Every finding on record at Hcc At White Horse Village

Based on facility policy and procedure review, observations and staff interview it was determined the facility failed to store food in sanitary manner in the kitchen. Findings include: Review of facility policy (unnamed and undated) regarding food storage, revealed that all food items stored in the refrigerator or freezer should be covered, labeled, dated, and discarded once expired, or beyond their use by date. Observation of facility main kitchen walk-in refrigerator #1 on [DATE], at 1:00 pm revealed one container of expired lime juice that was opened without a date of first use and three unopened expired containers of lime juice. All were expired and dated for [DATE]. Observation of facility main kitchen walk-in refrigerator #1 revealed a case of liquid egg cartons that were dated illegibly. These eggs were inside of a case that was dated for [DATE], Nursing Home Administrator and Employee E3 confirmed that the carton of eggs was illegible and discarded at the time of the findings. Observation of facility main kitchen walk-in freezer #1 on [DATE], at 1:15 p.m. revealed a box with a bag of unsealed frozen salmon. Observation on [DATE], at 1:15 pm in the presence of Nursing Home Administrator, Employee E3, and Employe E4 all confirmed the noted expiration dates and Employee E3 discarded these items. Interview with Employee E3 on [DATE] @ 1:30 pm revealed that the expired case of liquid eggs had recently arrived from the distributer and the case was opened and dated at the facility on [DATE]. Interview with the Nursing Home Administrator on [DATE] @ 11:00 a.m. confirmed that all food in the freezers and refrigerators were to be sealed, labeled appropriately, and dated and discarded once expired. 28 Pa. Code 211.6(f) Dietary services

Based on clinical records review and staff interview, it was determined the facility failed to follow the physician's order regarding medication for one of the 12 residents reviewed (Resident 44) Findings include: Review of Resident 44's clinical record including diagnosis list includes Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period). Review of Resident 44's clinical record including physician order dated June 20, 2023, revealed an order of Novolog (fast-acting insulin) Flex Pen U-100 Inulin administered seven units subcutaneously (Insertion of medication beneath the skin by injection) with meals. Hold if blood sugar is below 180 mg/dl. Review of Resident 44's clinical record including January 2024, Medication Administration Record (MAR) revealed from January 1, 2024, until January 31, 2024, Novolog insulin was administered to the resident on the following days out of parameter: January 9, 2024, at 8:00 a.m., (BS-134 mg/dl); January 13, 2024, at 8:00 a.m., (BS-140 mg/dl); January 15, 2024, at 8:00 a.m., (BS-97 mg/dl); January 16, 2024, at 8:00 a.m., (BS- 124 mg/dl); January 18, 2024, at 8:00 a.m., (BS- 143 mg/dl); January 22, 2024, at 8:00 a.m., (BS- 108 mg/dl); January 22, 2024, at 12 noon, (BS- 165 mg/dl); January 23, 2024, at 8:00 a.m., (BS- 90 mg/dl); January 23, 2024, at 12 noon, (BS- 90 mg/dl); January 24, 2024, at 8:00 a.m., (108 mg/dl); January 25, 2024, at 8:00 a.m., (BS- 153 mg/dl); January 27, 2024, at 8:00 a.m., (BS- 102 mg/dl); January 28, 2024, at 8:00 a.m., (BS- 129 mg/dl); January 29, 2024, at 4:00 p.m., (BS- 125 mg/dl). Review of February 2024 MAR revealed that from February 1, 2024, until February 22, 2024, Novolog insulin was administered to the resident on the following days out of parameter: February 1, 2024, at 8:00 a.m., (BS- 143 mg/dl); February 2, 2024, at 8:00 a.m., (BS- 171 mg/dl); February 3, 2024, at 8:00 a.m., (BS- 172 mg/dl); February 7, 2024, at 8:00 a.m., (BS- 124 mg/dl); February 7, 2024, at noon, (BS- 156 mg/dl); and February 19, 2024, at 4:00 p.m., (BS-139 mg/dl). Review of Resident 44's clinical record revealed Resident 44 was administered Novolog Insulin outside of parameter 14 times in January 2024, and six times in February 2024. The above information was conveyed to the Director of Nursing on February 23, 2024, at 11:00 a.m. The facility failed to ensure Resident 44's insulin parameters order was followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical records review and staff interview, it was determined that the facility failed to timely follow a wound treatment recommended by the physician for one of the four residents reviewed (Resident 38). Findings include: Review of Resident 38's clinical record revealed Resident 38 had Stage three (Thickness skin loss) to the sacrum (tail bone) with a wound treatment of Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), cover with foam dressing daily. Review of Resident 38's clinical record revealed a wound consult dated December 22, 2023, revealed a new wound treatment recommendation to cleanse the sacrum with normal saline, and apply Santyl (A topical medication used for removing damaged or burned skin to allow for wound healing and growth of healthy skin) to the base of the wound then secure with a bordered foam daily and as needed. Review of Resident 38's December 2023, Treatment Administration Record (TAR) revealed that the Medihoney treatment was discontinued on December 22, 2023. A review of the same TAR revealed that the Santyl treatment recommended by the wound NP (Nurse Practitioner) on December 22, 2023, was not implemented until December 27, 2023, five days after the wound treatment was recommended. Interview with licensed nurse Employee E3 on February 23, 2024, at 10:00 a.m., revealed the Nurse Practitioner's wound treatment recommendation to discontinue previous treatment of Medihoney was followed on December 22, 2023, but the recommendation to start new treatment of Santyl to the resident sacrum was missed until the error was discovered on December 27, 2023, five days after the wound treatment order was initiated. Employee E3 reported that the staff applied skin barrier cream to the resident Stage 3 sacrum. The facility failed to ensure wound care treatment for resident 38's stage three sacral wound was followed. 28 Pa. Code 211.5(f) Clinical 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 ensure that proper infection control practices were followed during wound care for one of one resident reviewed (Resident 10). Findings include: Observations on April 14, 2022, at 9:50 a.m. revealed that Registered Nurse, Employee E3 changed a dressing to a wound on Resident 10's sacrum. The nurse applied gloves, removed soiled dressing, washed hands and changed gloves, cleaned the wound with normal saline, applied medi-honey and applied a new dressing. Observations of the wound dressing process revealed the Registered Nurse Employee E3 did not change her gloves or wash her hands after cleaning the wound with the normal saline solution. Interview with Registered Nurse Supervisor, Employee E3 on April 14, 2022, at 10:15 a.m. confirmed she should have changed gloves and washed hands after cleaning the wound with normal saline solution and before applying the new dressing. 42 CFR 483.80(1)(2)(4)(e)(f) Infection Prevention and Control. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and appropriate indication provided before the administration of as-needed (PRN) anti-anxiety medication for one of 12 residents reviewed (Resident 25). Findings include: Review of the facility's policy titled [CONDITION(S)] Medication Usage/Review Program Approved Signature last reviewed August 12, 2014; revealed [CONDITION(S)] medications will only be used for the treatment of appropriate medical symptoms and their continued usage will be monitored on an ongoing basis. The same policy revealed that before administration of PRN medication, the nursing staff will document the non-pharmacological interventions on the Medication Administration Record (MAR) and will note their effectiveness in addressing target symptoms. Review of Resident 25's diagnosis list revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety disorder, and Major Depressive Disorder. Review of Resident 25's physician order (POS) revealed an order made on March 31, 2022, for [MEDICATION(S)] 0.5 mg (miligram) tablet daily with a discontinue date of April 6, 2022. The POS also revealed an order of [MEDICATION(S)] 0.5 mg every eight hours as needed for diagnosis of Anxiety disorder with start date of March 31, 2022, and April 6, 2022. Review of Resident 25's April 2022 MAR revealed, the as-needed [MEDICATION(S)] medicatrion was administered 11 times without providing a non pharmacological interventions and with a documented PRN reason of Anxiety, Behavior Issue, and Other from April 1-13, 2022. Interview with licensed Employee E4 and Director of Nursing (DON) on April 14, 2022, at 1:00 p.m., confirmed that Resident 25 was administered a PRN [MEDICATION(S)] without the appropriate indication, and non-pharmacological interventions were not provided before the administration of the medication. The facility failed to ensure non-pharmacological interventions were consistently attempted and documented appropriate indication provided before the administration of as-needed (PRN) [MEDICATION(S)] medication to Resident 25. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/26/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 3/26/21

Based on clinical records review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan regarding the depressive behavior of one of the twelve residents reviewed (Resident 25). Findings include: Review of Resident 25's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated April 6, 2022, revealed resident had severe cognitive impairment. Review of Resident 25's nursing progress notes dated April 2, 2022, at 7:45 a.m., revealed resident wanders to another resident's room with the use of an assistive device. Review of Resident 25's nursing progress notes dated April 6, 2022, at 6:49 a.m., revealed that during the night, the resident was very confused wandering in the hallway, verbalizing death stated wanting to die, talking about guns and knives, provided with snacks, as needed [MEDICATION(S)] (medication to treat anxiety) was given. Review of the Nurse Practitioner's (NP) notes dated April 6, 2022, revealed resident was awake all night, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 25's current care plan failed to reveal a plan of care developed for Resident's depressive behavior, verbalizing death, guns, knives, and wanting to die. Interview with the Director of Nursing on April 14, 2022, at 1:00 p.m., confirmed that the facility failed to develop a comprehensive care plan regarding Resident 25's depressive behavior, verbalizing death, guns, and knives. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/26/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 3/26/21

Based on review of facility policy, resident and staff interviews, observations, and clinical record review, it was determined that the facility failed to assess, monitor, and address weight loss in five of five residents reviewed. (Residents 9, 12, 27, 28, and 33). Findings include: Review of facility policy, Weight/Height Policy, last reviewed January 15, 2019, revealed: If there is > 5 lbs (5 pounds) weight variance from previous weight for residents that weigh > 101 pounds or a > 3 lbs (3 pounds) weight variance from previous weight for residents that weigh < 100 lbs a reweigh must be taken within 72 hours. If the weight is verified, nursing will immediately notify the Dietitian via email .The Dietitian will respond within 72 hours of receipt of written notification or via documentation in the [Electronic Medical Record.] Interview with Resident 9 on March 23, 2021, at 10:15 a.m. revealed that the resident had recent weight loss. Review of Resident 9's weights revealed the resident weighed 125.8 lbs on February 3, 2021. Further review of Resident 9's weights revealed the resident weighed 113.6 lbs on March 17, 2021, a difference of 12.2 lbs. Further review of Resident 9's weights failed to reveal a reweight taken within 72 hours of March 17, 2021. Review of Resident 9's progress notes revealed a nurse's note on March 17, 2021, which stated that the resident's practitioner was made aware of the weight loss, and no new orders were obtained. Interview with the Dietitian on March 24, 2021, at 2:45 p.m. revealed nursing notified the Dietitian of Resident 9's weight loss, and the Dietitian requested a reweight. Further interview with the Dietitian at 2:57 p.m. confirmed that the facility failed to obtain a reweight within 72 hours of March 17, 2021. Further review of Resident 9's progress notes revealed a note from the Dietitian on March 24, 2021, at 4:05 p.m., which stated, visited resident on 3/22/2021, regarding possible weight loss. Awaiting reweight to check the accuracy of the weight loss . [Resident 9] is currently down 9.6% x 1 month pending confirmation of accuracy of reweight. Review of Resident 9's weights on March 26, 2021, revealed that a reweight had not yet been obtained. Review of Resident 12's weights revealed that on January 2, 2021, the resident weighed 97 lbs. Further review of Resident 12's weights revealed that on February 7, 2021, the resident weighed 90.8 lbs, which is a -6.39% loss in one month. Further review of Resident 12's weights revealed the resident was not weighed again until March 2, 2021, one month later, and the resident's weight was 86.6 lbs, which is an additional 4.63% loss in on month. Further review of clinical documentation failed to reveal any weights obtained after March 2, 2021. Further review of clinical documentation failed to reveal the dietician or physician was notified of weight loss. Interview with the Dietitian on March 24, 2021, at 2:49 p.m. revealed the Dietitian was unsure if he was aware of Resident 12's weight loss. The Dietitian stated, that name sounds familiar. A review of Resident 27's vital sign record revealed that the resident weighed 141.6 pounds on February 23, 2021. On March 9, 2021, the resident weighed 122.6 pounds, and 121.4 pounds on March 10, 2021, a 13.42 % significant weight loss in 15 days. A review of the physician's progress notes dated February 25, 2021 at 8:19 a.m. revealed that the resident had left arm [CONDITION(S)] (A condition caused by a blockage in the lymphatic system), venous stasis (Pooling of blood in the veins), and chronic [CONDITION(S)]. A review of the same notes revealed 1+ pitting [CONDITION(S)] to the left foot and ankle. A review of the progress notes dated February 24, 2021, at 9:38 p.m. revealed resident refused to eat dinner. Clinical records review failed to reveal that the dietitian was notified of the resident's significant weight loss. An interview with licensed Employee E5 on March 26, 2021, at 12:00 p.m. revealed that she/he attempted to notify the dietitian regarding the resident's change in appetite but was informed by the staff in the dining department that the Dietitian was on leave and that the message will be forwarded to the interim dietitian. Employee E5 stated that she/he does not know the name of the dining staff. A review of the physician's progress notes dated March 11, 2021, at 8:34 a.m. revealed that the resident was declining and losing weight for the past weeks. A review of the same note revealed 1+ pitting [CONDITION(S)] to the left foot and ankle. The physician had reviewed to the resident and family regarding palliative and hospice, continued to decline hospitalization . Clinical records review failed to reveal that Resident 27 was assessed by the dietitian upon identifying a significant weight loss. A meal observation on March 23, 2021, at 12:40 p.m. revealed Resident 28 ate lunch post tray set up from the staff, consumed 50% of the meal served. An interview with Resident 28 on March 23, 2021, at 12:45 p.m. revealed that her/his appetite was not good due to feeling weak and due to the presence of a brace on her/his neck. A review of Resident 28's vital sign record revealed an admission weight of 157 pounds on February 7, 2021. On March 2, 2021, Resident 28's weight was 137.8, a 12.23% significant weight loss in one month. Clinical records review failed to reveal that the dietitian was notified of Resident R28's significant weight loss. An interview with the dietitian on March 24, 2021, at 2:40 p.m. was conducted. The dietitian stated that he/she was not aware that Resident R28 had a significant weight loss. An interview with the physician on March 25, 2021, at 10:00 a.m. revealed that she/he was not aware that Resident R28 had a 20 pounds weight loss from admission but would not be surprising due to the resident's medical condition. A dietary consult was ordered on March 25, 2021. Clinical records review failed to reveal that Resident R28's significant weight loss was addressed by the facility until March 25, 2021. Review of Resident 33's weights revealed that on February 2, 2021, the resident weighed 137 lbs. Further review of Resident 33's weights revealed that on March 2, 2021, the resident weighed 126.2 lbs, which is a -7.88 % loss in one month. Further review of Resident 33's weights revealed the resident was not weighed again until March 9, 2021, one week later, and the resident's weight was 127.6 lbs. Resident 33 was again weighed a week later on March 16, 2021, weighing 127.4 lbs. Resident 33 was again weighed a week later on March 23, 2021, weighing 125.2 lbs. Interview with the Dietitian on March 24, 2021, at 2:44 p.m. revealed the Dietitian was not aware of Resident 33's weight loss. The Dietitian stated that he just read the policy and that nursing should have reweighed Resident 33 within 72 hours of the March 2, 2021, weight and if the weight was verified, the Dietitian should have then been contacted within 72 hours. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical records review, and staff interview, it was determined that the facility failed to follow a physician's order for a speech evaluation timely for one of 12 residents reviewed (Resident R27). Findings include: A review of Resident R27's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Physician's order dated February 9, 2021, revealed a standing order for PT (Physical Therapy)/OT (Occupational Therapy)/ST (Speech Therapy) eval (evaluate) and treat. A review of the Physician's order dated February 9, 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident R27's progress notes dated February 24, 2021, at 9:38 p.m. revealed that Resident R27 did not want to eat dinner, did not take [MEDICATION(S)] (A vitamin for the eye), could not swallow. The physician made aware; referral made to speech. A review of Resident R27's progress notes dated March 1, 2021, at 12:04 p.m. revealed: resident coughing while taking pills MD is aware and order ST if coughing continues resident noted with occasional cough NS (Nursing Supervisor) make aware and to order ST per MD. A review of Resident R27's progress note dated March 3, 2021, revealed resident had a non-productive cough, rhonchi (Abnormal lung sound) auscultated to both lungs, Pulse Oximeter (A device that measures how much oxygen blood carries in comparison to its full capacity) 90-91% (Normal range: 95-100%) on room air sitting, and difficulty swallowing medications. The physician was made aware, a new order of chest x-ray, the responsible party was made aware. A review of the Chest x-ray results dated March 3, 2021, at 3:08 p.m. revealed: There are infiltrates (The filling of airspaces with fluid) noted in the right upper lobe. Left lower lobe infiltrate is also seen. Conclusion: Persistent right upper lobe infiltrates, left lower lobe to infiltrate. Recommend CT-Scan (A computerized tomography that combines data from several X-rays to produce a detailed image of structures inside the body) to exclude underlying neoplasm (a type of abnormal and excessive growth of tissue). A review of Resident R27's Physician's Order revealed an order made on March 3, 2021, for ST eval and treatment. An interview with Rehab Director Employee E4 on March 24, 2021, at 1:00 p.m. was conducted and revealed that when rehab referral is needed, a form must be filled up and send to the therapist. The therapist would then see the resident and document the findings. Employee E revealed that the rehab department did not receive a referral form from nursing until March 3, 2021. The resident was seen on March 3, 2021, and was placed on ST caseload on March 8, 2021. Clinical records review failed to reveal that a speech therapist had seen and evaluated the resident from the time a change in swallowing status was identified on February 24, 2021, until March 2, 2021. Clinical records review also failed to reveal that nursing had communicated with the rehab department regarding the delay in ST evaluation of the resident. A review of Resident R27's Physician order dated March 8, 2021, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Diet downgrade to mechanical soft (A food that does not require a lot of chewing) and continue with thin liquids. An interview with the Physician on March 26, 2021, at 10:00 a.m. revealed that she was not aware of the resident's initial complaint of difficulty swallowing the pills, the physician stated that the facility might have called the on-call physician. During the interview, the physician was not sure of exact dates but stated that a chest x-ray was ordered when the resident had a respiratory symptom. The physician confirmed that Resident R27 had an infiltrate on both lungs but unable to confirm if it was from aspiration. The physician also stated that the resident's abnormal chest x-ray could be due to a progressing cancer but the family had refused further tests to confirm the diagnosis. The resident was placed on antibiotics for lung infiltrates. The above was conveyed to the Director of Nursing on March 26, 2021, at 11:00 a.m. The facility failed to follow a physician's order for a Speech evaluation for Resident R27 timely. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on a review of clinical records, resident and staff interview, it was determined that the facility failed to accurately complete a resident assessment for one of 13 residents reviewed (Resident #8). Findings include: Review of Resident #8's [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set assessment (MDS assessment of resident care needs) dated (MONTH) 27, 2019, identified the resident as cognitively intact. Further review of the MDS assessment revealed under Section P title Restraints coded the resident as a 2 (indicated that it was used daily). Review of physician order [REDACTED]. Review of nursing progress note dated (MONTH) 26, 2019, revealed, Side rail use reviewed with resident and resident's daughter. Resident is requesting to keep both of his upper rails as he uses them for repositioning in the bed related to his [MEDICAL CONDITION]. He can safely demonstrate use. Consent obtained. Interview with Resident #8 on (MONTH) 16, 2019 at approximately 10:00 a.m., revealed that both siderails were used only at night to help him reposition self in bed. Furthermore, Resident #8 reported that the bed rails did not interfere with his movement in bed. Interview with Registered Nurse Assessment Coordinator (RNAC) Employee E2 on (MONTH) 16, 2019 at approximately 2:53 p.m., confirmed that side rails used daily as a physical restraint was incorrectly coded in quarterly MDS dated (MONTH) 27, 2019. 28 Pa Code 201.18(b)(1) Management Previously cited 3/26/18 28 Pa Code 211.5(f) Clinical records Previously cited 3/26/18 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 3/26/18

