Every finding on record at Immaculatemarycenter for Rehabilitation&Healthcare

Based on review of facility documentation, review of clinical records, observations, and interviews with staff and residents it was determined that the facility failed to ensure residents received modified diets consistent with assessed needs for one of 35 residents reviewed (Resident R215).Findings Include: Review of facility diet manual, dated 2023, revealed pureed foods are eaten and swallowed with minimal chewing and minimal jaw movement. Foods are pureed, homogenous, and smooth; and have pudding-like consistency. Review of Resident R215's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 31, 2025, revealed the resident was assessed with severe cognitive impairment and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), malnutrition (when the body lacks the proper amount of nutrients for proper function), and dysphagia (difficulty swallowing). Continued review of Resident R215's comprehensive MDS dated [DATE], revealed the resident received a mechanically altered diet (require change in texture of food or liquids). Review of Resident R215's speech therapy Discharge summary dated [DATE], by Speech Therapist, Employee E15, revealed puree consistency diet texture was recommended secondary to Resident R215 pocketing (holding food in the mouth without swallowing) trials of ground and chopped diet consistencies. Continued review of Resident R215's speech therapy Discharge summary dated [DATE], revealed the resident was unable to follow directions and had difficulty clearing pocketed food with liquids. Speech therapist, Employee E15, documented that on multiple occasions had to physically remove food from oral cavity. Review of Resident R215's physician order summary revealed a diet order dated September 26, 2025, for a pureed textured diet consistency. Observations on March 25, 2026, at 1:25 p.m. during lunchtime in the 3 Floor dining room revealed Resident R215 was sitting with a plate full of pureed food placed in front of him/her on the table but was eating a piece of regular (no texture modifications) cake with his/her hands. A review of Resident R215's meal ticket, located directly on the resident's meal tray, revealed the resident was ordered a pureed diet. Immediate interview conducted on March 25, 2026, at 1:25 p.m. with licensed nurse, Employee E12, who was standing nearby, reported Resident R215 was allowed to have the cake, although confirming that the meal ticket specified pureed texture diet consistency. Interview on March 25, 2026, at 1:27 p.m. with the Speech Therapist, Employee E14, confirmed Resident R215 was ordered a puree textured diet consistency without any exceptions or modifications to the diet. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on interviews with resident and staff and review of clinical records and facility documentation determined the facility did not ensure a resident's dignity was maintained during care for one of 35 resident records reviewed (Resident R85). Findings include: Review of Resident R85's clinical record revealed that the resident was admitted to the facility in February 2023 with the diagnosis of diabetic retinopathy, (a complication of diabetes that affects the eye), and legally blind. Review of R85's clinical record indicated the resident was incontinent of bowel and care planned to have the resident's activities of daily living needs met with staff assistances due to blindness. Review of documentation received by the facility dated August 7, 2025, indicated Resident R85 stated (she/he) was hit in the face during care by a nurse aide (NA) Employee E8. Review of a witness statement from the Assistant Director of Nursing (ADON), Employee E6 stated she and the unit manager (UM), Employee E9 heard Resident R85 yelling from the resident's room and went to investigate. Resident R85 told ADON that the NA, Employee E8, had hit her on the face. Review of the NA, Employee E8 witness statement stated that when the NA, Employee E8 lowered the head of the bed Resident R85 told her 'B***h I can't breathe.' The NA, Employee E8 stated she told the resident, Don't speak to me like that you asked to be changed. The NA, Employee E8 stated that Resident R85 began to get louder, and the NA walked out of the room. Continue review of the ADON's witness statement stated the NA was educated verbally about customer services. Further documentation received by the facility dated August 7, 2025, revealed Nurse Aide Employee E8 received counseling/education on being more attentive and validate the residents' needs. To reapproach the resident when calm, ask another staff member to assist, and to explain all tasks. Interview with Resident R85 on March 26, 2026, at 12:00 pm stated, I am blind, staff need to go slower and tell me what steps they are about to take before they just do it. The aide came into my room and without asking first and put my bed down. I couldn't see what she was about to do and I couldn't breathe. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure one resident received a gradual dose reduction of a psychotropic medication for one of five residents reviewed (Resident R193). Findings Include: Review of facility policy Psychotropic Medications revised September 2025 revealed psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Review of Resident R193's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 28, 2026, revealed the resident was assessed with severe cognitive impairment and had diagnoses of dementia (dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and bipolar disorder (is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior). Continued review of Resident R193's quarterly MDS dated [DATE], revealed the resident was taking antipsychotic and antidepressant medications. Review of Resident R193's comprehensive care plan revised September 20, 2024, revealed the resident was at risk for behavior symptoms related to dementia and bipolar. Intervention dated July 29, 2021, included attempt psychotropic drug reduction per physician orders. Review of Resident R193's clinical record revealed a physician order dated December 27, 2023, to administer Zoloft (also known as Sertraline) 25 milligrams one time per day for depression. Review of Resident R193's Consultant Pharmacist Review, Physician Report dated December 8, 2025, revealed recommendations to consider a gradual dose reduction for Sertraline 25 milligrams. The report was signed, but not dated, by the physician noting that he/she agreed with the recommendations and to further consult psych to adjust the medication dosage. Review of Resident R193's clinical record revealed a psychiatric exam was not conducted until March 20, 2026. Review of Resident R193's Comprehensive Psychiatric Exam dated March 20, 2026, revealed recommendations to stop Sertraline. Review of Resident R193's clinical record revealed the physician order for Sertraline was still active as of March 26, 2026, and no follow-up from the physician. 28 Pa. Code 211.10 (a) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on staff interviews and review of clinical records, it determined the facility failed to develop a comprehensive care plan related to diagnoses Diabetes Mellitus and urinary catheter for two of 35 resident records reviewed (Resident R15). Findings include: Review facility policy on Resident Plan of Care revealed that under section Policy Statement: Our facility's care planning interdisciplinary team is responsible for the development of a plan of care for each resident. Under section Policy Interpretation and Implementation: The care plan is based on the resident's assessment and is developed by a care planning/interdisciplinary team. The interdisciplinary disciplinary team, resident, the resident's family and or resident's legal representative or surrogate are encouraged to participate in the development under visions for the residence care plan. Review of Resident R26's clinical record revealed that Resident R26 was admitted to the facility on [DATE], with a diagnosis of but not limited to Urinary Tract Infection, Essential Hypertension (high blood pressure). Review of nursing evaluation dated February 21, 2026, revealed that the resident had indwelling urinary catheter (foley catheter). Review of Resident R26's admission MDS (minimum data set, a federally required resident assessment completed at a specific interval) Dated February 27, 2026, section H0100. Appliances, A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was coded yes. Review of physician's orders dated February 21, 2026, revealed the followingCatheter: Urinary Catheter Care every shift every shift for Foley catheter care AND every shift for catheter care Catheter Secure: Secure catheter with catheter secure or tape. Replace as needed. Monitor for placement every shift. as needed for Secure catheter Secure catheter with cath secure or tape. Replace as needed and every shift for prevention and Urinary Catheter Drainage Bag - Change as needed as needed CHANGE DRAINAGE BAG AS NEEDED. Review of Resident R26's care plan revealed a care plan for the use of a urinary catheter was not initiated developed until March 5, 2025. Continued review of the resident's care plan revealed that a care plan for At risk for infection r/t indwelling medical device r/t: Indwelling foley catheter. was not initiated until March 21, 2026. Observation conducted on March 23, 2026, at 1:45PM revealed that Resident R26 had a urinary catheter connected to a urinary drainage bag. Review of Resident R15's clinical record revealed the resident was alert and oriented, admitted to the facility diagnosed with type Diabetes Mellitus ( failure of the body to produce insulin) with bilateral proliferative diabetic retinopathy with macular edema, (a complication of diabetes that affects the eyes). Review of Resident R15 clinical record revealed the resident was seen by an eye specialist approximately monthly indicating that the resident was instructed to sleep with the head of the bed elevated and to avoid bending over at the waist. Interview with Resident R15 on March 24, 2026, at approximately 11:30 a.m. indicated she was not aware of the above orders, and only does she sleep with the head of the bed elevated when she is short of breath. Further review of Resident R15 clinical record revealed the facility failed to develop a care plan for the resident's diagnosis of type Diabetes Mellitus. The above was confirmed with the Assistant Director of Nursing, Employee E6, on March 24, 2026, at 10:00 a.m. 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of facility policy and interview with staff, it was determined that facility did not ensure that residents received treatment and care in accordance with professional standards of practice related to abnormal laboratory values for one of 35 residents reviewed (Resident R8)Findings include: Review of facility policy 'Charting documentation,' unknown revision date, indicates that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.' Review of Resident R2's clinical record revealed medical history of acute pulmonary edema, infection and inflammatory reaction due to indwelling urethral catheter (subsequent encounter), epilepsy (brain condition that causes recurring seizures), hypotension (low blood pressure), secondary malignant neoplasm of breast, down syndrome (a genetic condition cause by an xtra copy of chromosome 21), and intellectual disability. Review of Resident R8's Minimum Data Set (MDS- Resident Assessment and Care needs) revealed a brief interview for mental status (BIMS) score of 99 (resident interview was not successful). Review of Resident R2's laboratory results, collected on November 20, 2025, indicate ACTH, Plasma = 5.0 (Low) and Cortisol = 30 (High) Review of Resident R8's clinical record revealed physician progress note, completed by Physician, Employee E7, on November 24, 2025, at 2:55 pm, stated that laboratory data suggests the possibility of adrenal adenoma***or carcinoma***or primary adrenal hyperplasia***causing the disparity in the ACTH level (adrenocorticotropic hormone- test measures the level of ACTH in the blood, helping to diagnose conditions related to the adrenal and pituitary glands). and cortisol level. Due to Resident R8's underlying cognitive impairment due to down syndrome, Physician Employee E7 was reluctant to pursue diagnostic procedures, and will continue to monitor status. Further review of Resident R8 clinical record revealed no further explanation of what Resident R8 was to be monitored for and no evidence of documented nursing interventions to indicate steps were taken to prevent complications post abnormal laboratory results. 28 Pa. Code 211.2 (d)(3) Medical director 28 Pa Code 211.12(d)(5) Nursing services

Based on observation, review of clinical record, review of facility policy, interview with staff and residents, it was determined that the facility failed to ensure that a urine bags (nephrostomy bag) were draining by gravity for one of 35 residents reviewed. (Resident R17)Findings include: Review facility policy on care of nephrostomy 2 with the most recent revision date of May 2025 revealed that under section PURPOSE: the purpose of this procedure is to provide guidelines for the care of the resident with nephrostomy tube Under section GERNERAL GUIDELINES: #1. When evaluating the nephrostomy tube check placement and integrity of the tubing letter A encouraged resident to have placement of nephrostomy tube below the level of the kidneys. Under section IRRIGATION: #7. Slowly aspirate the saline back into the syringe. If there is resistance, remove the syringe and reattach the nephrostomy tube to the drainage tube and allow the solution to drain by gravity. Review of Resident R17's clinical record revealed that Resident R17 was admitted to the facility on [DATE], with their diagnosis of but not limited to Chronic Kidney Disease. Review of physician's orders dated December 7, 2025, revealed Left nephrostomy (a surgical procedure that involves inserting a thin tube, known as a nephrostomy tube through the back to drain directly from the kidney), monitor and record output every shift and Right nephrostomy monitor and record output. every shift. Continued review of physician orders revealed an order dated March 19, 2026, for Nephrostomy drain: Monitor and change q (every) shift and prn every day-shift AND as needed Review of Resident R17's MDS (minimum data set a federally required Resident assessment completed at a specific interval) dated December 13, 2026, reveal that section C-0500 BIMS (Brief interview for mental status) score was 11suggesting that Resident R17 had a moderate cognitive impairment. Further, section C0400. Recall-Resident R17 was able to recall with no cue required on all three recall testing conducted. Observation conducted om March 23, 2026, at 12:04PM revealed that Resident R17 had left and right nephrostomy bag, was lying flat on the bed. Interview with Resident R17 conducted at the time of the observation revealed that she has nephrostomy tube on both the left and right kidneys. Further interview with Resident R17 revealed that the nephrotomy bag was always placed by the staff on her bed and never hanging under her bed. Interview with Assistant Director of Nursing Employee E16 conducted on March 23, 2026, at 12:13PM confirmed that both Resident R17's had left and right nephrostomy bag. Further, Employee E16 confirmed that both left and right nephrostomy bags were lying flat on the bed. 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to identify, implement, monitor, and modify interventions to maintain acceptable parameters of nutrition for two of five residents reviewed for nutrition (Resident R173 and R282). Findings include: Review of Resident R173's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated October 24, 2025, revealed the resident was admitted to the facility on [DATE], assessed with severe cognitive impairment and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), dysphagia (difficulty swallowing), muscle weakness, and muscle wasting. Continued review of Resident R173's comprehensive MDS dated [DATE], revealed Section K - Swallowing/Nutritional Status that indicated Resident R173 sustained a weight loss of 5% or more in the last month, or weight loss of 10% or more, in the last 6 months and was not on a physician prescribed weight-loss regimen. Review of Section K further revealed Resident R173 had complaints of difficulty or pain when swallowing and holding food in mouth/cheeks after meals. Review of Resident R173's clinical record revealed the following weight history:10/18/2025: 120 pounds10/19/2025: 110.8 pounds10/22/2025: 100.2 pounds11/5/2025: 95.8 pounds11/18/2025: 97.8 pounds Review of Resident R173's documented weight history reflected a significant weight loss of 16.5% from October 18, 2025, to October 22, 2025. The significant weight loss was not addressed by the until October 30, 2025. Review of Resident R173's clinical record revealed a nutrition assessment dated [DATE], but not signed and completed until November 19, 2025. Review of Resident R173's nutrition assessment dated [DATE], revealed weight loss was probable due to cognitive impairment, dysphagia, and increased calorie and protein needs to support wound healing.Per Resident R173's nutrition assessment dated [DATE], revealed supplements to be initiated for nutrient repletion and weight gain. The nutrition assessment failed to identify the type and frequency of supplements being recommended. Review of Resident R173's clinical record revealed oral nutrition supplements were not initiated until November 20, 2025. Review of Resident R173's documented weight history revealed the resident's weight continued to have a downward trend of 2.4 pounds to a weight of 97.8 pounds on November 18, 2025. Review of Resident R282's clinical record revealed that resident was admitted to the facility on [DATE], with diagnosis of but not limited to Dysphagia (difficulty swallowing), Muscle Wasting and Atrophy. Review of nutrition assessment dated [DATE], revealed admission weight is pending. Nutrient needs estimated using IBW. Noted weight documented at 136lbs on 12/16/25 during hospitalization. Per review of transfer records, h/o (history) weight declines prior to facility admission noted. Review of Resident R282's care plan dated December 18, 2025 revealed a care plan for at risk for malnutrition r/t(related to) dx (diagnoses) of communication deficit, dysphagia, HF (heart failure), anemia, CKD (chronic kidney disease), HTN (hypertension), altered lab values, need for therapeutic/mechanically altered diet, need for thickened liquids, impaired skin integrity, and BMI(body mass index-Calculates a person's body weight relative to their height to estimate total body fat) less than 24. Review of Resident R282's physician's order dated December 17, 2025, revealed an order for: Weekly weight x 4 weeks from admission every day shift every 7 day(s) for Baseline for 4 Weeks. Review of Resident R282's weight record revealed that there was no admission weight. Further review of Resident R282's weight record revealed that Resident R282's initial weight was taken on January 8, 2026, at 127.6 lbs. (pounds), an 8.4 lbs. weight loss from the hospital weight record of December 15, 2025, at 136 lbs. Review of clinical records revealed that there was no dietary notes/intervention for the 8.4 lbs. difference between the hospital weight record dated December 16, 2025, at 136 lbs, and the initial weight dated January 8, 2026, at 127.6 lbs. Further review of Resident R282's weight record revealed that on March 17, 2026, Resident R282's weight was 136.7 lbs. and on March 18, 2026, Resident R282's weight was 87.8 lbs. (35.77% weight loss). Further, the next weight was on March 25, 2026, at 88.4 lbs. A re-weigh done on March 25, 2026, revealed a weight of 124.6 lbs. Further review of Resident R282's clinical records revealed that there was no dietary notes/intervention for the significant weight difference between March 17, 2026, and March 18, 2026. Further, there was no re-weight after the significant weight difference between March 17, 2026, and March 18, 2026. Continue review of weight records revealed a re-weigh obtained on March 25, 2026, of 88.4 lbs. Follow-up re-weigh done on March 25, 2026, revealed a weight of 124.6 lbs. Interview with Registered Dietician, Employee E4 and Dietetic technician, Employee E5 conducted on March 26, 2026, at 9:48AM revealed that Resident R282's was under weight for (his/her) height of 6'1 (73 inches). Further, Employee E5 also confirmed that there was no documented evidence of dietary intervention for the weight loss episodes. Further Employee E4 also confirmed that there was no admission weight for Resident R282. Interview with Regional nurse, Employee E3 conducted on March 26, 2026, at 10:50AM revealed that the weight for March 18, 2026, and March 25, 2026, were erroneous and new weight was taken on March 25, 2026, during the evening shift. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of facility policies and procedures, and interview with staff, it was determined facility did not ensure that drugs and biologicals were stored according to professional standards of practice for one of two medication storage rooms reviewed on 4th floor unit. (medication storage room [ROOM NUMBER] South) Findings include: Review of facility policy 'Medication storage,' effective on March 2020, indicates its purpose is to store all drugs and biologicals in a safe, secure, and orderly manner. On Wednesday, March 26, 2026, the medication storage room temperature indicated an ambient temperature of 80 F, exceeding the generally accepted controlled room temperature range of 68 F to 77 F. During a medication room inspection on Wednesday, March 26, 2026 at 9:30 am, 15 medications were stored at temperatures exceeding recommended limits. During a medication storage room observation on Wednesday, March 26, 2026, at 11:40 am, multiple over the counter (OTC) medications, were observed stored in an area where the ambient temperature exceeded the recommended storage range of 68 F to 77 F, as indicated on manufacturer labeling. During interview with unit manager, employee E11, on Wednesday, March 26, 2026 at 11:45 am, it was confirmed the medication storage room temperature was exceeding recommended temperature, at 80F; as well as no evidence of prior documented room temperature logs. Further review of medication storage room on unit 4 South revealed the following OTC medications stored at 80F: Five bags of 0.9% sodium chloride injections;15 Lidocaine relief gel patches;Three bottles of Acetaminophen 325 mg;11 nicotine transdermal patches;Seven tubes of CareAll Muscle Rub Pain Relieving Cream;Deep Sea nasal moisturizing spray;Omeprazole 20 mg;Two packs of Sevelamer carbonate tab 800 mg;Three tubes of Procure hemorrhoidal ointment;Two bottles of zinc 50mg;Three bottles of vitamin D3, 400 IU/10 mcg;Three bottles of docusate sodium soft gels 100mg;Fish liver oil 3000 mcg;Nine tubes of Microdot Glucose Gel Fast Acting Gel 40% w/w;Four packs of loperamide tablets 2mg. 28 Pa Code 211.12(c)(d)(1) Nursing services

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure laboratory values were timely reviewed for one of 35 residents reviewed (Resident R215).Findings Include: Review of facility policy Diagnostic & Lab Testing dated March 2020 revealed the physician will identify and order lab testing based on diagnostic and monitoring needs of a resident. Continued review of facility policy revealed a nurse will review lab results and communicate results to a physician who will review and be prepared to discuss. Review of Resident R215's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 31, 2025, revealed the resident was assessed with severe cognitive impairment and had a diagnosis of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Review of Resident R215's clinical record revealed a nursing note dated March 3, 2026, that at approximately 8:30 a.m. Resident R215 had episode of what appeared to be seizure like activity for approximately three minutes. Per the nurse note, the physician was made aware and ordered a panel of labs. Review of Resident R215's clinical record revealed labs were drawn and resulted on Marh 3, 2026, with ten lab values noted to be out of range. Further review of Resident R215's clinical record revealed no documented evidence that the labs were reviewed and followed up on by the physician. Interview on March 26, 2026, at 11:45 a.m. with Licensed Nurse, Employee E13, confirmed no evidence Resident R215's labs were discussed with and reviewed by the physician. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision for one of 13 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third-floor lockdown unit, accessing the elevator to the lobby, and walking out the front entrance of the facility. Resident R1 was located approximately two hours later at a family members residence, approximately 1.2 miles away from the facility. Resident R1 accessed a busy traffic area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy situation. (Resident R1) Findings include: Facility policy titled Residents at Risk for Elopement/ Elopement process, revised 2025, revealed on admission nursing personal will complete an elopement evaluation and thereafter routinely for residents. If a resident is deemed at risk for elopement, nursing staff will care plan the resident for being at risk for elopement. Further review of facility policy revealed if an employee observes a resident leaving the premises, he/she should:a. Attempt to prevent the departure in a courteous manner;b. Get help from other staff members in the immediate vicinity, if necessary; andc. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. Review of Resident R1's clinical record revealed that the resident was admitted on [DATE], with a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, and Major Depressive Disorder. Review of Resident R1's care plan, dated September 24, 2025, revealed Resident R1 was at risk for falls due to dementia. Continued review of the care plan revealed Resident R1 has impaired cognitive function related to dementia. Review of Resident R1's occupational therapy (OT) initial assessment, dated September 24, 2025, revealed the resident was referred to OT due to new onset of decrease in strength, decrease in functional mobility, and reduced activities of daily living (ADL) participation. Further review of Resident R1's occupation therapy initial assessment revealed Risk factors: due to documented physical impairments and associated functional deficits the patient is at risk for: falls and further decline in function. Review of Resident R1's elopement evaluation, dated September 23, 2025, revealed the resident was not at risk for elopement. Further review of the same elopement assessment it was noted the assessment was inaccurately coded and indicated the resident was not cognitively impaired or had a diagnosis of dementia. Review of facility reported documentation submitted to the department, dated September 26, 2025, revealed on September 23, 2025, Resident R1 was admitted to the third floor (secure unit). Resident R1 is able to make (his/her) needs known. Prior to [Resident R1] leaving the facility (he/she) was noted in bed Based upon investigation, it was determined [Resident R1] with the assistance of dietary staff, utilized the elevator to go to the first floor. Due to [Resident R1] presentation the front desk staff believed (he/she) was a visitor and exited the facility. The staff were informed of resident's absence when resident's granddaughter called to report incident to facility. Review of facility investigation, dated September 26, 2025, revealed the facility became aware of eloped resident via phone call from Resident R1's family member stating the resident went to his/her granddaughter's house. The resident exited the facility without the knowledge of staff. Resident consumed dinner and medication for the evening prior to the elopement. Resident R1 retuned to the facility with family member. Interview with Administrator, Employee E1 on October 03, 2025 at 9:30 a.m. revealed Resident R1 left the facility at 7:16 p.m. and returned to the facility at approximately 9:15 p.m. Review of a statement from Charge Nurse, Employee E16, revealed he/she saw Resident R1 in his/her room around 7:00 p.m. on the night of the elopement. Review of statement by Nursing Aide, Employee E19, revealed resident was assisted to bed and reeducated how to use the remote control for the television around 7:15 p.m. on night of elopement. Review of a statement by receptionist, Employee E17, revealed he/she was on duty when the resident exited the facility. The resident exited the facility at approximately 7:30 p.m. The resident was dressed in clothing that did not match typical resident attire nor have any identifying med bands and therefore did not appear to be a resident at first. The resident said, 'have a good night and have a good one.' The employee was unaware the resident left the facility until the facility when got the call after 9:00 p.m. Review of statement from dietary staff, Employee E18, revealed the employee was collecting carts off the 3rd floor nursing unit. A woman, who he/she did not recognize as a resident, came through the doors with him/her and went into one of the elevators. Interview conducted with Dietary Director, Employee E5, on October 03, 2025, at 11:39 a.m. revealed prior to Resident R1's elopement the dietary staff were able to use any available elevator during meal service. Since Resident R1's elopement, dietary staff are now only allowed to use the service elevator for meal service. Interview with Receptionist, Employee E3, on October 03, 2025, at 10:15 a.m., revealed the process prior to the elopement involved visitors using a machine, located outside of door in entry way, to sign in. Employee stated that prior to elopement there was no process in place to sign out visitors. Interview with Resident R1, on October 03, 2025, at 10:55 a.m., was attempted but unsuccessful due to cognitive impairment. Review of internet maps of the area revealed the house to which the resident traveled after elopement was 1.2 miles distant from the facility. Resident R1 accessed a high traffic area and busy street intersections. Based on the above findings, an Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1, on October 03, 2025, at 12:55 p.m. for failure to ensure Resident R1 received adequate supervision on a locked dementia unit. This resulted in Resident R1 exiting a secure unit, accessing the elevator to the lobby, and walking out the front entrance of the facility. Resident R1 was located approximately two hours later at a family member's residence approximately 1.2 miles away from the facility. Resident R1 accessed a high traffic area and busy intersections. This failure placed the resident at high risk for injury. An immediate action template (document which included the information necessary to establish each of the key components of the immediate jeopardy) was provided to the Nursing Home Administered (NHA) on October 03, 2025, at 1:11 p.m. On October 03, 2025, at 5:54 p.m. the facility submitted an immediate plan of action that included the following: - Resident on 9/26/25 returned to the facility with granddaughter. Resident was assessed by the nursing supervisor and no concerns were noted. On 9/26/25, resident was provided with an anti-elopement device and in addition, was placed on a one-to-one observation on 9/26/25 by staff until seen by Geri-Psych Nurse Practitioner 9/30/25.- Nurses reviewed or completed an elopement evaluation for all current residents from 9/27/25 through 10/3/25. All residents who were deemed high risk for elopement were also provided with an anti-elopement device and care planned from 9/27/25 to 10/3/25. - Facility Elopement Policy was updated on 10/3/25 by Administration to include how the facility will identify residents who are at risk for elopement. New process was put in place for the front desk staff to oversee the completion of entrance logs for visitors and staff on 9/27/25. Kitchen staff started on 9/27/25 a new process to not allow residents and visitors in facility elevators when in use for dietary functions. Elopement drills were completed on 9/27/25 at 11:58 a.m. and 9/30/25 at 4:00 p.m. Facility staff were educated on the updated elopement process between 9/27/25 through 10/3/25. Facility staff were educated prior to the start of their shifts with any per diem, part time, or agency staff education to occur before their next shift. - Director of Nursing or designee will complete an audit of resident's charts to ensure residents who are at risk for elopement have an elopement evaluation completed. The audit will be conducted twice a week for 30 days. Results of the audit will be presented to the monthly QAPI committee for review. The action plan was reviewed and interviews were conducted with staff to verify the implementation of the action plan. Staff confirmed, education was provided and were able to verbalize the elopement process and policies. Following verification of the immediate action plan the Immediate Jeopardy was lifted on October 03, 2025 at 7:45 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.18(e)(1) Management28 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 review of job descriptions, facility documentation, and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that adequate supervisor was provided to one of 13 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third floor locked down unit via elevator and walking out the front entrance of the facility. Resident R1 was located approximately two hours after the resident exited the facility approximately 1.2 miles away from the facility. Accessing high traffic areas and busy intersections. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1) Findings include: Review of the job description of the Nursing Home Administrator (NHA) revealed that, the primary purpose of the job position is to direct the day-day-day functions of the Center in accordance with current federal, state, and local standards, guidelines and regulations that govern long term care facilities to assure that the highest degree of quality of care can be provided to the residents at all times. As Administrator, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties. Review of the job description of the Director of Nursing (DON) revealed that, the primary purpose of the job description is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern the facility, and as may be directed by Administrator and the Medical Director, to ensure that the highest degrees of quality care is maintained at all times. Review of Resident R1's clinical record revealed that the resident was admitted on [DATE] with a diagnosis of dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, and major depressive disorder. Review of Resident R1's care plan, dated September 24, 2025, revealed Resident R1 was at risk for falls due to dementia (confusion). Continued review of the care plan revealed Resident R1 has impaired cognitive function related to dementia. Review of Resident R1's occupational therapy initial assessment, dated September 24, 2025, revealed the resident was referred to OT due to new onset of decrease in strength, decrease in functional mobility, and reduced activities of daily living (ADL) participation. Further review of Resident R1's occupation therapy initial assessment revealed Risk factors: due to documented physical impairments and associated functional deficits the patient is at risk for: falls and further decline in function. Review of facility reported documentation submitted to the Department of Health, dated September 26, 2025, revealed on September 23, 2025 Resident R1 was admitted to the third floor (locked unit). Resident R1 is able to make her needs known. Prior to resident leaving the facility he/she was noted in bed. Nursing staff were unaware of an elopement history of resident prior to coming to the facility. Based upon investigation, it was determined the resident with the assistance of the dietary staff, exited locked unit and utilized the elevator to go to the first floor. Due to the resident's presentation the front desk staff believed he/she was a visitor and opened door for resident to exit the facility. The staff were informed of resident's absence when resident's granddaughter called to report incident to facility. Review of facility investigation, dated September 26, 2025, revealed the facility received phone call from Resident R1's family member stating the resident went to his/her granddaughter's house. The resident exited the facility without the knowledge of staff. Resident consumed dinner and medication for the evening prior to the elopement. Resident R1 returned to the facility with family member. Interview with Administrator, Employee E1 on October 03, 2025 at 9:30 a.m. revealed Resident R1 left the facility at 7:16 p.m. and returned to the facility at approximately 9:15 p.m. Review of a statement from receptionist, Employee E17, revealed he/she was on duty when the resident exited the facility. The resident exited the facility at approximately 7:30 p.m. The resident was dressed in clothing that did not match typical resident attire nor have any identifying med bands and therefore did not appear to be a resident at first. The resident said, have a good night and have a good one. The employee was not aware that the resident left until the facility when got the call after 9:00 p.m. Review of a statement from dietary staff, Employee E18, revealed the employee was collecting carts off the floor. A woman, who he/she did not know was a resident, came through the doors with him/her and went into one of the elevators. Interview with Receptionist, Employee E3, on October 03, 2025 at 10:15am, revealed the process prior to the elopement involved visitors using a machine, located outside of door in entry way, to sign in. Employee stated that prior to elopement there was no process in place to sign out visitors. Review of internet maps revealed that the house in which the resident was located after elopement was 1.2 miles away from the facility. Resident R1 accessed a high traffic area and busy intersections. Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation. Refer to F689 Pa Code 201.14 (a)Responsibility of LicenseePa. Code 201.18 (a)Management

Based on clinical record review and interview with staff, it was determined that the facility failed to ensure that an elopement risk assessment was accurate for one of 13 residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted on [DATE] with a diagnosis of dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, and major depressive disorder. Review of Resident R1's care plan, dated September 24, 2025, revealed the resident has impaired cognitive function related to dementia. Review of Resident R1's elopement evaluation, dated September 23, 2025, revealed the resident was not at risk for elopement. Further review of the same elopement assessment it was noted the assessment was inaccurately coded and indicated the resident was not cognitively impaired or had a diagnosis of dementia. Interview on October 03, 2025 at 11:15 a.m. with Employee E4, Licensed Practical Nurse, confirmed the resident elopement assessments should be based on whether the resident can or can not make their own decisions and if they have past diagnosis or behaviors. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1) Nursing services

Based on the review of clinical records, podiatry consults reports and interviews with staff, it was determined that the facility failed to implement podiatry recommendation for wound care and promote wound healing for one of five residents reviewed. (Resident R1)Findings Include:According to National Library of Medicine Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, causing reduced tissue oxygenation. Blood vessel alterations observed in diabetic patients also account for reduced leukocyte migration into the wound, which becomes more vulnerable to infections. The hyperglycemic environment itself can compromise leucocyte function. In addition, peripheral neuropathy can lead to numbness of the area and reduced ability to feel pain, which can lead to chronicization of wounds that are not immediately noticed and properly treated. The described features are particularly relevant in the lower limbs and particularly the foot, more exposed to even minor wounds and thus more susceptible to chronicization. In addition, alterations of motor and sympathetic functions lead to physical deformation of the foot and increased plantar pressure, as well as excessive skin dryness which can further favor cracks and unnoticed small wounds.Review of care plan for Resident R1 dated April 10, 2025, revealed that the resident had a potential for alteration in skin integrity related to decreased mobility, incontinence, aged skin, related lateral ankle wound, opening to sacrum, peripheral vascular disease, and history of diabetics.Review of clinical record for Resident R1 dated August 15, 2025, revealed that the resident had wounds to heel/plantar foot deep tissue injury (DTI), and lateral foot wounds.Review of podiatry consult report dated August 7, 2025, revealed that the resident had right dorsal foot, lateral foot and heel deep tissue injury. The recommendations included betadine wet to dry dressing with abdominal pads, secure with tape. Optimize nutrition for healing, optimize glucose for healing with a blood glucose level less than 180 mg/dl.Review of podiatry consult report dated August 14, 2025, revealed that the resident had right dorsal foot, lateral foot and heel deep tissue injury. The recommendations included betadine wet to dry dressing with abdominal pads, secure with tape. Optimize nutrition for healing, optimize glucose for healing with a blood glucose level less than 180 mg/dl.Review of podiatry consult report dated August 21, 2025, revealed that the resident had right dorsal foot, lateral foot and heel deep tissue injury. The provider documented that the right heel was concerning and worsened depth with border line exposed bone. The recommendations included betadine wet to dry gauze with abdominal pads cover with kerlix or Kling, tape and apply Tubigrip. The recommendation included a glucose level of 140-180 mg/dl for healing. Review of podiatry consult report dated August 15, 2025, revealed that the right dorsal foot 2.5cm x2cm x0, 10% eschar, 90% granulation tissue, peeled skin, and Peri wound intact. Plan- betadine moistened adaptic due to dressing adherence. Right heel surgical wound measured 6.5cmx5cmx0.2cm, 25% slough, and 75% granulation tissue, moderate serous drainage, and peri wound erythema. Right Plantar DTI measured 5cmx2cmx0cm 100% dry eschar. Plan- continue Betadine-soaked gauze, gauze, abdominal pads, kerlix then ace wraps. Follows only by Podiatry. Review of physician order for Resident R1 revealed an order to check blood glucose level twice daily, notify physician for blood glucose below 70 or above 250.Review of Medication Administration Record (MAR)for Resident R1 for August 2025 revealed that the resident was noted with blood sugar of260 on 8/5/25 at 4:30 p.m.284 on 8/11/25 at 4:30 p.m.259 on 8/14/25 at 4:30 p.m.260 on 8/15/25 at 4:30 p.m.324 on 8/16/25 at 4:30 p.m.289 on 8/19/25 at 4:30 p.m.257 on 8/21/25 at 4:30 p.m.262 on 8/22/25 at 4:30 p.m.279 on 8/24/25 at 4:30 p.m.302 on 8/25/25 at 4:30 p.m.333 on 8/26/25 at 4:30 p.m.286 on 8/27/25 at 6:30 a.m.256 on 8/27/25 at 4:30 p.m.271 on 8/28/25 at 4:30 p.m.Further review of the MAR revealed that after the podiatrist made the recommendation to keep the blood sugar below 180 on August 7, 2025, the resident was noted with 39 blood glucose level entries out of 43 entries above 180.Review of Resident R1's clinical record from August 7 to August 28, 2025 revealed no documented evidence that the physician was notified of the elevated blood sugar blood sugar or facility attempted or modified nutritional or pharmacological interventions to control the elevated blood sugar.Review of clinical record for Resident R1 dated August 29, 2025, revealed that the resident was sent to the emergency from doctors' appointment for wound infection.Review of clinical record for Resident R1 dated August 29, 2025, revealed that the resident was admitted to the hospital with osteomyelitis (an infection of the bone)Interview with the Director of Nursing on September 15, 2025, at 2:30 p.m. confirmed that the podiatry recommendation for diabetic management for Resident R1 to promote wound healing was not addressed by the facility and staff did not notify the physician of the elevated blood sugar. 28 Pa. code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on the review of clinical records, observations, and interviews with resident representative and staff, it was revealed that the facility failed to provide appropriate services to promote and maintain hearing abilities for one of five residents reviewed. (Resident R3)Findings Include:Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Review of Resident R3's MDS (Minimum Data Set-Assessment of resident care needs) dated February 28, revealed that resident's ability to hear had moderate difficulty and Resident R3 was using a hearing aide.Interview with Resident R2's representative on September 15, 2025, at 10.50 a.m. revealed that the resident had difficulty hearing and she was missing her hearing aid. Resident R5 was not using a hearing aid when she was admitted to the facility however a week after her admission the hearing aid was missing. Resident representative said the resident was not seen by an audiologist or the hearing aid was replaced. Review of care plan for Resident R2 dated November 7, 2024, revealed that the resident had communication problems related to hearing loss/deafness and language barrier. The interventions included communication device, use hearing aids.Review of clinical record revealed no evidence that the resident was seen by an audiologist or scheduled to visit an audiologist to manage hearing impairment or potentially replacing lost hearing aids.Review of an audiology consult report dated March 10, 2025, revealed that the audiology consult was cancelled and a comment was provided patient could not understand. Italian is her main language.Interview with Director of Nursing, Employee E2, on September 15, 2025, at 2:30 p.m. confirmed that the resident was not seen by an audiologist and the resident did not have hearing aids.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services28 Pa. Code: 201.18 (b)(2) Management28 Pa. Code: 211.10 (d) Resident care policies

Based on clinical record review and staff interviews, the facility failed to ensure that a physician assessment was completed and that changes in medical status were addressed in accordance with professional standards of practice for diabetic management to promote wound healing for one of five residents reviewed (Resident R1).Findings Include:According to the National Library of Medicine, Chronic wounds often occur in patients with diabetes mellitus due to the impairment of wound healing. Impaired healing in diabetes is the result of a complex pathophysiology involving vascular, neuropathic, immune, and biochemical components. Hyperglycemia correlates with stiffer blood vessels which cause slower circulation and microvascular dysfunction, resulting in reduced tissue oxygenation. Blood vessel alterations observed in diabetic patients also account for reduced leukocyte migration into the wound, making it more vulnerable to infections. The hyperglycemic environment itself can compromise leukocyte function. In addition, peripheral neuropathy can lead to numbness of the area and reduced ability to feel pain, which can lead to chronic wounds that are not immediately noticed and properly treated. The described features are particularly relevant in the lower limbs, particularly the foot, which is more exposed to even minor wounds and thus more susceptible to chronic wounds. In addition, alterations of motor and sympathetic functions lead to physical deformation of the foot and increased plantar pressure, as well as excessive skin dryness, which can further favor cracks and unnoticed small wounds.Review of the care plan for Resident R1 dated April 10, 2025, revealed that the resident had a potential for alteration in skin integrity related to decreased mobility, incontinence, aged skin, lateral ankle wound, opening to sacrum, peripheral vascular disease, and history of diabetes.Review of the clinical record for Resident R1 dated August 15, 2025, revealed wounds to the heel/plantar foot with deep tissue injury (DTI) and lateral foot wounds.Review of the podiatry consult report dated August 7, 2025, revealed right dorsal foot, lateral foot, and heel deep tissue injury. The recommendations included betadine wet-to-dry dressing with abdominal pads secured with tape, optimizing nutrition for healing, and optimizing glucose for healing with a blood glucose level less than 180 mg/dL.Review of the podiatry consult report dated August 14, 2025, revealed right dorsal foot, lateral foot, and heel deep tissue injury. The recommendations included betadine wet-to-dry dressing with abdominal pads secured with tape, optimizing nutrition for healing, and optimizing glucose for healing with a blood glucose level less than 180 mg/dL.Review of the podiatry consult report dated August 21, 2025, revealed right dorsal foot, lateral foot, and heel deep tissue injury. The provider documented that the right heel was concerning with worsened depth and borderline exposed bone. The recommendations included betadine wet-to-dry gauze with abdominal pads covered with Kerlix or Kling, tape, and apply Tubigrip. The recommendation also included maintaining a glucose level of 140-180 mg/dL for healing.Review of physician orders for Resident R1 revealed an order to check blood glucose levels twice daily and notify the physician for blood glucose below 70 or above 250.Review of the Medication Administration Record (MAR) for Resident R1 for August 2025 revealed the following blood sugar results:260 on 8/5/25 at 4:30 p.m.284 on 8/11/25 at 4:30 p.m.259 on 8/14/25 at 4:30 p.m.260 on 8/15/25 at 4:30 p.m.324 on 8/16/25 at 4:30 p.m.289 on 8/19/25 at 4:30 p.m.257 on 8/21/25 at 4:30 p.m.262 on 8/22/25 at 4:30 p.m.279 on 8/24/25 at 4:30 p.m.302 on 8/25/25 at 4:30 p.m.333 on 8/26/25 at 4:30 p.m.286 on 8/27/25 at 6:30 a.m.256 on 8/27/25 at 4:30 p.m.271 on 8/28/25 at 4:30 p.m.Further review of the MAR revealed that after the podiatrist recommended maintaining blood glucose below 180 on August 7, 2025, the resident had 39 out of 43 blood glucose entries above 180.Review of Resident R1's clinical record from August 7 to August 28, 2025, revealed no documented evidence that the physician was notified of the elevated blood sugars, nor that the facility attempted and/or modified nutritional or pharmacological interventions to control the elevated blood sugar.Review of the clinical record revealed that podiatry recommendations for optimal diabetic management dated August 7, 14, and 21, were not addressed by the physician, and the resident demonstrated elevated blood sugar levels during most checks.Review of the clinical record for Resident R1 dated August 29, 2025, revealed that the resident was sent to the emergency department from a doctor's appointment for wound infection.Review of the clinical record for Resident R1 dated August 29, 2025, revealed that the resident was admitted to the hospital with osteomyelitis (an infection of the bone).Interview with the Director of Nursing on September 15, 2025, at 2:30 p.m. confirmed that the podiatry recommendations for diabetic management for Resident R1 to promote wound healing were not addressed by the physician.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Findings Include:Review of facility policy Enhanced Barrier Precautions dated September 2024 revealed that Enhanced barrier precautions (EBP) utilizes targeted gown and glove use during high-contact resident care activities to reduce the transmission of MDRO's(Multi drug Resistant organisms). Examples of high contact resident care activities requiring gown and gloves for EBP include but are not limited to Dressing, Wound care: any skin opening requiring a dressing.According to CDC (Centers for Disease Control and Prevention) guidelines Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings revealed that Wound care supplies such as dressing materials and equipment should be selected and gathered prior to entering the patient/resident care area to avoid accessing the supply cart/clean storage area during the procedure. Only the materials needed for an individual patient/resident should be brought into the patient/resident's room or treatment area and placed on a clean surface and away from potential sources of contamination (e.g., away from splash zones of sinks) prior to beginning wound care activities. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, Before moving from work on a soiled body site to a clean body site on the same patient, After touching a patient or the patient's immediate environment, After contact with blood, body fluids or contaminated surfaces, Immediately after glove removalObservation of Resident R5's room on September 15, 2025, at 10.00 a.m. revealed that the resident was sitting in a wheelchair. Employee E4, Licensed Practical Nurse and Employee E5, Nurse Aide was observed doing wound care. Both employees were not wearing a gown and gloves. It was observed on the resident door a sign of EBP. Interview with Licensed nurse, Employee E3, on February 24, 2023, at 10:00 a.m., confirmed that Employee E4, and Employee E5 did not wear appropriate personal protective equipment while providing wound care for Resident R5.A wound care observation of Resident R4 on September 16, 2025, at 11:00 a.m. with Licensed nurse, Employee E6, revealed the employee placed the dressing supplies including gloves, gauze, saline bottle, border dressing and wound care medication on resident's bed at the foot of the bed. It was observed that the employee wore clean gloves, removed old dressing and wound was cleaned with saline, it was observed that the saline was dripping from the gauze to the bed while employee was cleaning the wound.Further observation of the procedure revealed that the employee removed the worn gloves and applied new gloves from the gloves that were on the bed. There was no hand washing after the wound was cleaned and before applying the new dressing.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to report an injury of unknown origin to the local State Survey Agency as required for one of four resident records reviewed (Resident R1).Findings include:Review of facility policy Abuse Prevention/Reporting, revised 2023, revealed Staff is trained upon orientation and annually on the abuse prevention program. The training will include types of abuse, stress management tips, and the recognition of signs and symptoms of abuse which may include, but are not limited to the following:a. bruises, skin tears, welts, etc., of unknown origin;b. unexplained injuries.The facility will report all alleged violations involving mistreatment, neglect or abuse to the Department of Health, Division of Nursing Facilities, and to other agencies required by law and Act 13 (Ombudsman. Police, Department, Department of Aging Services, Protective Services). The facility will conduct an investigation of all suspected cases of abuse. The final report will be completed and sent to the respective agencies. The procedure for investigation, results, and corrective action must be included in the report.Review of clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnose that included atrial fibrillation (irregular and often rapid heart rhythm), muscle wasting and atrophy (thinning of muscle tissue), and chronic kidney disease (condition that affects your kidney's ability to filter blood). Review of Resident R1's Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated June 30, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment.Review of Resident R1's nursing progress note, dated July 25, 2025, revealed resident noted with pain, redness, and swelling to RLE (right lower extremity). Skin warm to touch. Further review of Resident R1's nursing progress note, dated July 26, 2025, revealed resident had a stat (immediate) order for an x-ray due to redness and swelling to RLE. X-ray completed today showing results of a fracture. Resident transferred to ED (Emergency Department) per physician order. Review of facility investigation, initiated on July 26, 2025, revealed resident found in bed with redness and swelling to RLE. X-ray ordered and results showed a fracture. Investigation revealed Resident R1 may have injured his/her leg while sitting near the nursing station. Review of 12 witness statements revealed no staff witnessed or was aware of an injury or change in Resident R1's condition prior to Resident R1 stating he/she was in pain.Review of July 2025 reports provided to the State Survey Agency from the facility revealed no submission of Resident R1's injury of unknown origin that resulted in a fibula fracture (lower leg) from the facility as required. Interview on August 08, 2025 at 11:30 a.m. with Director of Nursing (DON), Employee E1, confirmed that the facility failed to report Resident R1's injury of unknown origin to the state agency in the required timeframe. 28 Pa. Code:201.14(a)(c) Responsibility of licensee.28 Pa. Code:201.18(b)(1)(e)(1) Management.

Based on observation and interview with staff, it was determined that facility did not ensure to provide a safe, clean, sanitary and homelike environment for five of 51 rooms observed (Room#'s 200-B, 207-B, 209-B, 210-B, 425-B) Findings include: Review of facility policy 'Homelike Environment,' indicates that residents are to be provided with a safe, clean, comfortable and homelike environment Observations on 2nd floor unit, on Monday, April 14, 2025 at 10:30 am, in room [ROOM NUMBER]-B, revealed two used wash cloths on floor in front of resident's bed, unemptied trash bin, and unemptied bed side commode. Further observations in room [ROOM NUMBER]-B, at 11:00 am, revealed overflowing trash bin as well as excess trash on floor, three separate liquid areas on floor. Upon interview with nurse aide, employee E4, it was revealed that staff from previous shift were responsible for cleaning room [ROOM NUMBER]-B. Further observations of 2nd floor unit, revealed amount of trash under bed in room [ROOM NUMBER]-B. Further observations of 2nd floor unit, revealed food crumbs on floor and unclean bedside table in room [ROOM NUMBER]-B. Further observations of 2nd floor unit, revealed used/unemptied portable urinal on floor next to bed B, room [ROOM NUMBER]. On April 14, 2025, at 11:19 a.m., an observation was conducted and confirmed by the Unit Manager, Employee E15, in room [ROOM NUMBER]. The privacy curtain separating the two residents had large yellow and white stains. Additionally, the wall across from the bed in room [ROOM NUMBER]B had multiple brown stains, and the air conditioner vent cover also had visible brown spills. Two empty medication cups were observed on the right corner of the resident's room. 28 Pa Code 201.14 (a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II of the PASRR (Pennsylvania Pre-Admission Screening Resident Review) or three of three residents reviewed (Residents R119, R174, and R184). Findings include: The PASRR (Pennsylvania Pre-Admission Screening Resident Review), federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care, dated March 1, 2009, lists examples of serious mental illness including mood disorder, bipolar, and depression. The revised PA-PASRR-ID bulletin number dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status). On April 14, 2025, at 12:53 p.m., review of the PASRR form for Resident R184 completed on September 1, 2021, revealed that under Section III, Mental Health assessment, for question Does the individual have a mental health condition or suspected mental health condition, other than Dementia that may lead to chronic disability , the response was entered No. Review of the PASRR form for Resident R184 completed on September 1, 2021, revealed that under Section VIII, PASRR Level I Screening Outcome, the response was entered as Individual has negative screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, or Other Related Condition; no further evaluation (Level II) is necessary. On April 16, 2025, at 10:01 a.m., review of clinical record for Resident R184 revealed a diagnoses list which indicated that the resident was diagnosed with Schizoaffective Disorder, Bipolar Type {a mental health condition characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like mania or depression)}, on September 30, 2021; Unspecified Mood Disorder (mental health conditions characterized by significant and persistent changes in emotional state, affecting how individuals feel and behave), on September 1, 2021; and Major Depressive Disorder Recurrent, (Major Depressive Disorder, is characterized by an all-consuming feeling of sadness, lethargy and hopelessness), on March 21, 2023. On April 15, 2025, at 10:45 a.m., review of the PASRR form for Resident R174 completed on May 4, 2021, revealed that under Section III, Mental Health assessment, for question Does the individual have a mental health condition or suspected mental health condition, other than Dementia that may lead to chronic disability, the response was entered No. Review of the PASRR form for Resident R174 completed on May 4, 2021, revealed that under Section VIII, PASRR Level I Screening Outcome, the response was entered as Individual has negative screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, or Other Related Condition; no further evaluation (Level II) is necessary. On April 15, 2025, at 10:45 a.m., review of clinical record for Resident R174 revealed a diagnoses list which indicated that the resident was diagnosed with Schizoaffective Disorder (like hallucinations and delusions) on January 25, 2021; Anxiety disorder ( is a mental health conditions characterized by excessive fear, anxiety and related behavioral disturbances) on May 4, 2021 and Major Depressive Disorder Recurrent, ( is characterized by an all-consuming feeling of sadness, lethargy and hopelessness), on May 10 , 2021. On April 16, 2025, at 10:08 a.m., interview with the Social Worker, Employee E16, confirmed that Resident R184, R174 should have had an updated PASRR level II, completed with the diagnoses of Schizoaffective Disorder, Bipolar Type, and Major Depressive Disorder. Review of clinical record for resident R119 revealed that he was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis (paralysis affecting only on side of the body) following cerebral infarction (stroke) affecting the right dominant side, non-ST elevation myocardial infarction (heart attack), and aphasia (a language disorder that results from brain damage which affects an individual's ability to communicate). Further review revealed a PASRR, also dated June 29, 2018, which indicated that the resident had no diagnosis of neurocognitive disease or dementia, no serious mental illness, and no intellectual disability, resulting in a negative screening with no need for a level 2 evaluation. This PASRR was dated as reviewed by the state authority on July 26, 2018. Review of all diagnoses for the resident revealed that a diagnosis of psychosis was entered on May 2, 2019, diagnoses of major depressive disorder and anxiety disorder were entered on May 6, 2019, and a diagnosis of dementia was entered on March 24, 2023. There was no indication that the PASRR had been updated to include the new diagnoses. Interview with employee E1, the Nursing Home Administrator on April 17, 2025 at 2:30 p.m. confirmed that the PASRR had not been updated as required. 28 Pa Code 201.18(e)(1) Management 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.16(a) Social services28 Pa Code 211.16(a) Social services

Based on observations of care and services, interviews with staff, reviews of clinical records and policy and procedures, it was determined that the facility failed to develop a comprehensive care plan for oxygen therapy and antipsychotic medication for two out of 35 residents reviewed. (Resident R41 and R190) Findings include: A review of the policy titled Resident Plan of Care dated June 2024, revealed Our facility's Care Planning/Interdisciplinary Team is responsible for the development of a plan of care for each resident. The care plan is based on the resident's assessment and is developed by a Care Plan/Disciplinary Team. A review of a clinical record for Resident R41 revealed an admission on November 24, 2021, with chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform) and polyneuropathy (a general degeneration of peripheral nerves that spreads toward the center of the body). A review of the physician order dated October 25, 2024, revealed an order for oxygen 2 liter via N/C (per min via nasal cannula), every shift diagnosis of pneumonia. A review of the comprehensive care plan dated March 4, 2025, did not indicate a care plan for oxygen therapy. On April 15, 2025, at 10:37 a.m. an interview with Unit Manager, Employee E9 confirmed that there was no care plan for the oxygen therapy. Review of documentation for Resident R190 revealed that the resident was admitted to the facility on [DATE], with the diagnoses of dementia (progressive degenrative disease of the brain), depression (major loss of interest in activities), and malignant neoplasm (cancer) of the breast. Review of physician orders for the resident revealed an order for Rexulti (an antipsychotic medication which is FDA approved to treat dementia and depression) Oral Tablet 0.5 MG .give 1 tablet by mouth one time a day for behaviors entered on March 6, 2025. Antipsychotic medications carry the potential for adverse reactions such as involuntary movements, restlessness and difficulty with movement. Review of the care plan for the resident revealed that no care plan had been developed to adress the use of the antipsychotic, including the need to monitor for potential adverse reactions. Interview with Employee E2, the Director of Nursing, on April 17, 2025, at 2:30 p.m. confirmed that no care plan had been developed for antipsychotic use. 28 PA. Code 211.10(a)(b)(c)(d) Resident care policies 28 PA. Code 211.12(d)(2)(3)(5) Nursing services

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to provide the appropriate level of supervision to one of four residents reviewed, resulting in actual harm to Resident CL1, who sustained a second degree burn from a hot liquid. Findings include: Review of Resident CLl's closed clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnoses of dementia with behavioral disturbances, [CONDITION(S)] (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and diabetes (failure of the body to produce insulin to enable sugar to pass form the blood stream to cells for nourishment). Further review of Resident CLl's clinical record revealed a quarterly Minimum Data Set (MDS-a periodic review of the resident's needs), dated November 17, 2020, which indicated that the resident was severely cognitively impaired in decision making skills and required limited assistance with one person physical assistance for eating. A review of Resident CL1's care plan titled ADL (activities of daily living) self-care related to dementia, dated June 24, 2020, revealed that nursing interventions developed to promote resident safety included: .assist with eating, one staff member. A review of facility documentation dated February 5, 2021, revealed that on January 6, 2021, at 5:30 p.m. Resident CL1 received her dinner tray, reached for her cup of soup and spilled it on herself. Two nursing assistants heard the resident yell. Facility documentation further indicated that the resident was subsequently placed in bed and assessed by the nursing supervisor. Upon assessment, the nursing supervisor noted the right upper thigh was red with a small blister. A review of Employee E19, nursing supervisor, note dated January 6, 2021, at 7:02 p.m. revealed that the employee had been alerted by the charge nurse that Resident CL1 had spilled soup on her leg. Employee E19 further indicated that upon assessment the resident had reddening and blisters noted on her right lateral thigh. A review of a nurse practitioner note dated January 6, 2021, at 7: 05 p.m. revealed, .chief complaint: second degree burn to thigh during dinner. History of present illness: patient was eating dinner and spilled soup on her thigh causing redness and some small blistering within the reddened area. and .Will order pain management as well as dressing orders for wound. A review of wound care nursing note dated January 7, 2021, at 12:12 p.m. revealed that the resident was evaluated by the wound care nurse for a second degree burn to the right thigh which measured 17.5 centimeters by two centimeters with multiple fluid-filled blisters, periwound [CONDITION(S)] (superficial reddening of the skin), [MEDICATION(S)] (antibiotic cream used in treatment of second and third degree [CONDITION(S)]) applied and [MEDICATION(S)] (non-sticking pad) applied. Will follow up. A review of the facility documentation of an interview with Employee E21, agency nursing assistant, on January 8, 2021, revealed that Employee E21 was in the lounge on 3 South and had placed the resident's dinner tray on the table away from the resident. The employee then proceeded to pass out dinner trays to other residents. Ten to fifteen minutes later, he heard the resident yell and noticed that she had grabbed the soup bowl and spilled it on herself. Employee E21 stated he placed the soup bowl on the tray and cleaned up the excess soup off the resident's pants. Interview with Employee E16, the Director of Therapy, on February 10, 2021, at 3:45 p.m. revealed that Resident CL1's therapy discharge summary dated January 8, 2021, revealed that the resident was a partial moderate assist with activities of daily living (ADL-dressing, toileting, eating etc.) which means she needs 25 to 50 percent of help with all ADL's. Interview with Employee E19, nursing supervisor, on February 10, 2021, at 3:30 p.m. confirmed that the employee had worked on January 6, 2021, as the evening shift nursing supervisor when Resident CL1 had spilled soup on herself at dinnertime. Continued interview with Employee E19 confirmed that the dinner tray should not have been put in front of the resident before the staff were ready to feed her. 29 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing services

Based on review of clinical records, facility documentation, and interviews with the resident and staff, it was determined that the facility failed to be free of a significant medication errors for one of 34 records reviewed (Resident R3). Findings include: Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician order [REDACTED]. During the initial tour on August 29, 2017, at approximately 10:30 a.m. observation in the presence of the Assistant Director of Nursing (ADON), revealed that Resident R3 was crying in pain. The resident stated, my pain medication is not here yet. Her legs were swollen, with open wet areas, and what appeared to be fluid. This same day at 1;00 p.m., interview with Resident R3 revealed the resident was crying and the resident tearfully said, I would not recommend this facility to anyone. They do not address my pain. I receive [MEDICATION NAME], but I don't know the last time when I got it. I am in so much pain. I can't eat or sleep. The resident also stated, I said to the nurse (LPN, Employee E11) last night, please make sure my meds are here. I should have a new order for [MEDICATION NAME] every 12 hours for pain but the nurse last night said it's not here yet, it's on its way. When I asked the nurse (RN Employee E12) this morning she said, I'm sorry but it ([MEDICATION NAME]) medication still wasn't here. The resident indicated her pain scale was +20 out of a scale from one to 10 (10 being the worst). A review of the residents Medication Administration Record [REDACTED]. During an interview with Employee E12 date/time?, it was revealed that the resident was in pain and did not receive her 8:00 a.m. dose of [MEDICATION NAME] as ordered and there was a delay of five hours for the administration of the medication. Employee E12 revealed the medication was just received at the facility one hour ago. The nurse indicated she was aware the facility had an electronic medication dispense machine but she only worked part time and she does not use it. On August 31, 2017, at 9:30 a.m. observation revealed the resident was crying in pain. The resident stated, When is my pain medication getting here, I am in terrible pain! She revealed her pain scale was now +25 out of ten. Both her lower legs were still swollen, with numerous and unmeasurable sheaths of skin missing, oozing liquid that dripped onto her socks, staining her socks a pale yellow. During an interview with the nurse on duty, LPN Employee E13, it was revealed that the resident was crying in pain. The nurse indicated that the resident's last dose of [MEDICATION NAME] was given last night at 8 p.m. and was due to have another dose at 8:00 a.m. which was 1½ hours late. On August 31, 2017, at 8 a.m. the ADON indicated they only had 5 mg, not 10 mg in their First Dose (also known as the electronic medication machine). I would have had to call the doctor for two, 5 mg of [MEDICATION NAME]. She (the resident wouldn't have wanted to take two, 5 mg pills, only one, 10 mg pill. She only takes two, 2 mg of [MEDICATION NAME]. Interview with the ADON revealed there was no documentation that the resident was offered the pain medication and declined the two, 5 mg of [MEDICATION NAME]. Additional interview with the ADON to determine why the medication for [MEDICATION NAME] on August 28, 2017, at 8:00 p.m. was electrically signed out as given when the medication wasn't received in the facility until August 29, 2017, revealed the nurse put the wrong code in the computer. She revealed a letter signed by the nurse on duty, Employee E11, which indicated the wrong button was clicked in documenting the resident's pain medication. The letter revealed that the nurse incorrectly clicked administered instead of NA-awaiting delivery from the pharmacy. Furthermore, the physician was not notified of the missing medications. The facility failed to be free from a significant medication error related to physical pain for one resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/12/17, 08/19/16 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 08/19/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/12/17, 08/19/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/12/17, 09/02/16, 08/19/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 09/02/16, 08/19/16

Based on observations, staff and resident interviews, clinical records reviewed and review of facility's documentation, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practical physical well-being to ensure pain management was provided to three residents (Residents R3, R160 and R226), to maintain continuous oxygen level for three residents (Residents R200, R205, R215), and adhere to a toileting schedule for one resident (Resident R198). Findings include: The facility's policy and procedure related to Medication Administration, dated August 2016, indicated that if a needed medication was unavailable, the Med Dispense may be used. If the ordered Medication was not available in 1st dose and the STAT delivery will not be within ordered administration time, the physician must be called fort notification and determined if an alternate order was needed. The facility's policy and procedure, Unavailable Medication, dated February 2015, indicated medications shall be available for administration per physician order. 1. In the event a prescribed medication scheduled to be administered was unavailable or cannot be located, the following steps are to be taken: a. Determine if the medication is available in First Dose Machine (FDM) b. If unavailable in FDM, e-mail pharmacy for STAT delivery of the medication. 2. If the medication was unavailable from the Pharmacy, the physician will be notified so an alternative medication can be ordered if physician deems necessary. This order should be discontinued once the original medication is available from the pharmacy. Resident R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On August 28, 2017, the physician ordered [MEDICATION NAME] ER (extended release), 10 mg every 12 hours for pain, at 8 a.m. and 8 p.m. During the initial tour on August 29, 2017, at approximately 10:30 a.m. observation in the presence of the Assistant Director of Nursing (ADON), revealed that Resident R3 was crying in pain. The resident stated, my pain medication is not here yet. Her legs were swollen, with open wet areas, and what appeared to be fluid. This same day at 1:00 p.m., interview with Resident R3 revealed the resident was crying and said, I would not recommend this facility to anyone. They do not address my pain. I receive pain medication, [MEDICATION NAME], but I don't know the last time when I got it. I am in so much pain. I can't eat or sleep. The resident also stated, I said to the nurse (LPN, Employee E11) last night, please make sure my meds are here! I should have a new order for [MEDICATION NAME] every 12 hours for pain but the nurse last night said it's not here yet, it's on its way. When I asked the nurse (RN Employee E12) this morning she said, I'm sorry but ([MEDICATION NAME]) medication still wasn't here. The resident indicated her pain scale was +20 out of a scale from 1 to 10 (ten being the worst). During an interview with Employee E12 on August 29, 2017 at 1:30p.m., it was revealed that the resident was in pain and did not receive her 8:00 a.m. dose of [MEDICATION NAME] as ordered and there was a delay of five hours for the administration of the medication. Employee E12 revealed the medication was just received at the facility one hour ago. The nurse indicated she was aware the facility had an electronic medication dispense machine but she only worked part time and she does not use it. On August 31, 2017, at 9:30 a.m. observation revealed the resident was crying in pain. The resident stated, When is my pain medication getting here, I am in terrible pain! She revealed her pain scale was now +25 out of ten. Both her lower legs were still swollen, with numerous and unmeasurable sheaths of skin missing, oozing liquid that dripped onto her socks, staining her socks a pale yellow. During an interview with the nurse on duty, LPN Employee E13, it was revealed that the resident was crying in pain. The nurse indicated that the resident's last dose of [MEDICATION NAME] was given last night at 8 p.m. and was due to have another at 8:00 a.m. which was 1½ hours late. On August 31, 2017, at 8 a.m. the ADON indicated they only had 5 mg, not 10 mg in their First Dose (also known as the electronic medication machine). I would have had to call the doctor for two, 5 mg of [MEDICATION NAME]. She (the resident wouldn't have wanted to take two, 5 mg pills, only one, 10 mg pill. She only takes two, 2 mg of [MEDICATION NAME]. Interview with the ADON revealed there was no documentation that the resident was offered the pain medication and declined the two, 5 mg of [MEDICATION NAME]. Additional interview with the ADON to determine why the medication for [MEDICATION NAME] on August 28, 2017, at 8:00 p.m. was electrically signed out as given when the medication wasn't received in the facility until August 29, 2017, revealed the nurse put the wrong code in the computer. She revealed a letter signed by the nurse on duty, Employee E11, which indicated the wrong button was clicked in documenting the resident's pain medication. The letter revealed that the nurse incorrectly clicked administered instead of NA-awaiting delivery from the pharmacy. Furthermore, the physcian was not notified of the missing medications. The facility failed to ensure that pain management was provided to Resident R3. Review of Resident R160's physician's orders [REDACTED]. The orders also included; geri arms (arm covering wrist to upper arm) at all times to protect from skin tears, [MEDICATION NAME] (covering for the legs; ankle to thighs) on a.m., off at night to protect from skin tears. The resident was observed during the survey with a skin tear on the right wrist September 1, 2017, at 12:00 p.m. and on the left leg during wound care. The resident was observed on August 29, 30 and 31, 2017, without geri arms and [MEDICATION NAME]. Observation of Resident R160's wound care on August 29, 2017, at 11:30 a.m. with Employee E18, licensed nurse, revealed that Resident R160 was crying, and the resident indicated that the wounds on her left lower leg hurt her with dressing changes. Employee E160 confirmed during the observation that the wound care made the resident cry and there was no pain medication given prior to the wound care. The facility failed to ensure that pain management was provided to Resident R3. A review of the clinical record for Resident R226 revealed that the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set assessment (periodic assessment of needs) dated June 28, 2017, indicated that the resident experienced pain frequently. The resident BIMS (brief interview for mental status) score was 10 indicating that he had moderate cognitive impairment. Clinical record review revealed a physician's orders [REDACTED]. On August 29, 2017, at approximately 9:30 a.m. Resident R226 was observed trying to get out of bed. He screamed out in pain when the nurses repositioned him in bed. A review of the Medication Administration Record [REDACTED]. A review of the MAR indicated [REDACTED]. Observation revealed that on August 30, 2017, at approximately 10:50 a.m. Resident R226's left leg was bent at the knee and the right foot was off of the bed while attempting to pull self in an upright position. When the nurses touched his left arm and lower extremities to reposition him on the left side, he screamed, it hurts. When they turned him on the right side he said, my whole damn body hurts, I have arthritis. The charge nurse, Employee E4, stated, Resident R226 received Tylenol at 8:55 a.m. and he can't have anything else. The wound care nurse, Employee E5, stated that the resident's family does not want him to have narcotics. The resident did not straighten out his leg while he was being repositioned or during wound care. At 12:05 p.m. interview with the Director of Rehab, Employee E6, stated that the resident was not transferred to the restorative nursing program (RNP) for range of motion following discharge from rehab therapy. Employee E6 had the resident screened by rehab after the interview. A review of the rehabilitation screening revealed that Resident R226 was to receive occupational and physical therapy five to seven times a week for 41 days. An observation with Employee E3 & E4 at approximately 12:20 p.m. on August 30, 2017, revealed that Resident R226 did not receive the Icy Hot patch as prescribed. Interview with Employee E3, at this same time, revealed that she was not aware there was an order for [REDACTED]. Further review of the MAR for August 2017 indicated that Icy Hot patch was administered only one time on August 27th and Tylenol was not given at all on August 29th. The Treatment Administration Record for August 2017 revealed that the resident was being assessed every shift for right side abdominal pain only. The MAR for July 2017 indicated that the resident did not receive the Icy Hot patch during the entire month. New orders for pain medications were written on August 30, 2017, to be administered every eight hours which included Bengay and Tylenol. The facility failed to assess for pain other than abdominal; to administer PRN (when needed) pain medicine as prescribed to lessen pain. On August 29, 2017, at approximately 11:35 a.m. three residents were observed in the dining room waiting to be served a meal; they were seated in their wheelchairs with oxygen tanks in a carrier fastened to the back of the wheelchairs. Two of three residents had nasal cannulas in place. The oxygen gauge on all three tanks were in the red zone, marked 0 refill. Resident R200 has a [DIAGNOSES REDACTED]. Her BIMS score was 15 indicating that she was cognitively intact. Resident R200 has a physician order [REDACTED]. Resident R205 had a [DIAGNOSES REDACTED]. Her BIMS score was 11 indicating moderate cognitive impairment. Resident R205 had an order for [REDACTED]. Resident R215 had a [DIAGNOSES REDACTED]. Resident R215 had an order for [REDACTED]. Observation revealed that Employee E3 inspected the tanks; replaced them with full tanks and applied the nasal cannula for Resident R215 at approximately 11:45 a.m. on August 29, 2017. Resident R198 had [DIAGNOSES REDACTED]. According to facility documentation, Resident R198 had two falls in August 2017. On August 12th she fell at 7:45 p.m., she stated at that time that she was trying to go to the bathroom. On August 19th she fell at 9:45 a.m. and sustained a laceration to left lower leg that required sutures. Resident R198 was on the following toileting schedule for more than one month: toilet upon rising, after meals, around 7:30 p.m., offer 10:30 p.m. and PRN (when needed). A review of nursing documentation for the month of August for toileting revealed that on August 12th, the resident was toileted once at 14:03 (2:03 p.m.) and there was no indication of being toileted at 7:30 p.m. On August 19th, the resident was toileted once at 04:52 (4:52 a.m.) and there was no indication of being toileted after breakfast. The facility failed to follow the toileting schedule for Resident R198. 42 CFR 483.24, 483.25(k) Provide Care/Services for Highest Well Being Previously cited 03/29/17, 08/19/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 06/12/17, 08/19/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 08/19/16 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 08/19/16 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/02/16, 08/19/16 28 Pa. Code 211.12(c) Nursing services Previously cited 06/12/17, 08/19/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/12/17, 09/02/16, 08/19/16 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 08/19/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 09/02/16, 08/19/16

Based on review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision for one resident (Resident R233) who sustained a burn. Findings include: Review of the facility policy, Pantry Maintenance (sic), dated February 23, 2016, revealed that, Hot Beverage Temperatures will be taken before each meal. If a resident requests a beverage during off meal times one of the following must happen. A digital thermometer will be located on each coffee machine in each pantry. If the thermometer is missing or not working a Resident Dining Manager must be notified immediately. Temperature will be taken and hot beverage will be below 155 degrees F (Fahrenheit) before it is served to the resident Observations of the Second, Third and Fourth Floor Nursing Units revealed that each nursing unit had a locked pantry room, where each unit had a coffee/hot water machine. Observations revealed that Nursing Assistants (NA) and Licensed personnel (Registered Nurses (RN) and Licensed Practical Nurses (LPN)) had access to the pantry rooms via key card access. A request was made on August 19, 2016, at approximately 9:28 a.m. for Employee E15, a Dietary Staff, to test the Fourth Floor Nursing Unit's coffee/hot water machine located in the pantry room. The coffee/hot water machine had three outlets where the readings were 168 degrees F, 121 degrees F, and 145 degrees F. Review of Resident R233's clinical record revealed [DIAGNOSES REDACTED]., as a symptom of disease) and depression (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident R233's clinical record progress note dated August 2, 2016, revealed that the resident sustained [REDACTED]. The resident's burn area was noted to be an open shaped blister, with frayed edges around the burn area with large localized [DIAGNOSES REDACTED] (redness). Interview on August 18, 2016, at approximately 11:00 a.m. with Employee E16, a Unit Manager, revealed that Employee E17, a NA, on August 2, 2016, had gone into the Fourth Floor Nursing Unit's pantry room and proceeded to the coffee/hot water machine where hot water was poured into a cup for tea and delivered to Resident R233's room. Employee E16, stated that Employee E17, had deviated from the facility's policy by not checking the tea temperature prior to serving the tea to the resident. The facility failed to provide adequate supervision and assistance for one resident resulting in a burn injury with actual harm. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to revise a residents care plan to ensure the safe transfer of one resident resulting in a serious injury, (Resident R130). Findings include: Review of the clinical record for Resident R130 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS - an assessment of resident needs) dated December 7, 2015, revealed that Resident R130 had severe cognitive impairments (mental process of thinking, learning and judging), was non-ambulatory (did not walk) and was totally dependent on the assistance of two or more staff for dressing and transfers (moving from one surface to another). Additionally, the MDS indicated that the resident had severely impaired vision, rarely and/or never was able to understand others, did not speak, and had highly impaired hearing. The MDS also noted that Resident R130 did not wear hearing aides. Review of an individualized plan of care for Resident R130, initiated January 2011 and continued as current revealed that the resident had been identified at risk for injury and/or falls related to the resident's total dependence on staff. Interventions developed to reduce the risk of injury to Resident R130 included .Use extreme caution with the provision of care . and provide necessary safety measures. A review of a quarterly therapy, Screen/Referral Form dated December 18, 2014, indicated that Resident R130 had dementia, was unable to follow simple commands and was totally dependent on staff for all aspects of mobility and transfers. Further review of the quarterly, Screen/Referral Forms dated 01/22/15, 04/07/15, and 07/03/15, revealed that the resident remained totally dependent on staff for mobility and that the resident had limited range of motion with bilateral upper and lower extremity contractures (permanent shortening of muscles or tendons resulting in physical deformities). Nursing progress notes dated December 29, 2015, at 3:47 p.m. revealed that following morning care (daily washing and grooming) two nursing assistants (NAs) stood Resident R130 up from a sitting position on the side of the bed and attempted to pull up the residents pants. The resident wiggled and both staff members lost their grip on the resident. The resident subsequently fell to the floor striking her/his head. Resident R130 sustained a 2.0 centimeter (cm) long by 0.5 cm wide laceration to the left forehead as a result of the fall. The resident was transferred to the emergency room for further evaluation where he/she was diagnosed with [REDACTED]. Interview with Employee E20, Licensed Nurse, on August 18, 2016, at 10:30 a.m. revealed that per facility protocol all resident assessments related to transfers and/or the use of lifts when transferring residents are completed by the rehabilitation therapy department. Interview with Employee E25, the Director of Rehabilitation, on August 18, 2016, at 2:30 p.m. revealed that per facility protocol, the nursing staff conducts all resident assessments related to transfers and/or the use of lifts. Employee E25 stated that therapy staff was not qualified to conduct these assessments. Interview with Employee E20, a Licensed Nurse, on August 19, 2016, at 11:00 a.m. revealed that prior to Resident R130's fall, the staff had been utilizing a Hoyer lift (a mechanical device utilized to move residents from one area to another) when transferring Resident R130. Employee E20 reported that the staff stopped using the lift at Resident R130's spouse's request as the resident had sustained bruises when the lift was utilized. Further interview with Employee E20 revealed that the employee was unaware of any facility assessment tool and/or protocol for the use of the Hoyer lift and/or the safe transfer of a resident. Review of the clinical record revealed no documentation of the resident's bruises or of the spouses request to discontinue the use of the Hoyer lift. An interview with Employee E24, a Registered Nurse, on August 19, 2016, at 11:30 a.m. confirmed that there was no documentation in Resident R130's clinical record related to the spouse's request to discontinue the use of the Hoyer lift or the bruising that Resident R130 sustained from the use of the lift. An interview with the Director of Nursing on August 19, 2016, at approximately 2:15 p.m. revealed that the facility has not developed any formal process for the ongoing monitoring of residents' ability to safely transfer. The facility failed to develop and implement a systematic process for the assessment and continued monitoring of each resident's ability to transfer safely resulting in actual harm to one resident. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services