Every finding on record at Hopkins Center

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: The Food Storage: Cold Foods policy states, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. An initial tour of the Food Service Department was conducted on July 14, 2026, at 9:30 a.m. with Employee E13, Assistant Food Service Director (AFSD), which revealed the following: The dumpsters located outside the receiving area had some trash on the side and back of the dumpsters. There was a large stack of boxes setting on several wooden pallets in the receiving area stacked in front of and blocking entrance into a side entrance. Observations in the dry storage area revealed several boxes of beard nets and hair nets stored under the ductwork less than 18'' from these fixtures and case of crackers stored less than 18 inches from the ceiling in the storage area adjacent to the walk-in freezer. The fluorescent light fixture in the storage area outside the walk-in freezer had no covering exposing wires hanging down. Observations in the walk-in refrigerator revealed a one third size stainless steel pan containing a purple jelly like substance with no label or date. Observation of the heater hanging from the ceiling in the corner of the kitchen revealed a heavy build-up of dust and dirt on the back of the unit. Observation in the kitchen revealed several flies buzzing around the kitchen. Observation of the reach in refrigerator revealed that it was not operational, but there was no sign on the unit to alert staff not to use it for food storage. Observation of the dish machine revealed that it was a low temperature sanitizing machine. When the rinse water was tested the test strip did not change color revealing no chlorine present to sanitize the dishes. Interview with the Assistant Food Service Director, Employee E13, at 9:30 a.m. on July 14, 2026, at 9:30 a.m confirmed the above findings. 28 PA Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to protect resident's privacy related to clinical information for two of nineteen residents observed (Resident R10 and Resident R78). Findings Include: Review facility policy on Patient's Privacy Rights With the most recent review date of July 17, 2026, revealed that under section policy #4 information security and health records access control access to physical and electronic health records is restricted to personal directly involve in patient scare or organization operations authorize disclosures medical and personal information will only be shared with a patient or individuals that have explicitly authorized. Under section PURPOSE: Personal privacy is a fundamental right that applies to all aspect of a patient's experience including accommodations, medical treatment, written and electronic communications, personal care, visits, and meetings. Observation conducted on July 14, 2026, at 10:29AM revealed that medication cart on the second floor was parked across room [ROOM NUMBER]. Further observation revealed that the laptop was open facing the hallway and unattended. Further, Resident R78's medication information exposed. Interview with Employee E8 conducted on July 17, 2026, at 1:05PM confirmed that the laptop on the medication cart on the second floor was open and was unattended. Observation on July 15, 2026, at 11:00 a.m. of Resident R10's room revealed a sign that stated, Please stop giving 304D ice water.thickened liquids only. A follow up tour was taken of the third-floor nursing unit on July 16, 2026, at 10:36 a.m. and the sign was still observed on Resident R10's wall. Interview and observation held with licensed nurse Employee E12, confirmed that Resident R10 had the sign on the wall and indicated I am unsure who put that there. 28 Pa. Code 201.29(j) Resident rights. 28 PA Code 201.29(c)(3) Resident rights 28 Pa. Code 211.5(b) Clinical records. 28 PA Code 211.5(b) Medical records 28 PA Code 211.12(d)(1) Nursing services

Based on observation, review of clinical records, review of facility policy and interview with staff it was determined that the facility failed to ensure that controlled substances were securely stored for two of two units observed (second and third floor units). Findings include:Review of facility policy on Medication Storage with a most recent revision date of January 2026, revealed that under section POLICY: Medications and biologicals are stored properly following manufacturers or provider pharmacy recommendations to keep their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Under section PROCEDURES: #2. Controlled medications should be stored separately from non-controlled medication. The access system used to lock scheduled medications cannot be the same access system used to obtain the non-scheduled medications. Schedule II medications and preparations must be stored in a separately locked permanently affixed compartment. Controlled substances stored in refrigerator should be secured in a separately locked permanently affixed compartment. Review of Resident R81's clinical record revealed that Resident R81 was admitted to the facility on [DATE], with diagnosis of but not limited to adjustment disorder with Depressed Mood (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Review of Resident R81's physician's orders revealed an order for Lorazepam Oral Concentrate 2 milligrams (mg)/milliliter (ml) (Lorazepam) Controlled Drug Give 0.25 ml orally every 4 hours as needed for anxiety for 14 Days dated April 8, 2026. Review of Resident R30's clinical record revealed that Resident R30 was admitted to the facility on [DATE], with diagnosis of but not limited to Generalized Anxiety Disorder (intense, excessive, persistent worry or fear). Review of Resident R81's physician's orders revealed an order for Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Controlled Drug Give 0.25 ml orally every 4 hours as needed for anxiety dated June 5, 2026. Third floor medication room observation with unit manager Employee E12 conducted on July 14, 2026, at 1:42PMrevealed that a medication refrigerator was in the medication administration room. Observation of the medication refrigerator revealed two vials of unopened Lorazepam Oral Concentrate 2mg/ml. Further, both vials were labelled with Resident R81's name. Further, both vials were not stored in a separately locked permanently affixed compartment. Further observation revealed that the two vials of unopened Lorazepam Oral Concentrate 2mg/ml were in an open bin together with non-controlled medications. Interview with Employee E12 conducted at the time of observation, confirmed that two vials of unopened Lorazepam Oral Concentrate 2mg/ml labelled with Resident R81's name were inside the third-floor medication refrigerator. Further Employee E 12 also confirmed that the two vials of unopened Lorazepam Oral Concentrate 2mg/ml labelled with Resident R81's name were not in a separately locked permanently affixed compartment and was mixed up with non-narcotic medications. Second floor medication room observation with unit manager Employee E10 conducted on July 14, 2026, at 1:58PMrevealed that a medication refrigerator was in the medication administration room. Observation of the medication refrigerator revealed one vial of opened Lorazepam Oral Concentrate 2mg/ml. Further, the vial was labelled with Resident R30's name. Further, the vial was not stored in a separately locked permanently affixed compartment. Further observation revealed that the vial of opened Lorazepam Oral Concentrate 2mg/ml were in an open bin together with non-controlled medications. Interview with Employee E10 conducted at the time of observation, confirmed that one vial opened vial Lorazepam Oral Concentrate 2mg/ml labelled with Resident R30's name were inside the second-floor medication refrigerator. Further Employee E10 also confirmed that the vial of opened Lorazepam Oral Concentrate 2mg/ml labeled with Resident R30's name was not in a separately locked permanently affixed compartment and was mixed up with non-narcotic medications. Further interview with Employee E10 revealed that licensed nurses have the keys to the medication room. Further Employee E10 also revealed that the central supply person also has access to the medication room. 28 PA Code 211.9 (k) Pharmacy services.

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to maintain ongoing communication between the facility and a dialysis provider for one of nineteen residents reviewed (Resident R22). Findings include: A review of the Dialysis: Hemodialysis (HD) - Communication and Documentation, revised November 14, 2025, revealed that the Center staff will communicate with certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at a certified dialysis facility. Review of Resident R22's clinical record revealed that the resident was admitted on [DATE], with diagnoses including but not limited to end stage renal disease (condition where the kidney reaches advanced state of loss of function). Further review of Resident 22's clinical record revealed that the resident has dialysis treatments three times per week on Monday, Wednesday and Friday at a local dialysis center with a 9:30 a.m. pickup time. Continued review of Resident R35's clinical record revealed no documentation predialysis or post dialysis by the facility on 7/3/26. Further review revealed no documentation post dialysis by the facility on the following dates (7/13/26, 7/10/26, 7/8/26, 7/6/26, 7/1/26, 6/29/26, 6/22/26, 6/19/26, 6/15/26, 6/12/26, 6/8/26, 6/1/26 and 5/29/26). Further review of progress notes reveals no refusals or missed appointments in June or July 2026. An interview on July 16, 2026, at 11:00 a.m. with Employee 12, Unit Manager, who stated that he/she was not sure why these log papers were not completed post dialysis and that he/she is not here when the resident returns from dialysis. The Unit Manager acknowledged that both the pre and post dialysis parts of the log sheets should be completed each time the resident goes to dialysis. The facility failed to maintain ongoing communication between the facility and a dialysis provider. 28 Pa. Code: 211.10(c) Resident care policies 28 Pa Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(5) Nursing services

Based on observation, review of clinical records, review of facility policy and interview with staff, it was determined that the facility did not maintain an effective infection control program related to EBP (enhanced barrier precaution) for one of nineteen residents observed (Resident R66). Findings include: Preview a facility policy on EBP (Enhanced Barrier Precaution) with the most recent revision date of November 14, 2025, revealed that under section POLICY: In addition to standard precautions, enhanced barrier precautions will be used for novel or targeted multi-drug resistance organisms. Enhanced barrier precaution expands on the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gowns and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROS to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated. Because enhanced barrier precaution do not impose the same restrictions as contact precautions, they are intended to be in place for the duration of the patient's stay in the center or until resolution of wound or discontinuation of the indwelling medical device that plays them at higher risk. Under section DEFINITIONS: Enhanced barrier precautions our infection control intervention designed to reduce the transmission of novel or multidrug resistant organisms. It employs targeted personal protective equipment used during high contact patient activities Under section PURPOSE: To reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Review of Resident R66's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Pressure Ulcer (localized damage to the skin and/or underlying soft tissue) of left hip. Review of Resident R66's clinical record revealed progress notes dated July 15, 2026, July 10, 2026, and July 6, 2026, discussing the status of Resident R66's wounds which includes a pressure ulcer stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) and moisture associated skin damage (MASD). Observation conducted during initial tour of the facility conducted on July 14, 2026, at 11:59AM revealed that there was no EBP (enhanced barrier precaution) signage posted outside Resident R66's. Interview with Licensed Nurse, Employee E5, confirmed that Resident R66 has a wound. Further Employee E5 confirmed that there was no EBP signage outside of Resident R66's room. Licensed Nurse, Employee E5, confirmed that EBP was necessary for residents with wounds. 28 PA Code 211.10(d) Resident care policies 28 PA Code 211.12(d)(5) Nursing services

Based on review of employee personnel records and staff interview it was determined that the facility failed to complete annual performance review at least every 12 months for two of six nurse aides reviewed (Employee E16 and Employee E18).Findings Include: Review of the facility performance reviews revealed two of the nurse aides were not completed timely. Review of facility documentation provided revealed that nurse aide Employee E16 was hired on November 19, 2017. Review of documentation provided by the facility Employee Performance Appraisal Form revealed nurse aide, Employee E16, most recent performance review was dated March 22, 2025. The facility was unable to provide a performance appraisal form for the year 2026. Review of facility documentation provided revealed that nurse aide Employee E18 was hired on November 4, 2020. Review of documentation provided by the facility Employee Performance Appraisal Form revealed nurse aide, Employee E18, most recent performance review was dated March 27, 2025. The facility was unable to provide a performance appraisal form for the year 2026. Interview on July 17, 2026, at 1:33 p.m. the Regional Nurse Employee E9 confirmed the evaluations were not able to be found for the year 2026 for Employees E16 and E18. 28 Pa. Code 201.14(a) Responsibility of License 28 Pa. Code 201.19(2) Personnel Policies and Procedures