Based on observation, review of manufacturer's guidelines and clinical record review, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of five residents reviewed (Resident #23). Findings include: Review of manufacturer's guidelines for [MEDICATION NAME] Extended Release tablets revealed that the medication should be swallowed whole and not chewed or crushed. Review of manufacturer's guidelines for Potassium Chloride ER tablets revealed that the medication is to be swallowed whole without crushing, chewing or sucking the tablets. Review of Resident #23's (MONTH) (YEAR) and (MONTH) (YEAR) physician orders [REDACTED]. Review of Resident #23's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation of a medication pass administration on (MONTH) 23, (YEAR) at 8:31 a.m. revealed Licensed Employee E3 prepare medication for administration to Resident #23. During the preparation of the medications, Licensed Employee E3 crushed one tablet of Potassium Chloride ER and one and one-half tablets of [MEDICATION NAME] ER and administered them to Resident #23. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 26, (YEAR) at approximately 2:00 p.m. confirmed that the above medications were received by Resident #23 during (MONTH) (YEAR) and (MONTH) (YEAR) and should not have been crushed prior to administration. The facility failed to administered the medications Potassium Chloride ER and [MEDICATION NAME] ER to Resident #23 in accordance with manufacture's directions which resulted in significant medication error. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/10/17 28 Pa. Code 211.9(a)(1) Pharmacy Services

Based on review of facility policy and procedure, clinical record review and review of documentation provided by the facility, it was determined the facility failed to implement their policy and procedure for abuse/neglect for one of 23 residents reviewed (Resident #12). Findings include: Review of facility policy and procedure entitled Abuse, Neglect, Misappropriation of Property, Reasonable Suspicion of a Crime, revised (MONTH) (YEAR) revealed Should abuse, neglect, exploitation or misappropriation of property be witnessed or alleged, the facility will promptly and thoroughly investigate all reports. Review of Resident #12's [DIAGNOSES REDACTED]. Review of Resident #12's (MONTH) 15, (YEAR) clinical record revealed a notification to nursing staff from the resident's companion that the resident had bruise left eye and skin tear on right knee. Nurse notified supervisor. Review of documentation provided by the facility dated (MONTH) 15, (YEAR) revealed left eye bruise, right knee skin tear; right wrist and right forearm bruise. (Resident #12) could not fully explain how bruise and skin tear happened. Further review of documentation provided by the facility revealed that a (MONTH) 15, (YEAR) caregiver statement was missing from the documentation and further revealed that no written statement was obtained from the original caregiver who reported the bruises and skin tears. Review of Resident #12's (MONTH) 5, (YEAR) clinical record revealed ecchymosis (bruising) noted to top of left hand. Light purple in color. Slight [MEDICAL CONDITION]. Review of documentation provided by the facility dated (MONTH) 5, (YEAR) revealed bruise 8 cm (centimeters) x 7 cm. Further review of documentation provided by the facility revealed that four caregivers provided care to Resident #12 during the previous two shifts, however, only one statement from one caregiver was provided. Three statements for three caregivers remained blank. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 26, (YEAR) at approximately 1:45 p.m. confirmed that the facility failed to implement their policy and procedure for abuse/neglect for two injuries of unknown origin. The facility failed to implement their policy and procedure for abuse/neglect for two injuries of unknown origin. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 4/10/17 28 Pa. Code 201.14(c) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 4/10/17 28 Pa. Code 201.29(a)(c)(d) Resident Rights 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 4/10/17

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one of 23 residents reviewed ( Resident #26) Findings include: Review of Resident #26's clinical record revealed an admitted (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. of joint cartilage and underlying bone). Review of Resident #26's clinical record revealed a physician's orders [REDACTED]. Review of Resident #26's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed scheduled times that collar should be worn with noted staff signatures. Observation of Resident #26 on (MONTH) 23, (YEAR) from 8:00 a.m. to 10:00a.m. 11:00 a.m. to 12:00 p.m. and on (MONTH) 26, (YEAR) between 8:15 a.m. to approximately 10:30 a.m. revealed that the resident was not wearing the soft collar. Review of Resident R26's current comprehensive care plan failed to address usage of soft cervical collar along with interventions. The aforementioned findings were reported to and confirmed with the Administrator and Director of Nursing on (MONTH) 26, (YEAR) at approximately 2:15 p.m. The facility failed to ensure that the care plan was developed, reviewed, revised and/or implemented for Resident #26. 28 Pa. Code 211.5 (f) Clinical records 28 Pa Code 211.11 (a)(d) Resident care plan 28 Pa Code 211.12 (c)(d)(3) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure initial comprehensive physician visits were completed in a timely manner for one of 23 residents reviewed (Resident #8). Findings include: Review of Resident #8's clinical record revealed that the resident was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #8's clinical record revealed an admitted (MONTH) 26, (YEAR). Review of Resident #8's physician's progress notes revealed that Resident #8's physician completed a comprehensive physician visit on (MONTH) 18, (YEAR), 53 days after Resident #8 was initially admitted to the facility. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 26, (YEAR) at approximately 2:00 p.m. confirmed that Resident #8 did not receive an initial comprehensive physician visit until (MONTH) 18, (YEAR). 28 Pa. Code 211.2(a) Physician Services Previously cited 4/10/17

Based on observation, review of manufacturer's guidelines and clinical record review, it was determined that the facility failed to correctly administer medications to a resident and failed ensure that residents were free from a medication error rate of five percent or greater for one of five residents reviewed (Resident #23) resulting in a medication error rate of 6.67 percent. Findings include: Review of manufacturer's guidelines for [MEDICATION NAME] Extended Release tablets revealed that the medication should be swallowed whole and not chewed or crushed. Review of manufacturer's guidelines for Potassium Chloride ER tablets revealed that the medication is to be swallowed whole without crushing, chewing or sucking the tablets. Review of Resident #23's [DIAGNOSES REDACTED].), and constipation. Review of Resident #23's (MONTH) (YEAR) physician orders [REDACTED]. Observation of a medication pass administration on (MONTH) 23, (YEAR) at 8:31 a.m. revealed licensed nurse, Employee E3 prepare medication for administration to Resident #23. During the preparation of the medications, licensed nurse. Employee E3 crushed one tablet of Potassium Chloride ER and one and one-half tablets of [MEDICATION NAME] ER and administered them to Resident #23. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 26, (YEAR) at approximately 2:00 p.m. confirmed that the above medications should not have been crushed prior to administration to Resident #23. 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/10/17

Based on facility policy and procedure, clinical record reviews, staff interviews, it was determined that the facility failed to ensure that the attending physician maintained physician's orders and completed required progress notes for three of 14 residents reviewed (Residents B2, B7 and C14). Findings include: Review of policy, Telephone/Verbal Orders, no date approved or reviewed, indicated that it is the policy of the facility to accept verbal/telephone orders from each resident's attending physician or certified registered nurse practitioner. Procedure step 5 indicated that telephone orders must be counter signed by the physician within 48 hours for medications and seven days for treatments, of receiving the verbal order. Review of policy, Physician Services, dates reviewed April 2, 2012 and November 11, 2016 and date approved January 19, 2017, indicated that the attending physician would be responsible for the medical evaluation of the resident and would prescribe a planned regimen of total resident care. Physicians would provide quality medical care and comply with state and federal regulations regarding physician services, visits and documentation requirements. The six objectives of the physician services were to: admit to facility and provide orders for the resident's immediate care and needs; provide each resident with quality medical care; develop a medical treatment plan; provide routinely scheduled physician visits to each resident; provide emergency physician services as may be required and monitor resident care and to make changes as necessary. Physician services are under the general supervision of the facility's Medical Director. Review of Resident B2's clinical record revealed that the resident was admitted to the facility on [DATE] from the hospital. The resident was seen by the physician in the emergency room . Resident B2's clinical record revealed no documented progress notes by the attending physician, Employee E5 completed for two additional 30 day visits (for the first 90 days after admission) in December 2016 and January 2017 or any subsequent visits through April 1, 2017. Progress notes in the record were completed by the nurse practitioner. Review of Resident B7's clinical record failed to reveal any completed progress notes by the resident's attending physician, Employee E4 indicating a visit from May 2016 through March 10, 2017. Progress notes for this period were completed by the nurse practitioner. Review of Resident C14's clinical record revealed that C14 was admitted to facility July 6, 2015 under the care of physician, Employee E4. Review of Resident C14's clinical record revealed no documented evidence that the attending physician, Employee E4, had completed the required progress reports or signed the monthly medication and treatment orders for dates reviewed October 2016 through December 2016. The resident only received medical care regarding physician services and visits as documented by the certified registered nurse practitioner, Employee E6 for dates reviewed October 2016 through December 2016. Interview with the facility's Medical Director, on April 7, 2017 at 11:45 a.m. confirmed for the survey team that all residents receive physician care from two physicians, Employees E4 and E5; and one nurse practitioner, Employee E6. Medical Director confirmed that he became aware this date, April 7, 2017, that physicians Employees E4 and E5 were not writing their progress reports but were having the nurse practitioner, Employee E6 write their progress reports and complete physician orders and that this was a communication error. Interview with Administrator and Director of Nursing, on April 10, 2017 at approximately 2:15 p.m. confirmed these findings regarding Residents B2, B7 and C14. The facility failed to ensure that residents were being visited by the attending physician for directing and monitoring the resident's health and care program in the areas of progress reports and authorization of medication and treatment orders regularly and in accordance with facility policy for Residents B2, B7 and C14. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 3/31/2016 28 Pa. Code 201.18(b)(1) Management Previously cited 3/31/2016 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.2(a)(b) Physician services 28 Pa. Code 211.5(f) Clinical records Previously cited 3/31/2016 28 Pa. Code 211.5(h) Clinical records Previously cited 3/31/2016

Based on facility policy and procedure, clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were seen timely by the attending physician for six of 14 residents reviewed (Residents B2, B7, B 3, B15, and C14,D5). Findings include: Review of policy, Physician Services, dates reviewed April 2, 2012 and November 11, 2016 and date approved January 19, 2017, indicated that the attending physician would be responsible for the medical evaluation of the resident and would prescribe a planned regimen of total resident care. Physicians would provide quality medical care and comply with state and federal regulations regarding physician services and visits. The six objectives of the physician services were to: admit to facility and provide orders for the resident's immediate care and needs; provide each resident with quality medical care; develop a medical treatment plan; provide routinely scheduled physician visits to each resident; provide emergency physician services as may be required and monitor resident care and to make changes as necessary. Physician services are under the general supervision of the facility's Medical Director. Finally, Physician Visits indicated that the resident must be seen by a physician at least every 30 days or more often as the resident's condition warrants for the first 90 days after admission, and at least once every 60 days thereafter. At the option of the physician, required visits may alternate between personal visits by the physician and visits by a physician assistant or nurse practitioner. Review of Resident B2's clinical record revealed that the resident was admitted to the facility on [DATE] from the hospital. The resident was seen by the physician in the emergency roiagnom on that date. Resident B2's clinical record revealed no documented evidence that the attending physician, Employee E5 completed the two additional 30 day visits (for the first 90 days after admission) in December 2016 and January 2017. Further review of the resident's record revealed that only the nurse practitioner provided visits to the resident from admission through April 1, 2017. Review of Resident B7's clinical record failed to reveal that the resident had been visited by the physician, Employee E4 from May 2016 through March 10, 2017. The resident was only examined by the nurse pratitioner during this time. These findings were confirmed by the Nursing Home Administrator on April 10, 2017 at 2:00 p.m. Review of Resident C14's clinical record revealed that C14 was admitted to facility July 6, 2015 under the care of physician, Employee E4. Review of Resident C14's clinical record revealed no documented evidence that the attending physician, Employee E4, had completed the required physician visits for dates reviewed October 2016 through December 2016 and the resident was only visited by the certified registered nurse practitioner, Employee E6. Review of Resident B3 ' s clinical record revealed that the resident ' s physician, Employee E5, completed a visit and progress note on October 14, 2016. There were no further physician ' s visits. The resident only received visits from a certified nurse practitioner from November 1, 2016 through April 1, 2017. This was confirmed by the Director of Nursing and the Administrator on April 7, 2017, at approximately 1:20 p.m. Review of Resident B15 ' s clinical record revealed that the resident ' s physician, Employee E4, completed a visit and progress note on September 24, 2016. Resident B15 was not seen again by their physician, Employee E5 till March 25, 2017, a period of six months. The resident only received visits from a certified nurse practitioner from October 16, 2016 through March 18, 2017. This was confirmed by the Director of Nursing on April 7, 2017, at approximately 1:20 p.m. Review of Resident D5's clinical record failed to reveal that the resident had been visited by the physician, Employee E4 from May 2016 through March 2017, a period of six months. The resident was only examined by the nurse pratitioner during this time. These findings were confirmed by the Nursing Home Administrator on April 7, 2017 at 12:00 p.m. Interview with Administrator and Director of Nursing, on April 10, 2017 at approximately 2:15 p.m. confirmed these findings regarding Residents B2, B3, B7, B15, and C14. The facility failed to ensure that the physician was visiting residents regularly in accordance with facility policy to hands on examination and direct and monitor the residents health and care program. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 3/31/2016 28 Pa. Code 201.18(b)(1) Management Previously cited 3/31/2016 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.2(a)(b) Physician services 28 Pa. Code 211.5(f) Clinical records Previously cited 3/31/2016 28 Pa. Code 211.5(h) Clinical records Previously cited 3/31/2016

Based on facility policy; facility documentation; resident and staff interviews, it was determined that the facility failed to offer evening snacks to four of 14 residents reviewed (Residents B3; C7; C8 and D8). Findings include: The Evening Snacks, policy dated January 10, 2017 indicated that all residents must be offered snacks at bedtime daily unless otherwise specified in a resident's plan of care. Procedures for nursing staff indicated that nursing would offer bedtime snacks to all residents and that the acceptance or refusal of evening snacks would be recorded. During a group resident interview, conducted on April 6, 2017 at 11:00 a.m., in which six residents participated, Residents B3; C7; C8 and D8 indicated that they were never offered an evening or bedtime snack. Interview with the Administrator and the Director of Nursing, on April 6, 2017 at approximately 2:45 p.m. revealed that resident physician orders [REDACTED]. Review of Residents B3; C6; C7 and D8's medication administration records, accompanied by the Administrator and Director of Nursing, on April 7, 2017 at approximately 2:45 p.m. confirmed that they could not confirm for the following months: February 2017; March 2017 and April 2017, that bedtime snacks were offered to these residents. 28 Pa. Code 211.12(d)(3)(5) Nursing Services Previously cited 3/31/2016

Based on clinical record review, facility policy and procedure review and staff interview, it was determined the facility failed to monitor and control pain, and failed to notify the physician timely of the ineffectiveness of a pain medication and delay in acquiring a radiography study for one of 20 residents reviewed. (Resident B11) Findings Include: Review of facility policy and procedure titled, Pain Management Program, reviewed on February 13, 2016, revealed the staff is to administer medication according to pain intensity and physician order, assess for breakthrough and unrelieved pain, and notify the physician if pain is not relieved and implement a revised plan of care. Review of Resident B11's progress notes revealed a nursing entry on January 26, 2017 at 4:26 p.m. stating the resident was found on the floor by a housekeeper at 10:40 a.m. and the resident was complaining of pain to the left elbow. The Certified Registered Nurse Practitioner (CRNP) was notified and the resident was ordered to have an x-ray of the left elbow. Further review of Resident B11's progress notes revealed a nursing entry on January 27, 2017 at 3:35 a.m. that the facility received a physician order [REDACTED]. Further review of Resident B11's progress notes revealed a nursing entry on January 27, 2017 at stating that the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Review of the entire clinical record revealed there was no documented evidence that the x-ray ordered by the CRNP on January 26, 2016 was completed. Interview with the Director of Nursing on April 10, 2017 at 1:00 p.m. revealed that when the x-ray company was called with the order for the x-ray they were notified that there would be a delay in the service due to being busy and unable to do it timely. Review of the entire clinical record revealed there was no evidence that the CRNP had been notified of the inability of the x-ray company in obtaining the x-ray study timely resulting in a delay of treatment. Further review of Resident B11's physician orders [REDACTED]. Review of the resident Medication Administration Record (MAR) for January 2017 revealed the resident received the medication on January 26, 2017 at 5:43 p.m. for a pain level of 3 out of 10. Further review of Resident B11's MAR revealed the resident was assessed on January 26, 2017 at 7:43 p.m. as having no relief from the pain medication. Review of Resident B11's progress notes revealed a nursing entry on January 27, 2017 at 3:35 a.m. stating the resident complained of increased pain to the left elbow when her sweater was removed during pm care and the physician was notified on January 26, 2017 at 9:10 p.m. Interview with the Director of Nursing on April 10, 2017 at 1:00 p.m. revealed that the resident should have been assessed for the effectiveness of the as needed Tylenol administration one hour after administration and not two hours as was documented on the MAR. Further interview with the Director of Nursing revealed that the physician should have been notified at the time it was determined that the as needed Tylenol was ineffective at relieving the resident's pain so that another intervention could be put into place to relieve the residents pain. 28 PA Code 211.5(f) Clinical records Previously cited 3/31/2016, 9/22/16 28 PA Code 211.10(c) Resident care policies Previously cited 3/31/2016, 9/22/16 28 PA Code 211.11(d) Resident care plan Previously cited 3/31/2016, 9/22/16 28 PA Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 3/31/2016, 9/22/16

Based on clinical record review and staff interview, it was determined that the facility failed to develop a plan of care addressing an identified need for one out of 11 residents reviewed. (Resident A6) Findings include: Review of the current physician orders [REDACTED]. Review Resident A6's [DIAGNOSES REDACTED]. Review of the resident's care plan did not reveal any plan developed to direct staff in providing care to the resident receiving this medication and possible side effects or complications that should be observed for and reported to the nurse and physician. The Director of Nursing confirmed on September 22, 2016 at 10:00 a.m. that a care plan should have been developed for the administration of [MEDICATION NAME] for Resident A6. F279 483.20(k) Comprehensive Care Plans Previously cited 4/10/2015, 3/31/2016 28 PA Code 211.5(f) Clinical records Previously cited 4/10/2015, 3/31/2016 28 PA Code 211.10(c) Resident care policies Previously cited 4/10/2015, 6/12/2015. 3/31/2016 28 PA Code 211.11(d) Resident care plan Previously cited 4/10/2015, 6/12/2015. 3/31/2016 28 PA Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 4/10/2015, 6/12/2015. 3/31/2016

Based on Facility clinical documentation review and staff interview, it was determined the facility failed to follow physician orders [REDACTED]. Findings Include: Review of Resident D2 ' s [DIAGNOSES REDACTED]. Review of Resident D2 ' s August 2016 physician's orders [REDACTED]. (laxative) as needed if Bisocodyl was not effective in two hours. Review of Resident D2 ' s August 2016 bowel movement documentation revealed that on August 28, 2016 the resident had not had a bowel movement in two days. Review of resident D2 ' s Medication Administration Record [REDACTED] ineffective. On August 29, 2016 at 10:38 p.m., the resident was again administered Milk of Magnesia. On August 30, 2016 at 12:38 a.m., the Milk of Magnesia was documented as ineffective. On August 30, 2016 at 7:20 p.m., the resident was again administered Milk of Magnesia. At 9:20 p.m. that same evening, the Milk of Magnesia was documented as effective. Per physician orders, if no bowel movement occurred in six hours after taking Milk of Magnesia, the Bisocodyl suppository should have been administered on August 29, at 4:43 a.m. There were no bowel movements documented for Resident D2 on August 29, 2016. Interview with the Director of Nursing on September 21, 2016 at 11:15 a.m. confirmed that the physician's order [REDACTED]. Review of Resident C8 ' s August 2016 [DIAGNOSES REDACTED]. Review of resident C8 ' s physician orders [REDACTED]. Review of Resident C8 ' s June 2016 bowel movement documentation revealed that on June 12, 2016, the resident had not had a bowel movement in two days. Review of Resident C8 ' s Medication Administration Record [REDACTED] Not Effective at 7:15 a.m. Review of Resident C8 ' s clinical notes revealed a nurse ' s note written on June 14, 2016 at 12:19 a.m. stating resident with no BM (bowel movement) in 12 shifts. Review of Resident C8 ' s June 2016 bowel movement documentation confirmed that the resident did not have a bowel movement during 4 days period. Review of Resident C8 ' s June 2016 Medication Administration Record [REDACTED] effective. Per physician's order [REDACTED]. The Bisocodyl suppository was not given until June 14, 2016 at 3:00 p.m. Review of Resident C8 ' s September 2016 bowel movement documentation revealed that on September 9, 2016, the resident had not had a bowel movement in two days. Review of Resident C8 ' s September 2016 Medication Administration Record [REDACTED] Not Effective at 9:39 p.m. Per physician's order [REDACTED]. There was no documented evidence in the September 2016 Medication Administration Record [REDACTED]. Interview with the Director of Nursing on September 22, 2016 at 12:00 p.m. confirmed that the physician's order [REDACTED]. Review of Resident A10's [DIAGNOSES REDACTED]. The certified registered nurse practitioner ordered on May 2, 2016 that the resident was to be on a fluid restriction of 1500 cubic centimeters daily. This was to treat chronic [MEDICAL CONDITION], a decreased concentration of sodium in the blood. The facility was unable to provide documentation that revealed the amount of fluid taken daily to assure compliance with the physician's orders [REDACTED]. [REDACTED]. F309 483.25 Provide Care /Services for Highest Well Being Previously cited 6/12/2015, 4/10/2016, 3/31/2106 28 PA Code 211.5(f) Clinical records Previously cited 4/10/2015, 3/31/2016 28 PA Code 211.10(c) Resident care policies Previously cited 4/10/2015, 6/12/2015. 3/31/2016 28 PA Code 211.11(d) Resident care plan Previously cited 4/10/2015, 6/12/2015. 3/31/2016 28 PA Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 4/10/2015, 6/12/2015. 3/31/2016

Based on observation, review of clinical record, review of facility policies and procedure and staff interview it was determined that the facility failed to ensure care and services were in place for two residents with pressure ulcers of four residents with pressure ulcers (Residents A13 and A14). Findings include: Review of facility's policy for " Pressure Ulcer Prevention " revised June 23, 2014 revealed its goal to provide care to residents in order to prevent pressure ulcers from occurring. It revealed all new admissions/readmissions will receive a comprehensive skin assessment that includes the use of the Braden Scale for predicting pressure ulcer risk and a complete body audit. It revealed the dietician will be notified of residents with Braden Scale less than 13. A pressure ulcer preventive plan will be developed and residents will be checked daily for changes in skin condition during morning and evening care. The CNA (certified nursing assistant) will notify the nurse of any changes in skin condition. Review of the facility ' s policy titled " Pressure Ulcer Documentation " revised June 6, 2014 revealed its policy to have a flow sheet (wound skin assessment tracking record) for documentation of pressure ulcer to enable the wound nurse and interdisciplinary team to evaluate the status of wounds/pressure ulcers. It revealed an initial wound assessment form would be started as soon as a wound is identified by the charge nurse. The charge nurse will document the appearance and description of the wound on the Weekly Wound assessment Form. It indicated each wound will be measured weekly in centimeters. The length, width and depth as well as the presence or absence of drainage, the odor, the color and a short statement of effectiveness of treatment will be documented by the charge nurse. Review of Resident A14's admission record revealed that the resident was admitted into the facility on [DATE] and had no pressure ulcer on admission. Review of the resident's admission orders [REDACTED]. Review of the resident's Braden Scale (a tool for predicting pressure ulcer risk) score on admission, November 17, 2014 revealed a score of 16. Score of 15 to 18 indicates a mild risk for developing pressure ulcers. Review of Resident A14's Admission Minimum Data Set (MDS - an assessment of resident care needs and status) dated November 26, 2014 revealed that the resident was alert and oriented and depended on staff for bed mobility, transfer and activities of daily living. Review of Resident A14 ' s wound assessment sheet dated November 26, 2014 revealed that the resident developed a Deep Tissue injury to the left heel measured 4centimeters (cm) x 6.5 cm and treatment included to apply skin prep to the left heel every shift and to off load heels while in bed. Review of the resident's treatment administration record (TAR) for November, December, 2014 and January 2015 revealed no documentation that the resident's back was off loaded and the resident was turned every 2 hours as ordered. Review of Resident A14 ' s weekly wound assessment sheet dated December 31, 2014 revealed that the left heel wound continued to be described as a deep tissue injury, dark purple, dry, measured 3cm x 6 cm, periwound ( skin surrounding the wound) healthy and treatment included to apply skin prep to the left heel every shift and continue to off load pressure. Review of Resident A14 ' s wound specialist documentation dated December 31, 2014 revealed a recommendation for Multipodus boot (used for heel protection) to left heel at all times. physician's orders [REDACTED]. (ordered five days after recommended by wound specialist). Review of the resident's treatment administration record (TAR) for January, 2015 revealed that staff applied heel boots only while the resident was in bed and not at all times as indicated in the wound specialist's recommendation and as ordered by the physician. Review of Resident A14 ' s weekly wound assessment sheet dated January 21, 2015 revealed that and surrounding tissue measuring 6cm x 4cm. Resident A14 ' s wound assessment documentation dated February 25, 2015 revealed that debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of the heel wound was done at the wound center. Further review Resident A14 initial right buttocks initial wound assessment dated [DATE] revealed that the resident had an open pressure area in the right buttock fold measuring 1 centimeter (cm) 0.5 cm. Nurses notes dated December 28, 2014 stated right buttocks had no drainage, area cleansed and clean dry dressing applied. Resident A14 ' s nursing notes dated December 29, 2014 revealed another open area identified to the sacrum (large triangular bone at the base of the spine), Stage 3 pressure ulcer ( full thickness skin loss) 2.7cm x0.7 cm x 0.2 centimeters (cm) 90% slough (dead tissue), 10 % granulation and new order obtained. physician's orders [REDACTED]. Review of Resident A14 ' s Braden score dated February 17, 2015 reveals a score of 17 and Braden score on March 19, 2015 was 18, all indicating that the resident continued to be identified as a mild risk for developing pressure ulcers (score of 12 or less indicated high risk of pressure sore development). Resident A14 ' s wound specialist documentation dated February 18, 2015 identified the left heel ulcer smaller, eschar debrided off, and sacral ulcers. The specialist ' s recommendation included to see physician's orders [REDACTED]. Further review of Resident A14 ' s wound assessment sheet dated February 19, 2015 revealed a second sacral (proximal) wound was identified described as a stage III pressure ulcer measured 1.8cm x 0.5 centimeters (cm). Review of weekly wound assessment sheet dated February 25, 2015 revealed that the second sacral wound measured 0.9cm x 0.3 cm x 0.3 cm was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) at the wound center and to see consult. Review of Resident A14 ' s weekly wound assessment sheet dated February 19, 2015 revealed that the resident had developed another open area in the left anterior foot, it was described as a skin tear 4.5cm x 0.3cm x 0.1 centimeters (cm) had serosanguineous (bloody) drainage and the peri wound was described as red. Review of weekly wound assessment sheet dated February 25, 2015 revealed that the wound in the left anterior food was described as a stage III pressure ulcer and measured 1.8cm x 0.4cm x 0.1 centimeters. Review of Resident A14 ' s weekly wound documentation revealed Sacral (distal) wound was 1.0 cm x 0.4cm x 0.5 cm, unable to visualize wound bed. The left heel 1.6 cm x 2.2cm x 0.4 centimeters 100% [MEDICATION NAME]/slough (separation of dead tissue from living tissue) 0.2 centimeters undermining at 12 to 3 o'clock and left dorsal foot 1.2cm x 0.7cm x 0.1 centimeters, 100 % [MEDICATION NAME], peri wound red. Observation on April 10, 2015 at 12:10 p.m. of licensed nurse, Employee 7 confirmed that the resident had pressure ulcers on the left heel, left dorsal foot (anterior ankle) and the Sacrum (proximal). Interview with licensed nurses, Employees E5 and E6 on April 10, 2015 at 2:00 p.m. revealed Resident A14 that the pressure ulcer on the ankle area had developed from pressure from a shoe that the resident wore. Employee E6 also indicated that the resident obtained the heel ulcer because the resident did not always ask for staff help to reposition herself. The facility failed to ensure that care and services were in place to prevent the development of pressure ulcers and to promote healing for Resident A14 who was at mild risk for developing pressure ulcer resulting in actual harm to the resident and the development of a left heel, dorsal foot and sacral pressure ulcers. Review of Resident A13's admission record revealed that the resident was readmitted into the facility on [DATE] post pneumonia hospitalization [DIAGNOSES REDACTED]. Review of initial wound assessment dated [DATE] revealed that the resident had two sacral pressure wounds. Sacral wound #1 measured 1.5cm x 1.5 centimeters, #2 Sacral measured 0.5cm x 0.5 centimeters and #3 buttock pressure ulcer measured 0.5cm x 1.0 centimeters. The description of drainage, odor, wound infection and periwound were documented for the group of wounds but there was no individual description of each of the wounds documented. Review of Resident A13 ' s physician's orders [REDACTED]. Review of readmission notes dated March 16, 2015 stated Resident A13 was readmitted into the facility on [DATE], and included [DIAGNOSES REDACTED]. Review of Resident A13 ' s initial readmission wound assessment documentation dated March 16, 2015 revealed that the resident had four pressure ulcers in the buttock and sacral areas. Buttocks wounds #1 measured 4cm x 3 centimeter (cm), buttocks wound #2 measured 5.5cm x 3cm, sacral wound # 3 measured 1cm x 1.2 cm. and sacral wound # 4 measured 1cm x 2.5 cm. The description of drainage, odor, wound infection and periwound were documented for the group of wounds but there was no individual description of each of the wounds documented. Further review of weekly wound documentation dated March 19, 2014 revealed that wound # 1 was identified as a Stage 3 pressure ulcer (full thickness skin loss) 2 centimeters x 2.25 centimeters with inflamed periwound. Resident A13 ' s physician's orders [REDACTED]. Review of the March, 2015, TAR (treatment administration record revealed the treatment ordered for March 28, 2015 was not documented as done as ordered. Interview with licensed nurses Employees E5 and E6 in the morning on April 10, 2015 revealed that each wound required documentation to include the description of each wound separately. The interview also confirmed that here was no documentation available to indicate that Resident A13 received wound care/treatment to the sacral area bilateral buttocks wounds as ordered by the physician on March 28, 2015. F314 483.15 (c) Pressure sores Previously cited 5/5/14 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 5/5/14 28 Pa. Code: 211.5(f) Clinical record. Previously cited 5/5/14 28 Pa. Code: 211.10(c) Resident care policies. Previously cited 5/5/14. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 5/5/14 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services. Previously cited 5/5/14

Appeal Filed Based on a review of the electronic event reports submitted to the State Survey Agency, review of facility policy and procedures, facility documentation, clinical records review and resident, family and staff interviews, it was determined that the facility failed to ensure the safety for three of four residents reviewed that exited the skilled nursing unit, placing the health and safety of the residents in Immediate Jeopardy (Residents R1, R2, and R4). Findings include: Review of the facility policy and procedure entitled, "Missing Resident," last reviewed on [DATE], indicated that it was the policy of the facility to confirm the presence of all residents and to act responsibly whenever an elopement was suspected for a resident. Procedure Step 3 indicated that the nursing staff were to confirm the presence of all residents during medication administration, meal times and periods throughout the shift. When a resident was determined to be missing or a staff member became aware of a resident not being at a designated area, the staff would notify the nursing supervisor or the charge nurse on duty of this finding. Subsequently, the nursing supervisor and the charge nurse and the general nursing staff would look for the resident in the resident rooms, closets, bathing areas and all common areas in the skilled unit. If the resident was not located in the skilled unit, security staff would then be notified for assistance in searching for the resident in the Clubhouse/Commons areas. If the resident was not located in the Clubhouse/Commons areas, other facility personnel would be alerted and a code yellow alert for the missing resident would be called over the radio. The staff would search the campus grounds. When the resident had been found, the resident would be examined for injuries, the physician would be contacted and all staff would be notified that the resident had been found. Review of the facility policy and procedure entitled, "Guidelines for Identification and Monitoring of Residents at Risk for Elopement," last reviewed [DATE], indicated that all residents were identified for the potential of elopement on admission and when the resident experienced a change in mental or cognitive status or mood/behavior, which resulted in an attempt to leave the facility unaccompanied or a verbalization of leaving, going home, etc. Procedure Step 8 indicated that the care plan team was to update the support plan to include wandering and the specific interventions implemented to keep the resident safe. Review of the Risk Management and Safety Committee Meeting minutes dated [DATE], revealed that the Nursing Home Administrator (NHA) had updated the committee and indicated that since [DATE], there had been a higher number of elopements. The NHA stated in the minutes, "Any resident that leaves the healthcare units and does not inform the unit that they are leaving is considered an elopement. This item will be taken off the safety agenda, but will be monitored." Security noted in the minutes that, "there was an elopement with a fall in April and May from the skilled Canterbury unit." (The facility reported to the State Survey Agency five electronic elopement events during the period of April to May, 2013). Review of Resident R1's demographic information sheet revealed that Resident R1 was admitted to the facility on [DATE], following a gastrointestinal (GI) hemorrhage (bleeding from the GI track) for the aftercare following surgery of the digestive system and diagnosed with [REDACTED]. Review of the admission physician's orders dated [DATE], included feeding thru a Percutaneous Endoscopic Gastrostomy (Peg) tube (a tube that passes into the stomach through the abdominal wall to provide a means of feeding when oral (mouth) intake is not adequate). Review of the resident's admission assessment dated [DATE], included [DIAGNOSES REDACTED]. Review of the 60 day Minimum Data Set Assessment (MDS- an assessment of care and needs) dated [DATE], indicated that Resident R1's ability to hear was adequate and that the resident had no difficulty in listening to television. The activities of daily living assistance and functional status section indicated that the resident required extensive staff assistance for weight bearing support with the physical assist of one person for bathing. Physician's orders, dated [DATE], included for Resident R1 to receive a chopped diet (regular table foods that are chopped into small, bite-size pieces) and to discontinue the feeding through the Peg tube. Physician's orders for [DATE], also included Simethicone (antifoaming agent to reduce bloating/gas) 80 milligrams, take 1 tablet three times a day with meals by mouth. There was also an order dated [DATE], to flush the Peg tube with 60 milliliters of water every shift. Review of the nursing notes dated [DATE], indicated that Resident R1 was seen by the attending physician with a discussion on the Peg tube and going home. The doctor ordered a home safety evaluation. Review of the findings of the Functional Home Evaluation, dated [DATE], revealed the resident, "was not safe to be discharged to home because the resident needed scooter training to return home because the resident was extremely tired with walking from the outpatient area to her apartment and the resident did not want to make adaptations to a scooter." Interview with the Director of Therapy, Employee E15, on [DATE] at 12:00 p.m., confirmed that Resident R1 was not safe to be discharged back to her apartment because Resident R1 required scooter training (a device to assist mobility), endurance training and successful teaching of Peg tube cleansing and flushing. Review of the nursing notes for Resident R1 dated [DATE], ,[DATE] shift, indicated that staff attempted to perform teaching regarding the Peg tube site cleansing and the Peg tube flush; however, Resident R1 refused stating, "There are no orders or arrangements for me to go so why should I do it?" Nursing notes dated [DATE], at 10:00 p.m., indicated that Resident R1, "ambulated in hall with rolling walker gait slow tires easily." Additional nursing note, dated [DATE], (no time noted) and documented by licensed nurse Employee E11 indicated that "resident left unit to visit apartment" (in the independent living section of the complex). A review of an electronic event report submitted to the State Survey Agency reported that Resident R1 left the faciity on [DATE], to go to her apartment at approximately 12:30 p.m.-12:45 p.m., after Resident R1 had a manicure in the beauty shop. Resident R1 was later found dead in the bath tub in her apartment around 7:30 p.m. Resident R1 was further described as alert, oriented and capable of making her own decisions. Upon arrival to the facility on [DATE], at 12:35 p.m., the surveyor requested from licensed nurse, Employee E5, the Resident Sign Out/Sign In Registry book and Employee E5 indicated that this registry was being stored on the counter. The surveyor inquired of Employee E5, if there were any updates to where Resident R1 had gone on the date of the incident ([DATE]), and if the resident had signed out her destination location when the resident initially left the nursing unit. Employee E5 stated, "I guess she went to the Wine and Cheese Event with someone." Review of the facility Resident Sign Out/Sign In Registry book for the dates of Resident R1's stay, [DATE] through [DATE], revealed there was no documentation that the resident had signed the Resident Sign Out/Sign In Registry book. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE], at 12:45 p.m., described Resident R1 as cognitively intact and independent. The NHA and the DON both confirmed: no incident report for elopement was completed for Resident R1 because the resident was independent and this was not considered an elopement; the staff knew where Resident R1 was; and everyone knows Resident R1. The NHA further reported that Resident R1 died of natural causes and the facility did not cause Resident R1's death. The NHA and DON both confirmed that the facility had no formal assessment tool for determining a resident's elopement risk. Elopement risk is based on a resident's current cognitive status, a change in condition or as deemed necessary. During this interview, the NHA confirmed that for those residents assessed to be cognitively intact and independent, the staff would advise the residents to sign themselves off the unit in the Resident Sign Out/Sign In Registry book; however, this request is presented informally to the residents when they inquire about leaving the unit. The NHA and DON both reported, it is not an expectation that everyone is going to sign out because the residents could tell a nurse that they are leaving the unit. During the [DATE], interview with the NHA and DON beginning at 12:45 p.m, the surveyor requested all written witness statements completed by the staff to date related to the incident on [DATE], involving Resident R1 and the facility's investigation reports for any residents who had eloped from the nursing unit since [DATE], and all elopements reported to the State Survey Agency electronically since [DATE]. The NHA revealed that the facility may not have necessarily completed investigations for every resident who eloped off of the nursing unit. The NHA also confirmed during this interview, that the facility had not completed an investigation into Resident R1's death on [DATE], and further explained that the current procedures for missing residents, had not been evaluated for changes as of [DATE] because the NHA stated, "We have been providing emotional support to the staff and wanted to afford a lot of time for the investigation review." The DON indicated that she was reviewing the current procedures for those residents who leave the unit but as of [DATE], had only provided verbal reminders to the staff to check on the residents. The DON confirmed that there was no documented evidence/in-service to remind staff to check on the residents as of [DATE]. Also during this interview with the NHA and the DON, the surveyor asked if there were any further details of the elopement event reported to the State Survey Agency and the subsequent death of Resident R1. The NHA reported that according to the facility's interview with the nursing supervisor, Employee E6, Resident R1 was found in her apartment, lying unclothed in the bathtub, except for a shower cap and bilateral knee high stockings. The NHA related that the nursing supervisor, Employee E6, had reported to administration, stating, "She observed the water in the bathtub was up to her chest, and her head was slumped over, but there was no evidence that Resident R1 had been submerged in the water or that Resident R1's hair was wet." The NHA confirmed that Employee E6 stated, "the water in the bathtub was warm." (No thermometer was used by staff to confirm the temperature of the bath water). Seven witness statements completed by staff (Employees E9, E6, E8, E11, E23, E24 and E17) were provided to the surveyor on [DATE], pertaining to Resident R1's incident on [DATE]. Evening shift licensed nurse Employee E9's witness statement dated [DATE], indicated that Employee E9 received a shift change report at approximately 3:30 p.m. that Resident R1 was at a hairdresser appointment. At 4:45 p.m., licensed nurse Employee E9 went to medicate Resident R1 but Resident R1 was not in her room. Employee E9 notified the nursing supervisor, Employee E6 at approximately 5:00 p.m. Employee E9 checked the Resident Sign Out Book around 5:30 p.m. and Resident R1 had not signed out. At approximately 6:00 p.m., Employee E9 went back to Resident R1's room and Resident R1 was still not back. Employee E6 was notified and asked Employee E9 to call the main dining room to see if the resident was at the weekly Wine and Cheese event. Resident R1 was not in the main dining room. Supervisor notified. In review of the nursing supervisor, Employee E6's, witness statement, dated [DATE], Employee E6 indicated in this statement that Employee E9 reported to this supervisor that Resident R1 had not returned from the Wine and Cheese event or the cafe after dinner. When dinner was over around 7:00 p.m., Employee E6 went to the nursing unit and began looking for the resident in the lobby, library, card room, and auditorium and could not locate Resident R1. Employee E6 further indicated that she went to Resident R1's apartment to see if Resident R1 may have gone there and upon arrival the television volume could be heard in the hallway. Employee E6 documented that she banged on the door and got no answer. After no response to knocking on the door, Employee E6 called security to get an extra key for Resident R1's apartment door. Employee E6 further documented in this statement that the unit clerk, Employee E27, went to the security desk to get the resident's apartment key. Both Employee E6 and Employee E27, entered Resident R1's apartment and found Resident R1 as reported by Employee E6, "She was sitting in tub with chest level very warm water (with stool in water) and knee high nylons on and naked. She also had a shower cap on too. I called my DON to report it. The fire department came and then paramedics right after. The guy from fire department drained the tub and paramedics performed EKG and confirmed she had expired. My unit clerk then went back to skilled brought doctor up (Employee E28), and he pronounced her at 8:21 p.m. The fire department left along with paramedics and the doctor called the medical examiner, within 20 minutes the state police arrived (3) and started asking for information. Ten minutes later the medical examiner arrived and started assessing her and the scene. I assisted the medical examiner and took photos of the tub, he said that the fire department should not have drained tub." An interview on [DATE], at 2:40 p.m., with Employee E6, confirmed that Employee E6 did not implement the code yellow alert for a missing resident because Employee E6 did not consider Resident R1 missing. Witness statement with beautician, Employee E8, confirmed that Resident R1 was scheduled for an 11:45 a.m., manicure on [DATE], and left at approximately 12:30 p.m. The salon operating hours are 9:00 a.m.-3:00 p.m. Interview with Employee E9 on [DATE], at 2:30 p.m., confirmed that she was not aware of the beauty salon's hours of operation. Employee E9 further indicated that residents who are independent, should be telling a licensed staff that they are leaving the unit and are to sign out or "we sign them out" but confirmed that residents are not told to sign in. Employee E9 confirmed that she received orientation regarding the policy and procedure for a missing resident. During the ,[DATE] shift, Employee E9 indicated that she would always see Resident R1 in the chair or in bed because Resident R1 would eat supper in her room. Employee E9 confirmed that she did not perceive Resident R1 as a missing resident and didn't search the nursing unit because the general nursing staff thought she was in the main dining room because Resident R1 always went to the Wine and Cheese Event. An interview with day shift licensed nurse Employee E11, on [DATE], at 4:30 p.m., revealed that on [DATE], Employee E11 worked the ,[DATE] shift and Resident R1 informed her, "told me she was going to nails and then she said she has an appointment to meet somebody at her apartment. She knows to do it (sign out) but doesn't do it. I saw her leaving she didn't tell me she was leaving, I didn't remind her to sign out because I was giving meds to a resident generally residents don't sign out when they leave cause they are independent." Review of Employee E11's witness statement dated [DATE], documented that Resident R1 had not returned to the nursing unit by 3:00 p.m., on [DATE], since last seen at 11:40 a.m. Review of the witness statements for Employees E17 and E24 indicated that they looked for Resident R1 on [DATE], around lunchtime and did not find the resident. Review of the witness statement for Employee E23 related that she saw Resident R1 at the nurses' station around 1:30 p.m., [DATE], "walking in the rollator (device with four wheels and a seat that supports person who needs support with walking) and with a bag of clothes." Interview on [DATE], at 4:00 p.m., with Security Supervisor, Employee E7, reported that on the evening of [DATE], security Employee E25, "was not notified of elopement only a staff nurse asked for a key to her room." Employee E7 also related that, "heard she was found in the bathtub with her stockings up to her knees and that the TV was blaring." Interview on [DATE], at 1:45 p.m., with the Medical Director/attending physician for deceased Resident R1, revealed that the physician had no concerns with Resident R1 being off the nursing unit. The physician stated that, "she is decision capable when off unit it is none of my business what she does." The surveyor inquired of the Medical Director, "When would you would you be concerned for a resident who had left the nursing unit and had not returned?" The Medical Director stated, "Would not have been concerned until bedtime." Review of witness statements dated [DATE], by the independent apartment dwelling Residents R5 and R6 indicated that Resident R1 was not at the Wine and Cheese Event on [DATE] but indicated that routinely Resident R1 would come to this event and eat dinner at our table. During interview with skilled unit Resident R3 on [DATE], at 11:00 a.m., Resident R3 stated, "I don't eat with other residents due to their decline and she didn't like to sit across from them either. I have friends I regularly eat with and she would eat with us. They never know when I'm coming back. When I go to Bridge on Monday nights, I could be there until 10:30 p.m. or 11:00 p.m., and they never search for me." Review of facility policy and procedure entitled, "Code Alert: Resident Security System", last reviewed [DATE], indicated that the residents at risk for elopement from the facility would be monitored through the use of the Code Alert System. Procedure Step 1 indicated that residents would be assessed for potential elopement on admission and ongoing as the resident's condition changes. Procedure Step 2 indicated that the residents identified as elopement risks would wear a wrist bracelet that contained a radio frequency transceiver with an approximate battery life of two years. An escort function (keypad) was available at each protected door to allow a resident wearing a code alert bracelet to exit the protected door without the electromagnetic lock system engaging and alarming. For the escort function to be activated a number code would be entered in the keypad allowing for exit. This system would automatically reactivate after a specific time period (time period not defined in policy). The Code Alert System would be checked every two weeks by the security department to assure it was operating properly and the nursing supervisor would assure that the code alert bracelets were functioning on a weekly basis. Review of Resident R2's [DATE], physician's orders revealed [DIAGNOSES REDACTED]. Review of Resident R2's admission MDS assessment, dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of six which indicated severe impairment in cognition. Review of the electronic event submitted on [DATE], to report an elopement for this resident, revealed that he was sitting in the community clubhouse (outside the skilled unit) area. The NHA and Director of Nursing could not explain during the interview, on [DATE] at 10:00 a.m., if Resident R2's code alert bracelet was on when Resident R2 left the skilled area, as reported in the electronic event submission dated [DATE], or if the alarm did not function or even if Resident R2 had left the skilled area with someone else. Review of Resident R2's nursing note dated [DATE], revealed that the resident leaves the skilled unit without being accompanied and against our requests. Review of the resident's active care plan for fall risk indicated that the resident wanders off the unit frequently. Review of the active care plan for wandering behavior indicated a goal for the resident to exit the unit only with authorized personnel and that a code alert bracelet for wandering was in place for the resident. Review of the Resident Sign Out/Sign In Registry book, revealed that Resident R2's wife signed the resident out of the facility on 26 occasions from [DATE] through [DATE]. During this time, Resident R2's wife registered the resident as having returned to the unit on only five occasions. The log also revealed that for dates [DATE] and [DATE], Resident R2 had signed himself out of the skilled unit; but had not signed himself back in the unit. Interview with Resident R2's daughter-in-law on [DATE], at 11:30 a.m., indicated that it appeared to the daughter-in-law that Resident R2's wife was demonstrating a decline in cognition for the last several months. The daughter-in-law also reported that the facility never informed her that there were incidents when her mother-in-law had left Resident R2 somewhere/anywhere, but again this would not be surprising due to her mother-in-law's cognitive decline. The daughter-in-law further indicated that she had taken Resident R2 out of facility on numerous occasions since his admission, but the staff never advised her to sign Resident R2 out in the Resident Sign Out/Sign In Registry book when leaving the facility. An interview with the NHA and DON on [DATE], at 9:50 a.m., revealed that they were unable to explain why the facility staff would allow Resident R2 to sign off the nursing unit and how would Resident R2 be able to manage to exit through the electromagnetic locking system since Resident R2 was wearing a code alert bracelet. Interview with Employee E7 on [DATE], at 4:00 p.m., reported that a formal complaint needs to be received by security from nursing staff if the electromagnetic locking system does not engage or alarm for those residents with a code alert bracelet. Following a complaint and response by security, a work order is initiated. This response and repair service is a function of the security department and not the maintenance department. If security is unable to identify the cause of the malfunction, the security staff will immediately notify an outside vendor for service and repair. During an interview with Employee E7, the surveyor asked about the code alert's battery life and related that the policy stated that the code alert battery lasts for approximately two years. Employee E7 clarified that the code alert bracelet battery could expire before the two years anticipated expiration date if the wrist bracelet was repeatedly setting off the electromagnetic locking system alarm. Employee E7 confirmed that the entire Code Alert System is checked every two weeks by the security department to assure that the system is operating. Employee E7 also stated that the nursing supervisors check each residents code alert bracelet for function weekly (Wednesday). If the code alert bracelet battery drains after the weekly function check, it would not be noticed until the next week. Surveyor review of the Risk Management and Safety Committee Meeting from [DATE] to [DATE], had no information of a concern regarding the code alert batteries draining sooner than expected as related by security when the committee was discussing elopement concerns. Further interview on [DATE], at 4:00 p.m., with Employee E7 revealed that Resident R2 had a code alert bracelet. Resident R2 was frequently found off of the nursing unit and the alarm did not activate because Resident R2's spouse knew the keypad code. Security director, Employee E7 further related, "this was a safety concern because she (spouse) was confused and lived in the apartments (an apartment dwelling resident) and when she took him off of the skilled unit she would forget that he was her husband and walk away. The most recent incident was about two weeks ago when she left him in the library." When surveyor inquired of Employee E7 as to further clarity on how was it possible for nursing staff to not be aware that Resident R2 was exiting the skilled nursing unit, accompanied by his spouse, without staff being alerted to the code alert sensor alarming. Employee E7 stated, "she knew the code because the code was in a poem which was at the doorways." Interview with licensed nurse Employee E13 on [DATE], at 9:50 a.m., confirmed that a couple weeks ago, the skilled nursing staff had to leave the unit to collect Resident R2 from the library because Resident R2's spouse had left Resident R2 in the library. The NHA indicated in interview, on [DATE] at 10:00 a.m., that Resident R2's spouse did not have access to the keypad code for disengaging the door alarm when exiting the nursing unit with Resident R2. Resident R4 demographic sheet related that Resident R4 was admitted on [DATE]. Physician orders at admission revealed [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment, dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of six which indicates severe impairment in cognition. Interview with the NHA and the DON on [DATE], at 1:15 p.m., confirmed that the facility does not do a formal assessment for elopement risk, rather informally, based on resident behaviors, they might determine the need for a code alert bracelet for a resident . Review of an electronic event report for elopement, submitted on [DATE], revealed that Resident R4 was observed by a campus staff member, "Walking outside with his walker. Resident was last observed by staff in his room shortly before his elopement. The staff member called the nursing supervisor, who along with another staff member went to assist the resident, they found him lying on the ground. The resident was reported as being out of the building approximately 9 minutes." Review of facility documentation, dated [DATE], indicated that Resident R4 was, "Seen walking with walker outside away from health care building and resident has dementia and was found lying face down on sidewalk." Facility documentation also stated that the dementia [DIAGNOSES REDACTED]. Review of Resident R4's nurse note, dated [DATE], documented by nursing supervisor, Employee E6, that around 4:30 p.m. a telephone call was received from a campus staff member informing Employee E6 that Resident R4 was observed walking unsupervised by Building B. Employee E6 documented that Employee E6 knew the campus staff member was talking about Resident R4 and called security to see if they saw the resident. Employee E6 went to the campus outpatient department and asked the staff there to call the staff person who had initially observed Resident R4 walking outside. Employee E6 further documented that security was called a second time and consequently security informed and updated Employee E6 that they just received a call in the command center from independent living area that, "a man was on the ground bleeding." Employee E6 documented that with assistance from licensed Employee E4, they ran all the way down to the Mascot building and reached the resident at 4:55 p.m. In contrast to the electronic event report, Resident R4 was reported missing approximately nine minutes but the nurses' note dated [DATE] reported that Resident R4 was observed at 4:30 p.m. unsupervised walking outside and staff reached him at 4:55 p.m. Resident R4 was found face down on the walker and was bleeding from an injury to the forehead. Emergency services was contacted and Resident R4 was sent to the hospital for further medical evaluation and treatment for [REDACTED]. The facility failed to supervise Resident R4 resulting in injury and hospitalization and the facility failed to investigate the circumstances around this elopement. Interview with the Medical Director on [DATE] at 1:45 p.m., confirmed that the Quality Assessment and Assurance Committee meetings are scheduled quarterly and the last meeting was [DATE]. The Medical Director confirmed that as of [DATE], there were no identified concerns with elopement or missing residents. An interview with the NHA on [DATE], at 1:00 p.m., confirmed that the Quality Assessment and Assurance Committee members have not identified a concern regarding the frequency of residents eloping from the nursing unit or any concerns with residents who were reported missing. The NHA further indicated that since [DATE], all incidents are compiled each month and then the leadership team reviews these incidents and disseminates the findings. The facility failed to adequately assess and provide appropriate supervision to maintain resident safety, placing the health and safety of residents in Immediate Jeopardy. Immediate Jeopardy was called [DATE], at 3:15 p.m. The facility submitted and implemented an acceptable plan of action and the Immediate Jeopardy was removed on [DATE], at 8:55 a.m., five days later. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1)(3) Management. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE]. 28 Pa. Code 211.11(a)(d)(e) Resident care plan 28 Pa. Code 211.12 (a)(c) Nursing services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE].