Every finding on record at Hermitage Nursing and Rehabilitation

Based on observations, and resident and staff interviews, it was determined that the facility failed to prevent flying insects and maintain a clean, comfortable, home like environment for three of three resident care areas (Units 1, 2, and 3 hallways and shower rooms, room [ROOM NUMBER] and 16 on unit 2 room [ROOM NUMBER] on unit 1, activity area. Findings include:Observations on 8/24/26, at approximately 1:30-1:45 p.m. of the shower room areas on Unit 1, Unit 2, and Unit 3 with the Director of Environmental Services revealed that small flying gnats were observed in the shower areas on walls and flying around the room.During an interview on 8/24/26, at the time of the observations, the Director of Environmental Services confirmed the gnats in all three shower rooms on Units 1, 2 and 3.Observations in the hallways of Unit 1 and Unit 2, revealed flying gnats and flies in the common areas/ hallways and flying around the soiled linen hampers in the hallways. On 8/24/26, during the onsite observation, the Director of Environmental services confirmed the flying insects around the soiled linen hampers in the hallways.During an interview on 8/24/26, at approximately 1:00 p.m. with Resident R1 family member revealed he/she was happy with the care provided, and also stated there are a lot of gnats and flies every time I come to visit. They are everywhere.Observations in room [ROOM NUMBER] on 8/24/26 at approximately 2:30 p.m. revealed gnats and flies flying around the residents in the room, food, and around garbage cans in the room.Observations in room [ROOM NUMBER] on 8/24/26, at approximately 2:00 p.m. revealed gnats and flies in the room and around the garbage cans. During an interview with Resident R2, on 8/24/26, he/she revealed that gnats bother him/her while eating.Observations of residents in the activities room during an activity on 8/24/26, at approximately 2:30 p.m. revealed that gnats and flies were flying around the room and garbage can while residents were in the activity. During interview with the Activity Director, it was revealed that they try to clean the tables, get rid of any food that is left out and empty the garbage cans as soon as possible to prevent flying insects and gnats in the activity room.During an interview on 8/24/26, at 3:20 p.m. the Nursing Home Administrator confirmed the observations of gnats and flying insects in resident care areas and resident rooms.28 Pa. Code 201.14(a) Responsibility of Licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 201.18(e)(2.1) Management

Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of two resident refrigerators (Nursing Unit Two); failed to label food brought into the facility with the resident's name and use by date in one of two resident refrigerators ( Nursing Unit Two); failed to maintain sanitary conditions in one of two resident refrigerators (Nursing Unit One); failed to maintain dishwashing machine water temperatures in accordance with manufacturer recommendations for food service safety for the kitchen dishwasher; and failed to prepare food items in accordance with professional standards in the facility's main kitchen. Findings include:Review of facility policy entitled, Food Brought by Family/Visitors with a policy review date of 1/1/25, indicated that Residents/families are asked that containers be labeled with the resident ' s name, the item, and the date. The nursing or housekeeping staff will discard foods that are past their use by / expiration date or that are visibly rotten or rotting if not done so by the resident or family. Review of facility policy entitled, Monitoring of Cooler/Freezer Temperature with a policy review date of 1/1/25, indicated that Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, and refrigerators are to be cleaned weekly and remain free of spills, and spoiled foods. Review of facility policy entitled, Dishwasher Machine Use with a policy review date of 1/1/25, indicated to use Dish Machine Temperature log to record information at each use. High Temperature Dishwasher: wash 160 degrees F (Fahrenheit) minimum and final rinse 180 degrees F minimum and to stop dishwashing if wash and/or rinse temperatures are below required levels. Report to supervisor immediately and do not resume until temperatures are adjusted. Review of the facility temperature log sheets revealed that the minimum temperature requirements for the wash cycle was: Wash 150 degrees F and the Rinse 180 degrees F. Notify maintenance and supervisor if temperatures not appropriate. Review of facility policy entitled, Food Temperature Logs with a policy review date of 1/1/25, indicated that food temperatures must be recorded on hot and cold foods prior to service using the temperature evaluation form. Observations on 9/30/25, at 11:50 a.m. of the refrigerator in Nursing Station Two used for residents revealed a brown icy-like substance on the shelves, and walls of the freezer. During an interview on 9/30/25, at the time of observation, the Dietary Manager confirmed that the freezer was not clean. Observations on 10/1/25, at 9:55 a.m. of a refrigerator in Nursing Unit Two used for residents revealed an opened jar of pickled beets without a resident name or date; two extra cheesy pizza Lunchables without a resident name or date; a bag of cherries with a resident name and date of 8/16/25; and a Walmart bag with a resident name and dated 8/22/25 that contained an opened bag of cheese cubes, opened bag of turkey breast slices, and opened bag of ham slices. Further observations of the freezer revealed one opened bag of frozen strawberries without a name or date, and four frozen microwave meals without resident names or dates. During an interview on 10/01/25, at the time of observation, the Assistant Director of Nursing confirmed that food items in the resident refrigerator/freezer should have a resident name and opened date and should be discarded before or by their use by date. Review of dishwasher temperature log for the kitchen for the months of August and September 2025 revealed that the kitchen had 183 opportunities (three times daily) to record dish machine temperatures and only had 163 recorded, leaving 20 opportunities where temperatures were not recorded for monitoring. Further review revealed three opportunities where the wash temperatures were recorded below the required temperature of 150 degrees F, and 60 opportunities where the rinse temperatures were recorded below the required temperature of 180 degrees F. During an interview on 10/15/2025, at 9:45 a.m. the Dietary Manager confirmed that dishwashing machine temperatures are supposed to meet 150 degrees F during the wash cycle and 180 degrees during the rinse cycle. Staff should record their readings on the dishwasher temperature log and are to inform management and maintenance if the dishwashing machines do not meet the required temperatures for wash and rinse cycles. Review of food temperature logs for the kitchen for the months of August and September 2025 revealed that the kitchen had 183 opportunities (three times daily) to record meal temperatures and only had 168 recorded, leaving 15 opportunities where temperatures were not recorded for monitoring. During an interview on 10/15/2025, at 9:45 a.m. the Dietary Manager confirmed that food temperatures are to be checked and recorded for each meal. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure that staff completed all the required mandatory trainings for the yearly 12 hour mandatory trainings for five of five Nurse Aide (NA) records reviewed.Findings include:Review of NA in-service records dated from 10/2024 through 10/2025, revealed that for NA employees the facility did not have evidence of documentation that the required 12 hours of in-service trainings were completed.During an interview on 10/15/25, at 2:30 p.m. the Director of Nursing confirmed that there was no process in place to track in-service training for NAs as required.28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of facility policies, clinical records, and shower schedules, and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 13 residents reviewed (Resident R1). Findings include: The current facility policy entitled Resident Care, indicated that facility staff will provide general care as necessary for each resident per their preferences when able, and per physician orders. Residents will be given nursing care and supervision based upon individual needs. Facility policies and procedures, and nursing and other discipline's standards of practice will be utilized to promote physical, mental, spiritual, nutritional, and emotional status of the resident. Residents will be bathed or assisted to shower or bathe routinely and as needed per their preference with foot care given per order/need. A quarterly Minimum Data Set (MDS- periodic assessment of resident's abilities and care needs) Assessment for Resident R1, dated 7/15/25, revealed for Section GG area 0130E self care, ability to shower bathe self was documented as the resident needed substantial/maximal assistance. A care plan for Resident R1, dated 8/4/25, revealed that Resident R1 required assistance for ADL's (Activities of Daily living) related to immobility and multiple sclerosis. Review of resident tasks (tasks completed by staff related to resident care) revealed Resident R1 was to have bathing/showering on Wednesdays and Sundays on 3:00 p.m. to 11:00 p.m. shift. An interview with Resident R1 on 9/16/25, at approximately 11:30 a.m. revealed that Resident R1 identified that his/her shower schedule was Wednesdays and Sundays on evening shift and does not always get a shower and is usually given a bed bath. Resident R1 stated that the last shower given was last Wednesday (9/10/25) but was not given a shower on Sunday (9/14/25) and was not offered to get one. Resident R1 identified that if he/she was offered to get a shower in the shower room, they would prefer a real shower over a bed bath. Resident R1 revealed that he/she required full assist of staff and a hoyer lift (mechanical lift) to get out of bed to a chair and set up in shower room and full assist of staff was needed for a shower. A review of the bathing detail report and shower sheets for Resident R1 revealed that from 8/16/25 to 9/16/25, one partial bath was given on 8/27/25 at 9:02 p.m. Review of shower sheets revealed that on 7/30/25, it was documented that a shower was refused but the staff person provided a bed bath, nails cleaned, and lotion applied. The next documented shower sheet was 9/2/25. A shower sheet was also filled out 9/7/25, and on 9/10/25. Review of this documentation revealed that there was no documented evidence that the resident received a shower per his/her preference, order, or care plan, and there was no documented evidence that the resident refused her showers, requiring that a bed bath be given. During an interview on 9/5/25, at approximately 3:15 p.m. the Assistant Director of Nursing and Nursing Home Administrator confirmed that there was no documented evidence that Resident R1 received and/or refused showers from 7/30/25, through 9/2/25, as per the resident's preferences and shower schedule.28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of two medication rooms reviewed (Unit 1 medication room). Findings include: A facility policy entitled Controlled Substances dated 1/05/24, indicated that all controlled medications must be maintained in a separately locked, permanently affixed compartment. Observation of the refrigerator on Unit 1 medication room revealed a white locked box in the door of the refrigerator. The white locked box containing controlled medications was not permanently affixed to the refrigerator allowing the entire box to be removed from the refrigerator. During an interview on 11/13/24, at approximately 9:02 a.m. Registered Nurse Employee E1 confirmed that the white locked box in the door of the refrigerator contained controlled medications and was not permanently affixed to the refrigerator as required. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to send copies of notice of emergency transfer to the representative of the Office of State Long-Term Care (LTC) Ombudsman for four of four residents reviewed (Residents R18, R37, R56, and R88). Findings include: A facility policy entitled Transfer and Discharge (including AMA-[against medical advice]) dated 1/5/24, indicated the facility will provide copies of notices for emergency transfers to the Ombudsman, when practicable, such as in a list of residents on a monthly basis. Policy also indicated the facility will maintain evidence that the notice was sent to the Ombudsman. Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included stroke, dementia (loss of cognitive functioning affecting a persons memory and behaviors), chronic kidney disease (a gradual loss of kidney function). Departmental notes indicated that Resident R18 was transferred to the hospital on 2/11/24, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder resulting in tremors, stiffness, and slowing of movement), high blood pressure, and obstructive uropathy (urine cannot flow due to an obstruction). Departmental notes indicated that Resident R37 was transferred to the hospital on 4/30/24, and returned to the facility on [DATE]. Resident R37 was again transferred to the hospital on 5/10/24, and returned to the facility 5/14/24. Resident R37 was again transferred to the hospital on 10/26/24, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R56's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease, high blood pressure, and stroke. Departmental notes indicated that Resident R56 was transferred to the hospital on 3/29/24, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. Resident R88's clinical record revealed an admitted [DATE], with diagnoses that included cancer of the prostate, bladder, and glottis (opening between the vocal cords), tracheostomy (a hole is made through the neck into the windpipe and then a tube is place to allow for breathing), and high blood pressure. Departmental notes indicated that Resident R88 was transferred to the hospital on 8/03/24, and returned to the facility on [DATE]. There was no evidence that the Office of the State LTC Ombudsman was notified. During an interview on 11/14/24, at approximately 11:24 a.m. Regional Clinician confirmed that the facility failed to notify the Office of the State LTC Ombudsman of Residents R18, R37, R56, and R88's emergency transfers from the facility. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for four of four residents reviewed for hospitalization s (Residents R18, R37, R56, and R88). Findings include: A facility policy entitled Transfer and Discharge (including AMA-[against medical advice]) dated 1/05/24, indicated for emergency transfers / discharges the facility will provide a notice of transfer and the facility's bed-hold policy to the resident and representative. A facility policy entitled Bed Hold Notice Upon Transfer dated 1/05/24, indicated that in the event of an emergency transfer of a resident, the facility will provide within twenty-four hours written notice of the facility's bed-hold policies. Resident R18's clinical record revealed an admitted [DATE], with diagnoses that included stroke, dementia (loss of cognitive functioning affecting a persons memory and behaviors), chronic kidney disease (a gradual loss of kidney function). Departmental notes indicated that Resident R18 was transferred to the hospital on 2/11/24, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R18 and/or their representative was provided with a copy of the facility bed-hold policy. Resident R37's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder resulting in tremors, stiffness, and slowing of movement), high blood pressure, and obstructive uropathy (urine cannot flow due to an obstruction). Departmental notes indicated that Resident R37 was transferred to the hospital on 4/30/24, and returned to the facility on [DATE]. Resident R37 was again transferred to the hospital on 5/10/24, and returned to the facility 5/14/24. Resident R37 was again transferred to the hospital on 10/26/24, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R37 and/or their representative was provided with a copy of the facility bed-hold policy. Resident R56's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease, high blood pressure, and stroke. Departmental notes indicated that Resident R56 was transferred to the hospital on 3/29/24, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R56 and/or their representative was provided with a copy of the facility bed-hold policy. Resident R88's clinical record revealed an admitted [DATE], with diagnoses that included cancer of the prostate, bladder, and glottis (opening between the vocal cords), tracheostomy (a hole is made through the neck into the windpipe and then a tube is place to allow for breathing), and high blood pressure. Departmental notes indicated that Resident R88 was transferred to the hospital on 8/03/24, and returned to the facility on [DATE]. The clinical record lacked evidence indicating that Resident R88 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 11/15/24, at approximately 12:14 a.m. the Director of Nursing confirmed that there was no evidence that Residents R18, R37, R56, or R88 and/or their representatives received written notice of the facility bed-hold policy upon or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management