Based on review of facility policy, observations and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean and homelike environment for two of two nursing units observed (Second floor and Third floor units).Findings Include: Review of the facility policy titled, Safe and Homelike Environment last revised on November 24, 2025, reveals the resident has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. Further review of the facility policy revealed, Process- The Center must provide 1.1 A safe, clean, comfortable, and homelike environment, allowing the patient to use his/her personal belongings to the extent possible.1.1.3.3 Open and close bedroom and bathroom doors, easily access areas of the room and bath, and operate room lighting. Observation made on the second-floor nursing unit on July 14, 2026, at 10:00 a.m. revealed several observations throughout the second floor that were not clean, comfortable, and homelike. room [ROOM NUMBER] was observed with seven stained ceiling tiles with brown staining. room [ROOM NUMBER] was observed with curtains that were soiled with brown stains. room [ROOM NUMBER] was observed with three stained ceiling tiles with brown staining. Observation made on the third-floor nursing unit on July 14, 2026, at 11:44 a.m. revealed several observations throughout the third floor that were not clean, comfortable and homelike. room [ROOM NUMBER] was observed with a bathroom that had a broken door handle. Interview on July 14, 2026, at 1:00 p.m. with Maintenance Director, Employee E4, revealed doorknobs were ordered one and half weeks ago and should be coming any day. The bathroom door handle was observed with tan masking tape. The bathroom door handle was inoperable. Observations on July 15, 2026, at 11:45 a.m. revealed room [ROOM NUMBER] bathroom door handle was broken. The handle was observed with tan masking tape. The bathroom door handle was inoperable. room [ROOM NUMBER] was observed with curtains that were soiled with brown stains. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observation, review of clinical records, review of facility policy and interview with staff and residents, it was determined that the facility failed to provide oxygen to a resident according to physician orders for one of four residents observed (Resident R78). Findings include: Review facility policy on Oxygen: Concentrator with a most recent revision date of August 7, 2023, revealed that an oxygen concentrator extracts oxygen molecules from room air it can be used for low oxygen flow rates for example one to four liters per minute #10. Set litter flow per order #14 document 14.1 date and time oxygen started 14.2 method of administration 14.3 litter flow and 14.4 patient response to therapy. Observation conducted on July 14, 2026, at 11:44AM revealed that Resident R78 O2 on Oxygen concentrator via nasal cannula at 2 liters/minute. Interview with Resident R78 conducted at the time of the observation confirmed that she was on Oxygen and that she has been receiving Oxygen continuously via nasal cannula since last year. Review of Resident R78's clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnosis of but not limited to Atherosclerotic Heart Disease and Hypoxemia. Review of physician's orders revealed an order for Oxygen at 3 L/min via NC (nasal cannula) continuously for SS (signs and symptoms) of SOB (shortness of breath) or pulse ox below 92% every shift. Post Tx: Evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds related to HYPOXEMIA - dated July 15, 2026, Follow-up observation conducted on Resident R78 conducted on July 15, 2026, at 1041AM O2 concentrator via nasal cannula at 2 liters/minute. Interview with Employee E8 conducted at the time of the follow-up observation confirmed that Resident R78 was on Oxygen concentrator via nasal cannula at 2 liters/minute. 28 PA Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, observations, and resident and staff interview it was determined the facility did not ensure an environment free of accidents and hazards related to medications found bedside for two of two units reviewed (Second floor and Third Floor). Findings Include: Review of facility policy titled, Medication Storage dated January 2026 states, Policy- Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective administration. The medication supply shall be accessible only to a licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. A tour was taken of the second-floor nursing unit on July 14, 2026, at 9:30 a.m. Observation on July 14, 2026, at 9:41 a.m. in Resident R5's room revealed the resident had a plastic medication cup with pills and a plastic medication cup with a brown liquid. When Resident R5 was questioned about the medications, the resident stated he/she takes a while to take the medications one at a time so the nurse usually leaves it for him/her to take. Licensed nurse, Employee E7, was called to the room and confirmed he/she usually checks back to ensure Resident R5's takes all of his/her medications but today, he/she did not check back. Review of Resident R5 facility record revealed the resident was admitted to the facility on [DATE]. The resident had the following diagnosis: Type Two Diabetes (a chronic condition where sugar builds up in the blood because the body cannot use insulin properly or make enough of it), Hypertension (a common condition where blood pushes too hard against your artery walls at levels consistently at or above 130/80 mm Hg), Chronic Kidney Disease (a long-term condition where the kidneys are damaged and cannot filter blood well), Osteomyelitis (a painful infection and swelling of the bone most often caused by bacteria), and Protein Calorie Malnutrition (o a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Review of Resident R5's clinical record revealed no documented evidence the resident was assessed or had a physician order to safely self-administer his/her own medications. A tour was taken of the third floor on July 14, 2026, at 10:45 a.m. Observation on July 14, 2026, at 11:01 a.m. in Resident R17's room revealed the resident was in bed and appeared disoriented. Resident R17's tray table was located a few feet away with a plastic medication cup filled with pills. Resident R17 was unable to tell the surveyor if they were his/her pills. Licensed nurse, Employee E5, was located in the hall at 11:05 a.m. and came to Resident R17's room. Licensed nurse, Employee E5, came to the resident's room and confirmed they were Resident R17's medications. Licensed nurse, Employee E5, was asked if Resident R17 was able to self-administer medications to which Employee E5 responded, yes. Review of clinical record revealed Resident R17 was admitted to the facility on [DATE], and has the following diagnosis: Dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Major Depressive Disorder (is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), Schizoaffective Disorder (is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), Psychophysiologic Insomnia (is a chronic sleep disorder where anxiety and learned associations about sleep prevent restful sleep, often perpetuating a cycle of hyperarousal and sleeplessness), and Anxiety Disorder ( is a mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Review of Resident R17's clinical record revealed no documented evidence the resident was able to self-administer medications. Interview on July 16, 2026, at 2:33 p.m. with the Director of Nursing, Employee E2, confirmed Resident R5 and R17 are not able to self-administer medications. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility records, review of clinical record, review of facility policy and interview with staff and residents, it was determined that the facility did not ensure that a comprehensive person-centered care plan related to smoking was completed for one of nineteen residents reviewed (Resident R66). Findings include:Review of facility policy on Person-Centered Care Plan with a most recent review date of July 17, 2026, revealed that under section POLICY: The center must develop and implement a person-centered care plan for each patient/resident consistent with patient rights measurable objectives and time frames to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. Care plan includes measurable objectives and timetables to meet a patient's medical nursing nutrition and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be prepared by the interdisciplinary team. The interdisciplinary team in conjunction with a patient and or patient representatives as appropriate, will establish the expected goals and outcomes of care the type, amount, frequency and duration of care, and any other factors related to the effectiveness of the plan of care. The care plan will be reviewed and revised by the interdisciplinary team after each assessment. Under section PURPOSE: To attain or maintain the patient's highest practical physical mental and psychosocial well-being. To promote positive communication between patient, patient representative and team, to obtain the patient's, patient representative's input into the plan of care, ensure effective communication and optimize clinical outcomes. Under section PRACTICE STANDARDS: #2 Comprehensive care plans #2.1 a comprehensive individualized care plan will be developed within seven days after completion of the comprehensive assessment and review and revise the care plan after each assessment. Review of Resident R66 clinical record revealed that Resident R66 was admitted to the facility on [DATE], with diagnosis of but not limited to Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of facility smoking list revealed that Resident R66 was a smoker. Review of Resident R66's care plan revealed that there was no care plan for smoking. Interview with Resident R66 conducted on July 15, 2026, at 11:46 a.m. revealed that Resident R66 was a smoker. Interview with licensed nurse, Employee E9, conducted on July 16, 2026, at 12:45 p.m. confirmed that Resident R66 was a smoker. Further, Licensed Nurse, Employee E9, also confirmed that the facility did not develop a person-centered care plan related to smoking for Resident R66. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on review of clinical records, and interview with staff, it was determined that the facility failed to ensure that MDS (minimum data set- a federally required resident assessment completed at a specific interval) was completed accurately for one of nineteen residents reviewed). Findings include: Review of Resident R78's clinical record revealed that Resident R78 was admitted to the facility on [DATE], with diagnosis of but not limited to Atherosclerotic Heart Disease (a condition that causes arteries to narrow, restricting healthy blood flow to organs and other parts of the body). Review of physician's orders revealed an order for Oxygen at 3 Liters/minute (L/m) via Nasal Cannula, continuously, wean as tolerated to maintain blood oxygen (spo2) 92% or greater every shift- dated December 9, 2025, and Discontinued June 30, 2026. Review of quarterly MDS dated [DATE], section C0500. BIMS Summary Score revealed a score of 15 suggesting that Resident R78 was cognitively intact. Section O0110. Special Treatments, Procedures, and Programs C1. Oxygen therapy was coded NO. Observation conducted on July 14, 2026, at 11:44AM revealed that Resident R78 was on Oxygen concentrator via nasal cannula at 2 liters/minute. Interview with Resident R78 conducted at the time of the observation confirmed that she has been receiving Oxygen continuously via nasal cannula since last year. Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E11 conducted on July 17, 2026, at 10:43AM confirmed Resident R78 received Oxygen in June during the time Resident R78's quarterly MDS dated [DATE], was completed. Further RNAC, Employee E11, confirmed the MDS was marked as NO in section C1. Oxygen therapy of the MDS assessment. Further Employee RNAC, Employee E11, confirmed that Resident R76's quarterly MDS assessment dated [DATE], was coded incorrectly. 28 Pa. Code 211.5 (f) clinical records 28 Pa, Code 211.12 (d)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent surveys were posted in a place readily accessible to residents, family members, and legal representatives in one of one area reviewed (main lobby).Findings Include: Review of facility survey history revealed a full health survey was conducted on August 7, 2025, and various abbreviated surveys in response to complaints were conducted in 2025 and 2026. A tour was taken of the facility on July 14, 2026, at 10:00 a.m. Observation in the facility lobby area revealed the Department of Health Survey binder was located on the wall. The Department of Health survey binder was reviewed, and the last printed document was from the year 2024. Interview held with Employee E1 the Nursing Home Administrator on July 14, 2026, at 11:50 a.m. revealed that they were responsible for updating the survey binder and were unaware it had not been updated since the year 2024. The Nursing Home Administrator Employee E1 confirmed that they were responsible for ensuring that the Department of Health Surveyor binder should contain the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, review of the facility policy and staff and resident interview, it was determined that the facility failed to ensure that call bells were available and operable for resident use for one of 19 residents observed (Residents R57). Findings include: Review of facility policy, Call Lights, revised June 6, 2021, revealed that Patients will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow patients to call for assistance when unattended. Staff will respond to call lights and communication devices promptly. Interview with Resident R57 in room [ROOM NUMBER] bed D, on July 15, 2026, at 11:25 a.m. revealed that he/she uses roommate's call bell because his/hers is not working. Observation of the call revealed that the bell for bed D was cracked at the top and the red button was also cracked and could not be pressed in to operate the call bell. When the button was pushed, it did not activate. Further observation of the light on the ceiling outside Resident R57's door revealed that it did not ignite the light after pressing the button multiple times. Interview with the unit manager, E12, on July 15, 2026, at 11:30 a.m. confirmed that the call bell for bed 326-D was not working. 28 Pa. Code 205.67(j) Electric requirements for existing construction 28 Pa. Code 201.18 (b)(1) Management 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility documentation and staff interviews, it was determined that the facility failed to include active involvement from direct care staff and input from residents or resident representatives in the facility assessment process.Findings Include: Review of the facility assessment revealed the only assessment contributors as; The Medical Director, Director of Nursing, Nursing Home Administrator, and one Representative from a Governing Body. Further review of the facility assessment revealed there was no direct care staff, residents, or resident representative input in the facility assessment process. Interview held with the Nursing Home Administrator Employee E1 on July 15, 2026, revealed that the facility assessment is reviewed quarterly when administration meets for Quality Assurance and Performance Improvement but there were no opportunities for staff, residents, or resident representative involvement in the facility assessment. 28 Pa. Code 201.18 (b)(3) Management. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility did not ensure to accurately post information regarding daily nurse staffing data as required.Findings Include: Observation on July 14, 2026, at 11:45 a.m. revealed the nurse staffing was posted on the front desk in the lobby area. Review of the nurse staffing posting revealed it was dated July 7, 2026. Interview on July 14, 2026, at 11:45 a.m. with the front desk receptionist, Employee E20, revealed the staffing coordinator, Employee E21, has been out of work and that may be why the staffing is not up to date. Interview on July 14, 2026, at 11:50 a.m. with the Nursing Home Administrator, Employee E1, confirmed that nurse staffing was only posted at the front lobby and it was posted for July 7, 2026. Nursing Home Administrator, Employee E1, confirmed there is no other place in the facility where the nurse staffing is posted. 28 Pa. Code 201.14(a) Responsibility of licensee

