Every finding on record at Horsham Center for Jewish Life

Based on review of facility policy, clinical record reviews and interviews with staff, it was determined that the facility failed to revise resident care plans timely for four of thirty-five residents reviewed. (Residents R221, R222, R306, and R312)Findings Include: Review of facility policy titled, Care Planning-Interdisciplinary Team undated states, Policy Statement-The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation 1. Resident care plans are developed according to the timeframes and criteria established by 483.21 Review of resident clinical record for Resident R221 revealed the resident was admitted to the facility on [DATE]. Resident R221 had a care conference held on October 31, 2025. The next care conference was not held until April 7, 2026. The time in between care plans was over five months. Review of resident clinical record for Resident R222 revealed the resident was admitted to the facility on [DATE]. Resident R222 had a care conference held on September 30, 2026. The next care conference was not held until March 17, 2026. The time in between care plans was over five months. Review of resident clinical record for Resident R306 revealed the resident was admitted to the facility on [DATE]. Resident R306 had a care conference held on October 23, 2026. The next care conference was not held until April 9, 2026. The time in between care plans was over five months. Review of resident clinical record for Resident R312 revealed the resident was admitted to the facility on [DATE]. Resident R312 had a care conference held on September 30, 2025. The next care conference was not held until April 7, 2026. The time in between care plans was over five months. Interview held with the Director of Social Services Employee E22 on April 8, 2026 at 9:40 a.m. confirmed that the social work team had gotten off track with holding care conference timely. 28 Pa Code 211.10 (d)Resident Care Policies

Based on observations and staff interview it was determined that the facility did not to prominently display and maintain facility daily staffing hours as required for three days (April 6, April 7, April 8). Findings Include: Observation of the front lobby reception desk revealed a nurse staff posting from Monday March 23, 2025. A tour was taken with the Director of Social Services Employee E22 on April 8, 2026 at 10:30 a.m. revealed the lobby reception desk nurse staff posting was still from Monday March 23, 2025. A tour of the A1 unit revealed nurse staffing posting from April 7, 2026 no PPD or census was listed. A tour of C3 unit revealed nurse staffing posting from April 7, 2026 with no PPD or census. The Director of Nursing confirmed on April 8, 2026 at 11:15 a.m. that the person in charge of posting the nurse staffing was new and was unaware of how to complete the appropriate posting. The previous staff in charge has not been employed for approximately three weeks. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (b)(3)(e)(1) Management

Based on observations, and resident interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature for twelve of thirty five residents reviewed (Residents R5, R12, R22, R151, R119, R144, R188, R223, R257, R113, R128 and R322).Findings include: During the initial tour of the facility on April 6, 2026, the following resident interviews were obtained on units C1 and D1: Interview on Unit C1 with Resident R5 at 10:28 a.m. revealed that she does not like the food, particularly during Passover when she cannot eat the matzoh as it exacerbates her irritable bowel syndrome. Interview with the nurse aide, Employee E9, outside Resident R5's room revealed that the kitchen is very strict with Passover meals. Interview on C1 with Resident R188 at 10:35 a.m. revealed that she didn't like the food, thought it could be better, it's not edible, it's tasteless, not warm enough, that it was much better a year or so ago. Interview on Unit C1 with Resident R322 at 10:39 a.m. revealed that the food is really bad, the coffee is horrible and they only give you one tiny creamer, you don't always get what you ask for, the portions are too small too. Interview on Unit C1 with Resident R151 at 10:41 a.m. revealed that she did not like the food, the portions were too small, today she got a few grapes and a piece of pineapple for a fruit bowl, the meat and fish were overcooked, the vegetables are overcooked and too soft and the soup is too thin or mushy with a few carrots. Interview on Unit D1 with Resident R12 at 10:45 a.m. revealed that she does not always get enough to eat, the food is so bad that I often can't eat it, they cut the salad into big chunks that I can't chew, they used to shred the carrots now they are hard chunks. Interview on Unit D1 with Resident R223 at 10:52 a.m. revealed that the food is very bad, it's cold, it's just terrible, I end up eating snacks. Interview on Unit D1 with Resident R257 at 10:58 a.m. revealed that he did not like the food, it is not hot and tastes bad, don't get me started. Interview on Unit D1 with Resident R144 at 11:03 a.m. revealed that he did not like the food, it was not hot and the portions are too small. Interview on Unit D1 with Resident R113 at 11:09 a.m. revealed that she did not like the food, some things are overcooked, and the other night we had chicken that was raw, just disgusting how can you eat something like that that is not even cooked, I am surprised no one got sick. Observations during a test tray (Resident Tray Assessment) conducted by the Food Service Director (FSD), Employee E24 on April 7, 2026, at 12:15 p.m. revealed that the carrots were served at 128 degrees, below the acceptable range on greater than 130 degrees and the apple juice was at 33 degrees and was semi-frozen with ice throughout making it difficult to drink. The carrots were very bland and the manicotti, specially prepared for Passover had a hard leathery tasting shell that did not have a good flavor. The mushroom soup, which had a temperature of 141 degrees, below the acceptable range of greater than 150 degrees had an odd taste and the mushrooms were processed into tiny bits that gave a poor mouth feel. Interview with the FSD on April 7, 2026, at 12:25 p.m. confirmed the results of the test tray. Interview on Unit D1 in the dining room with Resident R113 on April 8, 2026, at 1:09 p.m. revealed that last night we had chicken that was raw, just disgusting how can you eat something like that that is not even cooked, I am surprised no one got sick. She had several pictures of the chicken that was clearly not cooked. Review of the posted menu showed that chicken with wine and mushrooms was served for supper on April 7, 2026. Interview on Unit D1 dining room with Resident R228 on April 8, 2026, at 1:11 p.m. revealed that she too was served raw chicken on her tray for supper the night before. She was upset and said that another resident at her table ate the chicken and she hoped that she did not get sick. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential equipment related to medication refrigerator on unit D3 and ice and water dispenser on unit C1 were in a safe and working condition for use by residents and nursing staff on two of twelve nursing units.Findings include: Interview with Resident R13 on Unit C1 on April 6, 2026, at 11:15 a.m. during the initial tour revealed that he had not had ice in his water for the last few days. Interview with Resident R188 on Unit C1 on April 6, 2026, at 11:19 a.m. during the initial tour revealed that she had not had ice since last Friday, April 3, 2026, and she was upset, I can't drink warm water. Interview with Resident R322 on Unit C1 on April 6, 2026, at 11:28 a.m. during the initial tour revealed that she had not had ice for three days, and why can't they get ice from the kitchen? Observation on Unit C1 on April 6, 2026, at 11:40 a.m. revealed three maintenance workers were wheeling the ice and water dispenser on a cart down the hall saying that they were taking it to be repaired. Multiple observations on Unit C1 from April 6, 2026, through April 9, 2026, revealed that there was no ice and water dispensing machine. Interview with the Unit Manager, Employee E6, on April 9, 2026, at 12:40 p.m. confirmed that the ice and water machine was taken on April 6, 2026, for repair and that they had not had a working ice machine since last week. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policy, resident clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure proper documentation was maintained to support continuity of hospice care for one resident (Resident R81) out of three residents reviewed. Findings Include: Review of the facility's policy titled Hospice Program dated July 2017 revealed that the facility maintains an agreement with a Medicare-certified hospice provider to support end-of-life care for eligible residents. The policy requires clear, timely communication and comprehensive documentation between the facility and hospice services. The facility is responsible for ensuring that hospice-related documentation is obtained, maintained, and accessible, including the hospice plan of care, election forms, physician certifications, medication information, and hospice contact information. The policy further requires that all communications with hospice providers be documented, and that the facility maintain ongoing coordination with the resident's attending physician and interdisciplinary team.Review of the facility's hospice contract further revealed that the hospice provider is responsible for completing an assessment upon admission, developing and updating the hospice plan of care, and providing the facility with current plan of care documentation. The contract also requires hospice to notify the facility of any changes in the resident's condition and to collaborate with the facility in revising the plan of care as needed.Review of Resident 82's Minimum Data Set (MDS) assessment revealed that the resident was readmitted to the facility on [DATE], following a fall with injury. The resident was originally admitted on [DATE]. The resident has a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The resident is wheelchair dependent and requires total assistance for sit-to-stand and chair-to-bed transfers, maximum assistance for showering, partial assistance for dressing, and is dependent for toileting.The resident's diagnoses include anemia (a condition characterized by a decreased number of red blood cells or hemoglobin, resulting in reduced oxygen delivery to tissues), congestive heart failure (a chronic condition in which the heart is unable to pump blood effectively), renal insufficiency (impaired kidney function affecting the body's ability to filter waste and maintain fluid balance), vertebral fracture (a break in one or more bones of the spine), and seizure disorder (a neurological condition characterized by recurrent seizures due to abnormal electrical activity in the brain).Review of the resident's hospice communication binder revealed only a nursing sign-in sheet present. All other required hospice documentation, including the hospice plan of care, clinical notes, medication information, and related communication records, were absent.Review of Resident R81's care plan dated March 31, 2026, indicated the resident was enrolled in hospice services with a terminal prognosis related to congestive heart failure. Interventions included comfort measures, emotional support, environmental modifications, and coordination with the hospice team to address physical, emotional, and psychosocial needs.Interview with the Administrator Employee E1 on April 7, 2026, at 10:50 a.m., revealed that hospice staff typically submit documentation to the facility every two weeks. The Administrator employee E1 acknowledged that there had been no updates received in the resident's hospice plan of care and confirmed that hospice documentation and communication were not being consistently maintained or available within the facility records.28 Pa. Code (b)(1) Management28 Pa. Code 211.12 (d)(7) Medical Director 28 Pa. Code 211.12 (d)(13) Nursing Services

Based on interviews with resident and facility staff, review of hospital documentation resident clinical documentation and facility policies, it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, to ensure facilities identify and provide needed care and services to maintain appropriate care for one resident's indwelling foley catheter and failed to assess and reassess the foley catheter to determine appropriate indications of use for one of 35 residents reviewed (Resident R271)Findings include:Review of the facility's policy titled Urinary Continence and Incontinence -Assessment and Management revised August 2022 states, Physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function Indwelling urinary catheters will be used sparingly, for appropriate indications only.If a resident is admitted from the hospital with a newly placed indwelling catheter the attending physician and staff will evaluate the potential for removing it and the rationale for its original placement.The physician and staff will address treatable causes or contributing factors such as changing medication, treating pain, providing adaptive equipment to help with mobilized individualsThe physician will identify situations in which an indwelling urethral are indicated and will document why other alternatives are not feasible.Indwelling catheters shall not be used as a substitute for nursing care of the resident with urinary incontinence.If a catheter is used the physician and staff will document the clinical indications for use of the catheter and utilize standardized tools to document its ongoing need. If an indwelling catheter is needed, staff will monitor and report complications such as evidence of a symptomatic infection. Review of Resident R271 clinical records revealed the resident was hospitalized on [DATE], for generalized weakness, poor mobility, diagnosed with heart disease, Type 2 diabetes (lack of insulin), multiple pressure ulcers (wounds develops when sustained pressure on bony area reduces blood flow often combined with immobility, fragile skin, moisture or traction), urinary retention (unable to completely empty bladder) , and used an indwelling foley catheter ( a tube inserted into the bladder to continuously drain urine when a person cannot urinate naturally). Hospital discharge instructions received by the facility on January 13, 2026, when the resident was admitted to the facility instructed the resident, in two weeks, to follow-up with a Urologist for an outpatient void trial to remove the resident's foley catheter (a test to confirm that a patient can spontaneously urinate after an indwelling Foley catheter is removed to prevent potential complications that could include overdistended bladder (muscle damage) and urinary tract infections). Review of Resident R271's Admission's MDS (an assessment of resident's needs) dated January 13, 2026, revealed the resident was alert and oriented, admitted with multiple pressure ulcers, one Stage III pressure ulcer (Full thickness tissue loss, depth of wound known) and six unstageable pressure wounds, (covered in slough and/or escar (dead tissue) incapable of determining the depth of the wounds. The same MDS indicated Resident R271 had poor bed mobility, incontinent of bowel, fully dependent upon staff for activities of daily living (ADL) that included toileting, showering/bathing, dressing, and needed substantial maximal assistants with personal hygiene.Review of wound specialist, Nurse Practioner (NP) Employee E29 initial assessment, dated January 14, 2026, noted Resident R271 with wounds located on the bilateral feet, pressure ulcers over numerous areas of the buttocks, thighs, and back. The specialist noted all prevention measures were discussed with staff that included, ongoing pressure reduction, turning, repositioning and to ensure the resident's urinary foley catheter securement device is in place to prevent pressure (a pressure injury from a Foley catheter is a type of medical device-related pressure injury (MDRPI). It occurs when the catheter or its securement device exerts sustained pressure or traction on the delicate mucosal tissue and surrounding perineal skin, leading to tissue breakdown.Review of attending physician note dated January 19, 2026, stated Resident R271 was admitted to the facility for rehabilitation and ongoing management of medical conditions after hospitalization for generalized weakness secondary to morbid obesity, dehydration, and multiple wounds, The same note stated a 'Foley placed in hospital secondary presumed obstructive uropathy. Recommended TOV (Trial of Void) patient refused. Will reattempt.Continue review of Resident R271's physician notes dated January 26, February 3, 11,13, 19,27, March 6, 16, and 27 2026 includes and references the note written on January 19, 2026, that states 'Foley placed in hospital secondary presumed obstructive uropathy. Recommended TOV patient refused. Will reattempt but no evidence the physician spoke again to the resident regarding the voiding trial. Further review of Resident R271's clinical file revealed on March 20, 2026, nursing progress note stated the resident's foley was Out (dislodged). The same note indicated upon inspection of resident's vaginal area a small, non-bleeding, notch like wound was found on the resident's right labia. Her vaginal area was also pink and presented with an appearance consistent with a vaginal yeast infection; resident stated, 'It did itch and burn at times.' At that same time during the Wound NP rounds he examined the vaginal wound and was to write a wound note with order recommendations. During that time Resident R271 agreed to try TOV and successfully voided three times in the nurses presence.Review of the Wound NP progress note dated March 20, 2026, reported a new wound found on Resident R271's labia identified upon removal of indwelling urinary catheter. Wound documentation describes the resident's Right labia wound primary etiology a pressure ulcer/Injury Stage/Severity, Unstageable Wound, Sized: 0.8 cm x 0.9 cm x 0.2 cm. Wound has 10% granulation (new tissue with active healing) , 90% slough (dead tissue that can impede recovery in a wound, that may be surgically removed for optimal wound recovery called debridement). Pressure ulcer of the right labia is related to prior indwelling catheter. Patient has an unstageable pressure ulcer with necrotic tissue (slough/eschar) present which prevents accurate depth assessment.March 23, 2026. wound note from Nurse Practioner Employee E30 noted Resident R271 was now incontinent of urine and described the pressure ulcer of the right labia related to Resident R271's prior indwelling catheter. Wound was assessed measuring: 0.8 cm x 0.9 cm x 0.2 cm. Wound Base, 50% granulation, 50% slough. The note indicated Resident R271 was in pain and refused wound debridement to rt labia wound. Per facility policy if a resident is admitted from the hospital with a newly placed indwelling catheter the attending physician and staff will evaluate the potential for removing it and the rationale for its original placement. During an interview with Resident R271 on April 6, 2026, at 11:30 a.m. the resident laughed when the surveyor asked why the foley catheter was placed. I have no idea. When surveyor informed the resident that the resident refused initially to have the foley catheter taken out, the resident smiled and said, I have no idea what I said when I first got here (facility) I was confused and not focused because I was just discharged from the hospital. The resident confirmed she had not spoken to the physician about having a voiding trial done to see if the resident needed the foley, Reviewing the progress note with Resident R271 on March 20, 2026, when the foley was found dislodged, the nurse noted that the resident complained that the foley Iitched and burned Per facility policy If an indwelling catheter is needed, staff will monitor and report complications., When asked if the foley gave her pain and discomfort, and what was done about it, the resident responded, Yes, it did, especially around the time if fell out. The resident stated, I asked the aide to look and see if she saw anything down there, she told me it looked red and she would tell the nurse. But the nurse never came back. Nursing never looked down there and the only aide that did was the one who saw the redness, but she no longer works here. Nursing sure did look when it fell out. All the nurses were in my room looking, even the wound care doctor saw. Review of the resident's nursing note revealed no evidence or noting of discomfort pertaining to the foley.Interview on April 8, 2026, at 4:00 p.m. with the Assistant Director of Nursing (ADON) Employee E7 for the facility's C&D Tower, Unit Manager, Licensed Nurse, Employee E27 for Resident R271 in the facility's A1 unit, and ADON for Tower A &B Employee E28 was told the above conversation with Resident R271 and the surveyors findings in the clinical chart. The three staff members were asked when the resident was asked again after January 19, 2026, when the resident refused to have the foley taken out and the physician would 'reattempt this conversation again with the resident. Surveyor offered to receive additional information to validate a reattempt, but no further correspondence was received during the survey. The unit manager stated the resident had many wounds for a reason why the foley catheter was not discontinued and the surveyor indicated the facility's policy is that and Indwelling catheters shall not be used as a substitute for nursing care of the resident with urinary incontinence. When reviewing the notes during the time the foley dislodged they were unaware the wound specialist classified the wound was from a pressure injury due to the foley. The unit manager stated she was one of the nurses that saw the area after the foley dislodged, It looked like a yeast infection, it was white. The surveyor read the wound report noting that the area was 90% slough, not yeast and that mucosal membrane pressure injuries from a medical device such as a foley may occur when the placement of the xx or the foley tube is not positioned correctly leading to cause pressure and pulling at the site which may not show typical signs, instead, they can present with pain, swelling, and bleeding, leading to soft clots that resemble slough. Further review of Resident R271's clinical records show no evidence nursing was monitoring and assessing the skin integrity of the surrounding area of the foley catheter. The wound specialist noted that pressure interventions were discussed with the staff and to ensure the resident's urinary foley catheter securement device is in place to prevent pressure. The securement device was documented as being used with the indwelling foley catheter but there is no evidence the integrity of the skin surrounding the foley had ongoing monitored and assessed for correct placement and positioning to prevent pulling and or pressure to the foley site. Review of the facility's policy titled, Prevention of Pressure Injuries, revised April 2020 states, the purpose of the procedure is to provide information regarding identification of pressure injuries risk factors and interventions for specific risk factors. The policy states to Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The same policy states for device -related pressure injuries review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. Monitor regularly for comfort and signs of pressure related injuries. Evaluate, report and document potential changes in skin. Review of Resident R271's clinical records revealed a care plan developed for the indwelling catheter, with goals the resident would remain free from catheter related trauma dated January 14, 2026. Interventions included to position catheter bag and tubing below the level of the bladder (to prevent urine backflow and prevent infections) and Check tubing for kinks each shift (so urine can flow easily). Ensure foley catheter tubing is secured by securement device (to aid in preventing unnecessary movement or pulling) Monitor and document urine intake and output. Monitor/record/report to physician signs and symptoms of urinary tract infections (UTI). Per the facility policy and during the time Resident R271 used the foley catheter the facility failed to assess the resident as a risk for developing device related injuries related to the use of the foley catheter and failed to develop and place preventive measures and ongoing monitoring and assessment of the resident's skin integrity surrounding the foley for pressure injuries, Monitor/record/report to physician signs and symptoms of ongoing skin assessments, and to monitor the foley tubing and securement device for proper positioning to avoid devise related injuries. Further review of Resident R271's care plans revealed the facility developed a care plan for foley catheter and/or device related injuries only after the pressure injury was found and the foley catheter was removed. Review of facility provided informaton dated April 9, 2026, revealed Type: Physician / Medical Provider Progress On follow up of visit on 3/27/26, resident again refused foley in place voiding trial and wanted to keep the foley in place. Resident verbalized understanding of risk.Review of facility provided informaton dated April 9, 2026, revealed Type: Physician / Medical Provider Progress Note Text : After review of the 3/20/2026 patient's note [Nurse Practitioner] in my professional opinion after reviewing records and images, the wound is not related to pressure but rather a mucosal membrane injury. At the time wound presented all preventions were in place including catheter securement device prior to removal per staff.

Based on observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to care and maintenance of oxygen concentrators for three of 35 residents reviewed (Resident R199, R13 and R119). Findings include: Observations during the initial tour on April 6, 2026, at 11:35 a.m. of Resident R199 room on unit C1 revealed that the filter on the oxygen concentrator was dirty having a thick whitish grey build-up on the black filter on the side of the machine. Interview with Resident R199 revealed that she uses the oxygen all the time. Follow-up observation on April 7, 2026, at 10:36 a.m. with Employee E10, LPN, revealed the filter was still dirty. A review of Resident R199's medical records revealed a March 16, 2026, physician's order to clean the oxygen concentrator filter weekly. Observations on April 6, 2026, at 11:42 a.m. of R113 room on unit C1 revealed that the filter on the oxygen concentrator was dirty having a thick whitish grey build-up on the black filter on the side of the machine. Interview with Resident R13 revealed that he uses the oxygen all the time. Follow-up observation on April 7, 2026, at 10:38 a.m. with Employee E10, LPN, revealed the filter was still dirty. Interview with Employee E10, LPN, on April 7, 2026, at 10:40 a.m. confirmed that the oxygen filters on both oxygen concentrators were dirty and that they were not cleaned as ordered. Observations on April 6, 2026, at 12:10 a.m. of Resident R119 room on unit D1 revealed that the filter on the oxygen concentrator was dirty having a thick whitish grey build-up on the black filter on the side of the machine. Interview with Resident R119 revealed that she was wearing the nasal canula connected to the oxygen concentrator, and that she only uses the oxygen when she needs it. Follow-up observation on April 8, 2026, at 10:38 a.m. with Employee E23, LPN, revealed the filter was still dirty. Interview with Employee E23, LPN, on April 7, 2026, at 12:30 p.m. confirmed that the oxygen filters on Resident R119's oxygen concentrators was dirty and that it was not cleaned as ordered. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)5 Nursing services

Based on observations, resident interviews, and review of facility policy, it was determined that the facility did not maintain a dignified environment for three of thirty-five residents observed (Resident R151, R194, R312) and on three of twelve dining rooms (C1, D1, D2). Findings Include: Review of facility policy titled, Homelike Environment undated states, Policy Statement-Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .i. comfortable sound levels . 3. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. On April 6, 2026 lunch observation was made on second floor A-pod dining room at 12:02 p.m. and the lunch plates were being served on trays to the residents. Staff were seen setting down the entire tray in front of the residents and not removing the tray from the table. All residents in the dining room were served on trays. There was no music on in the dining room. On April 7, 2026 lunch observation was made on second floor A-pod at 12:22 p.m. and the lunch plates were still being served on trays to the residents. There was no music on in the dining room. On April 8, 2026 lunch observation was made on second floor A-pod at 12:12 p.m. and the lunch plates were still being served to the residents on trays. During lunch service there were sixteen residents present in the dining room. There was no music on in the dining room. Resident council meeting was held on April 7, 2026 at 10:00 a.m. with nine awake, alert, and oriented residents. Two residents during resident council stated that they had been washed with a pillowcase due to not having any wash cloths. (Residents R151 and R194) During resident council on April 7, 2026 at 10:14 a.m. Resident R151 who has a BIMS (Brief Interview for Mental Status) score of 15 from a MDS (Minimum Data Set) completed January 13, 2026 stated, I had to get washed with a pillowcase today and we should not have to live like this, there is always a shortage on towels and linens. Resident R151 also stated, the food here is awful, the portion sizes are small, and the way they serve the food to use on trays is disrespectful, we aren't asking for a steak dinner or anything, we just want better customer service. During resident council on April 7, 2026 at 10:16 a.m. Resident R194 who has a BIMS (Brief Interview for Mental Status) score of 15 from a MDS (Minimum Data Set) completed March 16, 2026 stated I have been washed with a pillowcase before and it is degrading. They tell us we are only allowed to have two towels a day. During resident council on April 7, 2026 at 10:34 a.m. Resident R312 who has a BIMS (Brief Interview for Mental Status) score of 15 from a MDS (Minimum Data Set) completed March 25, 2026 stated we used to have two alternatives and now there is only one. You are given a tray of food, slammed down on the table, and told that is all there is. They always just say, the kitchen is closed, the kitchen is closed. Dining observation on April 6, 2026, at 12:50 p.m. in the C1 dining room revealed that the staff passed the resident lunch trays leaving the physical tray on the table along with the insulated domes which were tipped upside down on the table and had lids and other disposable paperware stacked on top. The trays remained for the duration of the meal. Dining observation on April 6, 2026, at 1:15 p.m. in the D1 dining room revealed that the staff passed the resident lunch trays leaving the physical tray on the table along with the insulated domes which were tipped upside down on the table. The trays remained on the table for the duration or the meal. Dining observation on April 7, 2026, at 12:23 p.m. in the D2 dining room during the test tray evaluation revealed that the staff passed the resident lunch trays leaving the physical tray on the table along with the insulated domes which were tipped upside down on the table and had lids and other disposable paperware stacked on top. The trays remained for the duration of the meal. Dining observation on April 8, 2026, at 12:56 p.m. in the C1 dining room revealed that the staff passed the resident lunch trays leaving the physical tray on the table along with the insulated domes which were tipped upside down on the table. Dining observation on April 8, 2026, at 1:07 p.m. in the D1 dining room revealed that the staff passed the resident lunch trays leaving the physical tray on the table along with the insulated domes which were tipped upside down on the table. The trays remained on the table for the duration or the meal in both dining rooms.

Based on a review of the clinical record, facility documentation, observations, and interviews with staff and residents, it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for one of 35 resident records reviewed (Resident R271).Findings included: Review of Resident R271's Admission's MDS (an assessment of resident's needs) dated January 13, 2026 once admitted to the facility revealed the resident was alert and oriented, and was admitted with one Stage III pressure ulcer (Full thickness tissue loss, slough may be present but did not obscure the depth of tissue loss) and six pressure areas known but not stageable due to coverage of wound bed by slough and/or eschar (dead tissue). The MDS indicated that the resident's functional capabilities were fully dependent upon staff for all activities of daily living that included toileting, showering/bathing, dressing, and needed substantial maximal assistants with personal hygiene.Observation and interview with Resident R271 on April 6, 2026, at 11:30 a.m. revealed the resident appeared unkept, with facial hair on upper lip and hair that appeared unwashed matted and oily. When asked if nursing staff offered the resident a shower the resident indicated she did not because she was unable to stand so she received bed baths instead. When asked the last time the resident's hair was washed, the resident indicated she had not had her hair washed since being admitted to the facility almost three months ago.Review of Resident R271's care plan indicated the resident was unable to perform activities of daily living (ADLs) due to activity intolerance, initiated on admission, dated January 14, 2026. Interventions included, Interview on April 8, 2026, at 4:00 p.m. with the Assistant Director of Nursing (ADON) Employee E7 for the facility's C&D Tower, Unit Manager, Licensed Nurse, Employee E27 for Resident R271 in the facility's A1 unit, and ADON for Tower A &B Employee E28 was told about the above conversation with Resident R271and that the resident was unaware the staff could accommodate the resident in showering. During the interview it was confirmed that documentation revealed in the past 30 days revealed only bed baths were given between the times of March 10 and April 4, 2026. There was no evidence showers were offered nor if the resident refusing them. In addition, there was no further documentation that revealed Resident R271's hair had been washed since being admitted to the facility. The staff was given an opportunity to reveal documentation that showed otherwise. During the remaining survey no additional documentation was received. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on record review and staff interview, it was determined that the facility failed to monitor resident weights and implement timely interventions for significant weight loss. Resident R81. Findings include:Review of the facility's policy titled Weight Assessment and Intervention (March 2022) revealed that residents are weighed upon admission and thereafter per physician order, with weights documented in unit records and the medical record. The policy requires monitoring for unintended weight changes, with any change of 5% or more reweighed for confirmation and, if verified, prompt notification of the dietitian. Significant weight loss is defined as 5% in one month (greater than 5% considered severe). The interdisciplinary team is responsible for evaluating causes, including medical conditions and medications, and developing an individualized care plan with goals, interventions, and ongoing monitoring. Interventions are based on resident needs, preferences, and clinical factors, including nutritional status, functional ability, swallowing issues, medications, and advance directives. Review of the facility's policy titled Change in Resident Condition or Status (undated) revealed that the facility is required to promptly notify the resident's attending physician and representative of any significant change in the resident's physical, mental, or emotional condition. A significant change is defined as a major improvement or decline that is not expected to resolve without intervention and requires interdisciplinary review and potential revision of the care plan. The policy also requires nursing staff to document all changes in the resident's medical record and to complete a comprehensive assessment in accordance with OBRA regulations and MDS guidelines when a significant change occurs.Review of Resident 81's admission Minimum Data Set (MDS-a federal mandated assessment tool for all residents) assessment dated [DATE], revealed that resident R81 was readmitted to the facility on [DATE], following a fall with injury. The resident was originally admitted on [DATE]. The resident has a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The resident is wheelchair dependent and requires total assistance for sit-to-stand and chair-to-bed transfers, maximum assistance for showering, partial assistance for dressing, and is dependent for toileting.Resident R 81's diagnoses include anemia (a condition characterized by a decreased number of red blood cells or hemoglobin, resulting in reduced oxygen delivery to tissues), congestive heart failure (a chronic condition in which the heart is unable to pump blood effectively), renal insufficiency (impaired kidney function affecting the body's ability to filter waste and maintain fluid balance), vertebral fracture (a break in one or more bones of the spine), and seizure disorder (a neurological condition characterized by recurrent seizures due to abnormal electrical activity in the brain).Continued review of resident R81's admission MDS, dated [DATE], revealed a Nutritional assessment that indicates the resident weighed 186 pounds and is 66 inches in height. The MDS reflects a weight gain of greater than 5% in the past one month and/or greater than 10% over the past six months. The resident was also noted to hold food in her mouth and report difficulty and/or pain with swallowing, which may indicate dysphagia (difficulty swallowing).Continued review of resident R81'2 MDS Medication review indicates the resident is prescribed an anticonvulsant (used to control or prevent seizures), a diuretic (used to reduce excess fluid by increasing urine output, commonly prescribed for heart failure), an antidepressant (used to treat mood disorders such as depression), and antibiotics (used to treat or prevent bacterial infections).Review of Resident R81's nutrition assessment dated [DATE], revealed the resident was on a regular diet with thin liquids and receiving Ensure Plus at breakfast. The resident's height was documented as 66 inches, with a weight of 195 pounds and a BMI of 30.2. Meal intake was reported as greater than 50% for all meals. The assessment indicated no chewing or swallowing difficulties. However, this documentation is inconsistent with the resident's MDS assessment and other clinical records, which identified the presence of chewing and swallowing difficulties. This discrepancy reflects conflicting documentation regarding the resident's actual nutritional and swallowing status.Continued review of resident R81's nutritional assessment indicated a weight gain of 4.5% over 30 days and 24% over 180 days. The registered dietitian identified increased nutritional needs related to higher metabolic demands and noted a physician-ordered weight loss regimen. The dietitian determined no new nutritional interventions were required, stating that the current diet was adequate to meet needs, with continued monitoring of weight, labs, medications, skin status, and oral intake. The summary further indicated that weight fluctuations were likely related to fluid shifts associated with congestive heart failure and edema, with continued monitoring recommended. The assessment was completed by the registered dietitian and documented on February 12, 2026. Review of Resident R81's dysphagia screening dated March 4, 2026, revealed that the resident exhibited signs of swallowing impairment, including loss of food or liquids from the mouth during eating or drinking, pocketing of food in the cheeks, residual food remaining in the mouth after meals, and coughing or choking during meals or when taking medications. The resident was determined to require a mechanically altered diet with ground texture and thin liquids. The screening also recommended skilled speech therapy evaluation and treatment due to aspiration risk associated with a regular diet. Review of physician orders for Resident R81, dated January 17, 2026, revealed an order for daily weights with instructions to notify the provider for a weight gain of greater than 2 pounds in one day or greater than 5 pounds over one week, in the morning, related to the resident's diagnosis of congestive heart failure. Further review of the resident's clinical record and staff interview revealed that this order was not followed. Review of physician orders dated February 11, 2026, revealed an order for weekly weights to be obtained every Thursday for four weeks. Further review of the resident's clinical record and staff interview revealed that this order was not followed. Review of the resident R 81's clinical record revealed the following documented weights over the last 90 days:January 31, 2026: 184.8 pounds (wheelchair scale)February 2, 2026: 184.5 pounds (wheelchair scale)February 3, 2026: 183.1 pounds (wheelchair scale)February 4, 2026: 186.6 pounds (wheelchair scale)February 5, 2026: 186.3 pounds (wheelchair scale)March 27, 2026: 141.2 pounds (Hoyer lift scale)April 1, 2026: 0 pounds (last documented weight; weights noted as discontinued without a written order or documentation from the dietitian) Review of Resident R81's care plan revealed that the resident is identified as having an actual or potential nutritional problem related to multiple diagnoses, including congestive heart failure, pulmonary conditions, atrial fibrillation, lymphedema, osteoarthritis, hypothyroidism, chronic kidney disease, epilepsy, anemia, vitamin D deficiency, hyperlipidemia, hypertension, and malnutrition. The care plan, initiated January 19, 2026, included interventions for a mechanically altered diet, monitoring and reporting signs and symptoms of dysphagia (difficulty swallowing, including pocketing, choking, coughing, drooling, holding food in the mouth, and refusal to eat), and monitoring for signs of malnutrition and significant weight loss greater than 3 pounds in one week. Additional interventions included dietitian referral for evaluation and recommendations and provision of nutritional supplements as ordered.The care plan was updated on February 17, 2026, to include supplementation, and on March 31, 2026, to reflect hospice services with an expectation of weight loss.Further review of the care plan revealed no evidence of updated or revised interventions specific to the resident's significant and ongoing weight loss, despite documented clinical decline. There was no indication that interventions were adjusted to address continued nutritional deterioration or that new measures were implemented to reflect the resident's changing condition.Review of the resident's clinical record, progress notes including nursing notes, dietary notes, and physician documentation, revealed inconsistent and fragmented documentation regarding the resident's nutritional status and intake. A nursing note dated February 12, 2026, indicated the resident weighed 195 pounds, with weight gain attributed to edema, and reported meal intake greater than 50%. A dietary note dated February 17, 2026, indicated poor meal intake. Nursing documentation dated March 19, 2026, revealed the resident did not consume dinner and refused all medications. A physician note dated March 24, 2026, indicated the resident had not been eating recently and included an order to increase medication mirtazapam. A nursing note dated March 26, 2026, again reflected poor appetite. A dietary note dated March 30, 2026, indicated the resident's current weight reflected significant weight loss, a reweigh was requested, which was not completed, and hospice evaluation was ordered, and nutritional decline with anticipated weight loss was noted.These records indicate that throughout March 2026, the resident exhibited decreased oral intake, medication refusal, and ongoing weight decline; however, there was no consistent evidence of timely interventions, physician notification, or documented care plan adjustments in response to the resident's declining nutritional status.Interview with the registered dietitian Employee E26 and regional dietitian, it was revealed that the dietitian was not aware of the resident's physician-ordered daily and weekly weight monitoring and was not notified of the resident's significant weight loss. The dietitian stated she first became aware of the weight loss after it had already occurred and indicated that follow-up was not completed due to the resident being placed on hospice care and discontinuation of weight monitoring orders. Registered dietician employee E26 further stated that earlier weight fluctuations were attributed to fluid shifts related to edema and congestive heart failure. Although an intervention of providing mashed potatoes to increase caloric intake was implemented, there was no documented order for ongoing intake monitoring and no evidence of additional interventions or reassessment of nutritional status despite continued decline. This failure resulted in a lack of timely recognition, monitoring, and intervention for significant weight loss, indicating the facility did not ensure appropriate nutritional care and services in accordance with professional standards and physician orders.28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.2 (d)(10) Medical Director 28 Pa. Code 211.10 (a)(c) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on a review of facility policies, clinical records, and interviews with staff, it was determined that the facility failed to promptly inform the resident's representative of a significant change in the resident's condition and hospital transfer. This failure affected one of three residents reviewed (Resident R1).Review of the facility policy titled Change in a Resident's Condition or Status, dated February 2024, indicated that the facility is required to notify the resident and/or the resident's representative of any significant change in condition, including transfer to the hospital.Review of the resident's clinical record revealed that Resident R1 legally designated her family member as Power of Attorney, dated August 1, 2023.Review of the medical provider notes for Resident R1 dated January 9, 2025, at 9:31 a.m., documented: Patient seen and examined at request for changing condition. Aide reports noticing large amounts of blood on the floor, wheelchair, and bathroom floor. Upon immediate evaluation, patient resting in bed; gown covered with blood, dried blood on sheets, and large amount of blood on floor and wheelchair cushion. Patient awake, alert, appears weak and pale with some increased confusion. Noted rectal bleed. Reviewed with unit manager and agreed to transfer resident to the emergency room for further evaluation.Further review of the resident's clinical record revealed a nursing note authored by Licensed Nurse Employee E2 dated January 9, 2025, at 4:02 p.m., approximately six hours after the resident's noted change in condition and hospital transfer. The note stated the resident was sent to the hospital per medical provider instructions for rectal bleeding and transfer to the main hospital for gastrointestinal bleeding. The note further indicated that the niece was contacted at that time to provide an update and address questions and concerns.Interview with Licensed Nurse Unit Manager Employee E2 on January 29, 2025, at 1:30 p.m. revealed she was on duty on January 9, 2025, when she received notification of Resident R1's change in condition and need for emergency hospital transfer. Employee E2 stated she contacted emergency services and completed paperwork to accompany the resident to the hospital. Employee E2 reported that it is ultimately the bedside nurse's responsibility to notify the resident's family and assumed that Licensed Nurse Employee E3 had notified the resident's representative. Employee E2 confirmed it was not until later that afternoon-approximately five to six hours after the transfer-that she personally spoke with the resident's family member and confirmed the resident had been sent to the emergency room, at which time it was evident the representative had not been notified immediately.Interview with Licensed Nurse Employee E3 On January 29, 2025, at 2:00 p.m. confirmed she was on duty on January 9, 2025, and assigned to Resident R1. Employee E3 stated she was called to the resident's room by an aide due to concerns of large amounts of blood on the resident's bedding, gown, sheets, and floor. Upon arrival, the physician assistant was already assessing the resident, and a decision was made to transfer the resident to the hospital. Employee E3 acknowledged it was her responsibility to notify the resident's representative; however, she assumed the unit manager had completed the notification while making emergency calls and preparing transfer documentation. Employee E3 confirmed she did not verify that notification had occurred and was unaware the resident's representative had not been informed.Interview with the Nursing Home Administrator on January 29, 2026, at 1:10 p.m., confirmed there was a lapse in timely notification to the resident's representative regarding the resident's significant change in condition and hospital transfer. The administrator acknowledged a communication breakdown, citing a failure to clearly assign responsibility for notifying the resident's representative. 28 Pa. Code 201.29 (c.3)(2) Resident Rights28 Pa. Code 211.12 9(d)(1)(2)(3) Nursing Services

Based on observations, resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one of 5 residents reviewed. (Resident R10) Findings include: Observation on December 22, 2025 at 09:20 a.m. of resident trays transported from kitchen to nursing unit using open carts.Observations during a test tray conducted with the Food Service Director, Employee E7, on December 22, 2025 at 09:35 a.m. revealed eggs registered 116 degree Fahrenheit (F), coffee 123 degree Fahrenheit (F), orange juice 51 degree Fahrenheit (F), chocolate milk 46 degree Fahrenheit (F).Follow-up interview with the Food Service Director, on December 22, 2025 at 9:35 a.m. confirmed that these food items were outside the acceptable temperature range and therefore not palatable.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3) Management

Based on review of facility provided documentation, review of policy and interview with staff, it was determined that facility did not ensure to report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law for two of seven residents reviewed (Resident R1, R9). Review of facility's policy 'Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,' revised September 2024, indicates that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Review of Resident R1's clinical record revealed she was admitted to facility on July 21, 2025 and discharged on August 8, 2025. R1 had a medical history of chronic obstructive pulmonary disease, asthma, and malignant neoplasm of upper lobe/right bronchus or lung.Review of R1's Minimum Data Set (MDS) - Resident Assessment and Care Screening, completed on July 27, 2025, revealed a Brief Interview for Mental Status score of 15, which indicated that the resident was cognitively intact. Review of grievance report completed on July 25, 2025, revealed that a concern was reported by Resident R1 as well as Resident R1's son regarding nebulizer treatments. Per report, Pt. (patient) and son report that pt. hasn't received her nebulizer treatments as ordered. Example given: on Thurs. 7/24, didn't receive her daytime or afternoon nebulizer tx (treatment). Only received her evening tx. Further review of grievance report revealed Pt. and son state they were told that the neb tx was signed off as being administered on 7/24 at 7 am & 1 pm but pt. & son state she didn't receive it.Review of facility reported documentation to the State Survey Agency for months of July 2025 and June 2025 revealed no evidence that facility reported the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law.Findings confirmed with facility's administrator, director of nursing and assistant director of nursing, Employee E1.Review of Resident R9's clinical record revealed resident admitted to facility on April 20, 2022. with a medical diagnosis of Heart Failure, and Dementia (progressive degenerative disease of the brain).Review of R9's Minimum Data Set (MDS- assessment of resident's care needs) dated October 1, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive deficit.Review of Resident R9's comprehensive care plan, initiated on October 30, 2025, revealed resident observed being intrusive towards other residents, therefore targeting her for aggression from other residents. Interventions included Resident placed on 1:1 for increased observation. Review of Resident R9's physician orders, date October 30, 2025, revealed resident placed on 1:1 observation. Review of Resident R9's skin evaluation, dated November 19, 2025 at 3:01pm, indicated no new skin issues. Review of Resident R9's nursing note, dated 11/26/2025 at 1:14p.m., stated UM (Unit Manager) made aware resident has a newfound bruise on RUA (right upper arm), and a yellowish healing bruise on R (right) chest fading. Resident on a 1:1 for increased observation/ safety. Resident denies any pain. Currently walking around the unit, no new skin issues noted. Monitoring for any new skin issues/ changes. Encouraged 1:1 aides to continue to observe movements of the resident. Review of facility investigation revealed no documented evidence of explanation of bruising. Review of facility's reported documentation to the State Survey Agency for the months of November and December 2025 revealed no evidence that facility reported injury of unknown origin or results of investigation. Findings confirmed with facility's administrator, Employee E2 and Director of Nursing, Employee E4 on December 22, 2025 at 3:00p.m. 28 Pa Code 201.14(a)(c) responsibility of licensee28 Pa Code 201.18(b)(1)(e)(1) management

Based on staff interviews and the review of facility documentation, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for bruises of unknown origin for 1 out of 1 residents reviewed (Resident R4).Findings include:Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a revision date of September 2024 indicated that all allegations are thoroughly investigated to the best of the facility's ability. The policy also indicated that the individual conducting the investigation reviews documentation and evidence; reviews the resident's medical records; interviews the person(s) reporting the incident, and interviews available staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of Resident R4's October 2025 physician orders included the diagnoses of cerebral infarction (a type of stroke); anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things and activities you once enjoyed); dementia (a loss of thinking, remembering and reasoning skills); hypertension (high blood pressure), and diabetes (a condition that happens when your blood sugar/glucose is too high).Review of a nursing note dated October 19, 2025 at 11:30 a.m. documented that on the above referenced date the nurse aide (Employee E4) caring for the resident on the 7:00 a.m. through the 3:00 p.m. shift discovered a bruise to the resident's posterior head. The area was dark purple in color and measures 7.5 cm x 3.5 cm. Continued review of the above referenced note indicated that when the nurse touched the referenced area, the resident showed signs of mild pain. Review of Nurse aide, Employee E4's statement dated October 19, 2025 indicated: When I was giving [Resident R4] care, I noticed around 10:30 a.m. a black and blue bruise on the back of her head and I notify the nurse. Review of the investigation indicated that witness statements from licensed nurses and nurse aides on various shifts worked on October 17, 2025-through October 19, 2025 stated that they either did not see the referenced bruise on her head, or they were not assigned to the resident at all during any the referenced shifts. Continued review of the investigation indicated that the resident's nurse aide (Employee E4) who was assigned to the resident on October 18, 2025 on the 7:00 a.m. through the 3:00 p.m. nursing shift was not interviewed regarding the bruise of unknown origin. During an interview with the Assistant Director of Nursing (Employee E5, ADON) on October 31, 2025 at 12:53 p.m. the above-referenced investigation regarding the resident's bruise of unknown origin was discussed and reviewed. During the interview the ADON confirmed that Nurse aide, Employee E4 was the assigned nurse aide for the resident on October 18, 2025 during the 7:00 a.m. through the 3:00 p.m. nursing shift, and that the assigned nurse aide was not interviewed by the facility during the investigation.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services

Based on staff interviews, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that medical records requested by/and or on behalf of residents were provided in a timely manner for 3 out of 3 records reviewed. (Resident R1, Resident R2, and R3)Review of the facility policy, Release of Information, with a revision date of November 2009 indicated that the resident may initiate a request to release information to anyone he/she wishes and that such request will be honored only upon the receipt of written, signed, and dated request from the resident or representative. The policy also stated that a resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written request. Continued review of the policy indicated that a resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight hour (excluding weekends and holidays) advanced notice of such request, and that a fee may be charged for copying services. Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R1 on July 3, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until July 21, 2025. Review of medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R2 on August 8, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until September 5, 2025. Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R3 on July 16, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until August 4, 2025.During an interview with Employee E3 (Medical Records Director) on October 30, 2025, at 2:00 p.m. the above referenced medical records request documentation for Resident R1, R2 and R3 was reviewed with Employee E3. During the above reference interview with Employee E3, it was discussed that the medical records request made by the resident and/or on behalf of the resident were not released to the requestor in a timely manner. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)(b) Resident rights

Based on clinical record review, and staff interviews it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of five resident records reviewed (Resident R1).Findings Include: Review of care plan for Resident R1 dated August 4, 2025, revealed that the resident was at risk to be verbally aggressive (yelling/cursing when redirected) related to dementia. Interventions included, Psychiatric/Psychogeriatric consult as indicated.Review of clinical record for Resident R1 dated July 1, 2025, revealed that the resident noted to be agitated, resident was going into other residents' rooms, several attempts were made to redirect the resident, and it was unsuccessful. Staff remained with resident for supervision, and the residents were not cooperative with therapy.Review of physician progress note dated July 9, 2025, revealed that staff reported patient had wandering and some inappropriate behaviors. Some agitation was noted related to living situation.Review of clinical record for Resident R1 dated August 4, 2025, revealed that resident's sister-in-law, called the social worker and reported that resident was angry, mean and cursing at her and his niece, over the weekend. Resident appears calm today. Social Worker sent referral to psych for consultReview of clinical record for Resident R1 dated August 16, 2025, revealed that the resident became increasingly agitated and verbally aggressive toward staff when approached regarding bedtime routine. At around 7 a.m., the nurse was notified by the front desk that resident had called 911. Dispatch reported that the resident appeared confused and stated he was located outside of the facility. The resident was reorientated. Continued review of clinical record revealed that the resident did not leave the facility.Review of clinical record for Resident R1 dated August 23, 2025, revealed that the resident observed to be agitated and combative. Resident was verbally redirected at times.Review of psych consult binder available at the nurses station revealed that the resident was not on the list to be seen or documentation that the resident was seen.Review of facility electronic communication log between the facility staff and psych provider revealed that a request for psych consultation for Resident R1 was sent 30 days ago. 12 days ago a follow up message was sent for consultation. Both of the messages were unanswered.Interview with director of nursing, Employee E2 on September 3, 2025, at 1:17 p.m. confirmed that the resident was not seen by psychiatric services and should have been seen as soon as possible.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policies and documentation and staff interview, it was determined facility did not ensure adequate supervision and assistance to prevent accidents during a mechanical lift transfer for one of two residents reviewed (Resident R2). Review of facility policy title Lifting Machine, Using a Mechanical, revised July 2017, revealed that at least two (2) nursing staff are needed to safely move a resident with a mechanical lift, when possible.A review of Resident R2's clinical record revealed that he was admitted to the facility on [DATE], with diagnosis of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).A review of Resident R2's allegation of abuse incident investigation report revealed that on June 18, 2025, Employee E13, nurse aide, was providing care to Resident R2 using a sit to stand lift. The report indicated that Employee E13 was by herself when she lifted the resident and transported him into the bathroom and bumped his arm in the doorway. Employee E13's statement states that she put Resident R2 onto the mechanical lift, and when she was turning the bathroom light on his arm was hurt on the door.Further review of Resident R2's incident investigation revealed that on June 18, 2025, Employee E13 was educated by Employee E19, Registered Nurse, to use two staff members when using a mechanical lift.Telephone interview with the Administrator on July 17, 2025, confirmed that Employee E13 was operating the mechanical lift by herself on June 18, 2025, when she was transporting resident R2 to the bathroom when his arm was bumped into the door, and that after this incident she was educated by the nurse to use two staff with a mechanical lift. The Administrator also indicated that Employee E13 had quit about a week after the incident and was not returning his calls related to this investigation. 28 Pa Code 211.12(d)(5) Nursing services 28 Pa Code 211.10(d) Resident care policies

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature. Findings include: Interview with Resident R80 on June 16, 2025 at 11:23am revealed that food does not taste good. Interview with Resident R230 on June 16, 2025 at 1:07pm revealed that food does not taste good and is not cooked to right temperatures, tends to be overdone or underdone depending on the dish. Interview conducted with Resident R137, during dining on June 16, 2025, at 1:27 p.m. revealed that the food was cold. During a group interview on June 18, 2025, at 10:03 p.m. when food was brought up and all the residents agreed that there were problems with the food. Residents R33, R110, and R230, stated that last week, chicken was served partially raw with visible blood. Observations during a test tray conducted with the Dietitian, Employee E9, on June 18, 2025, at 1:01 p.m. revealed pasta registered at 107.6 degrees Fahrenheit (F); green beans registered at 102.5 degrees F; salmon at 109.5 degrees F; and orange juice at 52.5 degrees F. Follow-up interview with the Dietitian, at 1:20 a.m. confirmed that the tested food items were too cool to be palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling for one of two residents reviewed for tube feeding (Resident R299). Findings include: Review of physician order for Resident R299, dated April 27, 2025, indicated, one time a day Administer Jevity 1.5 @50 ml/hr until total volume of 500 ml daily has infused . Observations on June 18, 2025, at 1:37 p.m. in Resident R299's room, revealed that the bottle of Jevity 1.5 Enteral Feed was dated June 10, 2025. Follow-up interview with the unit manager, Employee E11 at 1:39 p.m. confirmed the above-mentioned finding. Continued interview revealed that the enteral feed bottle must be discarded every 24 hours. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3)(5) Nursing services

Based on observations; review of clinical records, policies, and procedures; and staff interviews; it was determined that the facility failed to ensure that a resident was free from physical restraints for one out of 35 residents reviewed (Resident R156). Findings include: Review of Resident R156's clinical record revealed that the resident was admitted in the facility on June 1, 2024, with diagnoses including Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Parkinson's Disease with Dyskinesia (neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slowness of movement), Anxiety Disorder (Anxiety disorders are a group of mental health conditions characterized by excessive, persistent, and uncontrollable feelings of worry and fear), and Depression (major loss of interest in pleasurable activities). Review of Resident R156's physician orders revealed an order, dated October 25, 2024, to check placement of bed alarm for placement and function every shift for safety. Review of Resident R156's care plan, revealed; Chair alarm in place, date-initiated April 18, 2025, and Bed Alarm in place while in bed. Check for proper function daily, date-initiated July 2, 2024. Review of Resident R56's Minimum Data Set (MDS- assessment of resident care needs) dated May 6, 2025, indicated that bed alarm and chair alarm were used daily. Continued review of the MDS revealed that the resident was assessed as requiring partial to moderate assistance for sit to lying in bed, sit to stand and for lying to sitting on side of bed. Observation conducted on June 17, 2025, at 12: 36 p.m., revealed that Resident R156's has a bed alarm in placed. Review of Resident R156's clinical records of Resident R156 revealed no documented evidence that the resident was evaluated for the use of a chair/bed alarm. Interview with Employee E6, the Unit Manager, a Registered Nurse, on June 17, 2025, at 12:39 p.m., confirmed the findings. 28 Pa Code 211.8(f) Use of restraints

Based on review of clinical records, interviews with staff, and facility policy, it was determined the facility failed to ensure residents who require dialysis treatment receive such services, consistent with professional standards of practice, including ongoing assessment of the resident's condition and monitoring for complications before, during, and after dialysis treatments for one of three dialysis resident's reviewed (Resident R104). The facility's failure to properly monitor Resident R104's right arm fistula (used for dialysis access) resulted in actual harm to Resident R104 who required an emergent transfer to the hospital from the dialysis center when the resident's fistula was assessed as swollen, infected with purulent (thick, yellowish substance that occurs with infection) drainage and the development of a non-occlusive right brachial deep vein thrombosis. (Resident R104). Findings include: Review of the facility's policy titled, Hemodialysis Catheters-Access and Care of revised on, February 2023, indicates, after placement of the fistula or graft, the site cannot be accessed until it matures which may take 2-3 weeks for a graft and 6-12 weeks for a fistula. The primary goal is to prevent infection and maintain patency of the catheter (preventing clots). To prevent infection and/or clotting the site needs to be clean at all times. Check for signs and symptoms infection (warmth, redness, tenderness, or edema) at the access site when performing routine care. Check the color of the fingers and the radial pulse of the access arm when performing routine care and at regular intervals. Check the patency of the site at regular intervals, palpate the site to feel the Thrill or use a stethoscope to hear the whoosh sound or bruit. The nurse should document in the resident's medical record every shift the location of the catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis. Review of Resident R104's clinical record revealed, Resident R104 was admitted to the facility on [DATE], diagnosed with end state renal disease and ordered to receive hemodialysis (acts like an artificial kidney, removes waste and fluid from the body) three times a week on Tuesday, Thursday and Fridays. On November 13, 2024, Resident R104's nursing progress note revealed the resident returned from the hospital status post-surgery for the resident's right arm fistula (used for dialysis access) was noted wrapped with an ACE bandage from fingertips to the resident's upper arm, with no signs of swelling. Review of Resident R104's November 2024 physician's orders revealed there were no evidence the attending physician's orders were obtained for the care and monitoring of the resident's right arm fistula when returning from the hospital. Review of Resident R104's nursing skin checks documentation dated November 15, 2024, revealed no signs and symptoms of infection. Review of physician orders revealed an order obtained on November 25, 2024, for the antibiotic, Doxycycline Hyclate 100 milligrams tablet, to be given twice a day for 10 days due to erythema (redness) at the surgical sight. On November 26, 2024 nursing note for Resident R104 indicated the antibiotic was used for the resident's erythema at surgical site and that the right arm remained swollen and the resident returned from dialysis without issues. On November 27, 2024, nursing note notes indicated [Resident R104]'s use of antibiotic for erythema to surgical scar with no swelling or tenderness with arm wrapped with ace bandage. November 27, 2024, nursing note indicates, Resident R104 use of antibiotic for erythema to surgical scar with no swelling or tenderness with arm wrapped with ace bandage. Continuing the review of Resident R104's nursing notes dated, November 28, November 29, November 30, December 1, 2, 3, 4, and December 5, 2024 revealed the resident continued on the antibiotic, erythema was still observed at the surgical site, right arm remained swollen with the ace wrap in place. Continued review of Resident R104's nursing documentation revealed there was no evidence the resident's physician was notified by nursing staff that the resident right arm continued to be swollen when the antibiotics were completed on December 5, 2024. Further review of nursing notes from December 6, 2024 through December 9, 2024 did not reveal the resident's right surgical wound was assessed/evaluated. Review of facility documentation title Long term care evaluation dated December 16, 2024, noted non pitting edema, not dependent upon positioning, documented as 'not new,' was located on Resident R104's right palm of hand, right upper arm, right anterior elbow, and right forearm. Review of Resident R104's nursing skin check dated December 17, 2024, failed to document the status of Resident R104's swollen arm but stated at the time of assessment the resident was off the unit and the wound was wrapped. On December 19, 2024, Resident R104's nursing progress note indicated the resident was Sent out to the hospital ER (emergency room ) for evaluation on swollen right arm. Dialysis team called this nurse and stated that they reached out to nephrology in regard to resident swollen right arm and resident needs ER visit ASAP (as soon as possible). Review of hospital records revealed Resident R104 presented to the emergency on December 19, 2024, with right upper extremity erythema edema, cellulitis/abscess with purulent drainage (thick milky foul smelling drainage commonly called pus) from his fistula site, also with nonocclusive right brachial DVT (Deep Venous Thrombosis-blood clot) and was placed on Vancomycin (an antibiotic used for severe infections). The correspondence/communication between the facility and dialysis center during that time period was either incomplete or not found. Resident R104 was also found to have two dialysis communication books both with missing and/or incomplete data between both parties. Due to a lack of documentation, the Unit Manager Employee E19 on February 7, 2025, at 10:30 a.m. was asked about the progression of Resident R104's surgical wound and the infection. The Unit Manager could not provide any additional information other than stating, We were wrapping his arm and when his arm swelled, he was sent to the hospital. Interview with the Director of Nursing on February 7, 2025 at 5:00 p.m. confirmed there were no orders obtained related to the care of the right arm fistula upon the resident's returned from the hospital on November 13, 2024. The facility failed to properly monitor and assess Resident R104's right arm fistula (used for dialysis access) for complications during and after dialysis treatments which resulted in actual harm to Resident R104 who required an emergent transfer to the hospital from the dialysis center when the resident's fistula was assessed as swollen, infected with purulent drainage and the development of a non-occlusive right brachial deep vein thrombosis. 28 Pa. Code: 211.10(c) Resident care policies 28 Pa Code 211.5(f)(ix) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on the review of clinical records, facility documentation, facility policies, and interview with residents and staff, it was determined the facility failed to ensure a resident's environment was free of accident hazards, and failed to ensure hazardous materials were not accessible to one of nine residents (Resident R1). Staff failed to provide supervision for Resident R1 with documented history of suicidal ideation and who voiced suicidal thoughts. This failure resulted in Resident R1 obtaining a disposable razor and cutting her/his wrist. This failure placed Resident R1 at risk for serious injury and resulted in an Immediate Jeopardy situation for Resident R1. This deficiency is cited as past non-compliance. Findings Include: Review of facility policy Safety and Supervision of Residents dated August 2024, revealed Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance Improvement Plan) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Ensuring that interventions are implemented; and d. Documenting interventions. 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed Safety; b. Safe Lifting and Movement of Residents; c. Falls; d. Smoking; e. Unsafe Wandering; f. Poison Control; g. Electrical Safety; and h. Water Temperatures. i. Items that can have potential harm Review of facility policy Suicide Threats dated August 2024, revealed that Resident suicide threats shall be taken seriously and addressed appropriately. 1. Staff shall report any resident threats or alarming passive language of potential suicide immediately to the nurse supervisor/charge nurse. 2. The nurse supervisor/charge nurse shall immediately assess the situation and shall notify the charge nurse/supervisor and/or director of nursing services of such threats. 3. After assessing the resident, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician. 4. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 5. Staff will monitor the resident's mood and behavior and update care plans accordingly. 6. Staff shall document details of the situation objectively in the resident's medical record. Review of facility policy 1:1 (a facility staff individually providing observation to a resident) Supervision of Residents dated December 31, 2024, revealed Resident safety is a priority at Horsham Center for Jewish Life. Residents that are exhibiting behaviors that may cause harm, are placed on 1 :1 supervision until IDT (Interdisciplinary team) team meets and updates plan of care to ensure safety. The behaviors below are not all inclusive: o Active/passive suicidal ideation o Repeated or continuing attempts to seriously self-harm o Active exit-seeking-residents o Repeated aggressive behaviors o Acute psychotic episodes. Once resident is placed on 1 :1 the following steps are to be followed: o Staff who is assigned will be given report on resident. o Shift to shift report will be completed when changing shift with ongoing and off going shift. o If any of the above behaviors arise, the supervisor is to be notified immediately. o One to one will always be within arm's length as it relates to resident safety. Review of Resident R1's clinical record revealed that the resident was admitted to the facility with diagnoses of bipolar disorder with psychotic episode (a mental illness that causes extreme mood swings, often called manic-depressive disorder), major depressive disorder (major loss of interest in pleasurable activites), and generalized anxiety disorder. Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated December 3, 2024, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 13 which indicated that the cognitive status of the resident was intact. MDS mood assessment indicated that the resident felt down, depressed or hopeless 7-11 days in two weeks. Resident stated yes to Feeling bad about yourself - or that you are a failure or have let yourself or your family down, with a frequency of 2-6 days in 2 weeks. Resident also indicated feeling lonely or isolated. Review of care plan for Resident R1 dated August 11, 2024, revealed the resident had a history of suicidal ideation and/or intent. Care plan interventions included, assess for any suicidal ideations, consult psychology and/or psychiatry as ordered, If resident having active suicidal ideations check and remove any items/objects in room that could potentially be used for self-harm and place resident on 1:1, if needed. Review of hospital record for Resident R1 dated December 24, 2024, revealed the resident admitted to the hospital from the facility for worsening depression. Resident continued to display symptoms of calling out, making statements of wanting to die and was referred for inpatient psychiatric stay. Review of physician's note for Resident R1 dated December 24,2024, revealed the resident had a recent stay at the hospital for uncontrolled anxiety and behaviors. Resident's diagnoses from hospital included depression, anxiety and bipolar disorder. The physician recommended to monitor resident closely. Review of nursing note for Resident R1 dated December 29, 2024, at 4:56 a.m., revealed the resident displayed signs of anxiety throughout the beginning of the shift. Review of nursing note for Resident R1 dated December 29, 2024, at 9:27 a.m., revealed that Nurse reports resident stated (she/he) is going to cut (his/her) wrists. 1:1 started, MD (physician) notified, VM (voice message) left for daughter, room searched for harmful objects. Resident is to have plastic silverware, dietary/nursing made aware. DON (Director of Nursing) notified. Review of nursing note for Resident R1 dated December 29, 2024, at 1:56 p.m., revealed the resident had signs and symptoms of anxiety. The resident was on 1:1 supervision for suicidal ideation. Resident to have plastic silverware. Resident displayed signs of anxiety throughout the shift. Review of facility investigation revealed a written statement provided by Employee E4, Registered Nurse, dated December 29, 2024 revealed the resident expressed that (he/she) wanted to cut (his/her) wrists. Resident was placed on 1:1. Employee E4 searched the tables, bathroom and the tray tables. Employee E4 removed scissors, pens, and a sharp rock painting off the wall. Review of physician progress note for Resident R1 dated December 30, 2024, revealed the practitioner recommended to continue 1:1 supervision for safety related to expressed concern. Review of Psychiatrist, Employee E8's note for Resident R1 dated December 30, 2024, revealed Continue 1:1 supervision for safety due to expressed concerns. Caution to discourage dependence on aide as secondary gain for attention in light of isolation. Review of facility investigation dated December 31, 2024, related to Resident R1 revealed Resident R1 had a vertical 1.5 inch scratch and three vertical 3 centimeters scratches medial to 1.5 inch. scratch to inner aspect of left wrist which occurred on December 31, 2024, around 5:40 a.m. Resident stated (he/she) attempted to cut (his/her) own wrist. Wound was cleaned with normal saline and covered with a dry dressing. Cleanse scratch on left wrist with normal saline and bacitracin applied then covered with Band-Aid until healed. Review of nursing note for Resident R1 dated December 31, 2024, at 6:26 a.m., revealed, At approximately 0540 (5:40 a.m.) signee received a call from the Nurse Aide assigned to 1:1 explaining the resident acquired a razor and was threatening to cut her wrist. At the time of the call the CNA (nurse aide) didn't feel the resident would willingly relinquish the razor. Signee went to the resident's room to find she had given up the razor after she had scraped her wrist, causing a superficial abrasion. Wound was cleaned with NSS (normal saline solution) and covered with a clean dry dressing. Spoke with the resident to find she was feeling very down and lonely. Meanwhile the Nurse Aide swept the room for items the resident could potentially use to harm herself. Following our conversation . Mental Health Practitioner on-call contacted, message left requesting call-back. Physician called, message left requesting call-back; email sent reporting the incident. Strict 1:1 maintained. Report given to oncoming nurse and 1: 1 Nurse Aide. Review of nursing note for Resident R1 dated December 31, 2024, at 6:26 a.m., revealed While on unit A, passing morning medication. This nurse was notified by supervisor that resident had attempted to cut (his/her) wrist. Resident had several harmful items in (his/her) room upon searching by aide. After assessment, the resident received a superficial cut on the left inner wrist as 1: 1 aide was able to take item from resident. The supervisor notified the resident family as well as the psych nurse. Supervisor dressed resident cut. This nurse notified that resident will not go out at this time but will be seen by doctor. Items removed by aide. Resident complained of pain during this shift and received PRN (as needed) medication. Resident pleasant during this shift, however had moment of seeking excessive validation. Resident out of bed during most of this shift with 1 :1 aide in room. Resident plan of care is ongoing. Review of facility investigation revealed a written statement provided by statement from Licensed nurse, Employee E5, obtained by the Director of Nursing dated December 31, 2024, revealed that she confirmed the resident was on 1:1 during 11-7 with the resident. She stated that the resident was on precautions for norovirus (contagious virus that causes diarrhea and vomiting), and (he/she) was using the bathroom throughout the night into the early morning as (he/she) continued with gastrointestinal (GI) issues. Employee E5 stated that she gave the resident privacy in the bathroom and since (he/she) had norovirus while (he/she) was having ongoing GI issues. Staff remained outside the bathroom door Employee E5 stated that the resident came out of the bathroom and stated that (he/she) had cut (his/her) wrist with a razor that (he/she) found in the bathroom drawer. Immediately Employee E5 went into the bathroom to look in the drawer and she took a razor out of the drawer. She said that resident picked up the other razor and when Employee E5 asked for (resident) to give it to her Resident R1 declined. Employee E5 told (him/her) again that staff need to take the razor and if (resident) didn't give it to her, she would call security. The supervisor was called, and the resident handed over the razor. Review of progress note for Resident R1 by the Director of Nursing (DON) dated December 31, 2024, revealed that she assessed resident's left wrist, scratch marks are noted vertically on the inside of the wrist. Band-Aid was in place, some redness noted. Resident stated to the Director of Nursing, she/he did that with a razor that she/he found in the back of the bathroom drawer, and it was stupid of him/her to do, and regreted it. Interview with Employee E6, Licensed Practical Nurse, on January 7, 2025, at 11:50 a.m., revealed that she was working on December 29, 2024, when resident first expressed suicidal ideation. Resident told her that she/he was going to cut her/his wrist. Employee E6 stated the resident was placed on 1:1. Employee E6 stated 1:1 supervision should be provided all the time including inside the bathroom. Employee E6 stated razors were kept in locked clean utility room and she was not sure how resident obtained razors. Interview with Resident R1's husband who was a resident at the facility, on January 7, 2025, at 11:55 a.m., revealed that Resident R1 had severe depression since childhood. Husband stated the resident received the razors from the facility, it was the kind the facility provided. Interview with the Unit Manager, Employee E7 on January 7, 2025, at 12:00 p.m., stated she found potentially hazardous items during a search after resident cut her wrist. She stated the call bell cord was not removed after resident made the first threat, she had vaseline, lotions, and other personal product liquids in her room. Employee E7 stated resident told her that she/he got the razor from the bathroom drawer. Employee E7 stated razors should not be kept with residents with suicidal ideation and staff should stay at arms length of resident at all times when on 1:1 watch. Staff should have visual of resident even including the bathroom. Interview on January 7, 2025, at 1:00 p.m., with Employee E5, Nurse Aide who provided 1:1 supervision on December 31, 2024 to Resident R1 at the time that the resident cut her/his wrist stated that when she started 1:1 suicide watch shift, the aide I relieved informed me that the resident had been experiencing diarrhea. The resident remained awake throughout the night, frequently using the phone and going to the bathroom about every hour. At around 5:30 a.m., the resident came out of the bathroom and informed me that she/he had cut herself/himself while I was in her room. Resident R1 stated she/he had used a razor, and upon inspection, three disposable razors were found. The resident had stayed in her/his room all night, and the bathroom door had been closed during the resident use, preventing Employee E5 observing what the resident was doing in the bathroom. Employee E5 stated, she had assumed the resident had been searched before being placed on 1:1 observation. Staff stated she did not conduct a room sweep at the start of her shift. Employee E5 also stated she did not have proper PPE (Protective personal equipment), such as a mask, which limited her ability to provide supervision in the bathroom. Employee E5 stated she did not ensure the bathroom was safe before the resident used the bathroom and closed the door. After the incident, she conducted a room search and discovered a screwdriver and scissors in the desk drawer, two packs of thumbtacks in the drawer and some on the wall, two additional razors in the bathroom vanity drawer. Interview on January 7, 2025, at 1:40 p.m., with Employee E4, Registered Nurse, who searched resident room on December 29, 2024, when the resident expressed suicidal ideation stated she checked the bathroom, countertop, and drawers that was close to resident's bed, but didn't find anything. When asked if she thoroughly checked the bathroom vanity closet she stated I'm fairly certain I opened them fully, but nothing was removed from the bathroom. She stated she didn't search other cabinets and drawers other than the bedside table, where she only saw a pen and scissors. There was a sharp rock-like item on the wall which was removed. She stated she did not recall seeing a table or a cabinet next to the door. Employee E4 stated she didn't check other areas in the room, just the immediate area of the resident, and placed the resident on 1:1 supervision. Employee E4 stated the call bell cord was not removed as well. Employee E4 confirmed that the call bell cord should have been removed. Employee E4 stated resident was really anxious and a lot of time was spent calming the resident down. She stated she did not recall seeing any other items. Employee E4 also stated when residents were placed on 1:1, staff need to stay with the resident, keeping eyes on them at all times to monitor their actions. Interview with psychiatrist, Employee E8 on January 7, 2025, at 2:44 p.m. revealed that she ordered 1:1 supervision for safety related to suicidal ideation. Employee E8 stated due to resident's mental status she discouraged staff from providing companionship because she did not want resident to get used to it and to only use 1:1 for safety. Interview on January 7, 2025 at 1:40 p.m., with Employee E2, Director of Nursing, stated when resident who has a communicable disease is on isolation, staff should wear PPE and be with resident at all times. Staff should also thoroughly check the room for potentially dangerous objects when resident's express suicidal ideation. Director of Nursing confirmed that the staff did not thoroughly check Resident R1's environment when (he/she) expressed suicidal ideation on December 29, 2024, and did not provide 1:1 supervision consistently as ordered which resulted in resident obtaining razor and cut her wrist. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 7, 2025, at 3:55 p.m. for the facility's failure to ensure that resident's environment was free of accident hazards, and failed to ensure that hazardous materials were not accessible to a resident. Staff failed to provide 1:1 supervision for Resident R1 with documented history of suicidal ideation and voiced suicidal thoughts two days prior to the indicent. This failure resulted in Resident R1 obtaining a disposable razor and cutting her/his wrist. The facility's failure placed Resident R1 who had a history of suicidal ideation at risk for serious injury and resulted in immediate jeopardy situation. An IJ Template was presented to the facility on [DATE], at 3:55 p.m. The facility submitted a written plan of action on January 7, 2024, at 6:10 p.m. and implemented the plan of action which included: Resident's room was searched for all potentially dangerous objects and were removed. Documentation revealed 1:1 supervision continued, December 31, 2024, and remains in place. Review of residents with SI (suicidal ideation) was conducted on December 31, 2024, no other residents on December 31, 2024, were being observed for SI. The facility reviewed and implemented policies on December 31, 2024, to ensure that the residents with suicidal ideation/ behaviors that can lead to self-harm, do not have access to potentially dangerous objects such as sharp objects, medications, hazardous chemicals and staff provide appropriate 1:1 supervision when indicated. Education was started on December 31, 2024, for staff responsible for overseeing room searches on the policy of ensuring no sharp objects, medications, hazardous chemicals are accessible to the resident. December 31, 2024, achieving >77% and continued on January 1, 2025, with the facility completing >90%. Education will continue for any staff not educated, upon their return, prior to their 1:1 shift, until reaching 100%. Education was provided to staff providing 1:1 on ensuring that residents with SI are always within arm's length as per the supervision policy. Education was started on December 31, 2024, achieving >77% and continued on January 1, 2025, with the facility completing >90% and will continue upon their return for any staff not educated prior to their 1:1 shift until reaching 100%. Audit completed December 31, 2024, and continues Q (every) Shift for the resident on 1:1 for SI to ensure safe environment. QAPI meeting was conducted on December 31, 2024, with the IDT and will continue to be reviewed with the committee to determine if further action is needed. On January 8, 2024, at 4:45 p.m. the action plan was reviewed, observations were made of all nursing units and resident rooms. Interviews were conducted with staff to confirm that the in-service education was completed. Observation was completed to ensure consistent 1:1 observation was provided. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on December 31, 2024. Audits were initiated to ensure that no sharp objects, medications, hazardous chemicals are accessible to the residents with suicidal ideation and residents with SI are always within arm's length as per the supervision policy. The facility reviewed and updated their policy related to 1:1 supervision. Additionally, the facility educated all staff to the updated facility policy. Interviews were conducted with Nurse Aides, Licensed nursing staff and Registered Nurses regarding trainings and competencies related to ensuring that no sharp objects, medications, hazardous chemicals are accessible to the residents with suicidal ideation and residents with SI are always within arm's length as per the supervision policy. Staff also stated that they received sufficient trainings from the facility. The facility alleged compliance with their plan of correction as of January 1, 2025. The Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on January 8, 2025, at 4:45 p.m. This deficiency was identified as Immediate Jeopardy past non-compliance. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management

Based on interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure that adequate supervision was provided to a resident who verbally expressed to nursing staff that she wanted to kill herself, which resulted in an Immediate jeopardy to Resident R1 who ingested acetaminophen, was transferred out to the hospital, had elevated blood levels of acetaminophen, and received treatment for intentional acetaminophen overdose (Resident R1). Findings include: Review of the August 2024 physician orders for Resident R1 included the diagnoses of hypertension (high blood pressure); chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure); cerebral infarction (a stroke); muscle weakness; anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations) and depression (a mood disorder that cause persistent feelings of sadness and loss of interest). Review of the resident's annual Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated July 23, 2024 indicated that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 15, which indicated that the resident was cognitively intact. Review of a note written by the psychologist dated April 2, 2024, at 12:21 p.m. documented that the village leader (unit manager) called the psychologist and informed the psychologist that the resident left her (unit manager) several voicemails overnight reporting thoughts of being better off dead. The note also indicated that while meeting with the resident at the unit manager's request, the resident endorsed having felt overwhelmed with the thoughts of being better off dead last evening, but denied thoughts of self-harm then or in session. The psychologist reported that the resident stated that she was still having thoughts of being better off dead but denied suicide ideation. Review of a note written by the psychologist dated May 3, 2024, at 4:04 p.m. indicated a session with the psychologist where resident reported . thought of being better -off dead; she denied SI (suicidal ideation) on my interview . Review of a note written by the psychologists dated June 24, 2024, at 10:55 a.m. indicated a session with the psychologist .thoughts of being better off dead; she denied SI on my interview . Review of a nursing note dated August 3, 2022 at 10:20 p.m. by Licensed nurse, Employee E3 documented that while doing her rounds at the start of her shift (3:00 p.m. -11:00 p.m.), Resident R1 stated, I am going to kill myself. Licensed nurse, Employee E3 stated that she redirected the resident and the resident stated, know what to do and will do it. Licensed nurse, Employee E3 reported that she notified the supervisor, vitals were obtained, and she gave the report to the upcoming nurse for follow-up (11:00 p.m.-7:00 a.m.). Review of an interview conducted by the facilty on August 6, 2024, with Licensed nurse, Employee E3 revealed that the resident told her that she wanted to kill herself because she was upset at the care she received Friday night related to having a bowel movement after drinking prune juice and the call bell response time. Licensed nurse, Employee E3 reported that she contacted the Nursing Supervisor, Employee E5 asking that the nurse assess the resident, but reported that nursing supervisor, Employee E5 never came to the floor. Licensed nurse, Employee E3's statement also indicated that when she completed her first medication administration on her shift, the resident's assigned nurse aide, Employee E6 came to the nurses station with a bottle of Tylenol. Nurse aide, Employee E6 told Licensed nurse, Employee E3 that the resident said that she took 25 pills. Licensed nurse, Employee E3 indicated in her statement that she called the Nursing Supervisor, Employee E5 by phone, did not get an answer, so she contacted the Unit Manager, Employee E7 and asked her what she should do. Licensed nurse, Employee E3 reported that the Unit Manager, Employee E7 told her to contact the nursing Supervisor, Employee E5. Licensed nurse, Employee E3 reported that the nursing supervisor came to the floor for the first time between 8:30 p.m. and 9:00 p.m. and instructed her to take vitals and keep an eye on her. Licensed nurse, Employee E3 reported that she checked on the resident frequently throughout her shift approximately every 25-30 minutes and that she thought that the resident should have a 1:1 instead. Licensed nurse, Employee E3 reported that she gave the resident her 9:30 p.m. medications and that the resident's assigned nurse aide checked on the resident throughout his shift. Employee E3 reported that the resident was asleep at 9:00 p.m. During an interview with Licensed nurse, Employee E3 on August 19, 2024, at 3:43 p.m. the statement that Employee E3 provided to facility administration on August 6, 2024 was reviewed with her, and she confirmed that it was an accurate account of what occurred. Employee E3 reported that the resident's assigned nurse aide for the 3:00 p.m. through the 11:00 p.m. nursing shift (Employee E6) also informed her (Employee E3) that when he went to conduct rounds at the beginning his shift, the resident also told him that she wanted to kill herself. Employee E3 notified the nursing supervisor, but he did not come up. Employee E3 reported that she also notified the licensed supervisor (Employee E5) when the assigned nurse aide (Employee E6) notified her that the resident reported that she took Tylenol. Employee E3 reported that the nursing supervisor did not come up, so she called the Unit Manger (Employee E7) on day shift (7:00 a.m. through 3:00 p.m.) that the resident reported that she wanted to kill herself, and that the resident told her nurse aide (Employee E6) that she took 25 Tylenol, and that the nurse supervisor was notified, but he did not come to see the resident yet. Employee E3 reported that the Unit Manager told her to walk to the nurse supervisor's office to find him. Review of a written nurse aide statement obtained during an interview conducted with Nurse aide, Employee E6 (assigned nurse aide for 3:00-11:00 p.m. shift) on August 6, 2024, indicated that the nurse aide reported that at the start of his shift at 3:00 p.m. the resident also told him that she wanted to kill herself because she was unhappy with the way that she is taken care of. The nurse aide reported that he notified licensed nurse, Employee E3 who then went to see the resident. The nurse aide reported that she told the nurse I am [AGE] years old. I don't know why I am still alive. The nurse aide reported that when he brought the resident her dinner tray she did not want to eat and stated that she wanted to kill herself. The nurse aide reported that he checked on her at approximately between 5:00 p.m. and 6:00 p.m. and that is when the resident told the nurse aide that she took 30 pills of Tylenol and showed the nurse aide the bottle which he brought to Licensed nurse, Employee E3. Continued review of the nurse aide's statement indicated that the nurse supervisor came to the floor later and took vital signs. The nurse aide, Employee E6 explained that he was not assigned to be a 1:1 for the resident but stated that he checked on her throughout his shift. During an interview with Employee E6 on August 19, 2024 at 12:04 p.m. the statement that Employee E6 provided to facility administration on August 6, 2024 was reviewed with him, and he confirmed that it was an accurate account of what occurred. Employee E6 also reported that the resident's statements about wanting to kill herself occurred during the beginning of his shift. He stated that he checked on her throughout his shift and that when he went to deliver the resident's dinner to her, she was lying in her bed. He reported that he was not told that the resident had to have a 1:1 (a staff member assigned to monitor a resident at all times due to medical or safety concerns.) Employee E6 reported that when he went back to the resident's room to retrieve her dinner tray, she told him that she did not want anything to eat and stated to him again that she wanted to kill herself. Unit manager, Employee E7 (3:00 p.m. 11:00 p.m. shift) reported that Licensed nurse, Employee E3 contacted her at 5:43 p.m. on August 3, 2024, was frantic, and reported that the resident had suicidal ideations. Unit manager, Employee E7 reported that she told Licensed nurse, Employee E3 to notify the nurse supervisor and that Licensed nurse, Employee E3 told her that the supervisor was not answering her phone. Unit manager, Employee E7 reported that she told Licensed nurse, Employee E3 to physically go try to locate the nurse supervisor. Unit manager, Employee E7 reported that she contacted Licensed nurse, Employee E3 at 6:37 p.m. and told her that the nurse supervisor came. During an interview with Employee E7 on August 19, 2024 at 4:45 p.m. the statement that Employee E7 provided to facility administration on August 6, 2024 was reviewed with her, and she confirmed that it was an accurate account of what occurred. Employee E7 reported that she was not working when she was contacted by Licensed nurse, Employee E3 and told Employee E3 to go physically find Employee E5 (nurse supervisor) since he had not coming up to the floor regarding what she reported to him regarding the resident stating that she wanted to kill herself and telling her assigned nurse aide that she took Tylenol. Review of a statement obtained from Nursing Supervisor, Employee E5 indicated that he came to see the resident, he did not notice any changes with the residents and that he took the resident's vitals. Nursing Supervisor, Employee E5 reported that he went to assess the resident around 5:00 p.m. regarding her behavioral threat and the resident told her that she wanted the police and that she was not happy. Nursing Supervisor, Employee E5 reported that he assessed the resident again at approximately 10:00 p.m. and that the resident did not tell him that she took medication to kill herself but told him that she wanted the police. The nurse supervisor reported that he instructed Licensed nurse, Employee E3 to monitor the resident and inform him of any changes. Review of an interview conducted with Licensed nurse, Employee E4 indicated that Employee E4 reported that at the start of her shift, she was notified by Licensed nurse, Employee E3 that the resident took Tylenol and that the bottle was taken from her room. Licensed nurse, Employee E4 reported that Licensed nurse, Employee E3 told her that the nurse Supervisor, Employee E5 stated that she does not need a 1:1 but to monitor her every hour. Licensed nurse, Employee E4 reported that she questioned as to why the resident was not on a 1:1. Licensed nurse, Employee E4 reported that she checked on the resident and that she was sleeping when she received a call from the security office on the first floor informing her that the resident called 911 (Emergency Meidcal Services). Licensed nurse, Employee E4 reported that the resident told her that she took the pills before lunch and then told her that she took them at 6:00 p.m. Licensed nurse, Employee E4 also indicated in her statement that the resident reported that she was unhappy here and this is nowhere [sic} to live. Resident was transported to 911 and Licensed nurse, Employee E4 reported that she went into the resident room with the police present and the nurse supervisor for her shift present (Employee E8) and found another bottle of tylenol and eyedrops and removed them from the room. Review of a nursing note dated August 4, 2024 at 12:45 a.m. documented that the resident reported to Licensed nurse, Employee E4 ( 11:00 p.m. - 7:00 a.m.) that she called 911 because she took 25-500 milligram of Tylenol because she does not want to live here anymore. Licensed nurse, Employee E4 reported that 911 personnel transported the resident to the hospital and that Licensed nurse, Employee E4 left a voicemail message for the physician and contacted one of the resident's daughters. Review of an interview conducted with Nursing Supervisor, Employee E8 revealed that at the start of her shift she did not receive any information from the 3-11 p.m. nursing Supervisor, Employee E5 that the resident was having suicidal ideations. Nursing Supervisor, Employee E8 reported that the resident stated that she took 25 pills of Tylenol and told the Emergency Medical Technician and the police officer that she wanted to kill herself when she was assessed. Nursing Supervisor, Employee E8 reported that she told Licensed nurse, Employee E4 to search the resident's room for any other medications and that Licensed nurse, Employee E4 conducted the search and returned with a bag of medication that she found. Nursing Supervisor, Employee E8 was not available for interview with State Survey agency. Review of the resident's hospital records with the Director of Nursing on August 8, 2024 at 2:30 p.m. indicated that the resident's admitting diagnosis was intentional acetaminophen overdose and Cluster B personality disorders (a group of mental disorders that involve unpredictable dramatic or intensely emotional responses to things) and that the resident was treated with N-ACETYLCYSTEINE (also known as N-acetylcysteine (NAC), a medication that is used to treat paracetamol overdose, also known as acetaminophen overdose). Continued review of the hospital records indicated that the resident's acetaminophen level was 103.5 micrograms per milliliter (mcg/mL) of acetaminophen in her blood. A blood level of acetaminophen in the range of 10 to 20 mcg/mL is considered safe (Haldeman-Englert, Foley, [NAME], 2022). Review of the resident's clinical record did not show evidence that she was adequately supervised and interventions were implemented to ensure resident safety for a resident who verbally expressed to at least two facility staff that she wanted to kill herself, and then acted upon it by ingesting a large quantity of Tylenol pills. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on August 8, 2024 at 5:30 p.m. it was discussed that there was no information in the clinical record to show evidence that the resident was adequately supervised by staff to prevent self-harm. The facility failed to ensure that adequate monitoring and supervision was provided to a resident who expressed to nursing staff that she wanted to kill herself. The facility's failure to ensure that the resident received adequate monitoring and supervision resulted in the resident ingesting acetaminophen at the facility as an attempt to kill herself, being transferred out to the hospital, where she was assessed with an elevated blood level of acetaminophen, and received medical treatment for intentional acetaminophen overdose. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified to the Nursing Home Administrator (NHA) on August 19, 2024, at 10:53 a.m. for failure to adequately monitor and supervise a resident who verbally expressed to nursing staff that she had a desire to kill herself. 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 August 19, 2024, at 10:53 a.m. On August 19, 2024 at 3:18 p.m. the facility provided the following corrective action plan: 1. A facility sweep was completed to ensure that there is no medication in the rooms of residents who don't have a physician's order, or not approved for self-administration. 2. ROBO was made to all families on 8/4/2024 to remind them that if they are bringing in any medication for their loved ones, that they give it to the nurse's station to ensure that it is handled properly. 3. Touchdown (Closed Circuit TV) was updated on 8/4/2024 to add a message stating that medications must be received at the nurses' station and not directly to the resident's room. 4. All staff were educated on notifying the DON, NHA, and nursing supervisor that when a resident mention thought of self-harm and if medications are ever in a resident's room, they must notify the nurse supervisor to ensure that the resident has been approved to have the medications. Educations were completed for all staff working in the building on 8/5/2024. Ninety percent completion for overall staff was reached on 8/9/2024. 5. A minimum of 90% of licensed staff were in-serviced on immediately notifying the physician if a resident mentions thoughts of self-harm and to place the resident on 1:1 to ensure safety. 6. The policy regarding suicidal threats was updated to reflect any alarming language that might lead to potential suicide. All staff in the building will be educated today (8/19/24), or prior to coming in contact with any residents. 7. A random audit was conducted to ensure staff understood the above educations. These audits will continue weekly x 3 and monthly x 3. 8. The facility will continue to conduct random audits of resident rooms to ensure that there are no medications in the rooms of residents who don't have a physician's order, or who are not approved for self-administration of medications. Theses audits will continue weekly x3 and monthly x3. 9. A whole house audit has been completed for all residents that triggered for suicidal ideations to ensure that all interventions are in place and care plans were updated. Audits will continue and will include new admissions, weekly x3 and monthly x3. 10. Audit results will be reviewed at QAPI X3 months. 11. Facility will educate residents who have a history of suicidal ideation/intent that incoming packages will need to be checked, with their permission, for any items that could potentially be used for self-harm. 12. Supervisor was suspended pending the investigation. Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on August 20, 2024, at 5:32 p.m. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan

Based on review of clinical records, interview with resident and staff, review of facility policies, it was determined that the facility failed to adequately supervise one of six residents reviewed (Resident R1) who was able to board a taxicab and elope from the facility. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility's policy title Elopements (undated) revealed that the facility assesses to identify residents who are at risk for elopement and strive to prevent harm while maintaining the least restrictive environment for residents. The interventions listed on the policy included for the licensed nurse to complete an elopement evaluation upon the resident admission, re-admission and quarterly. If the resident was identified at risk for elopement, interventions were to be initiated and placed on the resident's care plan. If an employee observed a resident attempting to leave the facility who may not leave the building, he/she should initiate interventions to maintain the resident's safety. If a resident was not visualized exiting the facility, the Administrator, Director of Nursing, Responsible Party, the attending physician and law enforcement were to be notified. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of dementia (progressive [CONDITION(S)] disease of the brain) with behavioral disturbance, abnormalities of gait and mobility, muscle weakness and altered mental status. Review of Resident R1's Minimum Data Set (MDS- assessment of resident care needs) completed July 25, 2022, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 9, which indicated that the resident had moderate memory impairment. Further review of the assessment revealed that the resident required supervision for ambulation with the assistance of one person. The resident balance during transition and walking was not steady from a seated to a standing position, while walking and turning around and the resident used a walker. Review of Resident R1's care plan dated July 15, 2022, revealed the resident had impaired cognitive function and impaired thought processes related to dementia. Interventions included to cue, reorient and supervise as needed. to discuss concerns about confusion, disease process and engage the resident in simple structure activities that avoid overly demanding task. Review of an elopement assessment completed July 15, 2022, revealed that the resident was assessed at a low risk for elopement. Review of the nursing notes dated July 16, 2022, noted that the resident was alert and oriented to person and time only, with some confusion noted, and was able to make his needs known. Review of Resident R1's physician assessment on July 17, 2022, indicated that the resident's memory had declined over the last several months and that a review of symptoms was unable to be completed with the resident due to mental acuity. Review of the Recreational Therapy note dated July 18, 2022, revealed that the resident had some confusion/memory deficit; needs some memory cues .Will need transportation assistance, likely will need supervision off household. Review of Social Services notes date July 27, 2022, revealed that the Social Worker, Employee E9, received a voice message from the resident stating that he wanted to go home and for the Social Worker to meet with him. The Social Worker met with Resident R1 and explained the need for his placement at the facility. The Social Worker also requested that the resident had a psychological consult scheduled by the unit nurse. Continued review of Social Services notes revealed that on July 28, 2022, the resident again stated that he had to go home to get some more items and he really did not want to be at the facility. Social Worker validated resident's feelings and explained to him that this is his home now and his daughter would be called if he wants to get more items to make here more homelike. Resident's daughter was called and the above was discussed. Review of facility reported documentation submitted to the Department of Health on August 7, 2022, revealed that on August 2, 2022, Resident R1 told staff that he wanted to go on a leave of absence but did not inform staff where he was going. Resident R1 called a cab and exited the facility. The facility reported that Resident R1 was alert and oriented x3 (oriented to date, place, and person) and had a physician order to go out on an independent leave of absence. Review of Resident R1's July 2022 and August 2022, physician orders revealed that there was no physician order for an independent leave of absence. Interview with the Director of Nursing, Employee E1, on August 18, 2022, at 12:00 p.m. revealed it was discovered that Resident R1 left the facility at 11:15 a.m. and the facility did not realize the resident was missing until about 3:30 p.m. Interview with the security officer, Employee E8, on August 18, 2022, at 1:00 p.m. revealed when Resident R1 left the faciity on [DATE], the security officer did not stop the resident because they thought he was a visitor. Employee E8 reported an activities staff member came to the front desk around 3:30 p.m. questioning if they saw Resident R1 leave. Employee E8 reported they watched back the camera footage that showed Resident R1 exit the facility at 11:15 a.m. and leave the facility in a cab. Interview with licensed nurse, Employee E7, on August 18, 2022, at 2:15 p.m. revealed she was Resident R1's assigned nurse the day the resident eloped from the facility. Employee E7 reported that Resident R1 did not let this nurse know he was leaving. Employee E7 stated they thought Resident R1 was in therapy. Interview on August 18, 2022, at 4:00 p.m. with Regional Director of Operation, Employees E4 and Regional Nurse, Employee E5 confirmed that Resident R1 did not have a physician order for a leave of absence prior to his elopement from the facility. Interview with Director of Nursing on August 22, 2022, at 3:40 p.m. revealed that licensed nurse on the unit entered Resident R1's wife's room while she was on the phone with Resident R1 who was on the phone line. Resident R1's wife who is also a resident at the facility was overheard by licensed nurse, Employee E7 saying 30th station which is a train station. Licensed nurse, Employee E7 provided the information to the Director of Nursing and the Assistant Director of Nursing. Interview conducted with the Assistant Nursing Home Administrator on August 22, 2022, at 5:19 p.m. revealed that she called the police the moment she became aware that Resident R1 was missing. as he was seen in the video footage. The Business Officer called the cab company who provided the address where the resident was dropped off. The information was then provided to the police. Four officers searched the resident's home and a nearby neighbor told the police that she saw the resident getting into a cab; while that is happening another officer pin the cell phone showing (town) but unable to find the resident. We were instructed by the police to file a missing person report. The resident was located approximately at 7:30 p.m. at the 30th [street]Train Station (an intermodal transit station with a main concourse measuring 290 x 135 feet; located 23 miles from the facility). The Nursing Home Administrator and the Nursing Supervisor drove to the train station and brought the resident back. Phone interview on August 19, 2022, at 4:00 p.m. with the physician, Employee E6, revealed the physician was unaware the resident was leaving the facility on August 2, 2022. Employee E6 reported they still did not know the exact details of what happened [on August 2, 2022] and was not made aware of Resident R1's elopement until after the resident returned to the facility. Interview conducted with Resident R1 on August 22, 2022, at 2:21 p.m. revealed that the resident did remember leaving the facility. He stated that he called a taxi from the facility to his home and then walked two blocks to the train station. That he used to walked to the train station when he had to go downtown to do business. He took a train downtown to 30th and that he was thinking to go to Atlanta once he got to the train station. Based on the above findings, an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator (NHA) on August 22, 2022, at 5:15 p.m. and an immediate action plan was requested. The Immediate Jeopardy template was provided to the Nursing Home Administrator on August 22, 2022, at 5:38 p.m. On August 22, 2022, at 8:04 p.m. the facility's immediate action plan was accepted. The facility's action plan included the following: -On 8/2/2022 Resident was assessed by facility registered nurse and found to have no injuries. He was reassessed for elopement and a wander device was applied to his right ankle. On 8/22/2022 resident was moved to a secure unit within the facility. -On 8/2/2022 Facility completed an audit of all current residents for elopement risk, wander devices, and plan of care. Devices were checked for placement and function. If a resident is identified without their wander device the device will be replaced. Orders were updated to ensure continued monitoring of placement and function. -Facility updated the elopement policy to include completing an elopement assessment of admission, quarterly and with change in condition. The licensed nursing staff will be educated on facility policy for completion of assessments and what to do when identified as an elopement risk. -Reception and security staff will be educated on residents at risk for elopement, elopement binder and who to notify if a resident at risk is trying to exit. -The DON or designee will review newly completed elopement risk assessments in clinical meeting to ensure residents identified as risk have interventions and plan of care in place. -Education will be completed by Staff Development or designee with all licensed nursing staff to the updated elopement policy. -Education will be completed with licensed nursing staff starting on current shift with 70% completed by 8/23/2022 and will continue prior to the start of oncoming shifts until 100% compliance is achieved. -Future scheduled licensed nursing staff will be educated on elopements policy before they work. -Licensed nursing staff that received education will have a post test completed. Interviews were conducted with facility staff on August 23, 2022 between 2:10 p.m.- 5:15 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the completion of an elopement assessment. Resident R1 was observed with 1:1 supervision. A review was conducted of the education provided to facility staff related to resident elopement. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on Augsut 23, 2022, at 5:48 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of clinical records, facility documentation, hospital records and staff interviews, it was determined that the facility failed to document a physician order [REDACTED]. Findings include: Clinical documentation review revealed that Resident R1 was admitted to the facility from the hospital on June 27, 2017 with [DIAGNOSES REDACTED]. A review of the resident admission assessment (MDS - Minimum Data Set - a comprehensive assessment and care screening) dated July 4, 2017 indicated that the resident was moderately cognitively impaired and required extensive assistance of 2 to perform all activities of daily living such as dressing, ambulation and personal hygiene care. A review of the hospital transfer form revealed the medications that should be continued upon discharge. This list included [MEDICATION NAME] 7.5 mg every 7 days for [MEDICAL CONDITION] arthritis. A review of the physician orders [REDACTED]. A review of the nurses progress notes dated July 7, 2017 at 10:50 p.m. indicated that the resident was complaining of new sores in his mouth. A nurses note dated July 11, 2017 at 3:51 p.m. indicated that a Doppler study (Doppler test uses reflected sound waves to see how blood flows through a blood vessel. The test also can find blood clots in leg veins that could break loose and block blood flow to the lungs). This test revealed that the resident had [MEDICAL CONDITION] ([MEDICAL CONDITION] of the right arm and the physician order [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) is a good anticoagulant that reduces the risk of death or bleeding, and blood clots are less likely to happen). Nursing documentation dated July 13, 2017 at 11:25 p.m. indicated that the resident had blood in the incontinence brief. The note continues that at 10:00 p.m. that the resident had a blood clot and was actively bleeding dark red gelatinous (having a jellylike consistency) clotted stool. The Certified Nurse Practitioner was notified and order the resident to be sent to the hospital ER for evaluation. A review of the facility discharge medications indicated that the resident was still receiving the [MEDICATION NAME] 7.5 mg daily. According to Drugs.com [MEDICATION NAME] interferes with the growth of certain cells of the body. [MEDICATION NAME] is usually taken weekly and not every day. [MEDICATION NAME] can lower blood cells that help the body fight infections and bleed more easily. Side effects of the drug include diarrhea, vomiting, sores inside the mouth and blood in the urine and stool. If this drug is taken daily it can be fatal and the maximum weekly dose is 20 mg. A review of the hospital documentation indicated that upon arrival his condition was critical and immediately transferred to the intensive care unit. The hospital record indicated that the resident received a unit of platelets and 2 units of packed red blood cells to help bring up his platelet count and hemoglobin level. A review of a physician's progress note date July 19, 2017 stated It was in the rehab facility where he was supposed to be getting [MEDICATION NAME] weekly for [MEDICAL CONDITION] arthritis. Unfortunately rather than being given weekly it was given daily for about 17 days. This is the source of his pancytopenia (deficiency of all three cellular components of blood-red, whit and plateletes). A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. The facility failed to document a physician order [REDACTED]. 28 Pa Code: 201.14(a) Responsibility of licensee. Previously cited 3/31/17, 2/21/17, 1/12/17, and 7/22/17. 28 Pa Code: 201.18(b)(1) Management. Previously cited 3/31/17, 1/12/17, and 7/22/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/31/17, 2/21/17, 1/12/17, and 7/22/16.

Based on a review of facility clinical records, hospital clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free of a significant med error for one of four residents reviewed (Resident R1). Findings include: Clinical documentation review revealed that Resident R1 was admitted to the facility from the hospital on June 27, 2017, with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set assessment (MDS - a comprehensive assessment and care screening) dated July 4, 2017, indicated that the resident was moderately cognitively impaired and required extensive assistance of two staff to perform all activities of daily living such as dressing, ambulation and personal hygiene care. A review of the hospital transfer form revealed the medications that should be continued upon discharge from the hospital. This list included Aspirin 81 mg daily for [MEDICAL CONDITION] and [MEDICATION NAME] 7.5 mg every 7 days for [MEDICAL CONDITION] arthritis. A review of the physician's orders [REDACTED]. An interview with the Director of Nursing on August 2, 2017 at 1:00 p.m. indicated that the pharmacist notified the facility of the possible concern of the interaction of the aspirin and [MEDICATION NAME]. The Certified Registered Nurse Practitioner told the pharmacy to change the dosage of the [MEDICATION NAME] to 7.5 mg daily. A review of the facility's incident form dated July 21, 2017, indicated during the wrap up summary that the pharmacy did not alert the medical team at the facility of questionable dosing of medication. There was no documentation available for review in regards to the transcription error of the [MEDICATION NAME] 7.5 mg once weekly to [MEDICATION NAME] 7.5 mg daily. This transcription error led to the resident to receive 17 more doses of the [MEDICATION NAME] than ordered. Nursing documentation dated July 13, 2017, at 11:25 p.m. indicated that the resident had blood in the incontinence brief. The note continued to indicate that at 10:00 p.m. the resident had a blood clot and was actively bleeding dark red gelatinous (having a jellylike consistency) clotted stool. The Certified Registered Nurse Practitioner was notified and provided an order to transfer the resident to the hospital ER for evaluation. A review of the hospital documentation indicated that upon arrival to the hospital, Resident R1's condition was critical and he was immediately transferred to the intensive care unit. The hospital record indicated that the resident received a unit of platelets and two units of packed red blood cells to help bring up his platelet count and hemoglobin level. A review of a hospital physician's progress note dated July 19, 2017, stated, It was in the rehab facility where he was supposed to be getting [MEDICATION NAME] weekly for [MEDICAL CONDITION] arthritis. Unfortunately rather than being given weekly it was given daily for about 17 days. This is the source of his pancytopenia (deficiency of all three cellular components of blood-red, white and platelets). A hospital physician progress notes [REDACTED]. A hospital physician's progress note dated July 26, 2017, indicated that the family was struggling between Hospice care and trying rehab services in another skilled nursing facility. An interview with the Nursing Home Administrator and Director of Nursing on August 2, 2017 at 2:15 p.m. confirmed that there had been a transcription error and the facility was unaware of it until they had been notified by the hospital after the resident's discharge. The facility failed to ensure that a resident was free of a significant med error. Refer to F309. 28 Pa Code 201.14(a) Responsibility of licensee Previously cited 07/17/17, 03/31/17, 07/22/16 28 Pa Code 201.18(a) Management Previously cited 03/31/17 28 Pa Code 201.18(b)(1) Management Previously cited 07/17/17, 03/31/17, 02/21/17, 01/12/17, 07/22/16 28 Pa Code 201.18(b)(3) Management Previously cited 03/31/17, 07/22/16 28 Pa Code 201.18(e)(1) Management Previously cited 07/17/17, 02/21/17 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 07/17/17, 03/31/17, 02/21/17, 10/22/16, 07/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 07/17/17, 03/31/17, 02/21/17, 01/12/17, 10/22/16, 07/22/16