Based on a review of facility policy, facility grievances, and resident representative and staff interviews, it was determined that the facility failed to resolve a resident representative's grievance concerns related to care/treatment for one of 31 residents reviewed (Resident R1). Findings include: The Concerns-Grievances policy, dated 12/28/23, revealed the facility will honor the resident's right to voice concerns and/or grievances without discrimination or reprisal. Such concerns and/or grievances will include, but not limited to, treatment which has been furnished as well as that which has not been furnished and instances of behavior of other residents. Other forms of grievances could include management of funds, lost items and/or violation of rights. This process will provide a method of documenting Concerns/Grievances and resolutions. These processes combined will promote customer satisfaction with the facility care and services and identify areas of improvement. Social Services will be responsible for coordinating orientation and in-service training to ensure all facility staff are knowledgeable of the facility's Concern process and that they understand their role in providing responsive customer service to residents and their families in concern resolutions. Social Services Director will coordinate the facility system for collecting concerns and tracking concerns for timely and appropriate response. Social Services will instruct facility staff to submit to the Social Service Director that all concerns received will be investigated within seventy-two hours (72 hours) following receipt of the concern. Within seven (7) days following the receipt of the concern, the facility will inform the complainant with the results of the investigation. A review of facility grievances from the months of January through March 2024, revealed no grievances from Resident R1's family member. During an interview with Resident R1's resident family member on 3/19/24, at 6:00 p.m. it was indicated that a letter of concern was written by Resident R1's family member in February 2024, and provided to Employee E1 regarding care and treatment concerns for Resident R1. During an interview with Employee E1 on 3/20/24, at approximately 4:55 p.m. it was revealed that he/she did receive a letter of concern from Resident R1's family member in February 2024, but failed to provide it to any further facility staff to address the concerns. An interview with the Director of Nursing on 3/20/24, at approximately 6:00 p.m. confirmed that he/she was unaware of Resident R1 family member's care and treatment concerns and further confirmed that the above noted letter of concern regarding the care and treatment concerns were not addressed timely as per the facility grievance policy as stated above. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on observations and staff interviews, it was determined that the facility failed to ensure a safe environment for residents residing on two of three units regarding a soiled utility room area (Unit 1 and Unit 2). Findings include: Observations on 2/7/24, at 9:51 a.m. of the soiled utility rooms on Unit 1 with the Housekeeping/Laundry Director, revealed the following: To enter the soiled utility room, observed above the key number entry mechanism were two separate strips of tape with a four digit key code identified on each strip. The numbers were located at a level that any resident could visualize and open the soiled utility room door. The Housekeeping/Laundry Manager utilized the numbers identified on the strip to enter the soiled utility room. Observed inside the room was an uncovered red bag disposal area, a large tote with clear plastic bags with soiled attends and large styrofoam cups, a bag on the floor with dirty linens, and multiple empty boxes piled up from the floor to the countertop. A full gallon of apea care shampoo and body wash was sitting on the counter opened without a lid. During an interview at the time of the observation, the Housekeeping/Laundry Director stated that the numbers above the key pad are numbers utilized to open the soiled utility room door. The four digit numbers were tested and each four digit number opened the soiled utility room door. Observation of Unit 2 soiled utility room identified two strips above the entrance keypad with a separate four digit number on each strip. When tested , each four digit number opened the door. Inside the room was a large tote with clear plastic bags with garbage. An opened container lined with a red bag was also observed inside. The keypad and four digit number sequence was located at a level that any resident could visualize and open the door. During an interview on 2/07/24, at 10:05 a.m. the Director of Nursing confirmed the numbers were above the keypad and used to enter the soiled utility room. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on a review of facility policy, observations, and resident representative and staff interviews, it was determined that the facility failed to develop and implement a comprehensive activity program for one of three resident care units observed (Memory Care Unit Three). Findings include: Review of facility policy Activity Program dated 1/02/23, revealed This facility provides activity programs that are designed to meet the needs of residents with a range of cognitive and physical levels of functioning. 1. Activity programs are designed to encourage individual participation and are geared to the needs and preferences of residents in the facility. 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning of the programs, which may include self-directed activities. 3. Our activity programs consist of individual, small and large group activities that are designed to meet the needs and interests of residents and may include such things as: a: exercise, movement to music, pool b: Stimulating activities such as current events, trivia, word games, movies c: Field trips away from the facility such as shopping, going to the park, going out to eat, attending local events d: Spiritual programming as requested by the residents e: Creative activities, such as arts and crafts, painting, writing, music, f: Occasionally special activities such as birthday and holiday parties, outside entertainment and theme events g: activities may be scheduled per resident interest as a one-time event or more often 4. Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents, and family members may also provide activities. Observations on 12/18/23, between 11:00 a.m. and 4:00 p.m.; on 12/19/23, between 9:30 a.m. and 12:00 p.m.; and on 12/20/23, between 8:45 a.m. and 1:00 p.m. revealed no evidence of resident activities being conducted on the Memory Care Unit. During an interview on 12/19/23, at 12:45 p.m. Resident R35's Representative indicated there have not been activities for residents of the Memory Care Unit for months but was supposed to have a facility employee start doing activities on 12/01/23, but this has not occurred. During an interview with Employee E2 on 12/20/23, at approximately 10:30 a.m. it was confirmed that activities have not been taking place consistently for the residents of the Memory Care Unit for numerous days. During an interview with Employee E3 on 12/20/23, at approximately 11:00 a.m. it was confirmed that activities have not been occurring consistently due to the facility employee responsible for the Memory Care Unit was working on other responsibilities at the facility. During an interview on 12/21/23, at 10:15 a.m. the Nursing Home Administrator confirmed that an activity program was trying to be initiated, but due to staffing concerns, the staff responsible for the Memory Care Unit activities have not been able to do them as planned. 28 Pa. Code 211.10(d) Resident care policies

