surgery, that resulted in actual harm for Resident CL1. 28 Pa. Code:201.14(a)Responsibility of licensee. 28 Pa. Code:(b)(1)Management. 28 Pa. Code:211.12(d)(1)(5)Nursing services.