Every finding on record at Harmar Village Health & Rehab Center

Based on meal observation, clinical record review and staff interview it was determined that the facility failed to implement care and services to maintain activities of daily living (eating supervision and assistance) for three of twelve residents reviewed (Residents R1, R2, and R3).Findings include: Review of the facility policy Dining Experience at Mealtime dated 9/5/25, indicated all residents at a table are served at the same time. Meals are not to be served to residents in the dining room until at least one member of the staff is in the dining room to monitor the meal service. When needed, nursing staff will assist residents after the meal arrives. Review of the face sheet indicated Resident R1 admitted to the facility on [DATE], with the diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R1's physician order dated 6/12/26, indicated resident is a set up and feed with meals; diet ordered: Pureed diet/ thin liquid. Special Instructions: stroke unable to feed self. Review of the face sheet indicated Resident R2 admitted to the facility on [DATE], with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R2's care plan dated 6/11/26, indicated assist with activities of daily living, dressing, grooming, toileting, feeding, and oral care. Review of the face sheet indicated Resident R3 admitted to the facility on [DATE], with the diagnoses of stroke, diabetes, and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R3's physician order dated 6/12/26, indicated Regular, mechanical soft diet. Special instructions: supervision with meals. Observation of the second floor dining room lunch meal on 6/17/26, at 11:42 a.m. indicated Resident R1 was served the lunch meal and the tray was set up. Two other residents were actively eating at the table. Resident R1 did not attempt to initiate to feed themself. The Life Enrichment Director Employee E1 was intermittently in and out of the dining room and assisting residents to open items and cut foods. Sixteen minutes later Licensed Practical Nurse (LPN) Employee E2 entered the dining room and sat to assist Resident R1 to eat. Interview with LPN Employee E2 on 6/17/26, at 11:58 p.m. confirmed Resident R1 was sitting for sixteen minutes watching other residents at the table consume their food and staff was not present to feed Resident R1 per physician order. Observation of the second floor dining room lunch meal on 6/17/26, at 11:42 a.m. indicated Resident R2 was served the lunch meal and the tray was set up. Two other residents were actively eating at the table. Resident R2 did not attempt to initiate feeding themself. Resident R2 was wheeling away from the food distracted. Sixteen minutes later, Nurse Aide (NA) Employee E3 was alerted by State Agency that Resident R2 had not touched their food. NA Employee E3 positioned resident at their seat in front of their tray, handed a utensil and began to eat immediately. Observation of the second floor dining room lunch meal on 6/17/26, at 11:42 a.m. indicated Resident R3 was served the lunch meal and the tray was set up. Three other residents were actively eating at the table. Resident R3 was observed attempting to feed self. After a minute, resident dropped the fork and stopped eating. Resident did not attempt to use another utensil to feed self and simply sat there in front of the tray. There was not a staff member present at this time. Interview on 6/17/26, at 11:59 p.m. NA Employee E3 approached resident to assist with feeding and alerted by State Agency that resident stopped eating five minutes ago due to dropping the fork and not knowing what else to do to continue eating. NA Employee E3 sat and assisted the resident who then consumed the entire meal with supervision. Interview on 6/17/26, at 3:30 p.m. the Director of Nursing was informed of the events observed at the lunch meal in the second floor dining room on 6/17/26, at 11:42 a.m. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(c)(d)(1) Nursing services

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide appropriate respiratory care relating to CPAP (a continuous positive airway pressure machine used to keep airways open while you sleep/a positive airway pressure machine when breathing in and breathing out) machine for one of three residents (Residents R4).Findings include:Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4s Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/2/26, indicated the diagnosis of obstructive sleep apnea (breath pauses while sleeping), diabetes (high sugar in the blood) and anxiety. During an interview completed on 6/16/26, at 10:35 p.m. Resident R4 was lying in bed, her CPAP machine was on the over-the-bed table. Upon being questioned about the CPAP machine Resident R4 replied, my machine was broken, they put me on oxygen instead. I think it was about 14 days. I told them about it. There is no communication, I called the company and the part was shipped here the next day. Review of physician order dated 3/30/26, indicated CPAP: Auto CPAP with medium nasal pillows. Special instructions: Nurse only to place unit on at bedtime unless resident can apply properly by self. Secure mask, check skin integrity. Fill humidifier with water if applicable. Document minutes. Review of Resident R4's May Medication Administration Record (MAR) indicated on 5/31/26, CPAP not administered: Comment: Not functioning properly. Review of Resident R4's June MAR revealed:6/1/26, blank, reason does not put on until 12:30 am6/2/26, blank, reason machine needs service, not working,6/3/26, off6/4/26, blank, reason machine needs service6/5/26, off6/6/26, not on needs service6/7/26, blank reason machine needs service6/8/26, blank reason needs serviced Phone number provided for 7-3 nurse and Registered Nurse Supervisor aware.6/9/26, off6/10/26, refused machine needs serviced6/11/26, blank reason machine needs service6/12/26, off new tank6/13/26, off6/14/26, blank6/15/26 on 1:00 a.m. Off 5:30 a.m.6/16/26 on 1:00 a.m. Review of nursing progress notes 5/31/26, through 6/14/26, failed to reveal documentation concerning the CPAP not functioning properly, interventions put in place during that time as well as documentation of the facility contacting the CPAP machines supplier for repairs. On 6/17/26, at 11:20 a.m. a typed timeline was provided via e-mail from the Director of Nursing, however there was not any correlating supporting documentation available from the nursing staff. During a telephone interview completed on 6/17/26, at 11:45 a.m. the Director Of Nursing confirmed that the nursing staff failed to complete documentation concerning the CPAP machine malfunction, interventions put in place during that time as well as documentation of the facility contacting the CPAP machines supplier for repairs and that the facility failed to provide appropriate respiratory care relating to CPAP machine for one of three residents (Residents R4). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, resident observations, resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of five residents (Resident R1, and R2).Findings include: Review of the facility policy AM Care Policy dated 1/6/26, indicated care will be offered each day to promote resident to promote resident comfort, cleanliness, grooming, and general wellbeing. Showers and baths are scheduled two times weekly or more or less often according to resident preference. During an interview on 4/22/26, at 12:05 p.m. when asked if they felt the facility maintained enough staff to care for resident needs, Nurse Aide (NA) Employee E3 indicated there's not enough help. The residents are not getting the care they deserve. Showers? That all depends on how many staff we have, we need two staff for all the Hoyer lift residents who must stay in bed until we find a second person and when there is only three NA's it's hard to give my showers because it takes at least 30 minutes leaving only two other NAs on the floor. Plus, we have two meals to serve. During an interview on 4/22/26, at 12:15 p.m. NA Employee E4 indicated we've had only three aides a lot lately. It's hard to get anything done. Showers are out of the question when there are only three aides. During an interview on 4/22/26, at 12:45 p.m. NA Employee E5 indicated it's really hard with three aides for 39. We have to do two meals, get residents out and into bed, get them dressed, bathed, most are Hoyer lifts and you need two people for that, so the residents are always waiting longer than they should and showers are not always getting done, as hard as we try. I practically have this whole hall to myself. There have been times when it's only two of us NAs. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/31/26, indicated the diagnosis of anemia (the blood doesn't have enough healthy red blood cells), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and depression. Review of the Third Floor Shower schedule indicated Resident R1's showers were scheduled for Tuesday and Friday. Review of Resident R1's shower documentation dated 4/4/26, through 4/22/26, indicated no showers provided. Refusals were noted only on 4/14/26, and 4/17/26. Review of the admission record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated the diagnoses of high blood pressure, benign prostatic hyperplasia (BPH - a common enlargement of the prostate gland in aging men that squeezes the urethra), and spinal stenosis (narrowing of spaces within the spine). Review of the Second Floor Shower schedule indicated Resident R2's showers were scheduled for Monday and Thursday. During an interview on 4/22/26, at 10:10 a.m. Resident R2 indicated a shower schedule of Monday and Thursday. Resident indicated they are not receiving showers because there is not enough staff. Review of Resident R2's shower documentation dated 4/1/26, through 4/22/26, indicated showers provided only on 4/9/26, 4/13/26, 4/14/26, and 4/20/26. Interview on 4/22/26, at 2:00 p.m. the Administrator Employee E2 confirmed the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three of five residents (Resident R1, and R2). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services.

Based on observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident wheelchairs (Resident R56), two of five resident rooms (Resident R26, and Resident R59), and two of three resident elevators (beside dietary entrance).Findings Include: Review of the face sheet indicated Resident R56 was admitted to the facility on [DATE]. Observation on 3/30/26, at 11:22 a.m. Resident R56 was in the main dining room sitting in a wheelchair. The seat and cushion of the wheelchair were completely covered in dried foods, sticky substance, and dark grime. Interview on 3/30/26, at 11:23 a.m. Respiratory Therapist Employee E3 confirmed Resident R56 was in the main dining room sitting in a wheelchair. The seat and cushion of the wheelchair were completely covered in dried foods, sticky substance, and dark grime. Review of the face sheet indicated Resident R26 admitted to the facility on [DATE]. Observation on 3/30/26, at 11:28 a.m. a white pipe cover was on the floor under Resident R26's room sink. Interview on 3/30/26, at 11:29 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed a white pipe cover was on the floor under Resident R26's room sink. Review of the face sheet indicated Resident R59 admitted to the facility on [DATE]. Observation on 3/30/26, at 12:10 p.m. Resident R59's window blinds had three leaves missing and one lying on the floor under the air condition unit in the room. Interview on 3/30/26, at 12:11 p.m. LPN Employee E4 confirmed Resident R59's window blinds had three leaves missing and one lying on the floor under the air condition unit in the room. Observation and tour with Administrator Employee E5 on 3/31/26, at 9:54 a.m. the entire width of Resident R59's window was draped with thick cobwebs behind the blind. Interview on 3/31/26, at 9:55 a.m. Administrator Employee E5 confirmed the entire width of Resident R59's window was draped with thick cobwebs behind the blind. Observation on 3/31/26, at 9:40 a.m. the side-by-side elevators located next to the dietary entrance each had plastic bumpers to the lower walls and each of the bumpers had sharp shards of broken plastic exposed. Interview on 3/31/26, at 9:41 a.m. Maintenance Employee E6 confirmed the side-by-side elevators located next to the dietary entrance each had plastic bumpers to the lower walls and each of the bumpers had sharp shards of broken plastic exposed. Maintenance Employee E6 indicated carts bang into the bumpers causing the damage. Interview on 3/31/26, at 3:00 p.m. Administrator Employee E5 confirmed the facility failed to provide a clean, safe, comfortable, and homelike environment for one of five resident wheelchairs (Resident R56), two of five resident rooms (Resident R26, and Resident R59), and two of three resident elevators (beside dietary entrance). 28 Pa Code: 201.18 (e)(2) Management.28 Pa Code: 201.29 (a) Resident Rights.

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications without adequate indications for use for one of five residents (Resident R122)Findings include: Review of facility policy Psychoactive Medication Policy, dated 8/15/25, indicated all residents receiving psychoactive medication(s) will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. Review of Resident R122's admission record indicated he was admitted to facility 3/27/2026. Review of Resident R122's Nursing admission Observation report indicated diagnoses to include paraplegia (form of paralysis that primarily affects the lower half of the body), depression, anxiety disorder, and bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes). Review of Resident R122's clinical record revealed physician orders for the following psychotropic medications and failed to have a diagnosis for use of each medication:Buspirone (Buspar, antianxiety medication) tablet; 10 mg (milligrams); amount 2 tab; oral three times a dayEscitalopram oxalate (Lexapro, antidepressant medication) tablet; 20 mg; amount 1 tab; oral once a dayMirtazapine (Remeron, antidepressant medication)) tablet; 15 mg; amount 1 tab; oral at bedtimeQuetiapine (Seroquel, antipsychotic medication) tablet; 100 mg; amount 1 tablet; oral at bedtimeQuetiapine tablet; 25 mg; amount 1 tablet; oral once a day Review of Resident R122's clinical record failed to indicate any documented non-pharmacological interventions or effectiveness of pharmacological interventions; clinical record also failed to indicate evidence that the facility had implement side effect or behavior monitoring for psychotropic medication use. During an interview of 4/1/26, at 2:23 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E17 confirmed that Resident R122's psychotropic medication orders failed to indicate a diagnosis for usage and that the clinical record failed to contain documented evidence identifying interventions, medication effectiveness, and monitoring of side effects and behaviors. During an interview on 4/2/26, at 12:30 p.m., Administrator Employee E5 and Director of Nursing (DON) confirmed that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic medications without adequate indications for use for one of five residents (Resident R122). 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview it was determined that the facility failed to provide a dignified dining experience for one of three residents (Resident R81). Findings include: Review of the face sheet indicated Resident R81 admitted to the facility on [DATE]. Review of Resident R81's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/26, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and high blood pressure. Observation on 3/30/26, at 12:05 p.m. Resident R81 was in the main dining room sitting in wheelchair at the table being fed by the Director of Nursing. The Director of Nursing was standing up while feeding the resident. Interview with the Director of Nursing on 3/30/26, at 12:06 p.m. confirmed they were not in a seated position while feeding Resident R81 as required and that the facility failed to provide a dignified dining experience for one of three residents (Resident R81). 28 Pa. Code 211.10(a)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility had a physician order for a sling for one of two residents (Residents R124).Findings include: Review of the clinical record revealed Resident R124 was admitted to the facility on [DATE], with diagnoses of displaced fracture of surgical neck of right humerus, closed fracture, and fracture of lower end of left radius. During an observation on 3/30/26, ay 9:44 a.m. Resident R124 was observed wearing a right arm sling. During an observation on 4/1/26, at 9:23 a.m. Resident R124 was observed wearing a right arm sling. During an interview on 4/1/26, at 9:24 a.m. LPN, Employee E1 confirmed Resident R124 did not have an order for a sling. Review of Resident R124's clinical record failed to include a physician order or care plan for the resident's sling use. During an interview on 4/1/26, at 10:05 a.m. the Nursing Home Administrator confirmed the facility failed to ensure a resident with limited mobility had a physician order for a sling for one of two residents (Residents R124). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that pneumococcal vaccinations were tracked in the electronic health record (Residents R12, and R44).Findings include: Review of the facility policy Harmar Village Health and rehab Center Infection Prevention and Control Plan dated 8/15/25, indicated the Infection Preventionist (IP) ensures oversight of the infection prevention committee strategies and approaches to prevent and/or address, at a minimum vaccinations. Review of the face sheet indicated Resident R12 admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R12' immunization record indicated pneumococcal vaccine not due until 3/26/25. Interview on 3/31/26, at 2:06 p.m. Infection Preventionist Employee E10 indicated the facility could not provide documentation in the medical record that the immunization was assessed for Resident R12 on 3/26/25. Review of the admission record indicated Resident R44 was admitted to the facility on [DATE]. Review of Resident R44's MDS dated [DATE], indicated the diagnoses of stroke, hemiplegia (paralysis of one side of the body), and Parkinson's Disease (disorder of the nervous system that results in tremors). Review of Resident R44's immunization record indicated pneumococcal vaccine not due until 4/28/25. Interview on 3/31/26, at 2:06 p.m. Infection Preventionist Employee E10 indicated the facility could not provide documentation in the medical record that the immunization was assessed for Resident R44 on 4/28/25. Interview on 3/31/26, at 3:00 p.m. the Regional Risk Employee E9 confirmed that the facility failed to make certain that pneumococcal vaccinations were tracked in the electronic health record (Residents R12, and R44). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was assessed by a dentist for one of three residents (Resident R14).Findings include: Review of the facility policy Dental Services Policy dated 8/15/25, indicated the facility will assist residents in obtaining routine and 24-hour emergency dental care/services to meet the needs of each resident. All dental services provided are recorded / scanned in the resident's medical record. Review of the admission record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/9/26, indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), stroke (damage to the brain from an interruption of blood supply), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R14's progress notes dated 3/10/26, indicated social worker spoke with Resident R14's family who showed the social worker a picture of a lump that is in Resident R14's mouth on the gums. Social worker discussed this with the care team. Call to Dental vendor to schedule the dentist. Interview on 3/31/26, at 10:09 a.m. Social Worker Employee E8 indicated Resident R14 was seen by the dentist within the last two weeks. Indicated on 3/16/26, the dentist vendor saw the resident and indicated the lump was just like an extra piece of bone and the dentist didn't believe that Resident R14 required any surgical intervention at this time. That the lump is not interfering with anything. The family feels Resident R14 is unable to chew well because of the lump and not able to wear dentures. Request to review dental exam from 3/16/26, was provided by facility as it was not a part of the electronic health record, (not scanned in) which revealed date of service as 3/16/26. The resident was not seen. The resident was not on the team's final list, but the dentist talked to the family regarding the mandibular torus (slow-growing bony lumps on the inside of the lower jaw). Resident would need to see an oral surgeon for surgical removal. The family indicated that resident cannot be sedated so there was nothing the dentist could do. The form was not signed by the doctor and left blank. Interview with the Nursing Home Administrator on 4/1/26, at 2:00 p.m. confirmed that the dentist never saw or assessed Resident R14's mouth. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to obtain appropriate physician orders for a urinary catheter (insertion of a tube into the bladder to remove urine) for one out of two sampled residents (Resident R72).Findings include: The facility Indwelling urinary catheter care policy dated 8/15/25, indicated clinical staff may provide urinary catheter care. Such care will help to prevent catheter association urinary tract infections and prolong the life of the catheter system. Review of Resident R72's admission record indicated he was originally admitted on [DATE] and re-admitted on [DATE]. Review of Resident R72's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/31/25, indicated he had diagnoses that included repeated falls, anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), benign prostatic hyperplasia with lower urinary tract (enlarged prostate impacting urine flow), and history of lung cancer. Review of Resident R72's care plans dated 1/5/26, indicated that Resident R72 has history of obstructive uropathy, will remain free from catheter trauma, provide catheter care per routine, and change catheter as per physician order and as needed. Review of Resident R72's clinical nurse notes dated 3/25/26, indicated Resident was swishing liquid in his mouth. Asked resident if it was mouth wash. Resident R72 shook his head no. Resident R72 had a copious amount of mucus and spit, measuring 90cc's in cup. Asked resident if he felt congested. Resident R72 stated that he was. Lungs were clear upon auscultation, but his voice sounded gurgled. Resident R72 continued to gather saliva and mucus in his mouth and kept spitting. Assessed vitals, all vitals were WNL (Within normal limits) aside from pulse ox. Resident R72 was at 85% RA but had no complaints of SOB (shortness of breath). Placed resident R72 on 2 Liters oxygen, Resident R72 was sating low 90's. Upon rechecking, resident then went down to 81% on 2L. RN supervisor placed call to doctor and got order for 4L. RN Supervisor then got order to send resident out due to Resident R72 spitting copious amounts of mucus and saliva. Resident R72 was sent with face-sheet, order and POLST. Family is aware. Review of Resident R72's clinical nurse notes dated 3/29/26, indicated Resident returned to facility via stretcher after being admitted to hospital. Resident R72 was alert, pleasant and denied any pain. Review of Resident R72's physician orders dated 10/27/25, indicated to provide Catheter Care. Change supra-pubic catheter monthly and as needed. Use 18french/ 10 cc Special Instructions: Document catheter18 fr (French) and 10 ml size inserted. Order ends on 3/25/26. Review of Resident R72's physician orders and re-admission orders dated 3/30/26, did not include an order for Catheter care, catheter sizing, physician orders when to change the catheter or orders to irrigate Resident R72's catheter. During observations on 3/30/26, at 11:31 a.m. Resident R72 was observed in bed, his catheter in place via leg bag. During observations on 3/30/26, at 2:21 p.m. Resident R72 was observed in bed after lunch, his catheter in place via leg bag. During an interview on 3/30/26, at 2:21 p.m. Nurse aide Employee E18 stated: he has a leg bag. During observations on 3/31/26, at 9:24 a.m. Resident R72 was observed in bed, his catheter in place via leg bag. During an interview on 3/31/26, at 9:34 a.m. the Director of Nursing (DON) confirmed that the facility failed to obtain appropriate physician orders for Resident R72's urinary catheter as required. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing

Based on review of facility policies and clinical records, facility provided documents, as well as staff interviews, it was determined that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences and failed to address discontinued resident specific interventions for one of three residents (Resident R13) reviewed.Findings include: Review of facility policy Diet Orders dated 8/15/25, indicated the facility will ensure residents are provided meals as ordered by their healthcare provider. Diet orders will follow the facility formulary or an individualized diet as written/approved by the Registered Dietitian Nutritionist. The Food and Nutrition Services Manager will utilize a tray card identification system to ensure that each resident receives his or her diet as ordered, and that the diet in the medical record reflects the diet in the tray card system. Review of facility policy Comprehensive Care Planning dated 8/15/25, indicated an interdisciplinary plan of care will be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. Review of the admission record indicated that Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/24/26, indicated the diagnoses of diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels) , high blood pressure, and dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Medical Nutritional Therapy assessment dated [DATE], indicated that Resident R13's diet as ordered is Mechanical soft, LCS (Low Concentrated Sweets). Review of clinical progress note dated 2/24/26, indicated Resident R13 appears to be an appropriate candidate to return to baseline diet. Recommend diet advancement to regular solids/thin liquids. Review of Resident R13's physician order dated 2/18/26, revealed LCS, Mech soft diet order; discontinued 2/24/26. Review of Resident R13's current physician order dated 2/24/26, revealed Regular diet order. Review of facility provided EMR (Electronic Medical Record) Resident Diet Order Report indicated Resident R13 was ordered a Regular diet. Review of facility provided Consistency Census Report from Dietary Departments tray card system indicated Resident R13's diet order as Regular. Review of Resident R13's current nutrition status plan of care, updated 2/19/26, revealed an approach/intervention to Provide diet per order: LCS, Mech soft texture diet. During an interview on 4/3/26, at 9:30 a.m., Resident Nurse Assessment Coordinator (RNAC) Employee E17 confirmed that Resident R13's nutrition status care plan was not updated to reflect current diet order Regular. Review of clinical progress note dated 3/25/26, by Registered Dietitian (RD) Employee E21 indicated that Resident R13 is currently ordered a Regular diet. Further review of the clinical record failed to indicate documentation providing rationale for the discontinuation of therapeutic diet restriction LCS by the Registered Dietitian or physician. During an interview on 4/3/26, at 10:17 a.m., Regional Risk Employee E9 confirmed Resident R13's clinical record failed to provide rationale for discontinuing LCS therapeutic diet restriction. During an interview on 4/3/26, at 12:30 p.m., Administrator Employee E5 and Director of Nursing (DON) confirmed that the facility failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences and failed to address discontinued resident specific interventions for one of three residents (Resident R13). 28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 211.12(d)(3)(5)Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice for two of six residents (Resident R6 and Closed Record CR42), and failed to prevent the development of pressure ulcers (PU/PIs- injuries to skin and underlying tissue resulting from prolonged pressure on the skin) one of six residents (Closed Resident Record CR42). Findings include: Review of facility policy Pressure injury prevention policy dated 12/17/25, indicated that new pressure areas will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Residents will be assessed for pressure injury risk on admission, quarterly and with significant change of condition using the Braden Scale. Review of Resident Record R6's admission record indicated she was admitted to the facility on [DATE], with diagnoses of malnutrition, stroke, and high blood pressure. Review of Resident Record R6's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/15/25, revealed diagnoses were current. Section M- Skin Conditions indicated the resident had one stage three pressure ulcer that was present upon admission. Review of Resident R6's physician order dated 12/11/25, indicated to cleanse buttock pressure ulcer with soap and water, pat dry, apply thin layer of Triad paste (triad paste defined as a dressing paste is ideal for managing various wound types) once a day, and as needed. Review of Resident R6's physician order dated 12/11/25, indicated to cleanse buttock pressure ulcer with soap and water, pat dry, apply thin layer of Triad paste twice a day as needed. Review of Resident R6's Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) dated 12/11/25, revealed it was blank and incomplete. The facility failed to assess the residents' risk for developing pressure ulcers. No care plan was initiated upon admission. Review of Resident R6's clinical record failed to include evidence a care plan was initiated upon admission to include interventions related to the resident's left buttock pressure ulcer. Review of Resident R6's wound care assessment dated [DATE], completed by Wound consultant Employee E16 indicated the resident had a stage three left buttocks pressure ulcer that measured 2.5 cm x 2 cm x 0.2 cm. Wound care treatment orders included to cleanse with soap and water, pat dry, apply medical grade honey to base of the wound, secure with Bordered Dressing. It was indicated to change the dressing daily, and as needed. Preventative measures included to continue with turning and repositioning schedule per protocol for pressure prevention, use appropriate moisture barrier creams and when indicated to manage moisture and assess often. Review of Resident R6's physician orders failed to include evidence Resident R6's physician orders were updated to include the wound care treatment orders with medical grade honey from 12/12/25, to 12/18/26. Review of Resident R6's clinical record failed to include evidence the facility care planned the resident for preventative measures as the wound care consultant recommended on 12/12/25. Review of Resident R6's wound care assessment dated [DATE], completed by Wound consultant Employee E16 indicated the resident had a stage three left buttocks pressure ulcer that measured 4.8 cm x 1.5 cm x 0.2 cm. The wound status was documented as stalled and the area is larger on exam today. Treatment recommendations indicated to cleanse buttock pressure ulcer with soap and water, pat dry, apply thin layer of Triad paste (triad paste defined as a dressing paste is ideal for managing various wound types) once a day, and as needed. Review of Resident R6's wound care assessment dated [DATE], completed by Wound consultant Employee E16 indicated the resident had a stage three left buttocks pressure ulcer that measured 5.5 cm x 2.5 cm x 0.2 cm. The wound status was documented as stalled. Review of Resident R6's care plans dated 1/1/26, indicated the resident was admitted with pressure injuries due to comorbidities, immobility, and incontinence. Interventions included assessing the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization once per week. The care plan was initiated 21 days after the resident was admitted to the facility. Review of Resident R6's wound assessment dated [DATE], completed by Wound consultant Employee E16 indicated the resident's stage three left buttock pressure ulcer was larger on exam today. There was no assessment including the size (length, width, and depth) documented. Review of Resident R6's wound assessments indicated stage three left buttock pressure ulcer was stable after 1/2/26. Resident wound documented improving as of 1/9/26. Medi-honey was added 1/10-2/19. During an interview on 3/31/26, at 9:12 a.m. Regional Risk Manager, Employee E9 stated the facility utilizes an outside provider to assess and provide treatment recommendations for residents with wounds. It was indicated the wound provider visits the facility twice a week. During an interview on 4/1/26, at 12:59 p.m. Wound consultant Employee E16 indicated all recommendations for treatment must be cleared by primary physician, and someone else has to put in the orders. Wound consultant, Employee E16 stated there can be a lapse when orders are entered. Wound consultant Employee E16 confirmed there were no measurements of Resident R6's stage three pressure ulcer documented the week of 1/2/26, and Resident R6's treatment recommendations for medi-honey on 12/12/25, were not implemented. During an interview on 4/1/26, at 1:31 p.m. the Nursing Home Administrator and Administrator, Employee E5 confirmed the facility failed to timely implement wound care treatment recommendations and failed to document weekly assessments of Resident R6's stage three buttock pressure ulcer the week of 1/2/26. The facility failed to make certain Braden Assessments were accurately completed and a care plan for pressure ulcer risk was initiated timely. Review of Closed Resident Record CR42's admission record indicated he was admitted to the facility on [DATE]. Review of Closed Resident Record CR42's hospital records dated 12/31/25, indicated an occupational therapy assessment of Resident CR42 found he had right elbow fracture, right arm is non-weight bearing (NWB), right upper extremity in sling. There were no hospital orders for the right sling. Review of Closed Resident Record CR42's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 1/5/26, indicated he had diagnoses that included right humerus (elbow) fracture, history of pneumonia, left hip fracture, hyperlipidemia (elevated lipid levels within the blood), hypertension (a condition impacting blood circulation through the heart related to poor pressure), history of alcohol abuse, muscle weakness, and lung mass (lung cancer). Review of Closed Resident Record CR42's nurse admission assessment dated [DATE], indicated he was admitted with no wound concerns, a surgical skin area and no skin interventions necessary. The nurse clinical Braden assessment (a standardized, evidence-based tool used to assess a patient's risk of developing pressure injuries by evaluating six key risk factors) indicated a Braden Score of 19-not at risk for wound development. The Assessment did not indicate that the Resident CR42 had a right humerus fracture, a sling, or any limited mobility impairment. Review of Closed Resident Record CR42's Occupational therapy notes dated 1/2/26, indicated CR42 as non-weight bearing (NWB) to his right arm and with impaired safety awareness. Review of Closed Resident Record CR42's skilled nursing note dated 1/3/26, indicated CR42 skin was intact. The description of the sling is not documented in the nursing note. Review of Closed Resident Record CR42's care plans dated 1/5/26, indicated CR42's skin will remain intact, he was at risk for pressure ulcers due to decreased mobility, report any signs of skin breakdown, and to assess/document skin changes, skin inspection every shift. The care plan did not indicate to observe the skin under and around Resident CR42's sling. Review of Closed Resident Record CR42's physician orders dated 1/1/26 to 1/17/26 indicated the following: -no orders for skin checks under and around the sling prior to 1/10/26. -no order for CR42's right arm sling until 1/10/26. -1/10/26, order for treatment to Right Elbow Stage-2 pressure ulcer cleanse with Normal saline, pat dry, apply Grade-honey, and cover with border dressing. Change daily. -1/12/26, deep tissue injury right-upper ankle: apply Medi-honey, calcium alginate and cover with border gauze. Review of Closed Resident Record CR42's Physician Assistant assessment dated [DATE], indicated when CR42 was recently admitted to hospital after a fall at another nursing home resulting in right humerus fracture and left pubic fracture, right upper extremity observed in sling, and no skin issues noted. Review of Closed Resident Record CR42's physician visit on 1/5/26, he was seen and he denied any issues with skin, cardiac, musculoskeletal, or psychological problems. The physician assessment identified no skin issues. Review of Closed Resident Record CR42's clinical nurse notes dated 1/10/26, indicated that CR42's son requested to speak with staff regarding CR42's right elbow open wound and state of his sling. Staff spoke with son, assessed CR42 and found a large, open pressure injury to his right elbow with reddened skin. NHA (Nursing home administrator) notified, dressing orders entered and new sling provided to CR42. Wound care will follow up. Review of Closed Resident Record CR42's clinical nurse notes dated 1/10/26 did not include a physician assessment or nurse assessment with wound measurements. Review of Closed Resident Record CR42's clinical nurse notes dated 1/12/26, indicated that CR42's family notified of new orders for deep tissue injury (DTI) on right back of foot/ankle and red open area to right ankle. Review of Closed Resident Record CR42's clinical nurse notes and assessments dated 1/10/26 to 1/13/26, did not include a comprehensive assessment of the newly found wound areas or an additional Braden scale to determine further risk of development. Review of Closed Resident Record CR42's physician visit on 1/14/26, indicated he was seen wearing his sling, pain to right upper extremity, mild tender to palpitation (TTP-sensitive to touch and painful) to his right humerus. Review of Closed Resident Record CR42's physician visit notes dated 1/14/26 did not include a physician assessment with wound measurements. Review of Closed Resident Record CR42's initial wound assessment dated [DATE], indicated the following: Right elbow unstageable pressure injury measuring 1.5 cm x 1.5 cm x 0.2 cm. Right