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to ensure urinary catheter (tube inserted into the bladder to drain urine) care was completed and urinary output was documented per physician orders for one of 20 residents reviewed (Resident R50). Findings include: Review of the facility policy entitled Use and Care of Urinary Catheter Guidelines, dated 1/2/2023, revealed Catheter care will be done per facility policy and as needed. Drainage bags will be emptied every shift and as needed. Review of the facility policy entitled Medication and Treatment Orders, dated 1/2/2023, revealed Treatment orders will be documented in PCC (Point Click Care) and on the Treatment Administration Record (TAR). Resident R50's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Review of Resident R50's physician's orders dated 4/01/2023, revealed an order for foley (type of catheter) catheter care every shift and physician's orders dated 4/25/2023 to document foley output every shift. Review of R50's TAR completed by the Licensed Nurses for November 2023 and December 2023 revealed his/her foley catheter care was not completed every shift per physician's orders on 11/05/2023, 11/08/2023, and 12/01/2023, and urinary output was not documented every shift per physician orders on 11/01/2023, 11/02/2023, 11/03/2023, 11/04/2023, 11/05/2023, 11/06/2023, 11/08/2023, 11/11/2023, 11/12/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023, 11/29/2023, 12/01/2023, 12/04/2023, 12/07/2023, 12/09/2023, 12/10/2023, and 12/11/2023. During an interview on 12/20/2023, at 11:29 a.m. the Director of Nursing confirmed that the clinical records lacked evidence that catheter care was being completed per physician orders and lacked evidence that urinary output was being documented per physician orders for resident R50. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days and failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed (Resident R41), and failed to ensure PRN orders for psychotropic medications be used only when the medication is necessary to treat a diagnosed specific condition for two of five residents reviewed related to psychotropic medication usage (Residents R76 and R85). Findings include: Review of a facility policy entitled Use of Psychotropic Medication dated 1/2/2023, revealed that PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. and Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included chronic respiratory failure, type II diabetes, failure to thrive, heart failure, and repeated falls. A physician's order dated 11/22/2023, identified to administer Lorazepam (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 4 hours as needed for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days. Review of the November 2023 and December 2023 Medication Administration Record (MAR) for Resident R41 revealed that the PRN Lorazepam was used on 11/22/2023, 11/23/2023, 11/24/2023, 11/25/2023, 11/26/2023, 11/27/2023, 11/28/2023, 11/29/2023, 11/20/2023, 12/01/2023, 12/02/2023, 12/03/2023, 12/04/2023, 12/05/2023, 12/06/2023, 12/07/2023, 12/08/2023, 12/09/2023,12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/16/2023, 12/17/2023, 12/18/2023, and 12/19/2023. Review of the November 2023 MAR, December 2023 MAR, and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam for the 17 administrations of Lorazepam in November 2023 and 22 administrations of Lorazepam in December 2023. During an interview on 12/21/2023, at 10:20 a.m. the Director of Nursing confirmed that Resident R41's Lorazepam orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and R41's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to administering Lorazepam. Resident R76's clinical record revealed an admitted [DATE], with diagnoses that included Parkinson's disease (disease of the central nervous system that affects movement), dysphagia (difficulty swalling foods or liquids), muscle wasting and atrophy (a loss and break down of muscle), and dementia (disease of the brain that affects mood, behavior, and decision making). Resident R76's clinical record revealed a physician's order dated 4/29/23, Ativan Solution 2 mg/ml [milliliter] (Lorazepam) Inject 0.25 ml intramuscularly every 6 hours as needed for anxiety, agitation 0.5 mg. Resident R76's pharmacy medication regimen review (MRR) dated 11/08/23, revealed This resident has an order for Ativan 0.5 mg IM Q6H PRN for Anxiety/Agitation. This was started 4/29/23. The prescriber must then reassess the patient in order to continue the PRN order. If the medication is to be continued for PRN use, the prescriber must document clinical rationale for extended use AND the duration of treatment. The MRR further lacked evidence of a physician response to discontinue the PRN order as referenced above and/or to continue use with a clinical rationale. Resident R85's clinical record revealed an admitted [DATE], with diagnoses that included fracture of left hip, muscle weakness, unsteadiness of feet, and dementia. Resident R85's clinical record revealed a physician order dated 8/15/23, Ativan oral tablet 0.5 mg (Lorazepam) Give 0.25 mg by mouth every 8 hours as needed for anxiety. Resident R85's pharmacy MRR dated 12/13/23, revealed This resident has an order for Ativan 0.25 mg Q8H PRN for Anxiety/agitation. If the medication is to be continued for PRN use, the prescriber must document clinical rationale for extended use AND the duration of treatment. The physician indicated to discontinue PRN order referenced above. The clinical record lacked evidence, however, that the Ativan 0.25 mg by mouth every 8 hours PRN was discontinued per the physician order documented on 12/13/23. During an interview on 12/21/23, at 10:40 a.m. the Assistant Director of Nursing confirmed that Resident R76's clinical record lacked evidence of a physician response to the pharmacy MRR dated 11/08/23, to discontinue the PRN Ativan 0.5mg IM Q6H PRN and/or continue use with a clinical rationale, and Resident R85's clinical record lacked evidence that the Ativan 0.25 mg by mouth every 8 hours PRN was discontinued per the 12/13/23, physician order. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin (medication to treat elevated blood sugar levels) and tuberculin solution (used to test for the disease tuberculosis) with the date they were opened in one of three medication carts (Long Cart 2). Findings include: Review of a facility policy entitled, Administering Medication dated 10/01/23, indicated that that the date opened shall be recorded on the container. Observation on 12/18/23, at 3:32 p.m. of the Long Cart 2 revealed an opened multi-dose vial of Novolog insulin without a date when it was opened. At that time, Licensed Practical Nurse Employee E1 confirmed that the multi-dose vial of Novolog insulin did not identify an opened date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure food was stored and prepared in a safe and sanitary manner related to the walk-in freezer, dry storage area, cooking equipment, and fans in the dishwashing area for one of one main kitchens. Findings include: Review of a facility policy entitled, Sanitary Conditions dated 1/02/2023, revealed that All equipment will be maintained in a clean and sanitary fashion. Observations conducted on 12/18/2023, at approximately 10:05 a.m. of the main kitchen revealed dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove and overhead vents, and two fans in the dishwashing area with a thick layer of dust and a fuzzy substance. During an interview on 12/18/2023, at the time of the observations the Kitchen Manager confirmed that there was dirt and debris on the walk-in freezer floor, visible dust, debris, and food on the dry storage room floor, visible grease, and debris on the stove and overhead vents, and two fans in the dishwashing area with a thick layer of dust and a fuzzy substance. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and resident representative for four of 20 residents reviewed (Residents R50, R41, R86, and R89). Findings include: Review of a facility policy entitled, Baseline Care Plan dated 1/02/2023, revealed A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: The initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Resident R50's clinical record revealed an admitted [DATE], with diagnoses that included chronic kidney disease, retention of urine, and unsteadiness on feet. Resident R50's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R50 and his/her representative. Resident R41's clinical record revealed an admitted [DATE], with diagnoses that included chronic respiratory failure, type II diabetes, failure to thrive, heart failure, and repeated falls. Resident R41's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R41 and his/her representative. Resident R86's clinical record revealed an admitted [DATE], with diagnoses that included type II diabetes, history of falling, and muscle weakness. Resident R86's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R86 and his/her representative. Resident R89's clinical record revealed an admitted [DATE], with diagnoses that included fracture of right hip, muscle wasting and atrophy (loss and breakdown of muscles), lack of coordination, and muscle weakness. Resident R89's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R89 and his/her representative. During an interview on 12/21/2023, at 10:30 a.m. the Director of Nursing confirmed that the clinical record of the residents listed above lacked evidence that a written summary of the baseline care plan and order summary was provided the residents and his/her representatives upon admission to the facility. 28 Pa. Code 211.10(c) Resident care policies

Based on observations, review of facility policies and staff interviews, it was determined that the facility failed to provide a clean, comfortable and homelike environment for seven of 53 rooms (Rooms 51, 33, 34, 35, 37, 39, and 40.) Finding include: Review of facility policy entitiled, The 5 Step Daily Patient Room Cleaning dated 1/01/23, revealed the entire floor must be dust mopped . Observations conducted between 10:06 a.m. through 10:40 a.m. revealed the following: room [ROOM NUMBER] had loose debris under resident beds room [ROOM NUMBER] had loose debris under the bed by the door room [ROOM NUMBER] had loose debris noted on the resident floors room [ROOM NUMBER] had loose debris noted on the floor room [ROOM NUMBER] had a Kleenex box wedged under the window bed room [ROOM NUMBER] had debris on the floor and under the door bed Observations of rooms on Unit Three on 8/08/23 at 10:43 a.m. revealed that Housekeeper Employee E2 was cleaning resident rooms. During an interview at that time, Housekeeper Employee E2 stated that he/she had finished cleaning room [ROOM NUMBER]. During observation of room [ROOM NUMBER], loose debris was observed under the bed in the room by the window. During an interview with Housekeeper Employee E2 on 8/08/23 at 10:45 a.m he/she stated they had completed cleaning the room but had forgotten to clean under the resident's beds. Observations with the Housekeeping Assistant Manager on 8/08/23, at 12:33 p.m. revealed the prior morning observations were still present in Rooms 33, 34, 35, 37, 39 and 40 including the loose debris noted under beds, on the floors and the Kleenex box still under the bed in room [ROOM NUMBER]. During an inteview on 8/08/23, at 12:43 p.m. Housekeeper Employee E3 stated all rooms were completed on the North Hall except rooms [ROOM NUMBERS]. (North Hall included Rooms 30 through 45) 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations, review of clinical records and facility documentation, manufacturer's recommendations and staff interview, it was determined that the facility failed to ensure a safe environment for individuals care planned for elopement with alpha tags (device placed on resident to notify staff when resident is exiting the building) for three of three residents reviewed. (Residents R1, R2 and R3) Findings include: Review of manufacturer's recommendations Wander Control Systems Troubleshooting Tips for Testing RF(alpha) tags revealed we highly recommend testing the resident RF (alpha tag) tags every morning with a hand held tag tester. 4 .Tags should never be attached to wheelchairs. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included seizures, bipolar disorder (periods of depression and elevated mood), multiple sclerosis (disease that affects the nervous system) and anxiety. Review of a physician's order dated 1/05/23, revealed an order for an alpha tag to wheelchair due to increased elopement risk for Resident R1. Resident R1's care plan dated 4/4/23, revealed an alpha tag was ordered on 1/05/23 and check the device for functioning per facility protocol. Review of Resident R1's Treatment Record for July and August 2023, revealed alpha tag to wheelchair-check placement every shift. Review of Resident R2's clinical record revealed an admitted [DATE], with diagnoses that included unsteady gait, high blood pressure, and dementia. Review of a physician's order dated 7/27/23, revealed an order for an alpha tag to the right ankle- check placement every shift. Resident R2's care plan dated 4/21/23, revealed alpha tag per order for risk of elopement related to impaired cognition. Review of Resident R2's Treatment Record for July and August 2023, revealed alpha tag right ankle-check placement every shift for alpha guard check. Review of Resident R3's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease, anxiety, and impulse disorder (failure to resist urge or temptation). Review of a physician's order dated 10/13/21, revealed alpha tag on at all times for safety every shift. Resident R3's care plan last revised on 3/09/23, revealed staff will apply alpha tag for safety and check battery every bedtime per order. Review of Resident R3's Treatment Record for July and August 2023, revealed alpha tag on at all times for safety for Resident R3. The facility identified three residents with alpha tags. Observation on 8/02/23, at approximatley 2:00 p.m. with Maintenance Employee E1 revealed that the hand held tester used to test the alpha tag transmitter on Residents R1, R2, and R3 was not picking up a transmission for function. Residents R2 and R3 had alpha tags observed placed on their ankles. Resident R1 had an alpha tag placed on their wheelchair. Resident R1 gave permission to check their alpha tag near the exit doors and was assisted to the exit doors which were secured with a punch key code to exit. The front entrance door should lock in the presence of a resident with an alpha tag and an alarm should ring when exiting if not locked. Resident R1 was assisted to the front entrance and the door opened and no alarm sounded at 2:25 p.m. on 8/02/23. Review of the facility documention from May, June, and July revealed that the alpha tags for Residents R1, R2 and R3 were checked for functioning once a month and not daily as the manufacturer recommended. There was no documentation that the doors in the facility were checked to prevent residents care planned for elopement from exiting the building. During an interview on 8/02/23, at 2:25 p.m. the Nursing Home Administrator (NHA) confirmed that the door opened and the alarm did not sound during testing of Resident R1's alpha tag. During an interview on 8/03/23, at 10:22 a.m. the NHA confirmed they were unaware alpha tags were not to be placed on wheelchairs per the manufacturer's recommendations and was not aware that testing was recommended daily on resident alpha tags and also confirmed there was no documentation to show that the exit doors of the facility were tested for functioning to prevent an elopement. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of clinical records and staff and resident interviews, it was determined that the facility failed to provide the appropriate number of staff to provide the care and services in assisting residents with showers for two of seven residents reviewed. (Residents R4 and R5) Findings include: Review of Resident R4's clinical record revealed an admitted [DATE], with diagnoses that included high blood pressure, heart problems and stomach reflux. The 6/12/23, Quarterly Minimum Data Set (MDS-periodic review of resident care needs) Assessment revealed that Resident R4 was alert and oriented. The MDS also identified that choosing a bathing method was somewhat important to the resident and bathing required one person physical assist. During an interview on 8/08/23, at 1:33 p.m., Resident R4 stated that they had received their shower recently but had a span of time that they had not gotten a shower. The resident identified that Mondays and Thursdays were their shower days. Review of the bathing record revealed Resident R4 had not received a shower between 7/10/23 and 7/19/23 and then not again from 7/21/23 through 8/02/23. On 8/08/23, at 2:30 p.m. Resident R4 was interviewed again due to the facility identifying that the resident had received a bed bath. Resident R4 stated I never asked for a bed bath. I like to shower. Resident R4 also indicated that they do not get the shower because staff say they do not have enough staff. Review of Resident R5's clinical record revealed an admitted [DATE], with diagnoses that included cancer of the cecum (beginning of the large intestine). The 7/12/23, Quarterly MDS revealed Resident R5 was alert and oriented. The MDS also revealed Resident R5 indicated it was very important to choose between a bath, shower, bed bath or sponge bath and for bathing Resident R5 needed supervision with a one person physical assist. During an interview with Resident R5 on 8/08/23, at 1:42 p.m. he/she stated that they preferred to sponge bath in their room however had been asking the staff to help him/her wash their hair. Resident R5's hair was flat and somewhat greasy upon observation. Resident R5 stated I have been asking people to wash my hair, they (staff) tell me there is not enough staff. During an interview on 8/08/23, at 2:45 p.m. the Director of Nursing (DON) confirmed that documentation between 7/10/23 through 8/07/23 revealed Resident R4 did not receive showers on six of the nine days the resident was scheduled for showers and also was unaware that Resident R5 asked to have their hair washed. 28 Pa. Code 211.12 (d)(1)(3)(4)(5) Nursing services

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to perform post-discharge planning prior to discharge for two of five closed record residents (Residents CR2 and CR3). Findings include: Review of a facility policy entitled, Discharge Planning dated 2016, indicated that the facility will: develop and implement a discharge plan that will effectively transition residents to post-discharge care; document any referrals to local agencies or other appropriate entities; assist the resident and/or representative in selecting a post-acute care provider; develop and provide a post-discharge plan of care to the receiving provider which includes practitioner contact information, representative contact information, Advanced Directives, special instructions/precautions for ongoing care, care plan goals, and all other necessary information to ensure a safe and effective transition of care. Review of a facility policy entitled, Transfer-Discharge, Preparing a Resident for (no review date), indicated that a post-discharge plan will be developed and reviewed with the resident/representative at least 24 hours before the resident is discharged from the facility. Review of a facility policy entitled, Planned Discharge Procedure dated 7/2017, indicated that Social Services department is responsible for directly assisting the resident/representative with arrangements, and assist with obtaining equipment, home health services, hospice, etc., as requested. Review of Resident CR2's clinical record revealed an admitted [DATE], with diagnoses including Type 2 Diabetes (condition that effects the way the body uses glucose [sugar]), dementia, epilepsy (brain disorder that causes recurring seizures), spinal stenosis-multiple regions (condition where the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), and generalized weakness. The clinical record also revealed that Resident CR2 was discharged home on 4/15/23, and was to receive home health services. Review of a fax dated with a sent date of 4/14/23, requested the physician to sign an order to discharge Resident CR2 to home with medications, physical therapy, occupational therapy, and registered nurse services. Review of a physician's faxed order dated 5/03/23, identified the need for home health, physical and occupational therapies. Review of a Social Services progress note dated 5/11/23, indicated that Resident CR2's family had contacted the facility to report that home health services had not yet been started. Review of a fax dated with a sent date of 5/11/23, indicated that the facility sent the required documents to Home Health Intake and requested services to begin as soon as possible. Review of a Social Services progress note dated 5/12/23, indicated that Resident CR2's daughter had contacted the facility to inform them that the home health agency had contacted the family that morning to begin services (27 days after discharging from the facility). Review of electronic correspondence dated 6/02/23, revealed that Social Services employee confirmed that Resident CR2 did not begin receiving home health services until 5/12/23. Review of Resident CR3's clinical record revealed an admitted [DATE], with diagnoses including Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Type 2 Diabetes, and Fibromyalgia (condition that causes pain all over the body (also referred to as widespread pain), sleep problems, fatigue, and often emotional and mental distress). The clinical record revealed that Resident CR3 was discharged home on 5/10/23, and was to receive home health services. Review of a physician's order dated 5/10/23, revealed that Resident CR3 was to be discharged home with medications, home health, physical therapy, and occupational therapy. Review of electronic correspondences dated 5/10/23, and 5/11/23 from the home health services agency revealed a request for the required signed physician's order and progress notes to enroll Resident CR3 in home health services. Review of an electronic correspondence dated 5/12/23, from the facility to the home health services agency indicated that the required documents had been sent to allow Resident CR3 to begin services at home. Review of an electronic correspondence dated 6/02/23, revealed that Social Services employee confirmed that there was a delay in obtaining progress notes and signed physician's order for Resident CR3 to begin home health services. 28 Pa. Code 201.18(b)(1)(2) Management 28 Pa. Code 201.25(a) Discharge Policy

Based on observations, review of facility policies and staff interview, it was determined that the facility failed to maintain clean and sanitary bedrooms and/or bathrooms for five of eight resident rooms on Unit Three (Rooms 54, 53, 52, 51 and 49). Findings include: Review of the 5-Step Daily Patient Room Cleaning policy revealed step three: spot clean walls, vertical surfaces are not completely wiped down daily but must be spot cleaned daily. Walls-especially by trash cans, light switches and door handles will need special attention. The entire floor must be dust mopped, especially behind dressers and beds .All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur. During observations of Unit Three resident rooms/bathrooms on 4/10/23, between 9:00 a.m and 9:20 a.m., the following was identified: room [ROOM NUMBER] - tan color streaks on short wall on left side of room, bathroom floor had large stain noted in front of and around the toilet room [ROOM NUMBER] -stain noted on right side of room floor near resident bed and also stain on floor on left side of dresser. Also noted was a collection of dust and debris around the baseboard of the room. room [ROOM NUMBER] - reddish brown droplets noted on bathroom floor in front and around the toilet room [ROOM NUMBER] - floor mat on left side of room had multiple stains and the bathroom had an attends, towel and pants lying on the floor room [ROOM NUMBER] - floor stained on left side of room and floor was sticky throughout the room During an interview on 4/10/23, between 9:30 a.m. through 9:42 a.m., the Housekeeping Manager confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of facility policies, clinical records, and facility investigation and staff interviews, it was determined that the facility failed to implement adequate safeguards to protect one resident (Resident R2) from physical assault resulting in injury requiring transport to the emergency room for treatment. The facility failed to implement interventions after the assault to ensure that further physical assaults did not occur, placing 15 of 16 residents in the locked memory care unit in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Resident Abuse, Neglect and Misappropriation of Property dated 1/31/22, revealed under Section II Screening of Potential Residents, state the facility screens all potential residents prior to admission in order to determine whether the individual's needs can be appropriately addressed and met in the facility The facility will not admit an individual who has been determined as requiring services that cannot be provided by the facility. Review of CMS Guidelines 483.12 (a)(1) Freedom from Abuse, Neglect and Exploitation defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes .physical abuse . Also under the guidance under Abuse: Sections 1819 and 1919 of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Review of information submitted by facility dated 5/31/22, revealed that on 5/29/22, Resident R1 had physical and forceful contact with Resident R2's face, causing Resident R2 to fall to the floor. Resident R2 had a split lip with bleeding and redness on the knee. Resident R1 was taken to the emergency room for evaluation after assaulting Resident R2. The incident/event type was submitted as complaint of patient/resident abuse Review of a facility incident report, dated 5/29/22, at 5:45 p.m indicated that Resident R2 was sent to the emergency room at 9:45 p.m. due to complaints of headache and pain in both knees. Review of the facility notes by a facility affiliated Nursing Home Administrator (NHA), dated with the 5/29/22, event indicated after the incident that Resident R1 was moved to a room toward the nursing station and Resident R2 was moved to a room at the opposite end of the hallway to provide additional separation and staff to position between the residents to prevent additional contact. Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's Admission Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 5/17/22, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R1 scored a 00, indicating severe cognitive impairment. Section E0200 (B): behavior symptoms indicated Resident R1 displayed verbal behavior towards other (threatening others, screaming at others, cursing at others) which occurred one to three days during the assessment period. Review of hospital information provided, dated 5/07/22 thru 5/09/22, revealed a psychiatric consult was conducted for dementia with behavioral outbursts. Resident R1 was significantly agitated, attempted to climb out of bed, when redirected would swing at staff, combative and attempted to punch sitter, and displayed increased agitation when attempting to stop resident from leaving. While in the hospital, Resident R1 was provided a 1:1 sitter. Records indicated the sitter stated Resident R1 is pleasant at times but can turn on a dime. Information from Resident R1's family member indicated the past several months the resident would push her but he became upset and sucker punched the family member two times, threw the family member across the floor and tried to choke them. Nursing note, dated 5/10/22, at 12:38 p.m. documented they received a call from the hospital that Resident R1 is being admitted to facility with dementia and altered mental status. Resident R1 had attacked his wife physically four days ago and was brought to the emergency room by the state police. Resident R1 had a sitter with him at the hospital up until today. Nursing noted, dated 5/10/22, at 1:52 p.m., revealed Resident R1 was difficult to redirect out in hallway, upset .made a fist and threatened to hit staff member during redirection. Nursing note, dated 5/10/22 at 10:20 p.m., documented Resident R1 became verbally aggressive with another male resident .the doctor was in this afternoon and ordered [MEDICATION(S)] (antipsychotic medication) as needed four times a day. Nursing note on 5/11/22 at 4:37 a.m., revealed Resident R1 was agitated, argumentative, threatens violence and escape, follows staff members and enters rooms of other residents. Nursing note from 5/11/22 at 11:18 p.m., Resident R1 was exit seeking, easily agitated and threatens harm, especially when enters a female room and staff attempts to redirect. Nursing note from 5/12/22 at 11:08 p.m., around bedtime Resident R1 became agitated and aggressive with staff and other residents, wandering in and out of resident rooms and difficult to redirect.1:1 ineffective, [MEDICATION(S)] given around 9:10 p.m. Nursing note from 5/29/22 at 5:45 p.m., revealed Licensed Practical Nurse Employee E19 heard screaming, noted Resident R1 in room [ROOM NUMBER] sitting in a chair by window smiling. Resident R2 was lying on the floor face down with blood splattered on the floor in front of the bed by the door. Resident R2 was bleeding from their upper lip and noted a cut to inner lip. Resident R2 stated he punched me I was defending myself and said Resident R1 said they were going to kill me and punched me. Resident R2's cheek was red in color, Resident R2 stated to aide that Resident R1 is always coming into my room, when asked Resident R1 if they did this, Resident R1 replied yes . sitting in chair smiling. Resident R2 stated they had hit Resident R1, Resident R1 checked with no injuries. Resident R1 was taken out to the commons area for 1:1 per the aide, Resident (R1) has been in and out of females room all day. Nursing note, dated 5/29/22 at 6:50 p.m., Resident R1 was talking to another resident and aide reported hearing Resident R1 state I am going to finish the job and after redirected by staff, Resident R1 stated You will know if I hit you cause you will be dead. Nursing note, dated 5/29/22, at 7:36 p.m., Resident R1 was transported to the hospital. Nursing note: dated 5/30/22 at 12:45 p.m. indicated Resident R1 was sitting on the floor in front of the bathroom door. Nursing note, dated 5/30/22, at 1:13 p.m. revealed Resident R1 returned to the facility at 8:20 a.m. Nursing note: 5/30/22 at 10:39 p.m. revealed .putting on more clothes over top his clothes he already has on, pacing back and forth in room to commons area, refusing hour of sleep care, .going into bathroom and flushing toilet, nurse asked if Resident R1 needed to go to the bathroom , resident turned to nurse and stated I will put a bullet in your head., I want out of here. Nursing note, dated 6/01/22 at 2:54 p.m., .resident threatening another resident stating if she comes near me I might hit her. Documentation from Resident R2' records are as follows: Nursing note, dated 5/29/22 at 5:45 p.m., revealed Resident R2 was found lying on the floor face down in front of the bed by the door. Noted drops of blood splattered on the floor, noted blood in Resident R2's mouth noted cut to inner upper lip measuring 1 centimeter by 0.3 centimeter by 0.1 centimeter, upper lip swollen, ice applied, left check red in color, right knee has a raised black and blue bruised area measuring 6 centimeters by 4 centimeters, left knee slightly swollen Resident R2 stated they hit their head when asked where it hurt, resident pointed to left side of forehead. Resident R2 stated he punched me and I hit him back .I was defending myself, he said he was going to kill me and he punched me resident was shaking, resident R1 stated I can't stop shaking, . Nursing note, dated 5/29/22 at 9:45 p.m., .Resident R2 continues to complain her head hurting, Tylenol no effect, when asked where it hurts resident stated my whole head hurts ad pain going down my neck and my left cheek hurts, my knees hurt also noted pupil bigger, were 2 millimeters in size now 4 but reactive. Doctor called ordered transport to emergency room . Nursing note, dated 5/30/22 at 9:43 p.m. revealed Resident R2 with black and blue bruising to chin and upper lip, lip remains swollen, left cheek remains red and a small reddish area to the left side of forehead, while sitting in the commons area , Resident R2 kept an eye on her room and any resident that would enter the room, the resident would yell at them. Nursing note, dated 6/01/22, at 2:57 p.m., alert, skin warm and dry, neuro checks within normal limits, no complaints of pain, resident upset this morning over Resident R1 being on the unit stating he needs to leave, this is our home and he doesn't belong here especially after what he done to me . During observation of residents on the locked unit on 6/01/22 at 2:00 p.m., there were six residents in the common area, three male and three female residents unsupervised. Resident R1 was observed staring out the window. Two staff were working the unit and were in residents rooms providing care. Resident R2 was sitting in a chair at a table. Observed was a black and blue area above the left upper lip and chin area. Nurse Aide (NA) Employee E3 returned to the common area after toileting Resident R3. Resident R2 was discussing their knee, pulled their pant leg up and displayed a large black and blue area on the medial side of their right leg near the knee cap. During an interview on 6/03/22 at 11:00 a.m. NA Employee E2 stated that the employee was assigned the locked unit alone and had an incident occur with Resident R1 and Resident R2 a few days after Resident R1 was placed on the unit. The employee stated that they were not able to get to a phone to acquire assistance and had to open the locked memory care unit door to call for help. NA Employee E2 stated they had reported the incident to another staff person and the Registered Nurse Supervisor. Review of care plans for Resident R1 revealed a care plan focus issue resident exhibiting behaviors, dated 5/11/22, revealed interventions to attempt to establish a routine to reduce confusion for the resident: In the event there is a disruptive behavior, redirect the resident and report the behavior: Orient the resident to their surroundings: and Report any behaviors that could affect the resident's quality of life and/or could affect other residents. Review of care plans for Resident R1 revealed care plan focus issue Resident does not conform to/understand boundaries of socially accepted behaviors. Resident is verbally abusive towards staff and residents, Resident has potential for continued behaviors dated 5/23/22, revealed interventions of discuss with resident in a straight forward, but kind manner that his/her behavior is unacceptable: May use appropriate Crisis Prevention Intervention techniques as needed: Refer to Psych services for evaluation if continued behaviors: and remove from anger inducing situation immediately. Review of the care plans lacked any new interventions related to the incident between Resident R1 and Resident R2 that occurred on 5/29/22 until 6/02/22 (four days later). During a phone interview on 6/06/22, at 2:20 p.m. with the facility affiliated NHA, it was determined that the intervention Crisis Prevention Intervention is not a process utilized/understood in the facility nor does the facility have a policy describing the process but was placed in the care plan by the social worker from previous education. The facility failed to implement adequate safeguards to protect cognitively impaired residents from physical harm in a locked memory care unit resulting in harm for one of 16 residents. An Immediate Jeopardy situation was identified to the facility affiliated Nursing Home Administrator and Director of Nursing on 6/2/22, at 4:30 p.m., related to the facility's failure to protect Resident R2 from physical abuse and protect 15 cognitively impaired residents from the potential physical abuse from Resident R1. The Immediate Jeopardy template was provided to the facility on [DATE] at 4:30 p.m. The corrective action plan included: Medical Director notified of the event on 6/02/22 at 5:45 p.m. Administration/Management staff will provide education on one on one process to 104 facility staff by 9:00 p.m. 6/02/22 Staff members will not provide one on one care without education Identified Resident will be placed in continuous one on one visual observation effective immediately at 5:30 p.m. 6/02/22 Any variance in identified resident behavior indicating violence or abusive behavior will mandate physician contact One on one care provider will document any resident behaviors and immediately notify supervisor for additional review and action Supervisor will contact the Director of Nursing and Administrator for immediate remediation of resident behaviors, including transfer to an acute healthcare for evaluation The Director of Nusing or designee will review abusive behavior variances three times a week times four weeks and provide additional education for staff as indicated The Social Service staff will provide safety and psychological screening for 15 residents living on the dementia Unit by 2:00 p.m. on 6/03/22 The Administrative/Management Team will provide initial education for 104 facility staff on dementia/abuse and managing abusive behaviors by 2:00 p.m. on 6/03/22. Staff members will not start shift without completed education o abuse/dementia/abusive behavior Reinforcement education on dementia and behavior management will continue as indicated No new residents will be admitted for five days New referrals will be screened for past history and hospital admissions to determine admission decision and placement if appropriate Administrator will educate admission coordinator on preadmission screening process to prevent inappropriate admissions by 12:00 p.m. 6/03/22 QAPI will review documentation monthly Observation on 6/2/22 at 7:30 p.m. revealed Resident R1 had a sitter in the room. Employee E16 confirmed that they had received the one on one information,dementia/abuse and managing behaviors inservice prior to sitting with Resident R1. Observation of Resident R1 in the Dementia Unit on 6/03/22 at 9:00 a.m. revealed NA Employee E2 assisting Resident R1 with brushing their teeth. NA Employee E2 confirmed training regarding one on one, dementia/abuse and managing abusive behavior had been reviewed with the NA along with importance to document Residnet behavior and reporting During interviews of staff between 9:20 a.m. and 10:00 a.m., Registered Nurse Employee E12, Licensed Practical Nurse Employee E13, Physical Therapy Assistant Employee E11, NA Employee E10 and NA Employee E6 confirmed they had been informed of the one on one information and received training related to dementia, abuse and managing abusive behavior. Observation of Resident R1 in the Dementia Unit on 6/03/22 at 10:35 a.m. found Housekeeper Employee E17 sitting in room with Resident R1. Housekeeper Employee E17 stated they had received the one on one training and had been educated on the dementia/abuse and managing behaviors information. The Immediate Jeopardy was removed on 6/3/22 at 2:45 p.m. when the action plan implementation was verified. During an interview on 6/03/22 at 2:45 p.m., the facility affiliated Nursing Home Administrator and Director of Nursing confirmed that Resident R1 had physically abused Resident R2 on 5/29/22 and the facility failed to implement interventions after the assault to ensure that further physical assaults did not occur. 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)(3) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 211.12(d)(1)(3)(4)(5)Nursing services

Based on review of clinical records, facility documentation, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that one of four residents reviewed with food allergies (Resident R10) was free from exposure to a food allergen resulting in actual harm of an allergic reaction. This deficiency is cited as past non-compliance. Findings include: The facility policy entitled, Food Allergies and Intolerances, dated July 29, 2020, indicated that residents with food allergies would be identified upon admission and steps would be taken to prevent the resident's exposure to the allergen(s). The policy further indicated that all resident reported food allergies are documented in the assessment notes and incorporated into the resident's care plan. Resident R10's clinical record revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Resident R10's clinical record included a diet order and communication form dated July 20, 2019, that identified a food allergy to shrimp by the resident's daughter. physician's orders [REDACTED]. Registered Dietitian's (RD) admission note dated July 25, 2019, regarding Resident R10, and quarterly notes dated; August 9, 2019, November 11, 2019, January 13, 2020, and February 3, 2020, lacked the identification that Resident R10 had a shrimp allergy. The shrimp allergy was not noted until the May 7, 2020, in the RD's progress note with the nutritional care plan updated to reflect Resident R10's shrimp allergy. Facility documentation, revealed that on June 12, 2020, at 11:55 a.m. Resident R10, approached a staff nurse and stated, I think I ate shrimp and my throat is itchy and my tongue is going numb. physician's orders [REDACTED]. Resident R10 was transferred to the hospital via ambulance where the ambulance staff administered another 50 mg of [MEDICATION NAME] (medication used to treat [MEDICATION NAME], a serious allergic reaction that is rapid in onset) 0.3 mg and Solu [MEDICATION NAME] (corticosteroid medication to treat severe allergies) 125 mg. Resident arrived in emergency room and was monitored for two hours before being discharged back to the facility with a new medication order of [MEDICATION NAME] dose Pak (steroid medication to treat allergic disorders). During an interview on March 9, 2021, at 11:00 a.m. Licensed Practical Nurse, Employee E1 confirmed that the facility did not follow the physician's orders [REDACTED]. This deficiency is cited as past non-compliance. On June 12, 2020, the facility initiated plan of correction to address the exposure of a food allergen (shrimp) to Resident R10 that included the following: whole facility audit including affected resident for any signs or symptoms of any allergic reactions to foods immediately following incident; whole facility audit June 12, 2020, on all resident's allergies to compare with the electronic record, care plan and dining tickets; completed an allergy cross check on all residents on June 18, 2020; re-education of dietary staff by the dietary manager on June 12, 2020, facility policy; re-education of all staff including dietary manager on June 16, 2020, and June 19, 2020, on food quality, temperature, portion size, correct meal, allergies and diet per facility policy and physician order; the implementation of random, unannounced meal tray audits for tray accuracy, temperature, portions, appearance and quality of resident's meal trays on all units daily, then weekly beginning June 13, 2020, and ending the week of August 1, 2020, with no evidence of non-compliance with meal accuracy. The facility from the date of June 12, 2020 until March 9, 2021 had no evidence of residents with exposure to food allergens. Documentation provided by the facility during an interview on March 7, 2021, at 1:30 p.m. with the Nursing Home Administrator and the Director of Nursing confirmed that the facility had achieved compliance with measures to prevent residents from exposure to food allergens as indicated by Quality Assurance review at this time and will continue to monitor on a random basis. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services