Review of the facility ' s policy titled Abuse Prohibition revised October 2022 defines abuse as the willful infliction of injury resulting in physical harm injury or mental anguish. The same policy states anyone who witnesses an incident . injuries of unknown origin will report the incident to his/her supervisor immediately . the supervisor will report the suspected abuse immediately to the Administrator. Review of Resident R1's clincial record revealed the resident diagnoses of chronic obstructive pulmonary disease (lung disease), vascular dementia (a type of dementia caused by damage to the blood vessels in the brain leading to cognitive decline) and documented as severely cognitively impaired. Review of facility documentation and investigation dated October 6, 2025, revealed Licensed Practical Nurse (LPN), Employee E3 noticed a bruise on Resident R1 ' s hand. Nurse Aide (NA), Employee E4 witness statement revealed the NA first noticed the bruising when providing care on the resident on Sunday, October 5, 2025. The same witness statement revealed the NA immediately informed the charge nurse assigned to Resident R1, who was LPN Employee E5. Surveyor's observation on October 9, 2025 at 2:00 p.m. of Resident R1's revealed a dark blue/purple discoloration on top of the resident's left hand. During an interview with NA, Employee E4 on October 9, 2025, at 3:51pm stated she knew Resident R1 well and was scheduled as the resident ' s aide from Saturday, October 4, 2025 through Monday, October 6, 2025. The NA stated on Saturday [DATE], during the 7-3 shift the NA did not notice any bruising. On October 5, 2025 on 7-3 shift while the NA was washing the resident she noted the bruise that was described as red with part purple discoloration to the resident ' s left hand. The NA said the resident was in pain and would not let the NA touch it. The NA stated in the interview and noted in the NA ' s witness statement that the NA stopped care and immediately told the nurse, LPN Employee E5. The nurse looked at Resident R1 ' s hand and said, ' Maybe it is poor circulation. Review of LPN, Employee E5 ' s witness statement dated October 7, 2025, stated he, Was made aware of discoloration to resident ' s left hand. right hand. Further review of Resident R1 ' s clinical record revealed no documented evidence that the LPN made the facility aware of this potential abuse allegation. During an interview with the Nursing Home Administrator and the Director of Nursing on October 9, 2025, at 4:00 p.m. confirmed LPN, E5 failed to report the injury of unknown origin when the bruise was initially found.28 Pa Code 211.12(d)(1) Nursing services

Based on resident council interview, staff interviews, review of facility policy and reviews of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on the three of three nursing units. (First, Second, and Third Floors). Findings include:Findings include:A review of facility policy titled Snacks, Revised September 2017, revealed that bedtime snacks will be provided foal l residents. The dining services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. Continued review revealed that Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. A review of the established meal schedule for the residents revealed that the supper meal was scheduled for 4:45 p.m. on the first and second-floor nursing units; 5:00 p.m. on the third-floor nursing unit; and 5:15 p.m. on the third-floor nursing unit; and that the breakfasts meal the following morning was offered at 7:45 a.m. the following day. On August 6, 2025, at 10:30 a.m., a resident council was held with nine alert and oriented residents (R27, R42, R78, R50, R23, R46, R45, R65, R3). The residents reported that nourishing snacks were not offered at bedtime. They stated that they eat dinner at 4:45 p.m. and become hungry later in the evening.On August 7, 2025, at approximately 11:25 a.m., an interview was conducted with the Dietary Director, Employee E8, who stated that she maintains a list of all diabetic residents who are assigned afternoon and nighttime snacks. The remaining residents receive a regular snack, such as a cookie or milk. Night snacks are prepared and sent out by dietary staff; however, it is the responsibility of the nursing staff to offer them to all residents.On August 7, 2025, at approximately 11:30 a.m., an interview was conducted with the dietician, Employee E4. The interview revealed that dinner is served at 4:45 p.m. in the second-floor dining room, and breakfast is offered at 7:45 a.m. to the same residents, resulting in a 15-hour gap between these two meals.On August 7, 2025, at approximately 3:00 p.m., the Director of Nursing, Employee E2, and the Regional Nurse, Employee E3, confirmed that night snacks are delivered by the kitchen staff; however, it is unknown if the nursing staff are actually offering them to residents. 28 Pa. Code: 201.14(a) Responsibility of license

Based on review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for two of 18 residents reviewed (Resident R42 and R2). Findings include:Review of facility policy Prosthetics and Orthotics dated December 16, 2024 revealed that Nursing will routinely: inspect the prosthesis and/or orthostatic device to determine if it fits correctly and is functioning as intended, or if it is in need for repair. Evaluate skin/mucus membrane that comes in contact with the prosthesis to ensure it is free of abrasion, wounds, or irritation.Review of clinical record for Resident R2 revealed that the resident had diagnosis including acquired absence of right leg below knee, acquired absence of right leg below knee, and peripheral vascular disease.Review of clinical record dated June 27, 2025, revealed that the resident that while giving shower nurse aide noted new skin issue. Resident was noted stage 2 pressure injury to left lateral inner knee. Resident stated it was from his prostheses being too tight and mentioned therapy had recently adjusted it. Inspected both left and right leg as resident is bilateral below knee amputation and used prosthetics on both lower extremities.Review of care plan for Resident R2 dated June 4, 2025 revealed that the resident was at risk for skin breakdown related to decreased mobility and left and right knees amputation. Care plan interventions prior to June 27, 2025 revealed no care plan interventions for skin check prior to or after wearing prosthesis, evaluating the proper fit of the prosthesis and the proper functioning of the prosthesis.Interview with Lead Wound Care Nurse, Employee E12, on August 7, 2025, at 1:15 p.m., confirmed that staff should check residents' skin at the location where prosthesis touches the skin before and after placing the prothesis or periodically if resident wears the prosthesis independently. Employee E12 also confirmed that the care plan intervention for Resident R2 did not include interventions for skin check prior to or after wearing prosthesis, evaluating the proper fit of the prosthesis and the proper functioning of the prosthesis. Review of resident R42's clinical record revealed that the resident was admitted wo the facility on March 20, 2017, with diagnoses including legal blindness. Interview with the facility Director of Nursing and Regional Nurse, Employee E3, conducted on August 7, 2025, at approximately 2:30 p.m. confirmed that a care plan to address communication in relation to legal blindness for Resident R42; there were no focus, interventions, and goals care planned for Resident R42's diagnosis of Legal Blindness.28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain the facility in a clean, safe, comfortable and homelike condition in one of two nursing floors (2nd floor nursing unit). Findings include:On August 4, 2025, at approximately 11:00 a.m., the first-floor conference room began to experience a ceiling leak. The surveyor notified the Administrator, Employee E1, and three maintenance staff were sent to investigate the plumbing issue on the second floor. Upon arriving at room [ROOM NUMBER], it was observed that the sink was clogged and overflowing onto the bathroom floor. Standing water was present on the floor and leaking into the first-floor conference room. On August 5, 2025, at 12:52 p.m., an interview with Resident R80 revealed that her bathroom sink had leaking pipes, which caused water to drip onto the floor and resulted in water damage to both the floor and the first-floor conference room ceiling. She reported that this issue had reoccurred approximately three to four times over the past two months. Resident R80 stated that she had notified the maintenance staff.On August 7, 2025, at approximately 2:00 p.m., the first-floor conference room began to experience a ceiling leak again. The surveyor notified the Administrator, Employee E1. It was determined that the sink in room [ROOM NUMBER] was leaking once more. At that time, a Certified Nursing Assistant was providing care to Resident R80 and reported that the sink leak continues to occur. Over the past two months, the sink has been clogged twice, resulting in repeated damage to the bathroom floor. Administrator confirmed the bathroom leak.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) (3) Management.

Based on a review of facility policies, staff interviews, and observations, it was determined that the facility failed to maintain personal privacy for one of 18 residents reviewed (Resident R80).Findings include:On August 4, 2025, at approximately 11:00 a.m., the first-floor conference room began to experience a ceiling leak. Nursing Home Administrator, Employee E1, and three maintenance staff were notified. Upon arriving at room [ROOM NUMBER], it was observed that the sink was clogged and overflowing onto the bathroom floor. Standing water was present on the floor and leaking into the first-floor conference room. While three maintenance staff were working on the plumbing issue, Resident R80 was receiving morning care. It was observed that Resident R80's privacy curtain only covered a quarter of the resident's bed, failing to provide full privacy.On August 5, 2025, at 12:52 p.m., an interview with Resident R80 revealed that the resident only has half of the privacy curtain in (her/his) room. Resident R80 further stated that for the first nine months of (her/his) admission, the facility never provided a privacy curtain. Resident R80 explained, When my roommate has guests and I have a Nursing Assistant (NA) providing care at my bedside, I request that her guests leave because my curtain does not close, which prevents me from having full privacy during care. Resident R80 reported that (she/he) received half of a curtain approximately five months ago and, at that time, requested a full curtain, as the half curtain did not provide (her/his) with adequate privacy.On August 6, 2025, at 2:26 p.m., an observation conducted with the Administrator, Employee E1, confirmed that R80 had only half of a curtain and that there was a lack of privacy in her room.28 Pa. Code 201.29(a) Resident Rights.

Based on the review of facility documentation, clinical records, hospital records, and interviews with resident and staff, it was determined the facility failed to provide appropriate staff supervision and failed to complete a thorough assessment of the resident environment for Resident R75 with a diagnosis of alcohol dependency. This failure resulted in actual harm to Resident R75 who was found with symptoms of intoxication, transferred to the hospital, diagnosed with alcohol intoxication with a blood alcohol level of 276 mg/dL and required intravenous therapy for one of 38 residents reviewed. (Resident R75) Findings include: Review of Resident R75's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of alcohol dependence, Bipolar Disorder (condition in which a person has periods of depression, and periods of being extremely happy), history of transient ischemic attack (stroke), alcohol cirrhosis of liver (severe scaring of the liver), generalized anxiety disorder, and difficulty walking. Review of Resident R75's Minimum Data Set assessment (MDS- assessment of resident care needs) dated August 5, 2024, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed that the resident had no upper or lower extremities impairment and was independent with ambulation. Review of Resident R75's nursing notes dated September 17, 2024, (late entry 5:46 p.m.) revealed the resident was found to have a small water bottle with clear liquid in the bottom that smelled of alcohol. The resident did say (she/he) was drinking. (She/he) refused to say how (resident) obtained the alcohol. (Resident) stated everyone here was buying it. [Resident R75] was hitting elevator, slurring (his/her) speech order to send to ED (emergency room ) or evaluation was obtained however [Resident R75] refused to go with ambulance. (Resident) refused to allow NHA (Nursing Home Administrator) and DON (Director of Nursing) ro (sic) search (resident) room. MD (physician) was made aware and nursing. Plan of care ongoing. Review of Resident's R75's clinical record revealed that there was not evidence that a care plan was developed related to the resident's diagnosis of alcohol dependency and/or following the incident on September 17, 2024 in which the resident admitted obtaining and drinking alcohol. Review of nursing note dated October 2, 2024, at 9:00 a.m. revealed the resident met with the administrator team to address a drinking incident that occurred over the weekend. During the meeting, the team discussed the situation in detail, reviewed the impact of the incident and provided the resident with a formal 30-day notice of discharge. Review of Social Service documentation dated October 2, 2024, revealed that Resident R75 had a drinking incident that occurred over the weekend (9/29-9/30, 2024). A 30-day discharge notice was issued to the resident due to endangerment of resident safety related to multiple occasions where resident was found to be visibly intoxicated with verbal aggression towards others. Review of Resident R75's nursing notes from September 2024 through October 2024 revealed no documented evidence of verbal aggression toward other residents related to the use of alcohol. Review of Resident R75's nursing notes dated October 3, 2024, at 3:19 p.m. revealed Resident had screamed out in (her/his) room that (resident) stung by a bee .Patient was slurring (her/his) words and tipsy sitting up in bed. Resident went to bathroom and was tipsy walking to the bathroom. Nursing seen a water bottle hidden under a pillow in (resident) room. When UM (Unit Manager) opened the bottle to smell, you could smell liquor in bottle resident grabbed it from my hand and stated that is non of your business leave it alone. Patient than began to state (she/he) needs benadryl bc (because) (she/he) is allergic . [Physician] called an notified of above and gave verbal order to sent resident out to hospital . Prior to resident leaving (she/he) agreed to a room search and 3 more empty water bottles were found smelling of vodka, and empty mouth wash were also found. Review of facility documentation submitted to the State survey agency dated October 3, 2024, revealed that Resident R75 was observed by staff on 10/3/24, slurring (her/his) speech, arguing aggressively with staff and other residents. [Her/his] behavior appeared impaired. [Resident] refused to allow search of [her/his] room and belongings. [Resident] did state that someone from the kitchen brings in the alcohol. [She/he] refused to mention the name of the staff member. A facility investigation was conducted which included interview with Resident R75, other residents and all dietary staff and in-house staff. The resident refused room searches. Resident R75 does not receive any visitors but frequently orders from an online store and online meal service. The investigation was inconclusive of how resident received alcohol. Review of hospital discharged records dated October 4, 2024, revealed the resident primary diagnosis of alcohol intoxication. The resident's blood alcohol (BAC) level 276 (BAC as mg/dL: for every 100 milliliters (or 1 deciliter) of blood, there are 200 milligrams of alcohol) at admission. Patient received IV (intravenous fluids). Review of www.consumershield.com/articles/blood-alcohol-level-chart A revealed, a blood alcohol consumption level of 0.40%+ is typically lethal, while 0.25%-0.39% can cause coma or death. Severe alcohol poisoning at these levels may shut down vital functions. Review of Resident R75's care plan revealed, a care plan for substance abuse/ alcohol dependence was not developed until October 6, 2024. Interview with Nursing Home Administrator (NHA), Employee E1 and Director of Nursing, Employee E2 on March 12, 2025, at 1:35 p.m. confirmed there were no reported incidents or investigation relating to September 17, 2024, and during the weekend of October 2, 2024, that pertained to Resident R75 being observed intoxicated. Interview with Resident R75 on March 11, 2025, at 10:15 a.m. revealed the resident was aware of the thirty-day discharge notice and that she/he has been working with social work and care provider to aid in this transition. [She/he] looking forward to moving on with [her/his] life and eager to leave the facility. Interview with Resident R75 on March 13, 2025, at 9:05 a.m. revealed that she/he has had no problems with the administration and or any rules/ regulations of the facility. Resident R75 confirmed placing orders online for food and products. Review of the resident's clinical record revealed no documented evidence the faciltiy implemented interventions to monitor and supervise Resident R75's environment for the presence and consumption of alcohol. The facility failed to provide appropriate staff supervision and failed to complete a thorough assessment of the resident environment which resulted in actual harm to Resident R75 who was found with symptoms of intoxication, transferred to the hospital, diagnosed with alcohol intoxication with a blood alcohol level of 0.27% and required intravenous therapy. 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1) Nursing Services

Based on review of facility policy, facility documents, clinical records, and interview with staff; it was determined the facility failed to develop a comprehensive care plan and interventions to address Resident R75 diagnosis of alcohol dependency. This failure resulted in actual harm to Resident R75 who was observed with signs/symptoms of intoxication, transferred to hospital, and diagnosed with alcohol intoxication which required intravenous therapy for one of 38 residents reviewed. (Resident R75) Findings include: Review of facility policy titled Person Center Care Plan revised October 24, 2022, revealed the center must develop and implement a baseline person centered care plan within 48 hours of admission for each resident that includes instructions needed to provide effective and person-centered care that meet professional standards of quality care. A comprehensive person-centered care plan must be developed for each patient and must describe the following services that are to be furnished, any service that would otherwise be required but not provided due to patients exercise of rights including the rights to refuse treatment, any specialized service or specialized rehabilitative service that the center will provide as a result of the PASRR (Pennsylvania Pre-Admission Screening) recommendations. Care plans will be communicated to appropriate staff, patient, patient representative and family. Reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and the changing needs and goals; and documented. Review of Resident R75's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of alcohol dependence, Bipolar Disorder (condition in which a person has periods of depression, and periods of being extremely happy), history of transient ischemic attack (stroke), alcohol cirrhosis of liver (severe scaring of the liver), generalized anxiety disorder, and difficulty walking. Review of Resident R75's quarterly Minimum Data Set assessment (MDS- assessment of resident care needs) dated August 5, 2024, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident had no upper or lower extremities impairment and was independent with ambulation. Review of Resident R75's nursing notes dated September 17, 2024, (late entry 5:46 p.m.) revealed, the resident was found to have a small water bottle with clear liquid in the bottom that smelled like alcohol. The resident did say (he/she) was drinking. (Resident R75) refused to say how (he/she) obtained the alcohol. (He/she) stated every one here was buying it. Further review of same Resident R75's nursing note dated September 17, 2024 revealed, [Resident R75] was hitting elevator, slurring (his/her) speech, order to send to ED (emergency room ) or evaluation was obtained however [Resident R75] refused to go with ambulance. She/he refused to allow NHA (Nursing Home Administrator) and DON (Director of Nursing) ro (sic) search room. MD (physician) was made aware and nursing. Plan of care ongoing. Review of Resident's R75's clinical record revealed that there was not evidence that a care plan was developed related to the resident's diagnosis of alcohol dependency and/or following the incident on September 17, 2024 in which the resident admitted obtaining and drinking alcohol. Review of nursing note dated October 2, 2024, at 9:00 a.m. revealed, the resident met with the administration team to address a drinking incident that occurred over the weekend. During the meeting, the team discussed the situation in detail, reviewed the impact of the incident and provided the resident with a formal 30-day notice of discharge. Review of Social Service documentation dated October 2, 2024, revealed that Resident R75 had a drinking incident that occurred over the weekend (9/29-9/30, 2024). A 30-day discharge notice was issued to the resident due to endangerment of resident safety related to multiple occasions where resident was found to be visibly intoxicated with verbal aggression towards others. Continued review of nursing notes dated October 3, 2024, at 3:19 p.m. revealed Resident had screamed out in (his/her) room that (he/she) stung by a bee .Patient was slurring (his/her) words and tipsy sitting up in bed. Resident went to bathroom and was tipsy walking to the bathroom. Nursing seen a water bottle hidden under a pillow in (resident) room. When UM (Unit Manager) opened the bottle to smell, you could smell liquor in bottle resident grabbed it from my hand and stated that is non of your business leave it alone. Patient than began to state '[resident] needs benadryl bc (because) [resident] is allergic .' [Physician] called an notified of above and gave verbal order to send resident out to hospital . Prior to resident leaving (he/she) agreed to a room search and 3 more empty water bottles were found smelling of vodka, and empty mouth wash were also found. Review of Resident R75's hospital discharged records dated October 4, 2024, revealed the resident's primary diagnosis of alcohol intoxication. The resident blood alcohol (BAC) level 276 (BAC as mg/dL: for every 100 milliliters (or 1 deciliter) of blood, there are 200 milligrams of alcohol) at admission. Patient received IV (intravenous fluids) at admission. Patient received IV (intravenous fluids). Review of Resident R75's clinical record revealed a care plan for substance abuse/alcohol dependence which was not initiated until October 6, 2024. The goal of the care plan was for the resident to have decreased episodes of alcohol seeking behaviors. Interventions included to build resident relapse prevention skills by helping identify early signs of relapse, observe for signs and symptoms of withdrawal for detox, reassess resident to determine if substance use can be effectively managed in the current setting initiated, monitor conditions that may contribute to substance use, monitor medications for potential contribution to substance and or drug interaction. Interview with Licensed nurse, Employee E9 on March 13, 2025, at 9:50 a.m. who was on duty during the drinking incident that occurred over the weekend (9/29-9/30, 2024) per Social Service documentation on dated October 2, 2024, revealed that she has no knowledge of the resident diagnosis of alcohol abuse. Interview with Nursing aide, Employee E7 on March 13, 2025, at 10:05 a.m. This employee confirmed that she was familiar with Resident R75. Nursing aide, Employee E7 stated [she/he] is very nice and always happy. Employee E7 denies having any knowledge of Residents R75 history of alcohol abuse and denies any awareness of Resident R75 observed intoxicated with any behaviors. Interview with Nursing aide, Employee E8 confirmed that she was familiar with Resident R75. Employee E8 denied any knowledge of Resident R75's diagnosis of alcoholism and of incidents relating to the resident being intoxicated. Interview with Director of Nursing (DON), Employee E2 and Regional Nurse, Employee E5 on March 13, 2025, at 9:00 a.m. confirmed that the resident's care plan was initiated after October 4, 2024. DON, Employee E2 confirmed that the care plan was updated to reflect the resident's alcohol abuse after the last known occurrence on October 4, 2024. The facility failed to develop a comprehensive care plan and interventions to address Resident R75's diagnosis of alcohol dependency. This failure resulted in actual harm to Resident R75 who was found intoxicated on three different occassions while at the facility from September 17, 2024 through October 2, 2024. Resident R75 was transferred to the hospital, diagnosed with alcohol intoxication and required intravenous therapy on October 2, 2024. Refer to F689 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1) Nursing Services

Based on review of facility policies, clinical record, facility documentation, and interviews with residents and staff, it was determined the facility failed to prevent resident neglect by not following safe resident care guidelines which resulted in harm to Resident R1 who sustained fractures of the left humerus, the spine, and contusion to the right shin for one of seven residents reviewed (Resident R1). Findings include: Review of facility policy titled, Safe Resident Handling Program dated April 15, 2023, revealed, Transfer assistance, mobility, and other resident handling tasks are to be carried out in accordance with the Lift/Transfer Assessment and care plan. Review of facility policy titled Abuse Prohibition, dated October 24, 2022, revealed, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients. Continued review revealed, Neglect is defined as the failure, indifference or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident R1's Quarterly MDS Assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 9, 2024, revealed the resident was admitted to the facility on [DATE], and had diagnoses of Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), Respiratory Failure (not enough oxygen passes from the lungs to the blood), Renal Failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), morbid obesity (excess body fat) and Lymphedema (swelling caused by a buildup of fluid in one area of your body, usually an arm or a leg). Continued review revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. Further review revealed the resident required substantial/maximal assistance for rolling left and right in bed. Review of Resident R1's care plan, dated October 31, 2023, revealed the resident required assistance with activities of daily living care, including bed mobility. A care plan intervention, dated May 23, 2024, revealed the resident required two person assistance with all care. Continued review of Resident R1's care plan, revealed the resident was at risk for falls related to impaired mobility. Further review of Resident R1's care plan revealed an intervention, dated February 2, 2025, for the resident to have quarter side rails for mobility and repositioning. Review of Resident R1's Lift Transfer Evaluation, dated February 3, 2025, revealed the resident weighed 365 pounds and the resident required extensive/total assistance to turn/reposition in bed of more than two staff. Review of facility documentation, submitted to the Pennsylvania Department of Health on February 11, 2025, at 2:48 p.m. revealed on February 10, 2025, Resident R1 rolled out of bed and fell to the floor while Employee E4, nurse aide, was providing care. Resident R1 was subsequently transferred to the hospital. The hospital evaluation revealed Resident R1 sustained a left humerus fracture (breakage of the upper arm bone) and a T11 wedge compression fracture (breakage of the spine bone between the upper and lower back areas). The facility substantiated neglect and terminated Employee E4, nurse aide. Continued review of the facility documentation revealed a written statement from Employee E4, nurse aide, dated February 10, 2025, which indicated, [Resident R1] fell off the bed when I gave (him/her) care, it was about 7:30 p.m. When I finished to clean one side of (his/her) body, then (he/she) tried to roll onto the other side (he/she) fell with the side rail of the bed. I immediately called the charge nurse and the supervisor to let them know about the incident. Continued review of facility's documentation revealed an interview statement, dated February 11, 2025, in which Employee E4, nurse aide, stated to the Director Nursing, I went to change [Resident R1], (he/she) can roll (himself/herself) over and grab side rail. I was changing (him/her) and asked (him/her) to roll to left side, (he/she) quickly rolled over, grabbed the siderail and (he/she) kept going, rolling off the bed onto the floor. Employee E4, nurse aide, continued, I do (him/her) myself cause (he/she) can roll over. Employee E4, nurse aide, confirmed to the Director of Nursing the employee did not have anyone with him while he was providing care to Resident R1. Review of Employee E4's personnel file revealed that Employee E4 was hired by the facility as a nurse aide on March 13, 2012. Review of the facility job description for nurse aides revealed, nurse aides assist residents with activities of daily living and implement care according to residents' care plans. Continued review of Employee E4's personnel file revealed the employee completed Safe Resident Handling training on July 25, 2024. Review of Resident R1's hospital records, dated February 18, 2025, revealed the resident was admitted to the hospital on February 10, 2025, after having a fall from bed. The hospital records indicated the resident sustained three injuries as a result of the fall: left humerus fracture, T11 wedge compression fracture and right shin contusion (type of hematoma - collection of blood under the skin). Continued review revealed the resident was not allowed to apply any weight to the left arm due to the humerus fracture and the resident had to remain on bedrest due to the T11 fracture. Review of Resident R1's wound consultant evaluation, dated February 19, 2025, revealed the resident was assessed for the wound on his right shin (contusion). The wound consultant noted the wound was a complicated hematoma that encompassed the lateral (side) calf. The hematoma had evidence of extravasation (leakage from blood vessels causing damage to the surrounding tissues) and visible eschar (dead tissue) with moderate oozing of sanguinous drainage (blood), moderate amount of induration (hardening of the skin) and fluctuance (fluid under the skin) with concern for expansion. The wound consultant recommended to send the resident to the hospital for urgent surgical and vascular evaluation out of concern for vascular compromise due to the size and expansion of the hematoma. The resident was subsequently transferred to the hospital and returned to the facility on [DATE]. Review of Resident R1's wound consultant evaluation, dated February 26, 2025, revealed the resident was assessed for the wound on (his/her) right shin. The wound consultant noted the hematoma continued with evidence of extravasation, eschar, oozing of sanguinous drainage, induration and fluctuance. The wound consultant recommended wound care consisting of Xeroform (non adherent dressing), absorbent pad, kling and ace wrap from toes to knees to provide compression and to monitor the area for vascular compromise. Interview conducted on March 3, 2025, at 9:32 a.m. with Resident R1 confirmed that (he/she) fell from bed while Employee E4, nurse aide, was providing care. Resident R1 also confirmed Employee E4, nurse aide, provided the care by alone and no other staff were present in the room to assist with care or repositioning. Resident R1 confirmed the injuries to (his/her) arm, back and shin were caused by the fall. Facility documentation and details of the incident were reviewed with the Director of Nursing on March 3, 2025, at 1:30 p.m. The Director of Nursing confirmed the facility substantiated the incident as neglect and terminated Employee E4, nurse aide. The facility failed to ensure that Resident R1 was free from neglect during provision of care, which resulted in actual harm to Resident R1 who fell out of bed, required transfer to the hospital and sustained fractures to the left humerus, and to vertebrate T11 of the spine and a contusion to the right shin. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of clinical records, review of facility policies, observations, resident, and staff interviews, it was determined that the facility failed to timely ensure the location of a resident who went on a leave of absence and failed to provide education on how to monitor blood sugar levels per sliding scale and administration of insulin medication. This failure resulted in an Immediate jeopardy situation for Resident R1 who was provided insulin medication without education of blood sugar management and insulin administration prior to a leave of absence and for the failure to ensure the location of Resident R1 who failed to return to the facility per physician's order for one of 31 residents reviewed. (Resident R1). Findings include: Review of facility policy titled Leave of Absence/Therapeutic Leave: Patient revised November 1, 2023, revealed the patient must have a physician's order for a leave of absence (LOA)/ Therapeutic leave Therapeutic leave is described as an absence for the purpose other than required hospitalization . The release of Responsibility for Leave of Absence/ Therapeutic leave form must be completed when the patient leaves and returns to the center. Further review of this policy states Prior to leaving the center, the staff will review patient care and medication needs with the patient/ and or the person accepting responsibility for the patient. Review of the facility abuse policy titled Abuse Prohibition revised on October 24, 2024, revealed the term neglect is defined as the failure indifference, or disregard of the center, its employees, or service providers to provide care, comfort, safety, goods and service to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between the center, patient, practitioners, and patient representatives. Review of insulin manufacturer summary for safety of insulin (brand name Humalog, non-brand name insulin Lispro) revealed that possible side effects of omitted medication could possibly lead to low blood sugar (hypoglycemia), low potassium in your blood (hypokalemia), heart failure, sudden onset of high blood sugar (hyperglycemia) and high amounts of ketones in the blood or urine (ketoacidosis) due to insulin pump, all possible fatal consequences. Review of Resident R81's clinical record revealed that Resident R81 was admitted to the facility June 16, 2023, secondary to deficits in mobility and ADLs (activities of daily living). Review of Resident R81's clinical record revealed that the resident was admited to the facility on [DATE], from the hospital. Review of hospital documentation revealed Patient reported feeling dizzy and fell and was unable to get herself up. In the emergency room , blood sugar was found to be over 1000 (normal levels between 70-100) and sodium level of 113 (normal level 135). She was given IV (intravenous) fluids. CT (computed tomography) of her head showed chronic lacunar infarcts (stroke). Patient's mental status became altered and stopped responding leading her to the facility for skilled nursing. Review of Resident R81's quarterly Minimum Data Set (resident's care needs assessment) dated May 24, 2024, revealed that Resident R81 had diagnoses of asthma (lung disorder characterized by narrowing of the airways), depression (major loss of interest in pleasurable activities), schizophrenia (mental disease characterized by loss of reality), seizure disorder (neurological disorder that cause brief episodes of unresponsiveness), hypertension ( high blood pressure), renal failure, diabetes (failure of the body to produce insulin), and hyponatremia (low blood sodium levels). Continued review of Resident R81's quarterly MDS revealed that the resident had impairment on one side of the body and required assisted devices of a walker and wheelchair. Further review of this assessment revealed that Resident R81 had a BIMS (brief interview of mental status) score of 12 which indicated that the resident had moderate cognitive impairment. Review of Resident R81's current care plan revealed focus areas which included Resident/patient exhibits or has the potential to exhibit physical behaviors related to ineffective coping skills, i.e., poor anger management, poor impulse control. Resident R81 has diagnosis of psychiatric disorder depression and anxiety and is at risk for complications related to the use of psychotropic drugs Trazadone and Quetiapine. The resident has a diagnosis of diabetes and is insulin dependent. Access and record blood glucose levels before meals and administer hypoglycemic medications as ordered. Resident R81 is at risk for falls due to impaired mobility and history of falls. Resident exhibits or is at risk for respiratory complications related to tracheostomy, and a history of sleep apnea. Review of physician order by Nurse practitioner, Employee E10, dated June 3, 2023, revealed that Resident R81 was approved for leave of absence with family from June 8, 2024, at 8:30 a.m. until June 9, 2024, at 6:00 p.m. with medications. Review of Resident R81's nursing notes dated June 10, 2024, revealed that Resident R81 left the faciity on [DATE], and did not return on the anticipated ordered time of June 9, 2024, at 6:00 p.m. Continued review of Resident R81's nursing note dated June 10, 2024, written by Licensed nurse Employee E5 revealed Resident did not return from the LOA (leave of absence) at the time frame ordered. Call placed to listed number on information sheet for this resident and the voice mail said, this person is not accepting calls at this time. Call placed to guardian who did not have a mailbox set up at this time. Called residents sister, who I left a message for, re (reference) above and steps of calling the police for a wellness check. Sister called back states she did not know she went out on an LOA and she will try to get in touch with her. I asked if she had a different number than what I had, and she gave it to me. I called that number and left a message re above. [Resident R81] called back stating, I am on my way back, my sister just called and said that you were calling the police. I conformed the plan of care that was discussed with [resident sister] to which the resident replied that you gave me two bottles of meds so I thought that I could stay out for 2 days I explained to the resident that I ordered the meds that she would need for the time that she had requested her LOA. The resident replied, I am on my way back now my driver is coming now. DON notified of above and phone number updated. There was no documented evidence that the facility attempted to locate the resident prior to June 10, 2024 during the 7-3 shift. The facility was unaware of Resident R81's whereabouts. Continued review of nursing notes revealed that after Resident R81 returned she stated I took no meds but monitored my sugar, and took my insulin. I asked if she had a log of her blood sugars, she said no. Resident was educated on need to take meds as prescribed and to return to facility a time requested from her LOA. Resident was also shown the LOA med form with the time and dates that she the resident requested. The resident replied that she did not know that that paper was in there and that she was confused when she seen the order date of 6/3/24. DON and family advised of residents return. Interview with Nurse Practitioner, Employee E10 confirmed that she authorized Resident R81 leave of absence for the time of June 8, 2024, at 8:30 a.m. to June 9, 2024, at 6:00 p.m. Review of medication order for Resident R81's leave of absence revealed that Licensed nurse, Employee E5 sent a request to the pharmacy for the following medication for Resident R81 to take with her on her LOA. The detailed list of medication included: Metformin 500 mg (milligrams), ordered to take 2 tablets twice a day. (diabetic medication used to lower blood sugar levels) resident given 6 tablets. Quetiapine 100 mg ordered 1 tab at bedtime (antipsychotic used to treat schizophrenia) resident given 1 tablet. Quetiapine 50 mg ordered to take one tablet twice a day (antipsychotic used to treat schizophrenia) resident given 2 tablets. Trazadone 50 mg ordered to take 1/2 tab / 0.5 tab at bedtime for anxiety daily (antidepressive) Insulin glargine 100 ml ordered admin 4o units sub q at bedtime, (hormone) resident given 40 units. Insulin lispro 100iu inject 6 units inject subcutaneous (just under the skin) at bedtime 1 pen, resident given 1 pen. Insulin lispro 100 iu inject 20 units inject subcutaneous (just under the skin) before meals / hold if not eating resident given 1 pen. Aspirin 81 mg ordered to take 1 tab daily at 9am, resident given 1 tablet to prevent a stroke. Atorvastatin calcium 40 mg (cholesterol medication) ordered for 1 tab daily at 9 am resident given one tablet. Ferrous sulfate 300 mg ordered 1 tab daily at 10 a.m. (iron) resident given 1 tablet. Gabapentin 800 mg ordered (anticonvulsant) 1 tab by mouth three times a day, 6 a.m., 2 p.m., 10 p.m., resident given 4 tablets. Guaifenesin liquid 100mg/15 ml order to take 10 ml at 9 am and 9 pm (cough suppressant) resident given 20 ml. Lacosamide 150 mg ordered one tab every 12 hours (seizures medication), resident given 2 tablets. Interview with Licensed nurse, Employe E5 on August 13, 11:25 a.m. revealed the protocol of a resident's leave of absence was the resident has to request the leave to her (unit manager) a few days prior, (enough time to order medications for the leave) then she will get approval and order from the physician for the leave of absence. Upon returning the resident is required to provide the bag of medication to examine. The residents should then receive an accu check (blood sugar check) and skin check when arriving back to the facility. Licensed nurse, Employee E5 stated that Resident R81 came to her and requested the leave from June 8th through June 9th . Employee E5 then got physician orders for the leave and ordered medication based on the number of hours the resident would be out. Licensed nurse, Employee E5 stated that she was not on duty on June 8, 2024, when the resident left for LOA. When she arrived on the floor on Monday August 10, 2024, at 7:00 a.m. she became aware the Resident R81 has not yet returned. She immediately tried to call the resident and called resident's family to locate her. Licensed nurse, Employee 5 confirmed that she was concerned of the resident's need for crucial medications. When Resident R81 returned Licensed nurse, Employee, E5 requested accu check log, and it was noted that the resident failed to record her blood sugar levels. Interview with Resident R81 on August 13, 2024, at 11: 55 a.m. confirmed that she left for the weekend and everyone went crazy the DON threatened to call the police if she did not come back. Resident R81 stated that she told someone she was not coming back till after the weekend. Resident R81 stated that she went to Licensed nurse, Employee E5 and requested the leave and few days prior to leaving. The morning of June 8, 2024, Resident R81 stated she was in a hurry my ride is downstairs waiting and Licensed nurse, Employee E6 handed her a bag of meds with needles. Resident R81 stated she was not educated or told what to do with the medications. Interview with Director of Nursing, Employee E2 on August 13, 2024, at 1:25 p.m. revealed that the resident had told a nurse that she was going to extend her loa until Monday. Director of Nursing Employee E2 provided a nursing note that stated Resident R81 will be returning on Monday, June 10, 2024. Review of nursing note written by Licensed nurse, Employee E9 on June 8, 2024, at 5:41 p.m. indicated that Resident on LOA w/ friend and will return Monday 6/10/24 resident has all medication with her. Interview with Licensed nurse, Employee E9 on August 15, 2024, at 9:05 a.m. revealed that she was on duty the morning of June 8, 2024, as unit manager and she state that Resident R81 left the facility, she did not remember if anyone was with her, and said she would be coming back on Monday (June 10, 2024). Employee E9 wrote a note in the chart. There was no documented evidence that Licensed nurse, Employee E9 notify the physician or obtain a new order for extended LOA and additional medications required for Resident R81. Interview with Licensed nurse, Employee E6 on August 14, 2024, at 4:45 p.m. revealed that she provided the resident with the bag of medications for her to leave with. Licensed nurse, Employee E6 stated that bag was stapled shut, she stated that she eye bawled the medication to confirm the contents. Employee E6 was not able to confirm if she educated the resident at the time of departure or sometime previously. Licensed nurse, Employee E6 stated that she knew what to do with the medications. Licensed nurse, Employee E6 denied suppling the resident with supplies needed such as accu check glucose meter, lancets, and test strips, stating that Resident R81 told her she had all supplies needed. There was no evidence that the facility initiated efforts to locate the resident for 2 shifts after the resident failed to return to the facility on [DATE]. It was not until the 7-3 shifts on June 10, 2024, that the resident was able to be located. There was no additional physician order obtain for the resident stay out of the facility passed June 9, 2024. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on August 15, 2024, at 11:34 a.m. for the facility's failure to ensure that Resident R81 was provided education of how to monitor blood sugar level per sliding scale prior to leave of absence from the facility and how to administer insulin medication. The facility failed to timely ensure the safety and location of Resident R81 who was on a leave of absence. The following action plan was received and accepted on August 15, 2024, at 2:34 p.m. 1.Resident educated on how to assess, monitor, and administer blood sugar levels per sliding scale. 2. Thirty days look back completed on resident with active LOA orders that receive insulin to ensure insulin education has been provided. 3. DON (Director of Nursing) or designee to re-educated Licensed nursing staff on insulin education prior to the resident leaving for an ordered LOA. Licensed nursing staff will also be re-educated on LOA policy and when to initiate effort/ notification to locate a resident who does not return to the facility. 4. Weekly audits x 12 to be completed for all resident who went on a LOA that receive insulin to ensure education was provided prior to LOA occurring. Results of audits to be reviewed at QAPI meeting. Interview with all licensed staff confirm that they were in-service on Interview with Resident R81 confirmed that the resident received education on monitoring blood sugar levels per sliding scale. Interview with licensed nursing staff reported that they received inservice on the LOA policy. Review of facility thirty day look back of leaves of absence confirmed that education was completed on insulin administration. The Immediate Jeopardy was lifted on August 16, 2024, at 2:02 p.m. 2024. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.20 (a)(1)(b) Staff development 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement, and failed to secure windows on the unit, for one of five residents reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation as Resident R1 exited the building through a second-floor window and sustained serious injuries, including a laceration to his head requiring sutures and multiple facial fractures. Findings include: Review of facility policy, Elopement of Patient dated revised October 24, 2022, revealed, Patients/Residents will be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Continued review revealed, Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated August 10, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety disorder (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), alcohol dependence with alcohol induced disorder and acquired absence (surgical removal) of both left and right feet. Review of Resident R1's care plan, dated initiated August 8, 2022, revealed that the resident was at risk for elopement related to the resident expressing the desire to leave the facility while not medically ready for discharge and that the resident has made one or more attempts to leave the facility. Goals included for the resident to not attempt to leave the facility without an escort. Interventions included to utilize and monitor security bracelet per protocol. Continued review of Resident R1's care plan revealed that the resident required assistance/was dependent for mobility related to transmetatarsal amputation (surgical removal of part of the foot between the ankle and toes) of bilateral (both) feet. Further review revealed that the resident had impaired/decline in cognitive function or impaired thought processes related to short/long term memory loss. Review of Resident R1's Treatment Administration Records revealed physician's orders, dated August 5, 2022, for Wander Guard (security bracelet) to left lower ankle due to poor safety awareness. The orders specified to check the function of the device every night shift (once daily) and to check the placement of the device every shift (three times per day). Employee E11, licensed nurse, signed that the checks were completed on September 20, 2023, on the evening and night shifts. Review of progress notes for Resident R1 revealed a change in condition note, dated September 21, 2023, at 6:45 a.m. which stated, Resident found by staff outside in the facility's front yard sitting on the guard rail smoking a cigarette. Resident found by nursing supervisor with a laceration above left eyebrow and abrasions to fingers. Resident was transported back to his room via resident wheelchair and provided with assessment and first aide, cleansed with nss [normal saline solution] and gauze and bandaged. Telehealth NP [nurse practitioner] contacted and order was given by [nurse practitioner] to send resident to hospital to get sutures to laceration. Review of facility documentation submitted to the Pennsylvania Department of Health on September 21, 2023, revealed that Resident R1 was observed sitting on guardrail in front of building at 6:44 a.m. by staff with a laceration to his left forehead. Interview on September 25, 2023, at 6:24 a.m. Employee E5, scheduling manager, stated that she was walking up the sidewalk on her way to work on September 21, 2023, at 6:45 a.m. when she noticed an unknown person smoking by the edge of the facility property. Employee E5, scheduling manager, stated that she went into the facility to get the assistance of another staff person, as she did not want to approach the unknown person alone. Employee E5, scheduling manager, stated that she asked Employee E4, licensed nurse, to come outside with her. Upon approaching the person that was outside, Employee E5, scheduling manager, stated that they recognized the person as Resident R1. Employee E5, scheduling manager, stated that she noticed that Resident R1's left eye was swollen shut, that he had a laceration on his head, and that he had dried blood on his head, coat and pants. Employee E5, scheduling manager, stated that the resident reported being in significant pain due to his injuries. Interview on September 25, 2023, at 6:18 a.m. Employee E4, licensed nurse, stated that Employee E5 reported an unknown person smoking on the property and they went together to approach the person. Employee E4, licensed nurse, stated that they recognized the person as Resident R1 and that he had a laceration with dried blood above his left eyebrow as well as blood on his overcoat. Resident R1 told Employee E4, licensed nurse, that he walked down the steps to come outside to smoke. Employee E4, licensed nurse, stated that she went up along the back stairwell but did not see any blood or source for the resident's injuries. Employee E4, licensed nurse, stated that she continued to review the area and saw blood on the concrete and edge of the sidewalk directly below the resident's window. Observation, during the interview, Employee E4, licensed nurse, demonstrated where the blood was noted on the ground and showed that the resident's bedroom window was on the second floor, directly above the area where the blood was found. Employee E4, licensed nurse, stated that Resident R1 wore a Wander Guard device, that he was a known elopement risk and that no alarms were heard on the night of his elopement. Continued observation on September 25, 2023, at 6:34 a.m. with Employee E4, licensed nurse, revealed that Resident R1's bedroom had two windows directly above the PTAC (heating and air conditioning) unit. The window on the left side was bolted closed and unable to be opened. No screen was observed in the left window. The window on the right side opened via a handle on the top of the window with hinges along the bottom of the window. The window opening measured approximately nine inches. Interview on September 25, 2023, at 6:48 a.m. Employee E6, licensed nurse, stated that while she was not the assigned nurse for Resident R1 that night, she worked on the second floor unit on the night of the incident and that she did not hear any alarms or see Resident R1 try to leave the building. Interview on September 25, 2023, at 6:58 a.m. Employee E7, Maintenance Director, stated that he performs checks of the Wander Guard alarmed doors on a weekly basis and that two of the alarms have not been working for weeks, including the first floor middle door (near the receptionist desk) as well as the alarm panel on the elevator. Observation, at the time of the interview, confirmed that the Wander Guard alarm panels were not functioning. Continued interview, Employee E7, Maintenance Director, stated that he was unable to find the screen to Resident R1's window and that he bolted the window shut after the incident. Interview on September 25, 2023, at 8:53 a.m. Employee E11, licensed nurse, confirmed that she was the nurse on duty assigned to care for Resident R1 on the night of the incident. Employee E11, licensed nurse, stated that she last saw the resident between 10:00 p.m. and 10:30 p.m. during medication pass. Employee E11, licensed nurse, stated that she did not round on the resident throughout the night and admitted that it was her fault that the resident eloped. Employee E11, licensed nurse, stated that although she signed the Treatment Record that she checked Resident R1's Wander Guard, she did not actually check it and that she did not know where his Wander Guard was supposed to be located. Employee E11, licensed nurse, confirmed that she falsely signed the Treatment Record related to Resident R1's Wander Guard orders. Employee E11, licensed nurse, also confirmed that she was completely unaware that Resident R1 had eloped from the building until staff had reported that he was found outside. Employee E11, licensed nurse, stated that she assisted with providing first aide after the resident was found outside. Employee E11, licensed nurse, stated that the resident was wearing at least seven layers of clothing and that he had a laceration to his left eye, blood on the left side of his face and blood around his head. Employee E11, licensed nurse, stated that she cleaned up the laceration, cleaned the blood off of his hands and bandaged him up. Employee E11, licensed nurse, stated that she saw a pack of cigarettes tucked into the resident's sock on his right ankle and that she does not remember seeing the resident's Wander Guard. Interview on September 25, 2023, at 9:38 a.m. Employee E13, Housekeeping Director, stated that he assisted reviewing the camera footage of the incident. Employee E13, Housekeeping Director, stated that Resident R1 was seen walking across the parking lot over to the guard rail around 6:45 a.m. Employee E13, Housekeeping Director, stated that he reviewed the camera footage back until about 3:00 a.m. but did not see the resident. Review of the video footage timeline, provided by the Nursing Home Administrator on September 25, 2023, revealed that Resident R1 was attempting to get outside of his room through the window at around 11:15 p.m. In the video his feet were observed outside the window. Approximately 10-15 minutes later, the resident was observed falling to the ground. At approximately 6:25 a.m. resident was observed on the video walking towards the guardrail by the dumpsters. Interview on September 25, 2023, at 10:35 a.m. the Nursing Home Administrator stated that in response to the incident, the facility conducted audits of all windows and ensured that they were fitted with safety devices so that windows can not be opened more than six inches. Interview on September 25, 2023, at 11:20 a.m. the Director of Nursing confirmed the above findings of the video footage timeline, confirmed that the resident fell from his window at approximately 11:30 p.m. and confirmed that he was seen walking towards the guardrail by the dumpsters at 6:25 a.m. Resident R1 was not observed by staff until 6:45 a.m. Review of hospital records, dated September 21, 2023, for Resident R1 revealed that the resident was evaluated by the Trauma Surgery team for traumatic rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can result in kidney damage), laceration and multiple facial fractures. Review of Resident R1's CT scan (diagnostic imaging) revealed multiple facial fractures, including: nondisplaced fracture at the left second active process of the temporal bone (side of the skull bone); mildly displaced fracture at the inferior zygomatic process of the left temporal bone (cheek bones); mildly displaced fracture of the left sphenoid bone (middle of the skull base and back of the eye sockets); and nondisplaced fracture at the right lower mandible (jaw bone). Continued review of hospital records for Resident R1 revealed a nurses note, dated September 26, 2023, at 3:44 a.m. which indicated that the resident was received at start of shift from oral surgery. Jaw is wired shut, wire cutters at bedside, suction at bedside . Cold compresses given to help with pain, prn [as needed] dilaudid [pain medication] given with stated relief. Zofran given for nausea. IVF [intravenous fluids] and IV abx [intravenous antibiotics] continue. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to provide adequate supervision of a resident who was identified as an elopement risk by the facility. This failure resulted in the resident exiting the building through a second floor window and sustaining serious injuries, including laceration, traumatic rhabdomyolysis and multiple facial fractures, including: nondisplaced fracture at the left second active process of the temporal bone; mildly displaced fracture at the inferior zygomatic process of the left temporal bone; mildly displaced fracture of the left sphenoid bone; and nondisplaced fracture at the right lower mandible. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Director of Nursing on September 25, 2023, at 12:31 p.m. On September 25, 2023, at 5:06 p.m. the facility's action plan was accepted. The action plan included the following: Resident R1 - Supervisor assessed and provided first aid to resident. 911 was notified and transferred resident to emergency department for assessment. R1 was admitted to local hospital. Upon return, resident will be reassessed for wandering risk. Will implement every 15 minute checks for one week, every 30 minute checks for one week, every one hour checks for one week, then every two hour checks for one week. Reassess frequency of checks to ensure safety needs are met. Review elopement policy and protocol with all staff. All staff will be educated September 25, 2023. Education to be completed by Director of Nursing/Designee. Education will include review of elopement policy and protocol. Agency staff will be educated prior to taking their assignment. Education to all staff regarding resident supervision and elopement prevention. All staff will be educated today. Education to be completed by Director of Nursing/Designee. Education will include rounding every two hours, checking function once daily and placement of Wander Guard every shift, CODE Green (elopement drill), updating of care plans. Agency staff will be educated prior to taking their assignment. Conduct audits for all windows to ensure appropriate safety mechanisms are in place. Initial audit completed on September 21, 2023. Eight windows were found to be defective. The defective windows were secured by being bolted. All other remaining windows are able to be opened six inches. An audit of all windows will be completed daily for one week, then weekly for four weeks for proper window function, and that the restrictive mechanisms remain in place. Maintenance Director will conduct audits as indicated. Conduct audits of all door alarms and Wander Guard alarms to ensure proper functioning. September 25, 2023, Audit completed for all doors and Wander Guard alarms to ensure proper functioning. Parts have been ordered for the door alarm system and are awaiting delivery. Receptionist desk will be manned at all times. The electrician and elevator company are working to establish a date for repair. Elevators are equipped with a keypad system. Second floor and third floor units cannot be accessed without a code. Door alarms and Wander Guard alarms will be audited daily. Maintenance Director will conduct audits as indicated for all door alarms and Wander Guard alarms. Conduct audits of residents who are at risk for elopement to ensure interventions are in place in accordance with the resident's care plan. Interventions to include items such as Wander Guard placement and function checks, encouraging residents to attend activities or tasks of interest to the resident and redirecting residents away from elevators and doors. Initial audit was completed on September 21, 2023. Director of Nursing/ Designee to conduct daily audits for two weeks then weekly for four weeks. Results of audits to be reviewed monthly at QAPI meeting. Next QAPI is scheduled for October 23, 2023. A monitoring visit was conducted on September 26, 2023, to verify the implementation of the action plan. Staff on duty were interviewed and reported knowledge of key components of training provided, including rounding on residents, checking Wander Guard devices, elopement policies and procedures, and what to do in the event of an elopement. Observations of resident windows revealed that windows were fitted with safety devices and opened appropriate distances. Observations of door and Wander Guard alarms revealed that doors were functioning properly. Constant supervision was provided near doors that required repairs. Review of facility audits and interviews with staff confirmed that residents at risk for elopement are reviewed to ensure that care plan interventions are in place and staff are knowledgeable of elopement prevention strategies (checking placement and function of Wander Guard device, frequent rounding on resident, etc.). The Immediate Jeopardy was lifted on September 26, 2023, at 4:01 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record reviews, review of facility policies and documentation and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm with serious injuries, including a laceration requiring sutures and multiple facial fractures to Resident R1, for one of five residents reviewed. Findings include: Review of facility policy, Abuse Prohibition dated revised October 24, 2022, revealed, Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Continued review revealed, Serious bodily injury is an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated August 10, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), anxiety disorder (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), alcohol dependence with alcohol induced disorder and acquired absence (surgical removal) of both left and right foot. Review of Resident R1's care plan, dated initiated August 8, 2022, revealed that the resident was at risk for elopement related to the resident expressing the desire to leave the facility while not medically ready for discharge and that the resident has made one or more attempts to leave the facility. Goals included for the resident to not attempt to leave the facility without an escort. Interventions included to utilize and monitor security bracelet per protocol. Continued review of Resident R1's care plan revealed that the resident required assistance/was dependent for mobility related to transmetatarsal amputation (surgical removal of part of the foot between the ankle and toes) of bilateral (both) feet. Further review revealed that the resident had impaired/decline in cognitive function or impaired thought processes related to short/long term memory loss. Review of Resident R1's Treatment Administration Records revealed physician's orders, dated August 5, 2022, for Wander Guard (security bracelet) to left lower ankle due to poor safety awareness. The orders specified to check the function of the device every night shift (once daily) and to check the placement of the device every shift (three times per day). Employee E11, licensed nurse, signed that the checks were completed on September 20, 2023, on the evening and night shifts. Review of progress notes for Resident R1 revealed a change in condition note, dated September 21, 2023, at 6:45 a.m. which stated, Resident found by staff outside in the facility's front yard sitting on the guard rail smoking a cigarette. Resident found by nursing supervisor with a laceration above left eyebrow and abrasions to fingers. Resident was transported back to his room via resident wheelchair and provided with assessment and first aide, cleansed with nss [normal saline solution] and gauze and bandaged. Telehealth NP [nurse practitioner] contacted and order was given by [nurse practitioner] to send resident to hospital to get sutures to laceration. Review of facility documentation submitted to the Pennsylvania Department of Health on September 21, 2023, at 7:55 p.m. revealed that Resident R1 was observed sitting on guardrail in front of building at 6:44 a.m. by staff with a laceration to his left forehead. Continued review revealed that the resident had laceration with swelling to the left side of his head with moderate amount of blood, first aide administered pressure dressing applied. [Resident R1] stated 'I walked down the stairs to come outside to smoke.' The resident was subsequently transferred to the hospital for evaluation. Interview on September 25, 2023, at 6:24 a.m. Employee E5, scheduling manager, stated that she was walking up the sidewalk on her way to work on September 21, 2023, at 6:45 a.m. when she noticed an unknown person smoking by the edge of the facility property. Employee E5, scheduling manager, stated that she went into the facility to get the assistance of another staff person, as she did not want to approach the unknown person alone. Employee E5, scheduling manager, stated that she asked Employee E4, licensed nurse, to come outside with her. Upon approaching the person that was outside, Employee E5, scheduling manager, stated that they recognized the person as Resident R1. Employee E5, scheduling manager, stated that she noticed that Resident R1's left eye was swollen shut, that he had a laceration on his head, and that he had dried blood on his head, coat and pants. Employee E5, scheduling manager, stated that the resident reported being in significant pain due to his injuries. Interview on September 25, 2023, at 6:18 a.m. Employee E4, licensed nurse, stated that Employee E5 reported an unknown person smoking on the property and they went together to approach the person. Employee E4, licensed nurse, stated that they recognized the person as Resident R1 and that he had a laceration with dried blood above his left eyebrow as well as blood on his overcoat. Resident R1 told Employee E4, licensed nurse, that he walked down the steps to come outside to smoke. Employee E4, licensed nurse, stated that she went up along the back stairwell but did not see any blood or source for the resident's injuries. Employee E4, licensed nurse, stated that she continued to review the area and saw blood on the concrete and edge of the sidewalk directly below the resident's window. Observation, during the interview, Employee E4, licensed nurse, demonstrated where the blood was noted on the ground and showed that the resident's bedroom window was on the second floor, directly above the area where the blood was found. Employee E4, licensed nurse, stated that Resident R1 wore a Wander Guard device, that he was a known elopement risk and that no alarms were heard on the night of his elopement. Interview on September 25, 2023, at 8:53 a.m. Employee E11, licensed nurse, confirmed that she was the nurse on duty assigned to care for Resident R1 on the night of the incident. Employee E11, licensed nurse, stated that she last saw the resident between 10:00 p.m. and 10:30 p.m. during medication pass. Employee E11, licensed nurse, stated that she did not round on the resident throughout the night and admitted that it was her fault that the resident eloped. Employee E11, licensed nurse, stated that although she signed the Treatment Record that she checked Resident R1's Wander Guard, she did not actually check it and that she did not know where his Wander Guard was supposed to be located. Employee E11, licensed nurse, confirmed that she falsely signed the Treatment Record related to Resident R1's Wander Guard orders. Employee E11, licensed nurse, stated that she assisted with providing first aide after the resident was found outside. Employee E11, licensed nurse, stated that the resident was wearing at least seven layers of clothing and that he had a laceration to his left eye, blood on the left side of his face and blood around his head. Employee E11, licensed nurse, stated that she cleaned up the laceration, cleaned the blood off of his hands and bandaged him up. Employee E11, licensed nurse, stated that she saw a pack of cigarettes tucked into the resident's sock on his right ankle and that she does not remember seeing the resident's Wander Guard. Review of nurse aide documentation for Resident R1 revealed that Employee E12, nurse aide, signed that he assisted the resident with toileting on September 20, 2023, at 11:43 p.m. Further review revealed that there were no additional entries of care rendered to Resident R1 by Employee E12, nurse aide. An interview was requested on September 21, 2023, with Employee E12, nurse aide, however, the employee did not respond to the request from State Agents. Review of the video footage timeline, provided by the Nursing Home Administrator on September 25, 2023, revealed that Resident R1 was attempting to get outside of his room through the window at around 11:15 p.m. In the video his feet were observed outside the window. Approximately 10-15 minutes later, the resident was observed falling to the ground. At approximately 6:25 a.m. resident was observed on the video walking towards the guardrail by the dumpsters. Interview on September 25, 2023, at 11:20 a.m. the Director of Nursing confirmed the above findings of the video footage timeline, confirmed that the resident fell from his window at approximately 11:30 p.m. and confirmed that he was seen walking towards the guardrail by the dumpsters at 6:25 a.m. Resident R1 was not observed by staff until 6:45 a.m. Review of hospital records, dated September 21, 2023, for Resident R1 revealed that the resident was evaluated by the Trauma Surgery team for traumatic rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can result in kidney damage), laceration and multiple facial fractures. Review of Resident R1's CT scan (diagnostic imaging) revealed multiple facial fractures, including: nondisplaced fracture at the left second active process of the temporal bone (side of the skull bone); mildly displaced fracture at the inferior zygomatic process of the left temporal bone (cheek bones); mildly displaced fracture of the left sphenoid bone (middle of the skull base and back of the eye sockets); and nondisplaced fracture at the right lower mandible (jaw bone). The CT scan results were dated as finalized on September 21, 2023, at 11:32 a.m. Continued review of hospital records for Resident R1 revealed a nurses note, dated September 26, 2023, at 3:44 a.m. which indicated that the resident was received at start of shift from oral surgery. Jaw is wired shut, wire cutters at bedside, suction at bedside . Cold compresses given to help with pain, prn [as needed] dilaudid [pain medication] given with stated relief. Zofran given for nausea. IVF [intravenous fluids] and IV abx [intravenous antibiotics] continue. Interview on September 25, 2023, at 11:20 a.m. the Director of Nursing confirmed the above findings of the video footage timeline, confirmed that the resident fell from his window at approximately 11:30 p.m. and confirmed that he was seen walking towards the guardrail by the dumpsters at 6:25 a.m. Resident R1 was not observed by staff until 6:45 a.m. Continued interview with the Director of Nursing revealed that Employee E11, licensed nurse, and Employee E12, nurse aide, were terminated from employment at the facility. The facility failed to ensure that a resident remained free from neglect; staff failed to regularly round on Resident R1 to ensure his safety and falsified documentation related to the checking of the resident's safety device. Resident R1 subsequently eloped from his second floor bedroom window, was not discovered by staff until seven hours later, and sustained serious bodily inquires, including laceration and multiple facial fractures requiring hospitalization and surgery. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.14(c) Responsibility of licensee 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 201.18(e)(1) Management

Based on observation, clinical record review, facility documentation and staff interview, the facility failed to ensure Resident R19's care plan was updated to include one-to-one supervision with all meals after Resident R19 sustained a choking incident. This failure resulted in actual harm to Resident R19 who experienced a second choking incident, falling to the floor, requiring suctioning and was subsequently transferred to the hospital sustaining a laceration to the left eye which required stitches for one of 21 residents reviewed (Resident R19). Also, the facility failed to revise a resident's care plan related to hospice services for one of 21 residents reviewed. (Resident R88) Findings include: Observation of Resident R19 on [DATE], at 9:43 a.m. revealed that the resident was observed in the hallway in a hospital gown, in her wheelchair, the resident had a laceration to her left eye with yellow bruising. Review of Resident R19's quarterly Minimum Data Set (MDS-assessment of resident's care needs) dated [DATE] revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 7 which indicated that the resident had severe cognitive impairment. The resident required supervision with walking in the corridor, one person physical assist; for locomotion on unit lists needing limited assistance of one person physical assist. The resident was assessed as not steady while moving from a seated position to a standing position and requiring a wheelchair or walker. Continued review of the MDS revealed that for eating the resident required supervision and set up only. Review of Resident R19's nursing note dated [DATE], at 8:31 a.m revealed Breakfast was being served during the morning shift when resident consumed her entire plate and was found down in the hallway choking, CPR (Cardiopulmonary Resuscitation) and suction was performed until resident was able to start breathing on her own. DON and on call physician aware and chest x-ray ordered. Review of Resident R19's [DATE] orders revealed the resident had an order for one-to-one supervision during all meals starting [DATE], following the choking incident that occurred on [DATE]. Review of Resident R19's care plan last revised [DATE] revealed that a care plan was developed for the resident requiring assistance with activities of daily living including eating. The resident's care plan noted that the resident was independent with eating. The resident's care plan failed to include the intervention of the resident requiring one to one supervision during meals. Interview with Licensed nurse, Employee E15 on [DATE], at 2:52 p.m. revealed Employee E15 was on the Third floor passing meds on [DATE], Employee E15 stated when she came out of a resident room, she saw Resident R19 laying on floor in the hallway and she was blue. Employee E15 stated the other nurse yelled STAT (immediate) and other nursing staff came running including the unit manager and DON (Director of Nursing). Employee E15 stated Resident R19 was placed on her left side and Employee E15 ran to get the crash cart. Employee E15 stated when she came back with the crash cart, they had Resident R19 already in bed and they were doing chest compressions. At this point Employee E15 stated they checked her, and she was a DNR so they then stopped and just suctioned her. Employee E15 stated that while they were doing CPR (cardiopulmonary resuscitation), she helped by taking vitals and whatever else they needed. Employee E15 stated she did regain consciousness and they put her on the oxygen and at that time I went to see the other patients. Review of a nursing note dated [DATE], at 10:12 a.m. revealed, The resident was served breakfast while she was eating resident was seen in hallway choking and fell striking her head on the floor. A code was called and the nursing team transferred resident to her room and performed back blow while the resident was on her side. Resident's airway obstruction was removed and the team suctioned and placed oxygen 25 LPM (liters per minute) via non-rebreather. Residents' vitals obtained and her left eye was treated and wrapped, NP (Nurse Practitioner) and DON was present during incident and directed unit manager to call 911 (Emergency Medical Services) so resident can be sent out to be evaluated by Emergency personnel. Interview on [DATE], at 11:45 a.m. with unit manager, Employee E11 revealed that she was doing wound rounds when the incident occurred this morning with Resident R19. Employee E11 stated I was told she choked on breakfast. Review of the assignment sheet for the unit revealed Nurse aide, Employee E14 was assigned to care for Resident R19 on [DATE]. Interview with nursing assistant Employee E14 who was assigned to Resident R19 during the ,d+[DATE] shift was held on [DATE], at 12:12 p.m. regarding his presence during the morning shift. Employee E14 stated when he last had observed Resident R19 she was waiting for her breakfast in the dining room. When asked what he saw he stated, I was in resident room [ROOM NUMBER] when I heard her choking in the hallway. Employee E14 was asked if he was with her while she was eating breakfast, he stated no. Employee E14 was asked if Resident R19 needed to be supervised while she eats, he stated, Not really, she is mostly independent. When asked how familiar Employee E14 was with the resident they stated, fairly, I work Friday and the weekends, so this is my first day back. Interview with the Director of Nursing, Employee E2 on [DATE], at 3:12 p.m. regarding shift-to-shift report revealed that the charge nurse Employee E17 didn't give report this morning during huddle. The facility failed to ensure staff assigned to Resident R19 was informed about the updated need for one to one supervision during meals. The facility failed to ensure Resident R19's care plan was updated after the first choking incident sustained by the resident to included one to one supervision with all meals. This failure resulted in actual harm to Resident R19 experiencing a second choking incident on [DATE], in which the resident fell to the floor, striking her head, requiring suctioning, and being transferred to the hospital via Emergency Medical Services. Review of the hospital discharge summary from [DATE] revealed the resident sustained a laceration to her left eye on [DATE] which required stitches. Review of Resident R88's clinical record revealed the diagnoses of Malignant Neoplasm of Colon (The term malignant neoplasm means that a tumor is cancerous, Colon means large intestine), Anxiety Disorder (a persistent feeling of anxiety or dread, which can interfere with daily life), Depression (a common but serious mood disorder. It causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working), and Encounter for Palliative Care (admissions or encounters for comfort care, end of life care, hospice care and terminal care for terminally ill patients). Review of physician order for Resident R88, revealed an order, dated [DATE], for hospice services. Review of Resident R88's care plan initiated on [DATE], and revised on [DATE], indicated that the care plan included hospice care needs of Resident R88, with a target date of [DATE]. On [DATE], at 12:55 p.m., the Director of Nursing, during an interview stated that the hospice service for Resident R88 had been discontinued. On [DATE], at 1:07 p.m., the Director of Nursing, presented documentation from the hospice provider, dated [DATE], which confirmed that hospice services were discontinued for Resident R88 effective week of [DATE]. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(c) Nursing services 28 Pa. Code 211.11(d) Resident Care Plan 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, clinical record review, review of facility policies, review of facility documentation, and interviews with staff, it was determined that the facility failed to provide adequate supervision during meals for one out of 21 residents reviewed. This failure resulted in actual harm to Resident R19, who experienced two choking incidents, falls, and a laceration and stitches to the left eyebrow. (Resident R19) Findings Include: Review of facility policy titled, OPS300 Abuse Prohibition with the last revision date of [DATE], stated Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Observation of Resident R19 on [DATE], at 9:43 a.m. revealed that the resident was observed in the hallway in a hospital gown, in her wheelchair, the resident had a laceration to her left eye with yellow bruising. Review of Resident R19's quarterly Minimum Data Set (MDS-assessment of resident's care needs) dated [DATE], revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 7 which indicated that the resident had severe cognitive impairment. The resident required supervision with walking in the corridor, one-person physical assist; for locomotion on unit lists needing limited assistance of one-person physical assist. The resident was assessed as not steady while moving from a seated position to a standing position and requiring a wheelchair or walker. Continued review of the MDS revealed that for eating the resident required supervision and set up only. Review of Resident R19's Nursing note dated [DATE], at 8:31 a.m. revealed Breakfast was being served during the morning shift when resident consumed her entire plate and was found down in the hallway choking, CPR (Cardiopulmonary Resuscitation) and suction was performed until resident was able to start breathing on her own. DON and on call physician aware and chest x-ray ordered. Interview with Licensed staff, Employee E15 on [DATE], at 2:52 p.m., revealed Employee E15 was on the Third floor passing meds on [DATE], when the first choking incident occurred. Employee E15 stated when she came out of a resident room, she saw Resident R19 laying on floor in the hallway and she was blue. Employee E15 stated the other nurse yelled STAT (immediate) and other nursing staff came running including the unit manager and DON (Director of Nursing). Employee E15 stated Resident R19 was placed on her left side and Employee E15 ran to get the crash cart. Employee E15 stated when she came back with the crash cart, they had Resident R19 already in bed and they were doing chest compressions. At this point Employee E15 stated they checked her, and she was a DNR so they then stopped and just suctioned her. Employee E15 stated that while they were doing CPR, she helped by taking vitals and whatever else they needed. Employee E15 stated she did regain consciousness and they put her on the oxygen and at that time I went to see the other patients. Review of Resident R19's [DATE] orders revealed the resident had an order for one-to-one supervision during all meals starting [DATE], following the choking incident that occurred with Resident R19 on [DATE]. Review of Resident R19's care plan last revised [DATE], revealed that a care plan was developed for the resident requiring assistance with activities of daily living including eating. The resident's care plan noted that the resident was independent with eating. The resident's care plan failed to include the intervention of the resident requiring one to one supervision during meals. Observation of Resident R19 on [DATE], at 11:25 a.m. revealed that Resident R19 was observed in the hall attempting to ambulate by herself near the nurse's station without her wheelchair. Resident R19 started to fall, and two staff members were able to catch her and supported the resident by walking side by side to have the resident return to her room. Observation on [DATE], at 8:19 a.m. of Resident R19 in the dining room revealed that again the resident's wheelchair was not near her or in the dining room. Review of the assignment sheet for the unit revealed Nurse aide, Employee E14 was assigned to care for Resident R19 on [DATE]. Interview on [DATE], at 9:29 a.m. with Director of Nursing, Employee E2 confirmed that Employee E2 Director of Nursing was outside of a resident room when she grabbed the Nurse Practitioner to aide with Resident R19. Director of Nursing (DON) Employee E2 stated, I believe she aspirated and fell and hit her head. She has a laceration over her left eye. Review of a nursing note dated [DATE], at 10:12 a.m. revealed, The resident was served breakfast while she was eating resident was seen in hallway choking and fell striking her head on the floor. A code was called, and the nursing team transferred resident to her room and performed black blow while the resident was on her side. Resident's airway obstruction was removed, and the team suctioned and placed oxygen 25 LPM (liters per minute) via non-rebreather. Resident's vitals obtained and her left eye was treated and wrapped, NP (Nurse Practitioner) and DON was present during incident and directed unit manager to call 911(Emergency Medical Services) so resident can be sent out to be evaluated by Emergency personnel. Review of the documentation provided to the State Survey Agency confirmed that on [DATE], Resident R19 was assisted to her room and the Heimlich maneuver and mouth sweep was performed, and it was successful. Oral suctioning was completed. Resident provided with supplemental O2 (oxygen). BP (blood pressure) was elevated, and resident was tachycardia (a heart rate that exceeds the normal resting rate) and had tachypnea (respiratory rate greater than normal). Interview on [DATE], at 11:45 a.m. with unit manager, Employee E11 revealed that she was doing wound rounds when the incident occurred this morning with Resident R19. Employee E11 was stated I was told she choked on breakfast. Interview with nursing assistant Employee E14 who was assigned to Resident R19 during the ,d+[DATE] shift was held on [DATE], at 12:12 p.m. in regard to his presence during the morning shift. Employee E14 stated when he last had observed Resident R19 she was waiting for her breakfast in the dining room. When asked what he saw he stated, I was in resident room [ROOM NUMBER] when I heard her choking in the hallway. Employee E14 was asked if he was with her while she was eating breakfast, he stated no. Employee E14 was asked if Resident R19 needed to be supervised while she eats, he stated, Not really, she is mostly independent. When asked how familiar Employee E14 was with the resident they stated, fairly, I work Friday and the weekends, so this is my first day back. Interview with Licensed nurse, Employee E17 on [DATE], at 1:20 p.m. revealed that Employee E17 was present this morning when Resident R19 fell . Employee E17 stated she was in the hallway giving out meds when she was on her way to a resident room, she saw Resident R19 fall to the ground, hit the floor with her whole body. Employee E17 stated to her and another nurse who turned the resident over to the side and Resident R19 looked blue. Employee E17 stated there were remnants of french toast in the resident's mouth. Employee E17 stated they started to pat Resident R19 on her back, at that point she spit out the food but was still unconscious. Employee E17 stated everyone helped get her to the room, got her on her one side, a nurse got the crash cart, kept patting her back, gave her oxygen, and suctioning, and at that point she started to come back. Employee E17 stated that Resident R19 has a history of getting trays out of the food cart. When Employee E17 was questioned about the resident's food tray the Employee E17 stated she was unsure if she had been given her tray yet or not. Employee E17 stated there was a tray of food that was on top of the food cart at the time the incident occurred. Interview on [DATE], at 2:03 p.m with Registered Dietician, Employee E10 regarding the resident diet needs revealed that the resident had been on a dysphagia diet since February 21, 2022. Employee E10 stated the resident is impulsive with foods, she might help herself to something that is laying around, that is why we do the room checks. On [DATE], at 2:42 p.m. the Unit Manager, Employee E11 was asked for documentation regarding daily room checks for Resident R19. On [DATE], at 2:53 p.m. the Unit Manager, Employee E11 confirmed there was no documentation that daily room checks are being completed. Interview with the Director of Nursing, Employee E2 on [DATE], at 3:12 p.m. regarding shift-to-shift report revealed that the charge nurse Employee E17 didn't give report this morning during huddle. The facility failed to ensure staff assigned to Resident R19 was informed about the resident needing to be supervised during meals. The facility failed to ensure that the appropriate supervision was provided for Resident R19 with a history of falls and choking. This failure resulted in actual harm to Resident R19 with a laceration and stitches to her left eyebrow. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(c) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a clinical record review, facility documentation, and facility staff interviews, it was determined that the facility failed to assure a hazard free environment for one of 21 residents reviewed that resulted in actual harm. (Resident R 101). Findings include: Review of Resident R 101's MDS (minimum data set/periodic assessment) dated August 20, 2014 revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The nurse practicioner's note dated October 14, 2013 revealed that Resident R 101 had been hospitalized in July 2013 for an overdose of diet pills and required intubation (breathing tube placed to secure the airway) had convulsions and had brain injury. Review of the physician's psychiatry note dated May 15, 2014 revealed that the resident had a history of [REDACTED]. Review of Resident 101's nursing progress note dated January 11, 2014 revealed that the resident had agitation and suicidal ideation and reported to staff that he wanted to harm himself. Another nursing progress note dated May 8, 2014 revealed that the resident R 101's Fentanyl (narcotic/opiate used for pain management) patch was not in place. The physician was notified and a new Fentanyl patch was applied. There was no evidence that the facility initiated an investigation into the missing patch. On August 10, 2014 facility documentation revealed that Resident R 101 was found unresponsive with purple discoloration to the face and a respiratory rate of 2-6 breaths per minute and had a fentanyl patch between the resident's teeth. Resident R101 was transferred to the hospital 911. Review of facility investigation report and nursing progress notes dated May 13, 2014 revealed that resident R 101 was assessed with [REDACTED]. The report and nursing progress notes did not include the assessments and description of the cuts/scratches to include size, depth or how many cuts were observed. There was no evidence to include if the room was screened for sharp objects that could cause the cutting. The resident was sent to the hospital for a psychiatric evaluation on May 14, 2014. Review of Resident R 101's physician's psychiatry progress note dated May 15, 2014 revealed that the resident stated "I felt like I was hanging on by a thread" when he was asked what triggered him to cut himself. This resident had a history of [REDACTED]. Review of the facility's policy and procedure titled "Suicide Precautions" revised January 2, 2014 states that the resident's room is searched and remove objects that may potentially be used for self harm, such as knives, razors, pens, and nail clippers. " Review of Resident R 101's plan of care dated August 2014 revealed that the resident exhibits behavior: history of drug abuse, suicidal ideation, history of cutting himself and that the facility would maintain a safe environment and use plastic utensil with all meals. The facility failed to monitor and maintain a hazard free environment for this resident resulting in actual harm in two incidents on May 13, 2014 and August 10, 2014 that required hospitalization . 28 Pa. 201.14 (a) Responsibility of licensee. 28 Pa. 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (c) Resident care polices. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.