lateral heel deep tissue injury 1.5 cm x 1 cm x 0 cm. Right lateral malleolus pressure injury measuring 0.8 cm x 0.5 cm x 0 cm. Review of Closed Resident Record CR42's Physician Assistant assessment dated [DATE], indicated to monitor skin under right arm sling. Review of Closed Resident Record CR42's care plans dated after 1/16/26, did not include the developed pressure areas, a plan to check Resident CR42's skin under and around his sling, or the interventions related to healing the new pressure areas. Review of Closed Resident Record CR42's skin check records dated 1/1/26 through 1/31/26, indicated the following: 1/3/26-Skin clear 1/5/26-Skin clear 1/9/26-Skin clear 1/10/26-Skin clear 1/11/26-Skin clear 1/11/26-redness noted. Review of Closed Resident Record CR42's skin check records did not include skin observations on 1/2/26, 1/4/26, 1/6/26, 1/7/26, and 1/8/26. Review of Closed Resident Record CR42's skin check records did not include a skin inspection every shift. Review of Closed Resident Record CR42's record did not include evidence of skin checks under the right arm sling or orders to check daily under the right arm sling. Review of Closed Resident Record CR42's wound assessment dated [DATE], indicated a debridement (a procedure to remove damaged or infected skin from a wound to promote healing) was done to the right elbow area. Area observed moist, with wound healing within the wound bed. Wound consultant discussed with Resident CR42 him getting an elbow cushion during time of the visit. Sharp debridement was determined to be necessary for wound healing and included bleeding down to subcutaneous tissue or deeper but did not significantly change the depth of measurement of the wound bed at its deepest point. Measurements were as follows: Right elbow unstageable pressure area/ debrided area measured 1.0 cm x 1.5 cm x 0.2 cm. Right lateral heel deep tissue injury 1.5 cm x 1 cm x 0 cm. Right lateral malleolus pressure injury measuring 0.5 cm x 0.5 cm x 0 cm. Review of Closed Resident Record CR42's wound assessment dated [DATE], indicated the following: Right elbow stage-3 pressure injury measuring 1.5 cm x 1.0 cm x 0. cm. Right lateral heel deep tissue injury 1.5 cm x 1 cm x 0 cm. Right lateral malleolus pressure injury measuring 0. cm x 0. cm x 0 cm./ resolved. During an interview on 3/31/26, at 10:19 a.m. Physical Therapy director Employee E11 was asked about sling order and stated: they usually come in with a sling order. If it's something we issue, we write the order and the RNAC (Registered Nurse Assessment Coordinator) puts in a care plan, and we do skin integrity checks. The hospital order for the sling will carry over to the computer. During an interview on 3/31/26, at 10:29 a.m. the Director of Nursing (DON) was asked about CR42' s physician order for a sling and for skin integrity checks and stated: I do not see a sling order. Skin checks can be in TAR (Treatment Administration record) or plan of care (POC). We do skin checks weekly; those are under observations. There is a separate order for skin checks weekly. During an interview on 3/31/26, at 10:39 a.m. Licensed Practical Nurse (LPN) Employee E12 was asked where are sling orders put in? it depends; if the resident came from the hospital, they should have an order. If they need one, it will be done by the physician. When asked about the skin checks around the sling: the skin integrity checks should be checked every shift. It ' s documented and there should be order there. Staff document skin clear, intact, rash. This may fall into an observation note. There are also weekly skin checks. When asked how soon after skin issue identified are interventions put into place, she stated Immediately. During an interview on 3/31/26, at 2:13 p.m. the Regional Risk Employee E9 was asked where the wound measurements from 1/10/26 are located and she stated: I do not see the measurement here for the right elbow area. On 1/12/26, he was found with developed ankle and foot wounds. He started seeing wound care on 1/16/26 and he was assessed. And we did not order the sling until the 1/10/26. During an interview on 3/31/26, at 2:54 p.m. Occupational Therapist (OT) was asked did Resident CR42 ' s have sling when you first saw him? Resident CR42 was non-weight bearing and he had a sling on. During an interview on 4/1/26, at 9:24 a.m. Licensed Practical Nurse (LPN) Employee E1 was asked if he had resident with sling and does non-weight bearing mean to use a sling? : yes. one resident is Resident R124. He has a sling on his right arm. We check the skin by carefully taking off the sling and looking. I would imagine the record has skin check order. During an interview on 4/1/26, at 1:00 p.m. Wound consultant Employee E16 was asked what are the expectations for nursing to review skin when resident has sling and stated: I know when he first was admitted , he had a sling. I'm trying to pull up his record. He had a sling on when initially admitted . The expectation to check under the sling include removing the sling, looking up around the neck, look at all the parts of the skin that you cannot see with the sling on. I worry most about where the straps are under the neck. During an interview on 4/1/26, at 1:29 p.m. Regional Risk Employee E9, Nursing Home Administrator (NHA) and Administrator Employee E5 information was disseminated that the facility failed to make certain residents were provided necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for Closed Resident Record CR42. 28 Pa. Code: 201.29(a) Resident Rights. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of two resident reviewed (Resident 118).Findings include: Review of Resident 118's clinical record revealed an admission date of 3/16/26, with diagnoses that included encounter for attention to gastrostomy, adult failure to thrive, and malnutrition. Review of Resident R118's care plan dated 3/13/26, indicated to provide tube feed and flush per order. Review of Resident 118's physician order dated 3/16/26, revealed an order for Enteral: Pump Feed Set Up Special Instructions: Provide Isosource 1.5 at 60ml/hr x 22 hours. Hang at 11 AM. Take down at 9 AM or when 1320 ml total volume has been infused Review of Resident 118's physician order dated 3/16/26, indicated to give 150ml free water flush every four hours, six times a day. Observation on 3/30/26, at 10:30 a.m. Resident R118's 1.5 Isosource bottle and 1000 ml water flush bag were undated. Interview on 3/30/26, at 10:34 a.m. the Director of Nursing confirmed there was no date on Resident R118 tube feed or water flush. Observation on 3/31/26, at 11:35 a.m. revealed the water flush bag was not dated. Interview on 3/31/26, at 11:39 a.m. Licensed Practical Nurse Employee E14 confirmed Resident R118's water flush bag was undated. Interview with the Director of Nursing and Administrator, Employee E5 on 4/3/26, at approximately 12:30 p.m. confirmed the facility failed to ensure a resident receiving enteral feeding received appropriate care and services for one of two resident reviewed (Resident 118). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of three residents (Residents R56, R65, and R101).Findings include: Review of facility policy Oxygen Administration Policy dated 8/15/25, indicated all residents who are receiving oxygen therapy shall have tubing, mask, cannula changed weekly. Clean concentrator external filters weekly. Review of the face sheet indicated Resident R56 admitted to the facility on [DATE]. Review of Resident R56's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), muscle wasting, and abnormal finding of lung field. Review of Resident R56's physician order 1/12/26, indicated oxygen: clean oxygen concentrator and filter, change tubing weekly. Wipe down concentrator, remove filter, clean, and airdry. Change tubingonce a week. Observation on 3/30/26, at 11:22 a.m. Resident R56 was in the main dining room sitting in a wheelchair attached to an oxygen concentrator by nasal cannula (lightweight, flexible tube with two small prongs inserted in the nostrils to deliver supplemental oxygen). The humidifier bottle was empty and had the date of 3/5/26. The concentrator and the external filter were dusty with a layer of fuzz like debris. Interview on 3/30/26, at 11:23 a.m. Respiratory Therapist Employee E3 confirmed Resident R56 was in the main dining room sitting in a wheelchair, attached to an oxygen concentrator by nasal cannula. The humidifier bottle was empty and had the date of 3/5/26. The concentrator and the external filter were dusty with a layer of fuzz like debris. Review of the admission record indicated Resident R65 admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of constipation, high blood pressure, and pneumonia. Review of Resident R65's care plan dated 11/7/25, indicated to administer oxygen at 2 liters and observe oxygen precautions. Review of Resident R65's MDS dated [DATE], revealed the diagnoses were current. Review of Resident R65's care plan dated 3/18/26, revealed the resident had a increased nutrition/hydration risk related to constipation. The facility failed to implement interventions in the resident care plan to address constipation. Review of Resident R65's physician order dated 3/2/26, indicated to administer 2 liters of oxygen continuously. Review of Resident R65's physician order dated 3/2/26, indicated to change oxygen tubing every seven days. During an observation on 3/30/26, at 9:53 a.m. Resident R65's oxygen tubing was undated. During an interview on 3/30/26, at 10:20 a.m. Nurse Aide, Employee E20 confirmed there was no date observed on Resident R65's oxygen tubing. Review of Resident R65's clinical record failed to include evidence the resident's oxygen tubing was changed as ordered. Review of the face sheet indicated Resident R101 admitted to the facility on [DATE]. Review of Resident R101's MDS dated [DATE], indicated diagnoses of heart failure (heart doesn't pump blood as well as it should), high blood pressure, and depression. Review of Resident R101's physician order 1/12/26, indicated oxygen: clean oxygen concentrator and filter, change tubing weekly. Wipe down concentrator, remove filter, clean, and airdry. Change tubingonce a week. Observation on 3/30/26, at 11:30 a.m. Resident R101 was sitting in a wheelchair connected to a concentrator by nasal cannula. The tubing was not dated as required and the concentrator and the external filter were dusty with a layer of fuzz like debris. Interview on 3/30/26, at 11:32 a.m. Respiratory Therapist Employee E3 confirmed Resident R101 was sitting in a wheelchair connected to a concentrator by nasal cannula. The tubing was not dated as required and the concentrator and the external filter were dusty with a layer of fuzz like debris. Interview on 3/30/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide appropriate respiratory care and maintain oxygen equipment for three of three residents (Residents R56, R65, and R101). 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, staff interview, and observations, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on three medication errors out of 36 opportunities.Findings include: Observation of medication administration on 4/1/26, at 8:56 a.m., Licensed Practical Nurse (LPN), Employee E14 was observed preparing to administer Resident R61 40 milligram (mg) Ingreeza (a prescription medication used to treat involuntary movements caused by tardive dyskinesia and chorea associated with Huntington's disease) capsule softened in pudding. Resident R61 was ordered to have his medications crushed. LPN, Employee E14 failed to administer Resident R61's 50 MCG/ACTUAT fluticasone propionate (known as flonase, a nasal spray used to treat sneezing, itchy or runny nose, or other symptoms caused by hay fever) and 1 MG/ML olopatadine (used to treat eye itching caused by allergies) Ophthalmic Solution due to the medications not being available. During an interview on 4/1/26, at 9:23 a.m. LPN, Employee E14 confirmed she failed to administer Resident R61's fluticasone propionate 50 MCG/ACTUAT Metered Dose Nasal Spray [Flonase] and olopatadine 1 MG/ML Ophthalmic Solution due to the medications not being available. LPN, Employee 14 confirmed she failed to prepare and administer Resident R61's Ingreeza by sprinkling the contents of capsule in pudding. During an interview on 4/1/26, at 9:25 a.m. the Assistant Director of Nursing, Employee E22confirmed LPN, Employee E14 failed to appropriately administer Ingrezza medication as crushed, resulting in a significant medication error. During medication administration observations, there were three errors and 36 opportunities, resulting in a medication error rate of 8.33% During a staff interview on 4/1/26, at 9:56 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that it was free from a medication error rate of five percent or greater based on three medication errors out of 36 opportunities. 28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for two of four quarterly meetings (Quarter Two 2025, Quarter Three 2025).Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 8/15/25, indicated QAPI efforts are a component of the facility QAA (Quality Assessment and Assurance) Committee's responsibilities. The QAA Committee is responsible for both Quality Assessment and Assurance activities (QA) and ongoing, proactive, Performance Improvement (PI) activities. QAPI represents the merger of these two processes.The Committee will meet on a regular basis (at least quarterly, and as needed) to coordinate and evaluate activities of the QAPI program/plan. Review of Quality Assurance and Performance Improvement (QAPI) sign in sheets and attendance records, failed to reveal documentation that quarterly meetings were conducted during Quarter Two 2025 and Quarter Three 2025. During an interview on 4/1/26, at 9:08 a.m., the Administrator Employee E5 confirmed the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required. 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management

Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident R61).Findings include: Review of facility policy Medication Shortages/Unavailable Medications dated 1/12/25, indicated upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician/prescriber orders, as necessary. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, anxiety, and depression. Review of Resident R61's care plan dated 11/18/25, indicated to finely crush the resident's pills. Review of Resident R61's physician order dated 12/3/26, indicated to administer 40 milligram (mg) of Ingreeza (a prescription medication used to treat involuntary movements caused by tardive dyskinesia and chorea associated with Huntington's disease), one capsule, once a day for drug induced subacute dyskinesia. Review of Resident R61's physician order dated 1/30/26, indicated the resident is to have medications crushed. Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/25/26, indicated diagnoses were current. Observation of medication administration on 4/1/26, at 8:56 a.m., Licensed Practical Nurse (LPN), Employee E14 was observed preparing to administer Resident R61 40 milligram (mg) Ingreeza softened in pudding. LPN, Employee E14 failed to ensure all medications were finely crushed. LPN, Employee E14 failed to safely administer Resident R61 medication. During an interview on 4/1/26, at 9:23 a.m. LPN, Employee E14 confirmed she failed to administer Resident R61's Ingreeza by sprinkling the contents of capsule in pudding. During an interview on 4/1/26, at 9:25 a.m. the Assistant Director of Nursing, Employee E22confirmed LPN, Employee E14 failed to appropriately administer Ingrezza medication as crushed, resulting in a significant medication error. During a staff interview on 4/1/26, at 9:56 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that residents are free of significant medication errors for one of five residents reviewed (Resident R61). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on observations, and staff interviews, it was determined that the facility failed to store medications properly, for three of three treatment carts (Treatment cart outside room [ROOM NUMBER], Treatment cart outside room [ROOM NUMBER], and 2nd floor treatment cart) and one of three medication carts (East Medication Cart), and two of five residents with treatment medications at bedside (Resident R3, and R40).Findings include: Observation on 3/30/26, at 9:05 a.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Registered Nurse (RN) Employee E2 on 3/30/26, at 9:08 a.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 3/30/26, at 12:02 p.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Licensed Practical Nurse (LPN) Employee E4 on 3/30/26, at 12:04 p.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 4/1/26, at 8:57 a.m. the 2nd floor treatment cart was left unattended and unlocked in the South hallway. Interview on 4/1/2026, at 8:58 a.m. LPN, Employee E19 confirmed the 2nd floor treatment cart was left unlocked and unattended in the hallway. Observation of the East Hall Medication Cart on 4/1/26, at 9:07 a.m. indicated the following medications opened and not dated as required:-ipratropium bromide (breathing medication),-albuterol (breathing medication), and -fluticasone (nasal spray to treat allergy symptoms). Interview on 4/1/26, at 9:08 a.m. LPN Employee E7 confirmed the medications were in the East Hall Medication Cart opened and not dated as required. Observation on 3/30/26, at 9:05 a.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Registered Nurse (RN) Employee E2 on 3/30/26, at 9:08 a.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 3/30/26, at 12:02 p.m. indicated a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Interview with Licensed Practical Nurse (LPN) Employee E4 on 3/30/26, at 12:04 p.m. confirmed a treatment cart unlocked and unattended outside room [ROOM NUMBER]. Observation on 4/1/26, at 8:57 a.m. the 2nd floor treatment cart was left unattended and unlocked in the South hallway. Interview on 4/1/2026, at 8:58 a.m. LPN, Employee E19 confirmed the 2nd floor treatment cart was left unlocked and unattended in the hallway. Observation of the East Hall Medication Cart on 4/1/26, at 9:07 a.m. indicated the following medications opened and not dated as required:-ipratropium bromide (breathing medication),-albuterol (breathing medication), and -fluticasone (nasal spray to treat allergy symptoms). Interview on 4/1/26, at 9:08 a.m. LPN Employee E7 confirmed the medications were in the East Hall Medication Cart opened and not dated as required. Review of the face sheet indicated Resident R3 admitted to the facility on [DATE]. Observation on 3/30/26, at 9:10 a.m. Resident R3 was observed out of bed in wheelchair. On the night stand a container of Vashe (hypochlorous acid wound cleanser) was noted along with a tube of zinc oxide. Interview on 3/30/26, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the Vashe and zinc oxide were on the night stand. Review of the face sheet indicated Resident R40 admitted to the facility on [DATE]. Observation on 3/30/26, at 9:16 a.m. Resident R40 was sitting out of bed in a chair. On the bedside stand was a tube of triamcinolone cream. Interview on 3/30/26, at 10:03 a.m. LPN Employee E1 confirmed the triamcinolone cream was on the night stand. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(2)(3) Nursing services.

Based on review of facility policy, clinical record review, and staff and resident interviews, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders to treat constipation for two of six residents (Resident R31 and R65). Findings Include: Review of the facility's Bowel Tracking Protocol Policy last reviewed 1/31/26, revealed the facility will record and monitor bowel activity of residents each shift and address issues identified. Diarrhea, constipation, bloody stools, or any other concerns will be reported to the licensed nurse. The Director of Nursing will be responsible for ensuring a daily auditing process is in place to identify residents who have no had a bowel movement in 2 full days (48 hours). If the resident has not had a bowel movement for 2 full days (48 hours), and in the absence of other resident-specific orders, the nurse will determine if laxatives are indicated based on the resident's bowel habits and patterns.If 48 hours without a bowel movement:Step 1: Give Miralax (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) 17g in 4-8 oz. liquid (Polyethylene glycol 3350)Step 2: If no BM by 10 am the following day, repeat Miralax 17g in 4-8 oz. liquidStep 3: If no BM by next morning, administer Enemeez (a small, ready-to-use liquid solution administered rectally to relieve temporary constipation) micro enema 5 mL rectally. If no BM within an hour, contact provider. Review of the admission record indicated Resident R31 admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of anxiety, high blood pressure, and diabetes (a condition that causes blood sugar to rise). Review of Resident R31's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/4/26, revealed the diagnoses were current. Review of Resident R31's care plan dated 4/13/25, revised 3/10/26, revealed the resident was at risk for constipation. Interventions included the to administer medications, enemas, and suppository as ordered. Check resident for fecal impaction as needed. Document frequency and character of bowel movements. Determine presence/absence of awareness of need to defecate. Review of Resident R31's physician order dated 9/29/25, indicated to administer 283 mg/5 mL Enemeez (docusate sodium) enema rectally, once a day as needed. If no BM by morning of day 4, administer 1 Enemeez Micro Enema in the morning. Indication for use: Constipation. If no BM within one hour of administering Enemeez, contact provider. Review of Resident R31's Bowel Documentation revealed no evidence of a bowel movement on 3/26/26, 3/27/26, 3/28/26, and 3/29/26 (A total of four days). Review of Resident R31's March 2026 Medication Administration Record revealed the resident did not receive the enema as needed on 3/29/26, as ordered. Review of Resident R31's clinical record failed to include evidence the physician was notified the resident failed to have a bowel movement after four days. Review of Resident R31's clinical record revealed the resident had a large bowel movement on 3/30/26. During an interview on 3/30/26, at 10:28 a.m. Resident R31 revealed a concern related to constipation. Resident R31 stated when constipated, it causes her to bleed. During an interview on 3/31/26, at 10:41 a.m. Licensed Practical Nurse (LPN), Employee E14 stated the facility prints out a bowel list daily and the nurses review it, and any as needed medications ordered are administered to treat the constipation. If the resident does not defecate by mid shift then the supervisor is notified and the physician is notified. During an interview on 3/31/26, at 11:06 a.m. Unit Manager LPN, Employee E15 revealed the unit manager runs a report for residents who had not had a bowel movement. It was indicated most residents have a standard bowel protocol ordered upon admission. The ordered medications are administered to the resident as need and the information is passed along to the next shift. Unit Manager, LPN, Employee E15 stated when an as needed medication is administered, it is documented whether it was effective of ineffective. Review of the admission record indicated Resident R65 admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of constipation, high blood pressure, and chronic pain syndrome. Review of Resident R65's MDS dated [DATE], revealed the diagnoses were current. Review of Resident R65's care plan dated 3/18/26, revealed the resident had an increased nutrition/hydration risk related to constipation. The facility failed to implement interventions in the resident care plan to address constipation. Review of Resident R65's physician order dated 3/2/26, indicated to administer 17 gram Miralax if no bowel movement by Day 2 in the morning for constipation. Review of Resident R65's physician order dated 3/2/26, indicated to administer 17 gram Miralax twice a day as needed for constipation. Review of Resident R65's physician order dated 3/2/26, indicated to administer 8.6 mg Senna (used to treat constipation and promote bowel movements) twice a day as needed. if no bowel movement by Day 2 in the morning for constipation. Review of Resident R65's Bowel Documentation revealed no evidence of a bowel movement on 3/25/26, 3/26/26, 3/27/26 (a total of three days). Review of Resident R65's March 2026 Medication Administration Record revealed the resident did not receive Miralax or Senna as needed on 3/27/26, as ordered. Review of Resident R65's clinical record failed to include evidence the physician was notified the resident failed to have a bowel movement after three days. During an interview on 3/30/26, at 9:53 a.m. Resident R65 revealed a concern related to constipation. Resident R65 stated her bum hole was so sore. Resident R65 indicated she couldn't poop, it was hard as a rock and her stomach hurt so bad. During an interview on 3/31/26, at 12:51 p.m. the Assistant Director of Nursing (ADON), Employee E10 confirmed the facility failed to implement the bowel protocol ordered for Resident R31 and R65. During an interview on 3/31/26, at 1:04 p.m. the Nursing Home Administrator confirmed the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for two of six residents (Resident R31 and R65). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that Enhanced Barrier Precautions (EBP) were managed properly for one of three resident (Resident R12) and failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R44).Findings include: Review of the facility policy Enhanced Barrier Precautions Policy dated 8/15/25, indicated EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents are those with chronic wounds and indwelling devices. Staff will put on both gloves and gown before initiating the activity and remove personal protective equipment before exiting the room. Review of the facility policy Freezers and Refrigerators Policy dated 8/15/25, indicated monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures to be between 35 degrees and 41 degrees. Review of the face sheet indicated Resident R12 admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness) . Section K0520 indicated feeding tube while a resident. Review of Resident R12's physician order 1/11/26, indicated EBPs. Observation on 3/30/26, at 10:00 a.m. indicated Licensed Practical Nurse (LPN) Employee E1 wearing gloves and hanging a new bag of tube feeding supplement via pump to the gastrostomy tube. LPN Employee E1 failed to put a gown on prior to an act of high contact activity. Interview on 3/30/26, at 10:30 a.m. LPN Employee E1 confirmed they failed to wear a gown during high contact activity as required with EBP for Resident R12. Review of the admission record indicated Resident R44 was admitted to the facility on [DATE]. Observation on 3/30/26, at 9:16 a.m. Resident R44's personal refrigerator in the room had a temperature log on the outside. The month and year were blank. Fifteen of thirty days were blank. Interview on 3/30/26, at 9:30 a.m. Registered Nurse (RN) Employee E2 confirmed the temperature log for Resident R44's personal refrigerator had the month and year blank and that fifteen of thirty days were blank. Interview on 3/30/26, at 3:00 p.m. the Director of Nursing confirmed the facility failed to ensure that Enhanced Barrier Precautions (EBP) were managed properly for one of three resident (Resident R12) and failed to properly monitor a resident's personal refrigerator temperature for one of two residents (Resident R44). 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and interviews with staff, it was determined that the facility failed to accurately document the need to crush medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36) and failed to ensure that residents are free of significant medication errors which resulted in an immediate jeopardy situation for one of five residents (Resident R1).Findings include: Facility policy, General Dose Preparation and Medication Administration revealed staff will Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Review of Resident R1's clinical record indicated Resident R1 was admitted to the facility on [DATE] Review of the Minimum Data Set assessment (MDS, periodic assessment of resident care needs dated 10/8/25, included diagnoses of Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Chronic Obstructive Pulmonary Disease (COPD, group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R1's diagnosis list included Dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of Resident R1's plan of care for increased nutrition/hydration risk initiated 9/22/23, included the approach of, Continue to adhere to STRICT aspiration precautions. Further review of Resident R1's plan of care failed to reveal goals and interventions developed for dysphagia or the need to have crushed medications. Review of Resident R1's physician's order dated 8/20/25, revealed, Give meds crushed in pudding or applesauce until cleared by speech. During an interview on 11/13/25, at 2:25 p.m. Speech Therapist Employee E7 stated that the speech department adjusts diet consistency orders but does not address the need for a physician's order for crushed medications. When asked how nursing staff are aware of the need for a resident to have medications crushed, Speech Therapist Employee E7 stated, I would assume the staff know. Review of Resident R1's progress note dated 11/6/25, at 6:00 p.m. revealed Registered Nurse (RN) Employee E3 documented, This nurse was called to residents' room by RN supervisor to assist with resident in respiratory distress. This nurse performed Heimlich maneuver and suctioning with Yankauer (rigid, one-piece suction tip used in medical procedures to remove secretions, blood, and other fluids from the mouth, throat, or surgical sites) suctioning, which both were unsuccessful. Resident cyanotic (blue fingernails due to lack of oxygen in the blood) and unresponsive, unable to perform CPR due to resident's code status. Auscultated apical pulse for one full minute, absent heart sounds, verified with RN Supervisor Employee E1. Review of Resident R1's progress note dated 11/6/25, at 6:10 p.m. revealed RN Supervisor Employee E2 documented, At approximately 1745 (5:45 p.m.), Licensed Practical Nurse (LPN) Employee E1 called RN Supervisor to resident bedside as [he/she] was in respiratory distress. Resident was cyanotic, exhibiting agonal breathing (irregular, labored breaths). Nonrebreather placed on resident's face, while Heimlich was performed. LPN Employee E1 attempted to clear the resident's airway, but this measure was unsuccessful. At 1800 patient had no spontaneous respirations, no palpable carotid or femoral pulses, no apical heart sounds auscultated after 1 minute of continuous listening and no response to verbal or painful stimuli. RN Supervisor Employee E2 pronounced resident's death at 1800 (6:00 p.m.). Review of Resident R1's progress note dated 11/6/25, revealed Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified. Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.) Death was pronounced by [RN Employee E3] and RN Supervisor Employee E2. During an interview on 11/13/25, at approximately 11:45 a.m. LPN Employee E1 stated, Resident R1 had asked if [he/she] could take [his/her] medications whole, as [his/her] diet order had recently changed. LPN Employee E1 confirmed that he provided Resident R1's medications uncrushed. LPN Employee E1 stated that Resident R1 began coughing. LPN, Employee E1 stated that Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 stated that he removed Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) which brought forth food matter. During an interview on 11/13/25, at approximately 3:25 p.m. RN Employee E3 stated that on 11/6/25, LPN Employee E1 came out of Resident R1's for the suction machine and crash cart. RN Supervisor Employee E2 entered the room. RN Supervisor came out of the room and said he (LPN Employee E1) needed the oxygen key that was on her key ring. RN Employee E3 stated she did not have an oxygen key on her key ring. I started running around searching for a key. RN Employee E3 confirmed it was approximately three to four minutes before an oxygen key was found to access the oxygen tank on the crash cart. During an interview on 11/13/25, at approximately 3:35 p.m. revealed RN Supervisor Employee E2 stated that she was told LPN Employee E1 needed her in Resident R1's room. Resident R1 was visibly in respiratory distress and [his/her] color was not great. RN Supervisor Employee E2 stated LPN Employee E1 got the crash cart, as she began doing vitals on [resident], with [his/her] oxygen level about 60%. RN Supervisor Employee E2 stated that when they attempted to put the non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen in emergencies) they were unable to access the oxygen tank as there was not an oxygen key. RN Supervisor Employee E2 stated Resident R1 had an oxygen concentrator in [his/her] room, and [he/she] used that, but the oxygen concentrator only goes up to five liters. I mean, it helped a little bit, but then it was just clear that [resident] needed way more oxygen. So, I'm running around looking for the key, we're looking, and we can't find a key. Finally, somebody from the Second Floor brings one up. RN Supervisor Employee E2 revealed when LPN Employee E1 performed a finger sweep whole pills were removed from Resident R1's mouth/throat. RN Supervisor, Employee E2 confirmed Resident R1's oxygen saturation had risen slightly on the concentrator and that if there had been high-level oxygen replacement had been available, it may have provided additional time to clear Resident R1's airway. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed an Immediate Jeopardy situation existed for residents on 11/14/25, at 12:52 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 11/14/25, at 3:58 p.m. an acceptable Corrective Action Plan was received which included the following interventions: 1. Resident identified (Resident R1) ceased to breathe so facility is unable to retroactively correct deficient practice related to this resident.2. Facility had speech therapist complete a whole house audit on 11/14/25, by 2 pm to validate medication delivery method (crushed vs whole). All discrepancies were immediately addressed on 11/14/25 by 5 pm.3. An order will be obtained by physician for all current residents requiring crushed meds and all care plans will be updated to reflect the orders on 11/14/25 by 6 pm. 4. Education will be provided to all licensed staff on proper medication administration, following MD (physician) and the steps to take for resident refusals by 11/15/25 at 12pm. 5. For agency staff a binder will be created containing the education on proper medication administration, following MD orders and the steps to take for resident refusals. Agency staff will be educated prior to the start of their shift beginning 11/14/2025 at 11pm.6. LPN identified with deficient practice will receive 1:1 education and disciplinary process will be followed.7. DON, or designee, will audit 10 residents a day, 5 days a week for 4 weeks. The audit is to validate the nurse followed physician orders for medication administration.8. An ad hoc QAPI will be held 11/14/25 by 3 pm to discuss deficient practice and immediate Plan of Correction with the Interdisciplinary Team. During a review of current residents on 11/14/25, it was noted that four residents (Residents R2, R3, R4, and R5) had physician orders for crushed medications. During a review of the speech therapy audits on 11/15/25, at approximately 10:30 a.m. it was noted that 29 additional residents were documented as needing their medications crushed, (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36). Interviews conducted with staff on 11/15/25, beginning at approximately 11:15 a.m., five of five LPNs and two of two RNs on confirmed they received re-education on medication administration, following physician orders, and were able to demonstrate in the electronic charting system where to access if a resident required their medication to be crushed. The Immediate Jeopardy was removed on 11/15/25, at 12:25 p.m. when the action plan implementation was verified. During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to accurately document the need to crush medications for 29 of 33 residents (Resident R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, and R36) and failed to ensure that residents are free of significant medication errors which resulted in an immediate jeopardy situation for one of five residents (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined the facility failed to implement policies and procedures to protect residents from neglect that resulted in the actual harm of choking and subsequent death for one of five residents (Resident R1).Findings include: Review of facility Pennsylvania Resident Abuse Policy dated 10/23/25, revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set assessment (MDS, periodic assessment of resident care needs) dated 10/8/25, included diagnoses of Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Chronic Obstructive Pulmonary Disease (COPD, group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R1's clinical record including diagnosis list revealed Dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of Resident R1's plan of care for increased nutrition/hydration risk initiated 9/22/23, including the intervention of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed for dysphagia or the need to have crushed medications. Review of Resident R1's physician's order dated 8/20/25, revealed, Give meds crushed in pudding or applesauce until cleared by speech. Review of Resident R1's progress notes dated 11/6/25, Resident CTB (cease to breath) after going into respiratory failure post aspiration coughing event. Crash cart brought into the room and RN supervisors notified. Resident identified as a DNR (do not resuscitate) finger sweep, suction, Heimlich maneuver was not successful and patient CTB at 1800 (6:00 p.m.). Death was pronounced by [RN Employee E3] and [RN Supervisor Employee E2]. During an interview on 11/13/25, at approximately 11:45 a.m. Licensed Practical Nurse (LPN) Employee E1 revealed Resident R1 had asked if (he/she) could take (his/her) medications whole, as (his/her) diet order had recently changed. Employee E1 confirmed that he provided Resident R1's medications uncrushed. Employee E1 revealed Resident R1 began coughing. Licensed Employee E1 revealed Resident R1 began experiencing respiratory distress and additional staff responded. LPN Employee E1 revealed he removed Resident R1's upper denture and completed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) which brought forth food matter. During an interview on 11/13/25, at approximately 3:35 p.m. RN Supervisor Employee E2 stated when LPN Employee E1 performed a finger sweep whole pills were removed from Resident R1's mouth/throat. During review of facility documents on 11/15/25, revealed, LPN Employee E1 was given a disciplinary action for neglecting to provide medication in the form ordered by the physician. During an interview on 11/15/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to implement policies and procedures to protect Resident R1 from neglect that resulted in the actual harm of aspiration and respiratory failure. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on observations and staff interviews it was determined the facility failed to ensure equipment was in safe operating condition for two of two crash carts (carts maintained with equipment used in emergencies) which caused the actual harm of a delay in emergency care for one of five residents (Resident R1).Findings include: Review of the facility Emergency Equipment Check Policy dated 10/23/25, revealed, Emergency equipment/cart(s) will be checked daily and items which are outdated or opened will be replaced. The cart will be restocked promptly after any use. Check contents against community-specific emergency cart contents checklist. Replace missing items and items that have been opened. Initial/sign community specific emergency cart check sheet. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] Review of the Minimum Data Set assessment (MDS, periodic assessment of resident care needs) dated 10/8/25, included diagnoses of Dementia (group of symptoms that affects memory, thinking and interferes with daily life), and Chronic Obstructive Pulmonary Disease (COPD, group of progressive lung disorders characterized by increasing breathlessness). Review of Resident R1's diagnosis list included Dysphagia (difficulty swallowing) with a diagnosis date of 9/18/24. Review of Resident R1's plan of care for increased nutrition/hydration risk initiated 9/22/23, included intervention of, Continue to adhere to STRICT aspiration precautions. Further review of the plan of care failed to reveal goals and interventions developed for Dysphagia or the need to have crushed medications. Review of Resident R1's physician's order dated 8/20/25, indicated, Give meds crushed in pudding or applesauce until cleared by speech. Review of Resident R1's progress note dated 11/6/25, at 6:10 p.m. revealed, At approximately 1745 (5:45 p.m.), Licensed Practical Nurse (LPN) Employee E1 called RN (Registered Nurse) Supervisor to resident bedside as [he/she] was in respiratory distress. Resident was cyanotic (fingernails are blue due to lack of oxygen in blood), exhibiting agonal (irregular, labored) breathing. Nonrebreather placed on resident's face, while Heimlich was performed. LPN Employee E1 attempted to clear the resident's airway, but this measure was unsuccessful. At 1800 patient had no spontaneous respirations, no palpable carotid or femoral pulses, no apical heart sounds auscultated after 1 minute of continuous listening and no response to verbal or painful stimuli. RN Supervisor Employee E2 pronounced resident's death at 1800 (6:00 p.m.). During an interview on 11/13/25, at approximately 3:25 p.m. RN Employee E3 revealed on 11/6/25, LPN Employee E1 came out of Resident R1's for the suction machine and crash cart. RN Supervisor Employee E2 entered the room. RN Supervisor came out of the room and said he (LPN Employee E1) needed the oxygen key that was on her key ring. RN Employee E3 stated she did not have an oxygen key on her key ring. I started running around searching for a key. RN Employee E3 confirmed it was approximately three to four minutes before an oxygen key was found to access the oxygen tank on the crash cart. During an interview on 11/13/25, at approximately 3:35 p.m. RN Supervisor Employee E2 stated that she was told LPN Employee E1 needed her in Resident R1's room. Resident R1 was visibly in respiratory distress and [his/her] color was not great. RN Supervisor Employee E2 stated LPN Employee E1 got the crash cart, and she began doing vitals on [him/her] with [resident] oxygen level about 60%. RN Supervisor Employee E2 stated that when they attempted to put the non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen in emergencies) they were unable to access the oxygen tank as there was not an oxygen key. RN Supervisor, Employee E2 stated Resident R1 had an oxygen concentrator in [his/her] room, and she used that, but the oxygen concentrator only goes up to five liters. I mean, it helped a little bit, but then it was just clear that [resident] needed way more oxygen. So, I'm running around looking for the key, we're looking, and we can't find a key. Finally, somebody from the Second Floor brings one up. RN Supervisor Employee E2 stated that when LPN Employee E1 performed a finger sweep (first-aid technique to remove a visible foreign object from a person's mouth during a choking emergency) whole pills were removed from Resident R1's mouth/throat. RN Supervisor Employee E2 confirmed Resident R1's oxygen saturation had risen slightly on the concentrator and that if there had been high-level oxygen replacement had been available, it may have provided additional time to clear Resident R1's airway. During an observation on 11/13/25, at approximately 3:50 p.m. of the Third Floor Emergency Cart Daily Checklist for November 2025 revealed:11/1/25: No documentation a check was completed.11/2/25: Documented that no items were available on the cart.11/3/25: No documentation a check was completed.11/4/25: No documentation a check was completed.11/5/25: Documented that no items were available on the cart.11/6/25: No documentation a check was completed.11/7/25: No documentation a check was completed.11/8/25: Documented that no items were available on the cart.11/9/25: Documented that no items were available on the cart.11/10/25: Documented that no items were available on the cart.11/11/25: Documented that no items were available on the cart.11/12/25: Documented that no items were available on the cart. During an observation on 11/13/25, at approximately 3:55 p.m. of the Second Floor Emergency Cart Daily Checklist for November 2025 revealed:11/1/25: No documentation a check was completed.11/2/25: No documentation a check was completed.11/3/25: No documentation a check was completed.11/4/25: No documentation a check was completed.11/5/25: No documentation a check was completed.11/6/25: No documentation a check was completed.11/7/25: No documentation a check was completed.11/8/25: No documentation a check was completed.11/9/25: Documented that no items were available on the cart.11/10/25: No documentation a check was completed.11/11/25: Documented that no items were available on the cart.11/12/25: Documented that no items were available on the cart. During an interview on 11/14/25, at approximately 10:00 a.m. LPN Employee E6 was asked to provide the Third Floor nursing unit crash cart checklists. When the binder was provided, the checklist for August 2025 was observed, with multiple dates not documented, and no checklists were available for September and October 2025. During an interview on 11/15/24, at approximately 12:30 pm. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that equipment was in safe operating condition for two of two crash carts which caused the actual harm of a delay in emergency care for one of five residents. 28 Pa Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy and documents, clinical records, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and failed to identify a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1). This failure created an immediate jeopardy situation. Findings include: Review of the facility Elopement/Unauthorized Absence Policy policy dated 8/2/24, last reviewed 3/20/25, indicated the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Upon determining that a resident cannot be located a headcount will be conducted. If resident Is still missing Code Green using the resident name, room number, and unit name will be announced. Announce three times. The clinical supervisor or designs will notify the Administrator, the Director of Nursing (DON), and the attending physician. Review of the facility's admission Policy dated 3/16/23, last reviewed 3/20/25, stated the facility will admit only those individuals requiring care and services to meet their physical, psychosocial, and emotional needs and whose needs can be met by the facility. The facility will individually review and assess each prospective admission to determine if their specific needs can be adequately in the facility before acceptance. Review of Resident R1's admission record indicated she was admitted on [DATE], with diagnoses of dementia (loss of cognitive functioning- thinking remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), anxiety, and bipolar (a mental health condition that affects a person's mood, energy, activity, and thought and is characterized by manic (or hypomanic) and depressive episodes). Review of Resident R1's Hospital Discharge summary dated [DATE], revealed the resident required minimal assistance with sit to stand transfers. Orders for the next facility related to activity was as prior to hospitalization, with no restrictions. The resident was independent with a wheeled walker prior to admission. Review of Resident R1's admission assessment completed 4/25/25, at 2:37 p.m. by Licensed Practical Nurse (LPN), Employee E2 revealed the resident was ambulatory with assistance. The resident was disoriented, had a memory impairment, and disorganized thinking. The resident was assessed to be able to wheel at least 50 feet in a wheelchair with partial/moderate assistance. Resident R1's elopement risk assessment asked if the resident was ambulatory or independent in a wheelchair and LPN, Employee E2 selected No-Clinically not at risk for elopement. No further questions were asked and Resident R1 was not identified as an elopement risk. The facility failed to identify Resident R1 as an elopement risk and initiate an elopement care plan. Review of Resident R1's progress note dated 4/25/25, at 2:40 p.m. entered by LPN, Employee E2 revealed the resident was only alert to self and unable to make needs known. Resident was very confused. Review of Resident R1's progress note dated 4/25/25, at 9:56 p.m. entered by the DON stated a call was received from RN Supervisor that Resident R1 was confused and wandering. Resident R1 eloped from the unit and was found in the basement. Review of Resident R1's elopement evaluation dated 4/25/25, at 9:47 p.m. identified Resident R1 as an elopement risk. Immediate interventions included transferring the resident to the Memory Impairment Unit (MIU- secured memory care unit specifically designed to care for those with cognitive impairment or memory problems). Review of information submitted to the Department of Health on 4/26/25, stated on 4/25/25, at approximately 8:00 p.m. Resident R1 was missing, and a nurse aide notified the nurse. The resident was last seen around 7:30 p.m. drinking a chocolate milk and eating a snack on the unit. Upon admission, Resident R1 was not identified as a wandering risk and exhibited no behaviors. Staff searched all units and the outside perimeter of the facility. Resident R1 was found in the basement uninjured at approximately 8:30 p.m. Once escorted back to the unit, Resident R1 was reevaluated for a wander risk and the resident's room was changed to the memory care secured unit. The physician and family were notified. Review of Resident R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed the resident had a BIMS of 1, severe cognitive impairment. During an interview on 5/7/25, at 12:03 p.m. Nurse Aide, Employee E6 stated the resident arrived to the facility in a wheelchair. Resident was confused, observed climbing in other resident's bed, and attempting to walk around room. NA, Employee E6 indicated Resident R1 was placed back into a wheelchair. During an interview on 5/7/25, at 12:09 p.m. Licensed Practical Nurse, Employee E2 stated when the resident arrived LPN, Employee E2 did not receive report from family or the hospital. The supervisor handed over a packet of information about 45 minutes before the resident arrived. It was revealed the RN Supervisor failed to assist with the admission assessment. LPN, Employee E2 completed an admission assessment and did not identify Resident R1 as an elopement risk. During an interview on 5/7/25, at 12:27 p.m. NA, Employee E8 indicated they observed Resident R1 to be very confused on 4/25/25. Resident R1 was confused, opening doors to other resident rooms, and was placed in a wheelchair due to being found in roommates bed and trying to ambulate without staff assistance. Resident R1 was not stable on her feet. Once Resident R1 was placed in the wheelchair, she was moving around the unit. NA, Employee E8 stated Resident R1 was fast in the wheelchair. Staff attempted to keep resident occupied, the resident was provided snacks. When NA, Employee E8 came back from break, NA, Employee E8 asked where Resident R1 was. The staff on the floor checked twice in the resident's room and on the unit. A code green was called and Resident R1's chocolate milk was on the floor of the elevator. The resident was found in the basement on a dolly with no brief on. During an interview on 5/7/25, at 2:43 p.m. Registered Nurse, Employee E7 confirmed on 4/25/25, she was the RN Supervisor on duty. RN, Employee E7 stated she took report from the hospital for Resident R1. RN, Employee E7 entered the medications into the clinical record, but did not assess the resident. RN, Employee E7 indicated she reviewed the information from the hospital discharge summary. Review of Resident R1's referral documents on 5/8/25, at 9:17 a.m. revealed the resident previously resided in a MIU (a secured memory care unit specifically designed to care for those with cognitive impairment or memory problems) at a personal care home. Resident R1 was not admitted to the MIU at the facility. The facility failed to implement their admission policy and ensure the facility reviewed and assessed Resident R1 to determine if their specific needs can be adequately met in the facility before acceptance. Review of Resident R1's investigation on 5/8/25, revealed Resident R1 had an increase in mobility from the initial elopement assessment. When Resident R1's mobility increased staff intervened with snacks and drinks. The facility failed to reassess Resident R1 for an elopement risk and implement a care plan to prevent Resident R1 from eloping off the unit on 4/25/25. When RN Supervisor, Employee E1 was aware Resident R1 could not be located, RN, Employee E1 failed to follow the facility's resident elopement unauthorized absence procedure and call code green prior to notifying the DON. During an interview on 5/8/25, at 9:37 a.m. admission Director, Employee E4 stated prior to accepting a resident to the facility, hospital referral documents are reviewed from central intake which is comprised of four different people. Once central intake combs through it, a decision is made to accept the resident or not. If the resident is accepted, the admission Director reads through the hospital documentation to see if a resident needs to be placed in the MIU or needs medical equipment. admission Director, Employee E4 stated They have missed it, sometimes I miss things. Admissions Director, Employee E4 confirmed the facility's elopement risk assessment does not identify residents who are at risk for eloping. admission Director, Employee E4 indicated just because a resident is not ambulatory at the time of admission, does not mean they are not at risk for eloping. During an interview on 5/8/25, at 10:11 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) indicated the root cause of Resident R1's elopement was staff initially thought the resident was not going anywhere, then Resident R1 became more mobile. When asked what the facility did to prevent the incident from reoccurring, the NHA stated elopement assessments were completed for those who were previously identified as a risk and verbal education was provided to all nursing staff. The facility failed to assess all residents for a risk of elopement and educate all clinical and non-clinical staff. The NHA and DON confirmed the facility failed to identify Resident R1 as an elopement risk upon admission, ensure Resident R1 received adequate supervision, and follow the facility's resident elopement unauthorized absence procedure and call code green prior to notifying the DON. During an interview on 5/8/25, at 11:13 a.m. LPN, Employee E3 stated the nurse on the unit is responsible for completing elopement assessments for new admissions. When asked how often assessments are completed, LPN, Employee E3 stated I am not certain, I am agency. LPN, Employee E3 indicated Resident R1 was found about a half hour after code green was called. Resident R1 was found in the basement and was brought to the locked unit. On 5/8/25, at 11:20 a.m. the NHA and DON were notified that Immediate Jeopardy was called due to the elopement of Resident R1 on 4/25/25, and facility staff were provided an Immediate Jeopardy template, and a corrective action plan was requested. On 5/8/25, at 2:11 p.m. the NHA provided the facility's first plan of correction. On 5/8/25, at 4:45 p.m. an immediate action plan was received and accepted which included the following interventions: -R1 was reassessed on 4/25/25 and deemed an elopement risk and moved to the secure memory care unit. Her plan of care was updated. The family and physician was updated. -To ensure residents who are newly admitted to the facility are reviewed and assessed to ensure their specific needs can be adequately met in the facility before acceptance, the admission Policy will be reviewed, and a protocol developed to address pre-admission elopement risk factors. The protocol will consist of central intake and admissions director reviewing a referral for indications of an elopement risk. If there are elopement risk factors identified, the admissions director will review with the clinical department to discuss risk factors and interventions. The central intake and Admissions Director will be educated on this process on 5/8/25, by the Regional Director of Clinical Education. -All residents will be re-assessed on 5/8/25, with an elopement risk tool that includes all risk factors. If a risk factor is identified the resident will be deemed an elopement risk and their plan of care will be updated with interventions to prevent elopement. -The admission and Elopement Policy and procedures will be reviewed and updated as needed by the Nursing Home Administrator by the end of the day on 5/8/25. -All staff will be re-educated on elopement risks and supervision by the Director of Nursing or designee on 5/8/25 via in person, phone and/or other means of communication to ensure education is done timely. All staff will sign off on understanding of education prior to the start of their next scheduled shift if they are not currently in the facility. The Registered Nurses (RN) and Licensed Practical (LPN) nursing staff will be educated on the updated elopement observation and a Registered Nurse review of the elopement tool by the Director of Nursing or designee by end of the day 5/8/25, via in person, phone and/or other means of communication to ensure education is done timely. RN and LPN staff will sign off on understanding of education prior to the start of their next scheduled shift if they are not currently in the facility. -The Director of Nursing or designee will audit all new admissions weekly for 4 weeks then monthly times 2 months to ensure the elopement observation identifies any risk factors and interventions implemented as appropriate. -An Ad Hoc QA/QAPI will be conducted by the end of the day on 5/8/25. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. -On 5/8/25, an elopement preadmit referral review tool was created to assess risk factor for elopements. If risk factors are identified, the Admissions Director will review with DON/ADON and indicate on Admissions Notification Form. Risk factors and interventions will be communicated to clinical team members. On 5/8/25, 4 of 4 central intake team members were educated and the Admissions Director were educated. During interviews completed on 5/9/25, at 9:40 a.m. 4 of 5 staff members verified they were educated on elopement preadmit referral review tool. 1 of 5 staff members who was not available for interview signed in-service sign off sheet. -On 5/8/25, 104/104 residents were assessed with the elopement risk tool that included a total of nine risk factors. 13 of 104 residents were identified as an elopement risk. 13 of 13 care plans reviewed on 5/9/25, revealed 13 of 13 residents were care plan individually for their risk of elopement. -On 5/8/25, the admission and elopement policies were reviewed. No changes were made to the elopement policy. The elopement preadmit protocol was added to the admission policy. -98/123 staff members confirmed they were re-educated on elopement risks and supervision. During phone interviews completed at 5/9/25, at 11:11 a.m., 3/3 staff verified they were educated on elopement risks and supervision. If a resident is unable to be located, a code green is called after the initial head count. Staff are required to sign off understanding prior to the start of their next shift. During in-person interviews completed on 5/9/25, at 11:04 a.m. 24/24 staff confirmed they were educated on elopement risks, supervision, and what to do if a resident in unable to be located. Elopement risk assessments are completed upon admission, quarterly, and as needed with change in condition. Resident is identified as an elopement risk will have interventions in place to prevent elopement. -During in-person interviews completed on 5/9/25, at 11:04 a.m. 9/9 nursing staff confirmed competency on updated elopement risk assessment. During phone interviews completed on 5/9/25, at 11:11 a.m., 3/3 nursing staff confirmed they were educated on elopement tool, elopement risks, and supervision. Staff indicated if a resident is unable to be located, a head count will be conducted. If resident is still missing a code green will be called, then the clinical supervisor will notify NHA, DON, and attending physician. -As of 5/9/25, at 9:36 a.m. the facility has not had any new admission. Facility has audit tool that ensures admission elopement assessment was completed, all risk factors were assessed, if risk factor present, intervention is put in place, and the RN will review and sign off elopement risk assessments. -Ad Hoc QA/QAPI meeting was conducted on 5/8/25. The NHA, DON, Regional Director of Clinical Services, and Medical Director designee were present. Elopement audits were completed whole house, preadmission protocol for elopement risk was created, and education for elopement, supervision and the new elopement tool was implemented. Verification of the facility's Corrective Action Plan revealed all elements of plan were met. The Immediate Jeopardy was lifted on 5/9/25, at 11:27 a.m. During an interview on 5/9/25, at 2:54 p.m., the NHA and Regional Director of Clinical Services, Employee E5 confirmed that the facility failed to make certain each resident received adequate supervision and failed to identify and implement interventions for a resident who was an elopement risk which resulted in an elopement for one of five residents (Resident R1), resulting in Immediate Jeopardy. 28 Pa. Code 207.2(a)Administrators Responsibility. 28 Pa. Code§ 201.14(a) Responsibility of Licensee. 28 Pa. Code § 211.10(d) Resident care policies. 28 Pa. Code § 211.12(d)(5) Nursing Services.

Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R1), which resulted in actual harm of a left arm humerus fracture for Resident R1. This deficiency is cited as past non-compliance. Findings include: Review of facility policy Pennsylvania Resident Abuse last reviewed 1/15/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries on unknown source. Review of facility's current Nurse Aide (NA) job description indicated the primary purpose of your (NA) job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort. Performs direct care to the resident as assigned, in accordance with the resident's care plan, and as directed by your supervisor. Review of the admission record indicated R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/2/24, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and Parkinson's Disease (disorder of the nervous system that results in tremors). Section GG indicated resident is dependent for toilet hygiene, lower body dressing, and substantial/maximal assistance for toilet transfer. Review of Resident R1's physician order dated 8/21/24, indicated full body mechanical lift (a machine that safely lifts residents with limited mobility from point A to point B) for transfers, with assist of two staff members. Review of Resident R1's care plan dated 8/21/24, indicated full body mechanical lift for transfers, with assist of two staff members. Review of Resident R1's progress note dated 10/21/24, at 11:00 p.m. indicated resident's emergency contact updated that Resident R1 was being sent out to the hospital for evaluation of left shoulder, and left wrist for fracture. Review of Nurse Aide (NA) Employee E1's witness statement dated 10/21/24, indicated he was in the middle of performing care and Resident R1 was having trouble standing up as he was attempting to put a brief on. After struggling to stand up the resident was going down, NA could not hold her up anymore and had to put her on the ground. He leaned the resident against her wheelchair, tried to get resident back up in her wheelchair, but resident was too heavy. He leaned resident back on her wheelchair and had to get help from other aides on the floor. The resident was screaming, and the nurse was alerted, and saw resident on the ground. Review of documentation provided by the facility dated 10/21/24, at 6:30 p.m. indicated Resident R1 resides on the third-floor long term care unit since 9/2/21. Resident is alert to self and able to make needs known. On 10/21/24, at 6:30 p.m. resident was standing at the side rail after being toileted for staff to provide hygiene, and her legs became weak. NA Employee E1 lowered her to the floor. Resident complained of pain to the left arm following the event. Resident is an assist with mechanical lift for transfers. Physician was made aware and ordered x-ray to rule out fracture (a broken bone). X-ray obtained and results indicated possible left humerus (the long bone in the upper arm that runs from the shoulder to the elbow) fracture. Physician notified and ordered resident be sent to the hospital for follow up x-ray. Family notified. Resident was seen in the emergency department and confirmed left humerus fracture. Resident was splinted, and a sling applied. To follow up with ortho in one to two weeks. Resident returned to the facility with splinting and new order for oxycodone (pain medication). Review of documentation provided by the facility dated 10/22/24, indicated that Resident R1's fall that occurred on 10/21/24, indicated after obtaining NA Employee E1's statement, he was sent home pending investigation for not following the proper plan of care. Review of documentation provided by the facility dated 10/23/24, at 11:13 a.m. indicated NA Employee E1 was reported through a Mandatory Abuse Report for neglect. Review of NA Employee E2's witness statement dated 10/21/24, indicated he was providing care in a resident room when NA Employee E1 asked him for assistance with a transfer. He indicated he responded, No problem, give me a second and I'll be right there. When he came out NA Employee E1 was sitting down. The nurse stopped on the way to the shower room for assistance with Resident R1. That's when NA Employee E2 walked in the room and saw Resident R1 lying on the ground. He was told resident fell during an attempt to toilet by NA Employee E1. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement dated 10/21/24, indicated she was standing at nurses' station facing the south hall and heard Resident R1 screaming. She entered the resident's bathroom and observed Resident R1 on the floor, with her head leaning on the electric wheelchair that was in front of the toilet. Feet and legs lying in front with feet by the wall. Resident still screaming My arm is broke. My arm is broke! She asked NA Employee E1 what happened, and he replied that he stood resident to get her off the toilet and he couldn't hold her anymore, so he lowered her to the ground. Resident had no mechanical lift sling (a device used to support the resident's weight during transfer that is hooked onto the mechanical lift) on her chair or within reach. Review of LPN Employee E4's witness statement dated 10/21/24, indicated she entered the room and resident's head was resting on the back of her wheelchair seat and her left arm was under her body. Resident stated, I think my arm is broken. Resident was tearful and visibly in distress. Observation on 10/29/24, at 9:59 a.m. Resident R1 was resting in her bed. The left upper arm was deeply bruised and multicolored purple, red, and yellow. The left arm rested in a sling that went around the neck. Interview on 10/29/24, at 10:00 a.m. Resident R1 indicated He let me fall. when asked what happened to her left arm. Resident R1 also indicated the arm causes her a great deal of pain still. Interview on 10/29/24, at 10:15 a.m. NA Employee E5 indicated transfer status is found under the Care Profile in the computer, and that two staff are required for a mechanical lift. Interview on 10/29/24, at 10:18 a.m. NA Employee E6 indicated, transfer status is found in the kiosk (a small computer mounted on the wall) under the resident's profile. We also give each other report and have a report sheet. Interview on 10/29/24, at 10:20 a.m. NA Employee E7 indicated transfer status is in Matrix (electronic health record system). We always use two staff for lifts. Interview on 10/29/24, at 10:22 a.m. NA Employee E8 indicated transfer status is in the computer under the profile. Two staff are required for mechanical lifts. Interview on 10/29/24, at 10:26 a.m. NA Employee E9 indicated transfer status in the kiosk on the wall. Interview on 10/29/24, at 1:00 p.m. the Director of Nursing confirmed NA Employee E1 was terminated the day she interviewed him about the incident. He did not follow the resident plan of care, and transferred Resident R1 by himself rather than the two staff required with a mechanical lift resulting in harm of a left humerus fracture relating to the fall on 10/21/24. On 10/21/24, the facility-initiated a plan of corrective actions which included: 1. Re-education on the Resident Profile transfer status and abuse/neglect for all nursing staff completed on 10/22/24. 2. Interdisciplinary team and ad hoc QAPI (Quality Assurance and Performance Improvement) meetings held on 10/22/24. 3. Transfer status audit of all residents to ensure transfer status is in the Resident Profile for the proper plan of care. Completed 10/22/24. 4. Audits initiated regarding transfer status on 10/23/24. Seven audits conducted between 10/23/24, and 10/29/24. Review of education, audits, and staff interviews on 10/29/24, indicated that the facility has demonstrated compliance with the regulation as of 10/22/24. Interviews on 10/29/24, with 18 of 18 nursing staff present on site, and eight via telephonic interview confirmed receiving training on transfer status, and abuse/neglect. 28 Pa. Code: 201.14(a) Responsibility of licensee 28. Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident rights. 28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to identify a resident's risk for elopement and failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R1). This failure created an immediate jeopardy situation for one of 96 residents (Resident R1), who was not properly identified as an elopement risk, and the facility failed to document the appropriate assistance level for one of three residents (Resident R2), and failed to provide appropriate assistance to prevent an avoidable fall for one of three residents reviewed (Resident R2) resulting in actual harm of a laceration (a wound produced by the tearing of soft body tissue, often irregular and jagged). Findings include: Review of facility policy Elopement/Unauthorized Absence reviewed 1/15/24, indicated that the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or leave of absence) and/or necessary supervision to do so. All residents will be assessed using the facility Elopement Assessment for the risk of elopement on admission, quarterly, and as needed. When the Elopement Assessment score is 4 or higher, the resident is identified as at risk for elopement. Residents identified at risk will have their picture and face sheet or the demographic form placed in a binder that is kept in an area accessible by staff. Review of the Nurse Aide (NA) job description indicated the primary purpose of the job is to provide a safe environment, give emotional and social support and attend to the resident's physical needs and comfort and perform direct care to the residents as assigned, in accordance with the resident's care plan, and as directed by the Supervisor. Review of Resident R1's clinical hospital records from 6/8/24, included a hospitalist consultation note that stated the following: Resident R1 was admitted to the inpatient behavioral health unit under a 302 ( an involuntary commitment for emergency evaluation and treatment for persons who may be a danger to themselves or others) petitioned by his daughters which was upheld by the ED (emergency department) physician. According to review of the 302 the patient has been living in deplorable conditions and has not been caring for himself. He has been delusional. He was recently hospitalized for dehydration and malnutrition and was discharged to a skilled nursing facility. He apparently left against medical advice from the skilled nursing facility and was attempting to hitchhike. He later made his way home and his family went to check on him and that his home smelled like gas concerning for a gas leak. 911 was contacted and the patient was instructed to leave the home however he refused. One of his daughters picked him up and put him in her car to drive away from the home continue and he attempted to open the door and jump out of the moving car. Patient also was attempting to live in his shed if he was unable to live in his home. Review of clinical records from the hospital indicated that Resident R1 was discharged on [DATE] to a skilled nursing facility. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set Assessment (MDS-periodic assessment of care needs) dated 7/2/24, included diagnoses of delusional disorder (a type of mental health condition in which a person cannot tell what is real from what is imagined), mild neurocognitive disorder (some decreased mental function), and nontraumatic chronic subdural hemorrhage (an old clot of blood on the surface of the brain beneath its outer covering). Review of Resident R1's clinical record revealed an Admission Observation completed on 6/25/24, that indicated that resident stated he was not a smoker. Review of Resident R1's clinical record revealed an Elopement Observation completed on 6/26/24, which consisted of the following information: Note that the evaluator is to check the box next to each question if the answer is applicable. 1) Is resident ambulatory or independent in wheelchair locomotion? Yes 2) Does the resident have any of the following risk factors? New admission who has made statements questioning the need to be here. (This was NOT marked indicating that the question was not applicable to this resident). Resident is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, Organic Brain Syndrome, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, and schizophrenia). (This WAS marked indicating that the question was applicable to this resident). No Elopement risk factors identified or verbalized. (This was NOT marked indicating that the question was not applicable to this resident). 3) Does the resident exhibit any additional elopement risk criteria? Resident exhibits exit seeking behaviors. (This was NOT marked indicating that the question was not applicable to this resident). Resident verbalizes, wanting to go home, going on a trip, going to meet someone. (This was NOT marked indicating that the question was not applicable to this resident). Not accepting present residency situation/location. (This was NOT marked indicating that the question was not applicable to this resident). Resident wanders without a sense of purpose. (This was NOT marked indicating that the question was not applicable to this resident.) Recent multiple changes in environment. (This was NOT marked indicating that the question was not applicable to this resident). Resident wanders in and out of other resident rooms and/or rummages in other's belongings. (This was NOT marked indicating that the question was not applicable to this resident). Current acute exacerbation of medical conditions; (i.e.: infection, pain, blood sugar levels, sudden changes in cognition/confusion) (This was NOT marked indicating that the question was not applicable to this resident). No additional risk criteria noted (This WAS marked indicating that the question was applicable to this resident). Elopement Risk: Elopement Risk Score: 0.0000 Level: No Elopement Risk Care Plan Elopement care plan initiated. (This was NOT marked indicating that the question was not applicable to this resident). Elopement care plan not initiated - Resident not elopement risk. (This WAS marked indicating that the question was applicable to this resident) Elopement care plan reviewed and/or revised. (This was NOT marked indicating that the question was not applicable to this resident). Review of Resident R1's clinical record revealed that no elopement care plan was implemented. Review of Resident R1's clinical record revealed a nursing progress note dated 6/25/24, at 8:55 p.m. that stated the following: Resident forgot to turn the sink off two time this shift. Resident was educated on how to turn the sink off when he is done after the first incident. He Verbally Understood. The second time resident forgot to turn the sink off his room, hallway, and room [ROOM NUMBER] flooded. Staff and this writer cleaned the water up. Resident sink is now filled with water that will not drain. Safety and comfort measures maintained. Will continue to monitor. Review of Resident R1's clinical record revealed a nursing progress note dated 6/27/24, at 6:46 a.m. that stated the following: Resident moving through the hallways in the course of the night on his wheelchair, the resident repeatedly expressed the need to go home by morning. Resident also requested that he needs his cigarettes by morning, stating someone took them. The writer provided reassurance to resident and redirection and made resident know this a non-smoking facility. Review of Resident R1's clinical record revealed results of a MOCA test (Montreal cognitive assessment- a test used for early detection of mild cognitive impairment) dated 6/27/24, with a score of 19 out of 30 which is considered to be indicative of mild cognitive impairment. Review of Resident R1's clinical record revealed a nursing progress note dated 6/29/24, at 2:51 a.m. that stated the following: This nurse and another staff RN (registered nurse) were called to 2nd floor for a patient that was throwing things in his room. As we entered the room he was packing to leave. We reoriented him and he decided to stay and sit in the lounge and watch TV. Will monitor. Review of Resident R1's clinical record indicated that Resident R1 had a care plan dated 7/1/24, for choosing to exercise his right to AMA (leave against medical advise). Review of Resident R1's clinical record did not reveal any further documentation regarding any exit seeking behaviors from 6/29/24, through 7/19/24. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 10:49 a.m. that stated the following: Nurse Aide notified this writer that this resident had possibly left the facility/grounds. Aide stated the housekeeper saw him leave out the facility door by the smoke/break area with his bags saying he was going to Springdale (neighboring town) this writer immediately delegated a ground search internal and external to other aides and nurses. This writer asked nurse to call Code green (facility code to announce a missing person) since receptionist was not available. This writer and other staff did an external sweep since resident was not found internal. Code green was called around 930 am An external sweep extended to facility entrance with no results. This writer and another nurse decided to check up and down the street in their car. Nurse A went towards the turnpike and this writer went the opposite. This writer located this resident by an ambulance center (approximately 0.5 mile away from the facility) and pulled up beside him and asked him to head back to the facility with her. This writer offered this resident a ride which he refused and said I won't make it very far anyways and shut the writers car door and proceeded to walk away. This writer turned down the street by the ambulance center to turn around. About 50 feet. When finally back on the main road this resident was no longer on the sidewalk or anywhere else this writer could see while driving. This writer called 911 to report this incident. While driving around and talking to 911 operator this writer finally observed this resident across the street from where he originally was walking along the railroad tracks. This writer observed him crossing the street and standing in front of a local bar (approximately 0.7 miles away from the facility) when a police officer pulled up beside him. Resident at this point sat down on the retaining wall in front of the bar. This writer pulled into the parking lot and spoke to the two officers that pulled in. Officer 1 took down this residents name and offered to take him back to the facility. Resident said no he was going to go back with this writer in her car. Officer okayed this and said they would follow us back. Once here it was observed that the resident had grass blades and other [NAME] on his left lower pants and his back. When asked if he fell he said no he was hiding in the bush from the writer so she couldn't see him. Resident denies any sob (shortness of breath)chest pain or any other issues warranting EMS (emergency medical services) check in. Resident had his personal belongings with him in three clear garbage bags with his walker. He was wearing a black t shirt black pants and shoes with his black glasses and black cane. This resident reports he did try to call his brother but he didn't answer. Upon return staff checked resident and found him to be in same condition he had left. Applied a RoamAlert band (an electronic device that notifies staff when a resident leaves a safe area) to lower ankle. Provided resident education. Did staff safety huddle to ensure plan of care for safety is put into place. no questions from staff at this time. Will plan to have this resident stationed in MIU (memory impaired unit- a secured unit that prevents residents from leaving unsupervised) for closer observation for the day per the administrators request. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 1:19 p.m. that stated the following: RoamAlert band placed on patient. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 1:57 p.m. that stated the following: Initial safety plan was to place RomaAlert on resident and place in MIU for constant observation until neuro/cognitive checks (exam of brain function) were completed. Now that the checks are completed resident is to be taken out of MIU. He is deemed competent per BIMS( Brief Interview for Mental Status- a tool that measures orientation (year, month, and day), and learning (recall three words)) to be taken out of MIU. He is to be checked on frequently, about every 30 min, and more as needed if increased risk for elopement is observed. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 2:42 p.m. that stated the following: Spoke with resident regarding his current mental status. He states he is okay but wants to go home. I asked him about going home with no gas turned on as he had a previous gas leak. He stated he has freezer food he can live off of and had plans to call a plumber to get it fixed. I told him I wasn't sure if plumbers dealt with gas problems. He stated he also had a neighbor that was willing to help him when he needs it. He stated he was in the process of moving some of his clothes to his daughter and sister in law house, where he was going to build a shed outside on the property to live in. He stated now his sister in law texted him saying he moved all of his clothes back to house. Resident stated he daughters have all cut him off and he guesses he's not their father anymore. He said when he left the building this morning he was thought about stopping to buy a pack of cigarettes because of the stress he's been under. I discussed about talking with psych to help deal with some of his stress. He said he might be willing to speak with them. I asked him if he was going to start eating again, he said he did not want to if we were just going to keep him here to die. He was also stating that he thinks we are just trying to make him commit suicide but he would never do that because it is against his belief. I told him he needs to keep his RomaAlert on, and that we would be checking in on him often. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 6:30 p.m. that stated the following: Resident monitored post elopement event. Wandering halls, does not appear to be exit seeking. Calm and pleasant. Does not complain of pain or discomfort. RoamAlert was removed by the administrator. Will continue to monitor. Review of Resident R1's clinical record revealed a nursing progress note dated 7/20/24, at 9:37 p.m. that stated the following: The resident still shows interest going home. Resident have been placed under constant 30-minute monitoring. The family has been informed about the resident's persistent desire to leave. A call was made to doctor regarding the resident's interest going home, and a suicidal assessment was conducted. Doctor advised that if the resident continues to persist, an AMA (Against Medical Advice) procedure should be initiated. since resident cannot also be hold at the lock up unit considering his cognitive level. Review of Resident R1's medical record revealed an additional Elopement Observation was completed per facility policy on 7/22/24, which consisted of the following information: Note that the evaluator is to check the box next to each question if the answer is applicable. 1) Is resident ambulatory or independent in wheelchair locomotion? Yes 2) Does the resident have any of the following risk factors? New admission who has made statements questioning the need to be here. (This was NOT marked indicating that the question was not applicable to this resident). Resident is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, Organic Brain Syndrome, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, and schizophrenia). (This was NOT marked indicating that the question was not applicable to this resident). No Elopement risk factors identified or verbalized. (This was NOT marked indicating that the question was not applicable to this resident). 3) Does the resident exhibit any additional elopement risk criteria? Resident exhibits exit seeking behaviors. (This was NOT marked indicating that the question was not applicable to this resident). Resident verbalizes, wanting to go home, going on a trip, going to meet someone. (This was NOT marked indicating that the question was not applicable to this resident). Not accepting present residency situation/location. (This was NOT marked indicating that the question was not applicable to this resident). Resident wanders without a sense of purpose. (This was NOT marked indicating that the question was not applicable to this resident.) Recent multiple changes in environment. (This was NOT marked indicating that the question was not applicable to this resident). Resident wanders in and out of other resident rooms and/or rummages in other's belongings. (This was NOT marked indicating that the question was not applicable to this resident). Current acute exacerbation of medical conditions; (i.e.: infection, pain, blood sugar levels, sudden changes in cognition/confusion) (This was NOT marked indicating that the question was not applicable to this resident). No additional risk criteria noted (This was NOT marked indicating that the question was not applicable to this resident). Elopement Risk: Elopement Risk Score: 0.0000 Level: No Elopement Risk Care Plan Elopement care plan initiated. (This was NOT marked indicating that the question was not applicable to this resident). Elopement care plan not initiated - Resident not elopement risk. (This WAS marked indicating that the question was applicable to this resident) Elopement care plan reviewed and/or revised. (This was NOT marked indicating that the question was not applicable to this resident). Additional information: Resident voiced he will work with social worker for planned discharge and will not leave building without permission. Review of the above evaluation from 7/22/24, compared to original evaluation from 6/26/24, revealed that Resident R1 was no longer marked as cognitively impaired, and remained no elopement risk. Review of Resident R1's clinical record revealed that no elopement care plan was implemented. Review of Resident R1's clinical record revealed a physician's order dated 7/25/24, that stated: Please obtain orders for discharge and home health. Review of Resident R1's clinical record revealed a nursing progress note dated 7/26/24, at 12:45 p.m. that stated the following: This case manager was notified by nursing staff on third floor that resident is on the third floor asking staff for a ride home. When this case manager alerted the back-up social services worker of the situation, back-up social services worker informed this case manager that she obtained the keys to the resident's house and went to and inside of the resident's home this afternoon and the home is infested and deplorable and that MD was notified and an order was now obtained from the MD to cancel discharge and resident is aware and agreeable. Therapy notified. Therapy was not involved in home assessment on this date and was unaware of any home assessment being conducted on this date. Per back-up social services worker, nursing is to be putting MD order in to cancel discharge at this time. Again, social services worker is aware that resident is actively seeking a ride home. Review of Resident R1's clinical record revealed a nursing progress note dated 7/26/24, at 11:06 p.m. that stated the following: Resident alert and oriented x 2( knows who they are and where they are, but not what time it is or what is happening to them). Resident took medication with no adverse reaction. Resident inform staff he wanted to hang out at the courtyard outside for a while. Call was placed to doctor seeking for an LOA (leave of absence) order for resident who states he don't intend leaving and will be in and will have a talk with someone on Monday on when he may leave the facility. Doctor approved for an LOA order for resident, resident then went out to the courtyard and was back. Currently in room resting at this time. Review of Resident R1's clinical record revealed a nursing progress note dated 7/27/24, at 10:04 a.m. that stated the following: Nurse brought to writers attention that resident was outside in the courtyard. She was concerned if he was permitted outside alone. Checking orders, it was found that this resident has LOA with supervision. Resident reports he was able to go out yesterday as long as he signed out in the book at the nurses station. Nurse caring for resident was concerned about letting him go alone and she was busy, this writer okay resident to go outside and provided him with instruction to not leave the premises. Also put facility phone number into his phone in case he has any issues outside or while off the unit. Resident will return to the unit anywhere from 30-90 minutes. This writer will check on resident often. Review of Resident R1's clinical record revealed a social service progress note dated 7/30/24, at 10:07 a.m. that stated the following: Spoke with resident and advised him to refrain from asking staff or residents for cigarettes and to please stay on the resident floors and not to be going through employee breakroom to go outside. Resident understood and agreed to the rules. During an interview on 7/30/24, at 12:10 p.m. Director of Nursing (DON) stated that Elopement Observations are completed at admission, quarterly as needed. DON stated that she did not want to leave Resident R1 on MIU as he Doesn't have a diagnosis of dementia. DON confirmed that updated Elopement Observation indicated that resident is not at risk for elopement and that the Elopement Observation form does not include a question regarding any history of elopement, and that Resident R1 had a history of elopement per hospital records that were provided to the facility prior to admission. DON stated that Resident R1 has stated that he will not attempt to leave the facility again and that she has staff checking on him every 30 minutes. When DON was asked about any available documentation that Resident R1 is being checked on every 30 minutes, DON confirmed that the facility failed to document that this was being completed. Review of Resident R1's clinical record revealed a physician's order dated 7/30/4, at 12:11 p.m. that Resident R1 is to have one-on-one supervision. During a facility tour on 7/30/24, at 1:10 p.m. Agency was able to walk through the employee breakroom and exit the door that leads to the outdoor employee smoking area and exit into the parking lot without meeting any obstacles. On 7/30/24, at 2:55 p.m., the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for one of 96 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During an interview on 7/30/24 at 4:22 p.m. DON informed State Agency that Resident R1 was outside and refused to come back in the building. During an observation on 7/30/24, at 4:24 p.m. Resident R1 was noted to be sitting outside on a bench with other staff members around him who were trying to get him to come back in the building. Resident R1 stated that he was going to leave because staff told him he couldn't go outside without supervision. Resident stated he was going to leave. When asked where he would go he said I don't know. When asked how he would get there he stated hitchhike. DON strongly encouraging resident to come back in the building. Resident R1 was left outside with supervision. Review of Resident R1's clinical record revealed a nursing progress note dated 7/30/24, at 4:47 p.m. that stated the following: Resident left nursing unit stating that he would like to go home. Resident was escorted off of unit by staff, however, resident does not feel that he needs supervision. Spoke with resident outside on back patio. Resident states he does not need to be here and he is going to go to his home. Reminded resident that his home is not clean at this moment and we do not recommend that he lives in it at this time. Resident states that he has food in the freezer and he feels as though he would be fine in his home. Attempted to re-direct and explain to resident that he is better off to stay in the building but he is insisting to stay outside at this time. Resident remains outside with staff supervision. During an observation on 7/30/24, at 5:05 p.m. Resident R1 was being escorted back in building by staff. Review of Resident R1's clinical record revealed a nursing progress note dated 7/30/24, at 5:58 p.m. that stated the following: Resident requesting to leave AMA early in shift, RN (registered nurse) aware. DON aware, Resident packed belongings and stated that he was leaving. Resident one on one (supervision) at this time. Nurse aide sitting with and trying to calm resident. Resident came back up to bedroom and is not exit seeking at this time. On 7/30/24, at 6:43 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: Possible elopement was identified on 7/20/24, at approximately 9:22 a.m., when Resident R1 was observed leaving the facility with his belongings. Code [NAME] was called, and property was searched. 911 was called, as well as doctor and Resident R1 s responsible party. Staff conducted search of local streets and located Resident R1 who agreed to return to the facility. Resident R1 returned to the facility approximately seven minutes after reported elopement and was assessed for injuries and found to be in stable condition. New Elopement Assessment was conducted for Resident R1. Resident R1's care plan updated to include one on one supervision until otherwise assessed or discharged Resident R1 was assessed to determine what will make him more comfortable and update plan of care accordingly. Residents: All other residents were assessed to determine if they had a desire to discharge outside of their planned timeline completed on 7/20/24. System Correction: Review of Elopement policy by Medical Director, DON and NHA. Elopement Risk Tool will be updated to include the question about history of elopement. All residents will be evaluated for their elopement risk using this updated tool. All residents will be evaluated for behaviors of packing, desire to leave, or exit seeking, and their care plans will be updated accordingly based on identified risk. In person staff education started 7/30/24, which included any updates made to the elopement policy and on follow-up required when a resident has behaviors of packing, desire to leave, or exit seeking. Education was completed in person if staff was on duty or via telephone. Monitoring: Nursing documents were audited for behaviors of packing desire to leave, or exit seeking immediately, then weekly for four weeks, and monthly for two months. Results will be reported to Quality Assurance and Process Improvement Committee for tracking and trending. Review of Resident R1's clinical record revealed a nursing progress note dated 7/30/24, at 7:02 p.m. that stated the following: Resident taken outside by CNA. Writer sitting with resident in smoking area and resident stood up and started walking towards the road stating that he is just going to hitchhike and is not waiting any longer. RN called and came to assist. Review of Resident R1's clinical record revealed a nursing progress note dated 7/30/24, at 11:00 p.m. that stated the following: Resident at the beginning of the shift was so worried and wanted to get out of the building to go home. Resident packed off all his stuff and took the elevator to the first floor before heading toward the exit door down stair. Several attempts made in trying to make Resident see a reason for staying in the facility for a while for arrangement to be made for him to get home in a safe comfortable environment. DON and other staff member where call in to intervened. Resident still persisted going home on his own. At that point resident was then placed on one on one supervision. Resident later changed his decision to go home and came back to the floor, accompanied by the aide. Resident had his dinner and later went outside accompany by a staff member; while sitting outside with staff resident decided to start walking towards the main road stating he was ready to go home. Staff members followed resident right to the main road in so doing staff called this writer on Resident intention to leave. This writer rushed to see resident with another staff. DON was present at the scene trying to ensure resident was safe and encouraged to return to the building. Resident finally agreed returning to the facility as such walked back into the building but promised leaving the next day. Resident still a one on one and currently in bed sleeping at this time. During an interview on 7/31/24, at 9:56 a.m. RN Employee E9 stated that Resident R1 has expressed the desire to leave the facility before and added I wasn't here yesterday when he was freaking out. During an interview on 7/31/24, at 11:19 a.m. Nurse Aide (NA) Employee E10 stated that she was working the day that Resident R1 eloped on 7/20/24. That was a scary day when he went out. I was collecting trays after breakfast and they called a Code [NAME] (facility code for alerting staff of a missing resident). Another resident told me she saw him packing his bags the night before. It's scary out on the road, and with the train tracks. It's dangerous. During an interview on 7/31/24, at 11:25 a.m. RN Employee E2 stated that Resident R1 has been expressing desire to leave prior to the elopement. RN Employee E2 stated that Resident R1 is so impulsive and expects everything quickly and that this appears to be what he expects for discharge. RN Employee E2 stated that Resident R1 Was a challenge from the beginning. His goal was to go to a facility with his wife, but wife doesn't want him. It's been quite a journey. It's gotten worse since admission (statements of wanting to leave the facility). He was smoking and saying things like 'I'm in a prison' He doesn't have a plan on where to go, he just wants to leave. When SA stated that it was explained that Resident R1 had stated that he would not attempt to leave the facility again, RN Employee E2 stated He said he wasn't a smoker before too, but had cigarettes and was trying to smoke outside. During an interview on 7/31/24, at 11:34 a.m. NA Employee E5 stated that she was assigned to Resident R1 for one on one supervision. We played cards today. NA Employee E5 stated that Resident R1 is still expressing desire to go home, and that he has always stated that since admission, but it Got worse after the doctor told him he couldn't leave yet. During an interview on 8/1/24, at 9:43 a.m. NA Employee E11 stated that Resident R1 Seems like he is competent for a while and then he gets a little out there [TRUNCATED]

Based on facility policy review, clinical record review, facility documents, and staff interview, it was determined that the facility failed to implement effective safety measures by not providing hot beverages in a manner that promotes safety for one of four residents reviewed (Resident R1), which resulted in actual harm of a second degree burn (involving the epidermis and dermis layers of the skin that is red blistered swollen and painful). This was identified as harm for past non-compliance for one resident (Resident R1). Findings include: Review of the facility policy Accidents and Supervision last reviewed in January 2023, indicated the facility will implement measures for residents at risk for accidents to prevent serious injury when possible. A review of the facility policy, Hot Beverage Temperature, dated 7/23/22, indicated the facility will provide hot beverages to residents in a manner that promotes safety and meal satisfaction. Hot beverage temperatures should be taken prior to being served. Hot beverage temperatures will be taken prior to exiting the kitchen for service. Hot beverage temperature will not exceed 150 degrees Fahrenheit at the point of service. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included heart failure, anemia (low red blood cells), and anxiety. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/7/23, indicated that Resident R1 is alert and oriented and can feed self. A review of a nurse progress note dated 3/10/23, indicated resident R1 spilled hot coffee on herself. Resident R1 stated It was the hottest coffee I had here, it's always lukewarm when I get it. Right upper thigh was noted to have redness and blistering. Cold compress applied and the physician was notified. A review of an incident report dated 3/10/23, indicated Resident R1 was attempting to drink her coffee and spilled it all over her lap. Redness and blistering were noted to right upper thigh. Injury type observed at the time of the incident was a burn to the front right thigh. A review of facility witnesse statements dated 3/10/23, indicated the following: Laundry Aide (LA) Employee E4 indicated I was delivering personal clothes to Resident R1, and she showed me the burn on her right thigh and the nurse was notified. Resident R1 indicated she was holding the coffee cup and it was hot. She tried to remove the lid and it spilled on her leg. Dietary Cook Employee E5 indicated The nurse called for a late tray on 3/10/23. I prepared the tray, including the coffee. I did not temp the coffee. A review of a nurse progress note dated 3/14/23, indicated Resident R1 had generalized discomfort to the area. A review of a physician progress note dated 3/16/23, indicated right thigh 2nd degree burn, blister and pus. Levaquin (antibiotic) started. A review of a service report dated 3/14/23, indicated the coffee machine in the kitchen was set at 196 degrees Fahrenheit. During an interview on 3/21/23 at 11:20 a.m., Dietary Cook Employee E5 revealed I got the coffee from the coffee machine in the kitchen. I did not temp it and delivered the tray to the nursing unit. Someone else usually temps the hot beverages on the tray line before they leave the kitchen, so I just did not think to do it. I made a mistake. A review of Dietary Cook Employee E5's transcript dated 5/23/22, indicated they received education on safe food handling techniques. During an interview and observation on 3/21/23 at 1:00 p.m., with Licensed Practical Nurse (LPN) wound nurse Employee E6, revealed Resident R1 stated I got my coffee, and I could see it was steaming and the cup was hot. I tried to take the lid off and accidently spilled it in my lap. It was so painful at first, and it still hurts at night when I am trying to sleep. Resident R1's right thigh was noted to have a healing burn site measuring approximately 10 cm (centimeters) x 2 cm, dry and scabbed over, no signs of infection. LPN Employee E6 confirmed the above interview and observation. During an interview on 3/21/23, at 3:00 p.m. the Regional Director of Performance Improvement Employee E1 confirmed that the facility failed to implement effective safety measures by not providing hot beverages in a manner that promotes safety for Resident R1, which resulted in actual harm of a second-degree burn. This deficiency is cited as past non-compliance. The facility provided documentation of the in-service training that was provided to the dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, at the facility on 3/13, 3/14, and 3/15/23, which addressed following the facility policy and procedures for safely serving hot beverages. The facility reviewed like residents for non-compliance with hot beverages and meal service on 3/10/23 and audited all residents' meals for accuracy 3/10/23 through 3/14/23 and determined substantial compliance on 3/13/23. Facility audits continue weekly. A review of a Service Report dated 3/14/23, indicated the kitchen coffee machine was turned down from 196 to 186 degrees Fahrenheit. Facility dietary policy and procedure for Hot Beverage Temperatures was updated 3/13/23. New temperature logs require dietary staff to temp hot beverages at the time of dispensing and before service and verify the temperature does not exceed 150 degrees Fahrenheit. A review of the temperature logs dated 3/13 through 3/21/23, indicated hot beverages were served at the required temperatures. A review of the QA (Quality Assurance) documentation dated 3/14/23, indicated substantial compliance for serving hot beverages has been achieved 3/13/23, and is ongoing. During interviews with dietary staff on 3/21/23 from 1:00 p.m. through 1:45 p.m. revealed Dietary Director Employee E8, Assistant Dietary Director Employee E10, Dietary Aide Employees E7, E11, and Dietary Cook Employees E9, and E5 confirmed they received in-service training and understood proper procedure for serving hot beverages. During an interview on 3/21/23, at 4:00 p.m. the Regional Director of Performance Improvement and Regional Director of Clinical Support Services, and review of the facility's immediate actions, education, and review of the QA monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided hot beverages in a manner that promotes safety. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1) Management. 28 Pa Code: 211.10 (c)(d) Resident care policies. 28 Pa Code: 211.11 Resident care plan.

Based on review of facility policy, clinical records, incident reports and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing hot beverages in a manner that promotes safety for one of four residents reviewed (Resident R1), which resulted in actual harm of a second degree burn (partial thickness involving the epidermis and dermis layers of the skin that is red blistered swollen and painful) that required treatment. This was identified as harm for past non-compliance for one resident (Resident R1). Findings include: A review of the facility's policy, Abuse, dated October 2022, indicated that the resident has the right to be free from neglect. A review of the facility's policy, Hot Beverage Temperature, dated 7/23/22, indicated the facility will provide hot beverages to residents in a manner that promotes safety and meal satisfaction. Hot beverage temperatures should be taken prior to being served. Hot beverage temperatures will be taken prior to exiting the kitchen for service. Hot beverage temperatures will not exceed 150 degrees Fahrenheit at the point of service. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included heart failure, anemia (low red blood cells), and anxiety. A review of the Minimum Data Set (MDS = periodic assessment of care needs) dated 3/7/23, indicated that Resident R1 is alert and oriented and can feed self. A review of a nurse progress note dated 3/10/23, indicated resident R1 spilled hot coffee on herself. Resident R1 stated It was the hottest coffee I had here, it's always lukewarm when I get it. Right upper thigh was noted to have redness and blistering. Cold compress applied and the physician was notified. A review of an incident report dated 3/10/23, indicated Resident R1 was attempting to drink her coffee and spilled it all over her lap. Redness and blistering were noted to right upper thigh. Injury type observed at the time of the incident was a burn to the front right thigh. A review of facility witnesse statements dated 3/10/23, indicated the following: Laundry Aide (LA) Employee E4 indicated I was delivering personal clothes to Resident R1 and she showed me the burn on her right thigh and the nurse was notified. Resident R1 indicated she was holding the coffee cup and it was hot. She tried to remove the lid and it spilled on her leg. Dietary Cook Employee E5 indicated The nurse called for a late tray on 3/10/23. I prepared the tray, including the coffee. I did not temp the coffee. A review of a nurse progress note dated 3/14/23, indicated Resident R1 had generalized discomfort to the area. A review of a physician progress note dated 3/16/23, indicated right thigh 2nd degree burn, blister and pus. Levaquin (antibiotic) started. A review of a service report dated 3/14/23, indicated the coffee machine in the kitchen was set at 196 degrees Fahrenheit. During an interview on 3/21/23 at 11:20 a.m., Dietary Cook Employee E5 revealed I got the coffee from the coffee machine in the kitchen. I did not temp it and sent the tray to the nursing unit. Someone else usually temps the hot beverages on the tray line before they leave the kitchen, so I just did not think to do it. I made a mistake. A review of Dietary Cook Employee E5's transcript dated 5/23/22, indicated they received education on safe food handling techniques and abuse/neglect. During an interview and observation on 3/21/23 at 1:00 p.m., with Licensed Practical Nurse (LPN) wound nurse Employee E6, revealed Resident R1 stated I got my coffee, and I could see it was steaming and the cup was hot. I tried to take the lid off and accidently spilled it in my lap. It was so painful at first, and it still hurts at night when I am trying to sleep. Resident R1's right thigh was noted to have a healing burn site measuring approximately 10 cm (centimeters) x 2 cm, dry and scabbed over, no signs of infection. LPN Employee E6 confirmed the above interview and observation. A review of a facility Investigation Report submitted on 3/15/23, indicated neglect was substantiated for Resident R1 on 3/10/23. During an interview on 3/21/23, at 3:00 p.m. the Regional Director of Performance Improvement Employee E1 confirmed that the facility failed to ensure that residents were free from neglect by not providing hot beverages in a manner that promotes safety for Resident R1 resulting in a second-degree burn. This deficiency is cited as past non-compliance. The facility provided documentation of the in-service training that was provided to the dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, at the facility on 3/13, 3/14, and 3/15/23, which addressed following the facility policy and procedures for serving hot beverages and abuse/neglect. The facility reviewed like residents for non-compliance with hot beverages and meal service on 3/10/23 and audited all residents' meals for accuracy 3/10/23 through 3/14/23 and determined substantial compliance on 3/13/23. Facility audits continue weekly. A review of a Service Report dated 3/14/23, indicated the kitchen coffee machine was turned down from 196 to 186 degrees Fahrenheit. Facility dietary policy and procedure for Hot Beverage Temperatures was updated 3/13/23. A review of new temperature logs require dietary staff to temp hot beverages at the time of dispensing and before service and verify the temperature does not exceed 150 degrees Fahrenheit. A review of the temperature logs dated 3/13/23 through 3/21/23, indicated hot beverages were served at the required temperatures. A review of the QA (Quality Assurance) documentation dated 3/14/23, indicated substantial compliance for serving hot beverages has been achieved 3/13/23, and is ongoing. During interviews with dietary staff on 3/21/23 from 1:00 p.m. through 1:45 p.m. revealed Dietary Director Employee E8, Assistant Dietary Director Employee E10, Dietary Aide Employees E7, E11, and Dietary Cook Employees E9, and E5 confirmed they received in-service training on neglect to include service beverages at proper temperatures to prevent burns. During an interview on 3/21/23, at 4:00 p.m. the Regional Director of Performance Improvement and Regional Director of Clinical Support Services, and review of the facility's immediate actions, education, and review of the QA monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are free from neglect by provided hot beverages at proper temperatures to prevent burns. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to provide adequate supervision for the transfer needs for two of 6 residents (Resident R1 and R2), and utilize a mechanical lift with two staff as required, to promote resident safety resulting in harm for Resident R1. Findings include: The facility policy Lift Policy dated 1/18/21, indicated the facility will utilize a lift program to protect residents and employees from injuries during lifting and transferring. If the transfer is a full body lift, two staff members are required for transfer. A review of the resident face sheet indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking, [CONDITION(S)], [CONDITION(S)]. A review of a physician order dated 4/21/21, indicated transfer status full body mechanical lift. A review of Resident R1's care plan revised 8/25/21, indicated transfer status is full body mechanical lift. A review of a nurse progress note dated 10/25/21, indicated sent to ER (emergency room ) due to cut leg. A review of a nurse progress note dated 10/26/21, indicated nursing assistant (NA) states that during transfer resident sustained a skin tear to leg. Outer left calf area open area noted about 6 inches long. Resident states that leg is hurting when moved. Sent to ED (emergency department) for treatment. A review of the Emergency Evaluation Final Report form dated 10/25/21, indicated laceration to left leg through the subcutaneous (below the skin) tissue to the fascia (connective tissue that provides internal structure) minimal adipose (fat tissue) and continuous skin tear 4 cm with laceration. Laceration repair 2 sutures. A review of an incident report and witness statements, dated 10/26/21, indicated NA Employee E1 transferred Resident R1 from the wheelchair to the bed, using the Hoyer Lift (full body mechanical lift) without assistance. During an interview on 11/4/21, at 3:00 p.m. NA Employee E1 confirmed they transferred Resident R1 on 10/25/21, using the mechanical lift without assistance, was aware needed two persons, and staff was available to assist. Stated, I was impatient and did not want to wait for another person to assist. If another person was there, they may have seen the resident's leg moving too close to the wheelchair. During an interview on 11/4/21, at 1:35 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision for the transfer, and utilize a mechanical lift with two staff as required, to promote resident safety for Resident R1's transfer needs which resulted in a left leg laceration. A review of the resident face sheet indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included dementia and [CONDITION(S)] (neurological disease that causes muscle tremors). A review of a physician order dated 9/14/21, indicated transfer status minimal assist of two. A review of Resident R2's care plan revised 9/28/21, indicated transfer status minimal assist of two. A review of a nurse progress note dated 10/8/21, indicated Resident R2 had a 20 x 24 cm (centimeter) bruise to the left thigh/knee area. A review of an incident report dated 10/8/21, indicated Resident R2 had a large bruise to the back of the left leg that measured 20 x 24 cm. A review of a nurse progress note dated 10/14/21, indicated the origin of the bruise was investigated and found to be caused when the resident was lowered to the floor on 10/2/21. A review of an incident report and witness statements, dated 10/2/21, indicated NA Employee E2 was attempting to transfer Resident R2 into her chair without assistance. The resident's knees buckled, and the resident was lowered to the floor. Large bruise to back of left leg. During an interview on 11/4/21, at 4:30 p.m. the DON confirmed the facility failed to provide adequate supervision for the transfer needs for Resident R2. 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to make certain that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (laceration to left leg) for two of five residents reviewed (Resident R1) and failed to provide adequate supervision for the transfer needs for Resident R2. Findings include: A review of the facility policy Abuse dated 1/18/21, indicated the facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the implementation of screening, training, prevention, identification, investigation, protection, and reporting. A review of the facility policy Lift Policy dated 1/18/21, indicated the facility will utilize a lift program to protect residents and employees from injuries during lifting and transferring. If the transfer is full body or sit to stand (mechanical lift), two staff members are required for transfer. A review of the resident face sheet indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS (Minimum Data Set - resident care assessment screening) dated 8/13/21, indicated the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a physician order dated 4/21/21, indicated transfer status full body mechanical lift. A review of Resident R1's care plan revised 8/25/21, indicated transfer status is full body mechanical lift. A review of a nurse progress note dated 10/25/21, indicated sent to ER (emergency room ) due to cut leg. A review of a nurse progress note dated 10/26/21, indicated nursing assistant (NA) states that during transfer resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident states that leg is hurting when moved. Sent to ED (emergency department) for treatment. A review of the Emergency Evaluation Final Report form dated 10/25/21, indicated laceration to left leg through the subcutaneous (below the skin) tissue to the fascia (connective tissue that provides internal structure) minimal adipose (fat tissue) and continuous skin tear 4 cm with laceration. Laceration repair 2 sutures. A review of an incident report and witness statements, dated 10/26/21, indicated NA Employee E1 transferred Resident R1 from the wheelchair to the bed, using the Hoyer Lift (full body mechanical lift) without assistance. During an interview on 11/4/21, at 3:00 p.m. NA Employee E1 confirmed they transferred Resident R1 on 10/25/21, using the mechanical lift without assistance, was aware needed two persons, and staff was available to assist. Stated, I was impatient and did not want to wait for another person to assist. If another person was there, they may have seen the resident's leg moving too close to the wheelchair. During an interview on 11/4/21, at 1:35 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that a resident was free from neglect by not providing the necessary services for Resident R1's transfer needs which resulted in actual physical harm (laceration to left leg). A review of the resident face sheet indicated Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 9/14/21, indicated transfer status minimal assist of two. A review of Resident R2's care plan revised 9/28/21, indicated transfer status minimal assist of two. A review of a nurse progress note dated 10/8/21, indicated Resident R2 had a 20 x 24 cm (centimeter) bruise to the left thigh/knee area. A review of an incident report dated 10/8/21, indicated Resident R2 had a large bruise to the back of the left leg that measured 20 x 24 cm. A review of a nurse progress note dated 10/14/21, indicated the origin of the bruise was investigated and found to be caused when the resident was lowered to the floor on 10/2/21. A review of an incident report and witness statements, dated 10/2/21, indicated NA Employee E2 was attempting to transfer Resident R2 into her chair without assistance. The resident's knees buckled, and the resident was lowered to the floor. Large bruise to back of left leg. During an interview on 11/4/21, at 4:30 p.m. the DON confirmed the facility failed to provide adequate supervision for the transfer needs for Resident R2. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services 28 Pa Code 211.12(d)(3) Nursing services.

Based on review of facility policies, clinical records, incident and accident reports, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent a fall, resulting in death for one of eight residents reviewed (Resident R1). Findings include: The facility policy entitled, Fall Guidelines, dated [DATE], indicated that the resident will be assessed to determine the risk for falls, the staff will implement resident specific interventions to reduce the risk of falls and there will be an ongoing review of the interventions to re-evaluate for effectiveness. Review of the Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated [DATE], indicated that Resident R1 had [DIAGNOSES REDACTED]. chronic disease causing narrowed airway passages). The [DATE], MDS also indicated that Resident R1 had no cognitive impairment, no communication problems and required the extensive assistance of one person for transfer and toileting. Review of the physician's orders [REDACTED]. Review of a nursing progress note dated [DATE], indicated that Resident R1 was able to use the call bell when necessary and would transfer herself to the bathroom at times. Review of a fall risk assessment dated [DATE], indicated that Resident R1 was a high risk for falls due to an unsteady gait, visual disturbances, seizure disorder and bladder dysfunction (urinary incontinence) and interventions included supervising the resident during toileting. Review of the plan of care dated [DATE], indicated that Resident R1 had a problem of potential falls and injury, and interventions included that the staff were not to leave the resident in the bathroom unattended. Review of the information dated [DATE], submitted by the facility indicated that Resident R1 was transferred to the hospital after a fall in the bathroom at 12:45 a.m. The report indicated that the nurse aide was outside of the bathroom when the resident began to fall and was unable to reach the resident to prevent the fall. The [DATE], information indicated that Resident R1 sustained facial lacerations and was transferred to the hospital for evaluation and treatment. Review of a facility Incident/Accident Report dated [DATE], at 2:45 a.m. indicated that Resident R1 was found on the bathroom floor after falling when Employee E1, a Nurse Aide (NA), called for assistance. The [DATE], Incident/Accident Report indicated that Employee E1 was turning off the bed alarm (an alarm that sounds when the resident is no longer in the bed) on the resident's bed while Resident R1 was pulling her pants down to go to the bathroom. Resident R1 had bleeding from a facial laceration, bruising to the left shoulder and was complaining of left sided head pain. Review of the hospital physician's history and physical report dated [DATE], indicated that Resident R1 was admitted to the hospital with [REDACTED]. Review of the hospital physician's death summary report indicated that Resident R1 had expired on [DATE], due to respiratory failure secondary to an unstable cervical spine fracture and a subdural hematoma. Review of a county Medical Examiner report dated [DATE], at 7:57 a.m. indicated that the cause of Resident R1's death was blunt force trauma to the head. During an interview on [DATE], at 11:50 a.m. the Director of Nursing (DON) indicated the physician's orders [REDACTED]. During an interview on [DATE], at 12:30 p.m. Restorative Nursing Program (RNP) Nurse, Employee E2, stated that Resident R1's physician's orders [REDACTED]. Employee E2 stated that if the resident desired privacy the staff must be close enough to the doorway to prevent a fall. During an interview on [DATE], at 3:20 p.m. Nurse Aide, Employee E1, confirmed that he had gone to turn off the bed alarm and was unable to reach Resident R1 in time to prevent her fall. Employee E1 stated that he was not aware of the order to not leave the resident in the bathroom at that time, but confirmed that he did have access to the computerized care plans for all resident care needs and interventions. The facility failed to assure the implementation of the physician ordered supervision, resulting in a fall with injury, a traumatic subdural hematoma, an unstable cervical spine fracture, multiple facial fractures and a left scapular fracture and the resident's subsequent death from respiratory failure secondary to an unstable cervical spine fracture and a subdural hematoma. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited [DATE]. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE].