Every finding on record at Independence Rehab and Nursing

Based on review of policy, review of clinical record, and interviews with resident and staff it was determined that facility failed to ensure one resident was free from a significant medication error for one of two residents reviewed (Resident R1).Findings Include: Review of facility policy Pharmacy Services facility reviewed January 20, 2026, states that the provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including but not limited to: provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week. Review of policy Medication Administrator approved on December 12, 2023, states that medications that are not readily available for administration will be obtained from the emergency kit, drop shipped from the pharmacy, or obtained from an alternate pharmacy. Interview with Resident R1 on Monday, August 24, 2026, at 9:15 am, revealed concern of inconsistent medication administration related to his/her seizure (abnormal electrical activity in the brain) and Parkinson's diagnosis (a progressive disorder of the nervous system that affects movement). Review of Resident R1's clinical record revealed medical diagnosis of localization-related symptomatic epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and epileptic syndromes with complex partial seizures, and parkinsonism. Review of Resident R1 brief interview for mental status score, completed on July 3, 2026, revealed score of 15 (cognitively intact). Review of Resident R1's electronic medication administration record revealed a physician order for Lacosamide oral tablet 200 milligrams (mg) (anti-seizure medication) to be administered as 1 tablet by mouth every 12 hours; with missing doses on following dates: August 1, 2026, at 9 am and 9pmAugust 2, 2026, at 9 am and 9 pmAugust 4, 2026, at 9 am and 9 pmAugust 5, 2026, at 9 amAugust 10, 2026, at 9 pmJuly 11, 2026, at 9 pmJuly 12, 2026, at 9 am and 9 pmJuly 13, 2026, at 9 amJuly 14, 2026, at 9 am and 9 pm Further review of Resident R1's electronic medication administration record revealed an order for Levetiracetam oral tablet 500 mg (anti-seizure medication) to be given as 3 tablets by mouth every 12 hours; with missing dose on August 10, 2026, at 9 pm. Further review of electronic medication administration record (e-MAR) revealed a physician order for Oxcarbazepine oral tablet 600 mg (a prescription anticonvulsant medication used to treat seizures in adults and children), start date of April 18, 2026, to be given as 1 tablet by mouth every 12 hours; with missing doses on dates: August 1, 2026, at 9 am and 9 pmAugust 10, 2026, at 9 pm Further review of Resident R1's electronic MAR revealed a physician order for Carbidopa-Levodopa oral tablet disintegrating 25-100 mg (prescription combination medication used to treat symptoms of Parkinson's disease, such as tremors, stiffness, and slow movement), to be given as 1 tablet by mouth four times a day; with missing doses on dates: August 10, 2026 at 5 pm and 9 pm. Interview with facility's Nursing Home Administrator on August 24, 2026, at 9:45 am confirmed the above findings findings. 28 Pa. Code 211.9 (d) Pharmacy services. 28 Pa. Code 211.12 (d)(1) nursing services

Based on review of clinical records, review of facility documentation, review of facility policy, and interview with staff and residents, it was determined that the facility failed to ensure that residents were free from abuse/neglect for one of two residents reviewed (Resident R1).Findings Include: Review of facility Policy on Abuse Prevention and Reporting revised June 1, 2026, revealed that it is the policy of the facility to protect its residents from mistreatment, neglect, abuse and misappropriation of resident property and that all reports of abuse will be reported to the appropriate agencies and thoroughly investigated. Neglect is defined as failure to provide goods and services necessary to avoid physical harm mental anguish or mental illness. neglect occurs when a resident experiences a lack of care in one or more areas, such as incontinent care, personal hygiene, etcetera., unless the individual accused demonstrated that such neglect was caused by factors beyond the control of an individual. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Unspecified Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and Muscle Weakness. Review or Resident R1's MDS (minimum data set-a federally required resident assessment completed at a specific interval) dated June 5, 2026, Section C0500 BIMS (brief interview for mental status) revealed a score of 03 indicating severe cognitive impairment. Review of Resident R1's progress note dated July 24, 2026, at 21:47 p.m. revealed that Charge nurse responded to resident lying on dayroom floor. Resident was laying on left side on top of a blanket. Review of facility investigation revealed that on July 24, 2026, Resident R1 was observed lying on his/her left side on top of a blanket on the floor in the sunroom. Resident R1 was assessed by the nurse for injuries with none observed. Nurse aide, Employee E4, was assigned to the sunroom at the time of the Resident R1's fall but did not see Resident R1 fall. Continued review of facility investigation revealed that nurse aide, Employee E4, said she did not see how Resident R1 got on to the floor because she dozed off. Further, review of the investigation revealed that Employee E4 was terminated, and allegation of neglect was substantiated. Interview with Director of Nursing (DON), Employee E2, conducted on August 20, 2026, at 11:23 AM confirmed that Employee E4 fell asleep while assigned to monitor the sunroom. Further Employee E2 also confirmed that Employee E4 failed to monitor the sunroom because she fell asleep. Further, Employee E2 confirmed that the incident was neglect and that the facility investigation substantiated neglect. Further Employee E2 revealed that that Employee E4 was terminated. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical record, review of facility documents, review of facility investigations, review of facility policy, and interview with staff and resident, it was determined that the facility failed to timely report allegations of neglect and subsequently report results of all investigations within 5 working days to the State Survey agency for one of two residents reviewed (Resident R2). Findings include: Review of facility policy on Abuse Prevention and Reporting, revised June 1, 2026, revealed that it is the policy of the facility to protect its residents from mistreatment, neglect, abuse and misappropriation of resident property and that all reports of abuse will be reported to the appropriate agencies and thoroughly investigated. The allegation of abuse will be investigated and documented within 24 hours of discovery of the incident. Information received will be forwarded to the administrator and or designee immediately. #2. The administrator or designee and his slash her absence will file the initial verbal report to the Pennsylvania Department of Health Local Field Office immediately upon notification and verification of the information. communication to the field office is the nature of the allegation, the name of the resident and the name of the individual against whom the allegation is made. #3. The administrator or designee will conduct an investigation into the allegation and complete the PB22 form. #4. The completed PB22 will be submitted to the Pennsylvania Department of Health within five days of the conclusion of the facility's investigation. Review of resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy (an acute neurological emergency caused by thiamine (vitamin B1) deficiency), and anxiety disorder (intense, excessive, persistent worry or fear). Review or Resident R1's MDS (minimum data set-a federally required resident assessment completed at a specific interval) dated August 5, 2026, Section C0500 BIMS (brief interview for mental status) revealed a score of 15 indicating intact cognition. Review of the facility investigation revealed that on March 24, 2026, Resident R1 with a BIMS score 7 reported an allegation of sexual harassment by an unidentified male staff member, which he/she states occurred over one month ago. The resident is unable to clearly identify the staff member allegedly involved. It is important to note that the resident has provided inconsistent accounts of the alleged incident. Under description of follow-up action: the attending physician and responsible party were notified. Law enforcement was contacted and responded to the facility, at which time they interview the resident regarding the allegation. An internal investigation has been initiated and remains ongoing. Facilities statewide staff education is currently in progress, with emphasis on timely reporting of all allegations of regulatory requirements. Further review of facility investigation record revealed that the investigation was not concluded. Further, there was no documented evidence that the investigation was completed. Interview with Resident R2 conducted on August 20, 2026, at 9:15 AM revealed that back in the wintertime he/she was harassed by a male staff member who was working in one of the offices downstairs, once in his office and once in the elevator. Further interview with Resident R2 revealed that the resident was not able to identify the names of the staff members and did not recall the actual date when it occurred. Interview with Director of Nursing, Employee E2, conducted on August 20, 2026, at 10:30 AM confirmed the facility initiated an investigation in March in response to Resident R2's allegations. Further, Employee E2 confirmed that the investigation was not completed until August 2026. Director of Nursing, Employee E2, revealed that the facility identified an alleged perpetrator and a PB22 was not submitted to the state survey agency until August 2026. Further Employee E2 confirmed that the investigation was completed late and that results to the investigation was also reported late. Interview with ADON (assistant director of nursing) Employee E3 conducted on August 20, 2026, at 11:05 a.m. confirmed that he/she did not timely finish the investigation on Resident R2's allegation of abuse because he/she was swamped with a lot of work. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and staff interview, the facility failed to ensure that an allegation of sexual abuse involving Residents R1 and R2 was properly and timely reported to law enforcement for 2 of 8 records reviewed (Resident R1, R2).Findings include: Review of an incident submitted to the State Survey Agency on June 2, 2026, revealed that on 05/25/2026 at approximately 2:25p.m. nursing staff reported an alleged inappropriate resident encounter involving Resident R1, a male resident and Resident R2, a female resident. The incident reportedly occurred in Resident R1's room located on the 3rd floor. Resident R2 resided on the 1st floor. The allegation was reported by a staff member who entered the room to retrieve lunch trays and observed both residents in bed unclothed. Upon questioning, both residents denied engaging in sexual intercourse or any sexual activity and stated they were just talking. Both residents subsequently dressed independently. Nursing assessment was initiated immediately following the report. Vital signs for both residents were obtained and noted to be stable. Interview conducted on May 26, 2026, at approximately 2:50 p.m., with the Social Work Director, Employee E7, revealed that she responded to the incident and stated that she called the police, however she was unable to provide a dispatch number or any supporting confirmation that law enforcement had been contacted. Employee E7 further indicated that she only documented the action in her personal notebook and did not provide formal verification of the report. Due to the lack of confirmation that law enforcement had been notified, concern was raised regarding whether the allegation had been appropriately reported. Consideration was given to verifying the report directly with law enforcement. On June 2, 2026At approximately 2:58 p.m., the Administrator, Employee E1, contacted 911 (Emergency Medical Services) to verify whether a call had been received related to an allegation of sexual abuse occurring on 5/26/2026 through 5/27/2026. Confirmation of prior notification from the facility was not established at the time of verification. 28 Pa. Code 201.18(b)(1)((e)(1) Management

Based on observation, resident and staff interview, the facility failed to serve food at safe temperatures during meal service one of four nursing units. (4th floor)Findings include:A review of the facility policy titled Healthcare Service Group, Inc. Food: Preparation, last revised February 2026, revealed under Procedure #4 that the Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 F and/or less than 135 F, or per state regulations.On June 1, 2026, at 10:01 a.m., an interview with Resident R1 revealed that the food is cold.On June 1, 2026, at 10:49 a.m., an interview with Resident R2 revealed that the food is sometimes cold.On June 1, 2026, at 10:55 a.m., an interview with Resident R3 revealed that the food is bad-everything, temperatures cold.On June 1, 2026, at 11:31 a.m., the Dietary Director, Employee E8, and the surveyor exited the kitchen and followed the food truck to the elevator. Employee, E8 reported that there are only two elevators in the facility and one is out of service, which results in delays in getting meal trays to the units. At 11:36 a.m., the food cart arrived on the 4th floor. There were four trays on top of the food truck that were not enclosed or insulated, but left open on top of the truck.On June 1, 2026, at 11:47 a.m., in the presence of the District Manager of Health Care Services, Employee E9, a test tray observation was conducted on the 4th floor. The following temperatures were obtained:Ham: 122 ( F) Fahrenheit Sweet Potatoes: 147 FGreen Beans: 119 FCoffee: 124 FMilk: 45 FApples/Pears: 68 FThe temperatures of the ham (122 F) and green beans (119 F) were below the recommended hot holding temperature of 135 F. Additionally, the milk (45 F) exceeded the recommended cold holding temperature of 41 F.During an interview at the time of the observation, the District Manager of Health Care Services, Employee E9, confirmed the observed food temperatures and acknowledged that the ham and green beans were below the expected hot holding temperature and that the milk exceeded the recommended cold holding temperature.28 Pa. Code 201.18(b)(3) Management

Based on observations, resident and staff interviews, it was determined that the facility did not provide a safe and homelike environment related to the condition and functionality of resident sinks for four out of nine-bathroom sinks. (First-floor nursing unit).Findings Include:On April 27, 2026, at 9:27 a.m., an interview was conducted with the Maintenance Director, Employee R3, and the Director of Nursing, Employee E2, who confirmed the following observations:room [ROOM NUMBER] had a sink with slow water drainage.room [ROOM NUMBER] had a hole by the Bed B below the windowOn April 27, 2026, at 10:00 a.m., during an interview, Resident R1 reported that the bathroom sink sometimes does not shut off properly and that both faucet knobs must be aligned in order for the water to be turned off.On April 27, 2026, at 10:46 a.m. observations were conducted with the Administrator, Employee E1 and revealed the following:room [ROOM NUMBER]: No light in the bathroomroom [ROOM NUMBER]: Sink had slow drainage of waterroom [ROOM NUMBER]: Broken faucet that would not shut off water; no knob on the left side of the faucetroom [ROOM NUMBER]: Sink faucet would not shut off water28 Pa. Code 201.18(e)(2.1) Management

Based on observations, facility measurements, and staff interviews, it was determined that the facility failed to ensure resident bedrooms provided at least 80 square feet of usable living space per resident for multi-occupancy rooms, excluding toilets, bath areas, closets, lockers, wardrobes, alcoves, and vestibules, for two of two rooms reviewed (rooms [ROOM NUMBERS]).Findings Include:A review of the facility policy titled Room Square Footage, last revised November 1, 2025, revealed under section 4.2 that semi-private resident rooms shall provide a minimum of 80 square feet of usable floor space per resident.On April 27, 2026, at 9:27 a.m. observations and measurements were conducted with the maintenance director, Employee R3 and Director of Nursing, E2 which revealed:room [ROOM NUMBER] bed B provided (9 feet 4 inches x 7 feet) 65.8 square feetroom [ROOM NUMBER] bed C provided (9 feet 4 inches x 7 feet) 65.8 square feetroom [ROOM NUMBER] bed A revealed (9 feet 5 inches x 6 feet 5 inches) 61.75 square feetroom [ROOM NUMBER] Bed revealed (7 feet 3 inches x 8 feet 5 inches) 61.62 square feetroom [ROOM NUMBER] Bed C revealed (7 feet 3 inches x 6 feet 5 inches 47.12 square feetOn April 27, 2026, at approximately 10:15 a.m., a meeting was conducted with the Director of Nursing and the Administrator to review the above-calculated resident room square footage. Upon review, the Administrator, who was not in the building at the time the measurements were taken, requested that the rooms be remeasured to verify the findings and to determine whether any alcoves or vestibules could be included in the calculation as usable living space.On April 27, 2026, at 10:22 a.m. observations and measurements were conducted with the maintenance director, Employee R3 and Administrator, Employee E1 and revealed the following:room [ROOM NUMBER] Bed B revealed (9 feet 4 inches x 7 feet), 65.8 square feet with an additional 5.33 square feet of common area before entering the room, resulting in a total of 71.13 square feet.room [ROOM NUMBER] bed C provided (10 feet x 7 feet) 70 square feet with an additional 5.33 square feet of common area before entering the room, resulting in a total of 75.33 square feet.room [ROOM NUMBER] bed A revealed (10 feet 5 inches x 6 feet 7 inches) 70.35 square feetroom [ROOM NUMBER] Bed revealed (10 feet x 7 feet) 70 square feetroom [ROOM NUMBER] Bed C revealed (10 feet 10 inches x 7 feet 5 inches 75.1 square feetThe Nursing Home Administrator confirmed that the room sizes were less than 80 square feet as required.28 Pa. Code: 205.20(f) Resident bedrooms

Based clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was determined for three of eleven residents reviewed that the administrative staff failed to conduct and complete a thorough investigation into an incident of physical altercation between two residents (Resident R1 and Resident R2) and a physical altercation between Resident R1 and nursing staff member (Employee E7).Findings include:A review of the facility's policy titled accidents and incidents investigation and reporting dated July 2017 revealed that all accidents and incidents involving residents, employees, visitors and vendors occurring on the premises were to be investigated and reported to the administrator. The policy indicated that the nursing supervisor, charge nurse or department director was to promptly initiate and document the investigation of the accident or incident. The policy indicated that the following data was to be included in the documented investigation report: date and time of the incident, nature of the injury, circumstances surrounding the incident, where the incident took place, names of the witnesses and their accounts of the incident, the condition of the persons involved in the incident, any corrective action taken, follow-up information, other pertinent data as necessary and the signature and title of the person completing the report. The policy indicated that the director of nursing was to ensure that the administrator received a copy of the incident investigation. Interview with the Nursing Home Administrator at 2:30 p.m., on April 13, 2026, confirmed that the Nursing Home Administrator had no documentation of the completed incident investigation that occurred on February 15, 2026. Further interview with the administrator revealed that the former director of nursing took the documented incident investigation. Clinical record review for Resident R1 revealed a nursing progress note dated February 15, 2026, that indicated Resident R1 hit Licensed Nurse, Employee E7, and began punching the roommate Resident R2. Clinical record review for Resident R1 revealed a nursing note dated February 15, 2026, that indicated the Registered nurse, Employee E6, was called to the second-floor nursing unit because Resident R1 was being physically aggressive toward staff and the roommate. The Registered nurse documented that the Licensed nurse proceeded to adjust the air temperature in the residents' room and Resident R1 backed her up against the wall and slapped her face. The Employee E7 reported yelling for help several times. Registered nurse, Employee E6 documented that Resident R1 started punching Resident R2 in the face, in the hallway outside their bedroom. The Registered nurse, Employee E6 said that another nurse helped separate the residents. The progress note indicated that 911 (Emergency Medical Services) was called and Resident R1 was taken into custody. Clinical record review for Resident R1 dated February 15, 2026, indicated that Licensed nurse, Employee E8, documented that Resident R1 was arrested and removed from the facility at 5:49 a.m. There was no documentation available for review that indicated statements were obtained from Employees E6 or E8. There was no documentation available for review that indicated Resident R1, Resident R2 or Resident R3 were asked to give a statement of their accounts of the incident that occurred on February 15, 2026. Interview with the social worker, Employee E9 at 1:45 p.m., on April13, 2026 confirmed that Resident R1, R2 and R3 were roommates on February 15, 2026. Observations of Resident R1 and R3 on April 13, 2026, revealed that they occupy the same bedroom on the second-floor nursing unit. Interview with Resident R3 at 1:30 p.m., on April 13, 2026 revealed that Resident R1 controls the air temperature in their room. Resident R1 adjusts the room temperature so hot, at times that it negatively affects his breathing. Resident R3 reported having a diagnosis of asthma. Resident R3 also reported that after the Resident R1 had been aggressive with their former roommate Resident R2, he would think it was unsafe asking Resident R1 to change the air temperature in the room so that it would be comfortable for both of them. Resident R3 had requested to have a room change at 1:30 p.m., on April 13, 2026. Clinical record review revealed a quarterly comprehensive assessment (MDS-an assessment of care needs) dated March 17, 2026, for Resident R3 that indicated this resident had the ability to understand others and was able to make self-understood by verbal expression. Clinical record review revealed a comprehensive quarterly assessment (MDS-an assessment of care needs) dated February 17, 2026, for Resident R2 that indicated this resident had the ability to express ideas, wants and need to staff. The assessment said that Resident R2 was understood and had clear comprehension. Clinical record review for Resident R2 listed diagnoses of Alzheimer's disease and dementia on March 27, 2023. Clinical record review revealed a psychiatric nurse practitioner's progress note dated February 26, 2026, that indicated Resident R1 reported that he got into a fight with his roommate and tried to punch the roommate Resident R2. Resident R1 also reported that the police department came into the facility and arrested him and brought him to the police station. The progress note indicated that the nursing staff confirmed that Resident R1 got into a fight with his roommate and tried to punch Resident R2. Clinical record review revealed a psychiatric nurse practitioner's progress note dated February 26, 2026, that also indicated that Resident R1 was assessed as being linear coherent. The nurse practitioner also said that Resident R1 was oriented to person, place and time. The nurse practitioner assessed Resident R1 as having adequate cognition. The nurse practitioner indicated that Resident R1 had a diagnosis of frontotemporal dementia (a progressive neurodegenerative disease that effects behavior, personality and language abilities). 28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services28 PA. Code 211.10(d) Resident care policies28 PA. Code 201.14(a) Responsibility of licensee28 PA. Code 201.18(b) (1) Management

Based on clinical record review, staff interview, review of facility policy and information of alcohol-based hand sanitizer, it was determined the facility failed to adequately supervise and monitor Resident R1. This failure resulted in Resident R1 obtaining and ingesting alcohol-based hand sanitizer on three separate dates resulting in an Immediate jeopardy situation for one out of three residents reviewed (Resident R1). Findings include: Review of the facility's policy, Accident & Injury Prevention and Response Policy dated January 1, 2026, indicated that the purpose of the policy was to ensure that all residents of the facility are protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response. Review of the Safety Data Sheet for the ProCure Alcohol Gel Hand Sanitizer 70% indicated the chemical name as Ethyl Alcohol with 70-75% concentration. The first aide measure to follow if ingested stated to contact a physician or a poison control center immediately, do not induce vomiting, and to never give anything by mouth to an unconscious person. Review of Resident R1's MDS (Minimum Data Set - periodic assessment of resident's abilities) assessment dated [DATE], revealed Resident R1 was assessed with a BIMS score of 10, indicating the resident had moderate impaired cognition. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on March 10, 2026 at 10:45 a.m. it was discussed Resident R1 drank and/or was observed with hand sanitizer in a cup on 3 separate occasions, has a history of alcohol abuse, and continued to have access to hand sanitizer at the facility. Review of Resident R1's March 2026 physician orders revealed the diagnoses of alcohol abuse (medical condition characterized by impaired ability to control alcohol consumption despite negative consequences); Bipolar Disorder (condition of periods of depression and periods of extreme happiness), Chronic Obstructive Pulmonary Disease (disease process that causes decreased ability of the lungs to perform), Heart Failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and Dementia (group of symptoms affecting memory, thinking and social abilities). Review of Resident R1's hospital records dated May 24, 2025, revealed the resident was brought to the local hospital by (her/his) son on May 24, 2025. The resident had been staying with (her/his) son due to (her/him) being discharged from another long term care facility the prior week for alcohol abuse, issues with (her/his) insurance and behavioral issues. Review of Resident R1's nursing note dated January 23, 2026, at 2:15 p.m. by Licensed nurse, Employee E3 revealed While rounding, this nurse observed the resident drinking hand sanitizer. Nurse informed and educated resident that the substance was hand sanitizer, not water. The hand sanitizer was immediately removed from residents possession. A full assessment was completed, and vitals 128/76 (normal blood pressure 120/80); 87 (normal pulse 60-100); 97% (normal oxygen saturation 95%-100 %), 97.4 (normal temperature 97.5 degrees Fahrenheit) are stable. This nurse will continue to monitor residents, reassess as indicated, and follow up throughout the shift. Resident paired care. Continued review of Resident R1's clinical record failed to reveal documented evidence the physician was notified of Resident R1 drinking hand -sanitizer on January 23, 2026, and failed to reveal documentation of interventions to monitor and supervise the resident in relation to the consumption of hand- sanitizer. Review of a nursing note by Unit manager, Employee E4 dated February 28, 2026, at 9:04 a.m. revealed Resident found drinking a cup of hand sanitizer. Cup thrown away. Residents educated on why she should not drink hand sanitizer and the dangers of ingestion of the product. MD (physician) and RP (resident's responsible party) made aware. Review of Resident R1's person-centered plan of care included a care plan dated February 28, 2026 indicating Resident drinks hand -sanitizer, with interventions including: administering medications as ordered, analyzing key times, places, circumstances, triggers and what deescalates behavior and document, assess resident's coping skills and support system, continue to provide reeducation and discuss risks/benefits of refusals, and encourage resident to discuss feelings and allow resident to vent. Review of a nursing note on March 1, 2026, at 12:42 p.m. confirmed that Resident R1 was observed by Licensed nurse, Employee E3 in her room with a bottle of hand- sanitizer and a cup with hand sanitizer inside of it. Upon helping resident put on shoes this nurse observed a bottle of hand sanitizer and a cup with hand sanitizer in it, in resident room. Bottle and cup were removed. Review Psychologist's notes on March 2, 2026, at 12:00 p.m. stated: Resident was observed drinking hand sanitizer from a cup There was no other documentation that this was further addressed with the resident or interventions to prevent reoccurrence. Review of Psychologist's notes from October 2025 to March 2026 including the following dates: 3/2/26; 2/21/26; 2/9/26; 1/25/26; 1/14/26; 12/28/25; 12/10/25; 11/30/25; 11/16/25; 11/2/25; 10/26/25 included resident's alcohol and cocaine abuse history, in addition to documentation of the resident reporting to the psychologist that (she/he) currently drinks, does not plan to stop and that (she/he) drank at (her/his) previous nursing home. Interview conducted with Unit manager, Employee E4 on March 9, 2026, at 1:55 p.m. the unit manager revealed she notified the physician once she observed the resident with the half-filled medication cup of hand sanitizer in (her/his) room, and the physician ordered labs (bloodwork) for the resident and to monitor the resident for diarrhea. Unit manager, Employee E4 revealed she took the 4-ounce medication cup from the resident, [Resident R1] walks throughout the building unrestricted, explaining this statement revealed the resident could get more on (her/his) own without anyone knowing. Unit manager, Employee E4 further revealed resident replied, sorry, when confronted with the hand filled cup. Unit manager, Employee E4 revealed she did not ask the resident where the resident got the cup of hand sanitizer from because I don't think (she/him) would have told me anyway. Employee E4 stated that she updated Resident R1's plan of care and referred the resident to psych (psychologist) as intervention. Employee E4 reported that she was unaware of the previous occurrence when Resident R1 drank hand sanitizer on January 23, 2026. Continued interview with the Unit manager, Employee E4 revealed on, March 1, 2026, she was notified by Licensed nurse, Employee E3 that Resident R1 had bottle of hand sanitizer and a cup filled with hand sanitizer with ice, which was taken from the resident by the Licensed nurse, Employee E3. Interview conducted with Licensed nurse, Employee E3 on March 10, 2026, at 11:47 a.m. regarding her nursing notes from January 23, 2026. It was discussed with Licensed nurse, Employee E3 the clinical record failed to evidence in nursing notes that Employee E3 notified the physician regarding the incident or notified any other clinical staff. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on March 10, 2026 at 10:45 a.m. it was discussed Resident R1 drank and/or was observed with hand sanitizer in a cup on 3 separate occasions, has a history of alcohol abuse, and continued to have access to hand sanitizer at the facility. Based on the above findings an Immediate Jeopardy to the safety of Resident R1 was identified to the Nursing Home Administrator on March10, 2026 at 1:08 p.m. for failure to ensure Resident R1 was provided with an environment free of hazardous substances and adequate supervision. This failure placed Resident R1 in an Immediate Jeopardy situation, who had access to alcohol-based hand sanitizer and ingested the hand- sanitizer in three different instances. The Immediate Jeopardy template was provided to the Administrator, and an immediate action plan was requested. On March 10, 2026, at 4:09 p.m. the facility provided the following corrective action plan: 1. Resident R1's personal environment audited to ensure no hazardous substances are in possession or in reach. 2. Resident R1 CP (care plan) updated to include hx (history) of alcohol and substance. 3. Entire staff in-service initiated on sign and symptoms of alcohol and substance consumption. As well as need to report to direct supervisor. Supervisor will notify MD (physician) and family in the event of consumption. All staff in building at this time were in -serviced. This is a 97 or our 155 (62%) current staff. In -service will continue until every staff member in-serviced. Every staff member will be contacted by tomorrow morning. 4. Staff notified/in-serviced of residents behaviors and educated to monitor when Resident R1 comes in view. In-service completed for all staff currently in building. 5. All sanitizers that potentially can be accessible to resident were removed from units, (all refills from wall dispensers removed at this time, actual dispensers are being removed as well), this includes wall dispensers as well as other self-standing bottles. 6. All staff in building received and will continue to be provided will be provided with pocket sanitizers going forward. No Hand sanitizer will be available in the facility aside from these. 7. Staff educated to keep sanitizers on person only at all times. 8. Audit report of all residents with hx (history) of alcohol and substance abuse conducted. All residents identified. Care Plans are now being updated to include this history and appropriate interventions. 9. Facility will continue to audit units on every shift (7-3, 3-11, 11-7) x 4 weeks. 10. Followed by monthly x 3 months. Results of both will be reported to QAPI (Quality Assurance Improvement Plan) Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on March 11, 2026, at 4:54 p.m. The Immediate Jeopardy identified for Resident R1 occurred from March 23, 2026, to March 11, 2026 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 PA. Code 211.10(d) Patient care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility documents, review of clinical records, and interviews with staff it was determined that the facility failed to provide adequate supervision for 1 of 1 sampled resident identified as being at risk for elopement and failed to implement interventions following prior elopement behavior. (Resident R1) Findings include: Review of the facility's admission Agreement indicated that residents may temporarily leave the facility on a Leave of Absence or pass in accordance with facility policies and procedures. The agreement states that the resident or legal representative assumes responsibility for the resident while the resident is away from the facility and releases the facility, its owners, directors, officers, and employees from liability for injury, illness, or decline in condition that may occur during the absence. The agreement also indicates that residents leaving on pass must follow facility requirements, which may include obtaining a physician's order for medications and medical information, meeting escort requirements if applicable, and providing advance notice of the planned leave in accordance with facility policy. Review of the facility's 'Elopement Prevention Policy' undated indicated residents are to be assessed for elopement risk upon admission, routinely, and with any significant change in condition. The policy states that residents identified as an elopement risk will have individualized care plan interventions implemented to promote safety and monitoring. Staff are required to document exit-seeking behaviors, promptly report attempts to leave the premises, and remain with the resident while notifying the charge nurse and obtaining assistance if a resident attempts to leave the facility. Review of the facility's Leave of Absence (LOA) Policy undated, indicated that a Leave of Absence is a temporary period when a resident leaves the facility with the expectation of returning. The policy requires staff to ensure the resident is clinically stable prior to departure, obtain a signed LOA form, document the date and time of departure, and provide any necessary instructions. Upon the resident's return, staff are required to document the time of return, complete a nursing assessment, and update the care plan if indicated. The policy also states that if a resident does not return as expected, staff must attempt to contact the responsible party and take additional steps, including notifying authorities if the resident's safety cannot be confirmed. Review of Resident R1's Minimum Data Set (MDS- a federally required assessment) dated January 10, 2026, revealed the resident was admitted on [DATE]. The resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment indicated the resident required partial to moderate assistance with sit-to-stand, chair-to-bed transfers, toilet transfers, and ambulation of 10 and 50 feet with turns, and was totally dependent for car transfers. Resident R1's diagnoses included coronary artery disease (narrowing of the arteries that supply blood to the heart), hypertension (high blood pressure), diabetes mellitus (a disorder affecting blood sugar regulation), cerebrovascular accident (CVA), also known as a stroke caused by interrupted blood flow to the brain, malnutrition (inadequate intake of nutrients needed for health), generalized weakness (reduced muscle strength affecting mobility), and a history of falls. The resident's medication regimen included antiplatelet medications (to prevent blood clots), hypoglycemic agents including insulin (to control blood glucose), and anticoagulant therapy (blood thinners used to prevent clot formation). Review of resident R1's elopement risk evaluation dated December 17, 2025 (upon admission) revealed a score of 0, indicating no identified risk for elopement at the time of admission. There were no findings suggesting the resident was at risk for leaving the facility unsafely. Review of Resident R1's elopement risk evaluation dated January 20, 2026, revealed that the resident is at risk for elopement, with a score of 2.0. The evaluation was based on several factors, including a history of attempting to leave the facility without informing staff, wandering behavior, and behavior that could compromise the safety or well-being of self or others. Additionally, the resident had been recently admitted within the past 30 days and had not fully adjusted to the facility. According to facility protocol, a score greater than 1 indicates that the resident is considered at risk for elopement. Review of Resident R1's nursing notes dated February 3, 2026, revealed that Resident R1 was picked up for a leave of absent (LOA) and returned to the facility the same evening without incident. Further review of Resident R1's clinical record revealed social service notes dated February 4, 2026, which revealed that the resident left the faciity on leave of absence at approximately 11:00 AM. Resident did not return as expected social service director attempted to contact resident via phone with no response. Social service director contacted the shelter were resident previously resided but was not located. Review of the Leave of Absence log maintained at the front desk, where residents and family sign out when leaving the facility, revealed the following:On February 3, 2026, Resident R1 left the facility at 10:20 AM and returned at 3:20 PM, accompanied by (his/her) brother.On February 4, 2026, Resident R1 again left the facility at 11:05 AM, also accompanied by (his/her) brother. Resident did not return Interview with Medical Director Employee E4 on February 26, 2025, at 10:50 a.m. stated that he does not write blanket orders for Leave of Absence (LOA). He indicated that it would be highly irregular to issue an LOA order on the same day a resident was admitted to the facility. He explained that an order should be written each time a resident leaves the facility. The Medical Director further confirmed that if a resident is identified as an elopement risk, the resident should not leave the facility without staff supervision. He stated that he would not give an order permitting a resident identified as an elopement risk to leave the facility independently. Interview with the Director of Nursing (DON)on February 26, 2026, at 11:30 a.m. Employee E2 stated that when residents leave the facility, it is considered a day pass. The DON, Employee E2 reported that documentation for LOA/day passes is limited to the resident signing out. She stated that for one-day passes, there is no requirement for formal documentation, education, or medication reconciliation. While nurses may verbally speak with the resident or escort prior to departure, she indicated that this communication does not require documentation. Interview with Social Worker, Employee E3 on February 26, 2026, at 8:55 a.m., confirmed she was familiar with Resident R1 and had spoken with him on January 20, 2026, regarding the facility's Leave of Absence policy. She stated that on that date, the resident was not allowed to leave because the physician was unavailable to provide consent. Employee E3 stated not being aware that the resident had been identified as an elopement risk. Employee E3 further reported that she was unfamiliar with the facility's policies regarding elopement and Leave of Absence procedures. 28 Pa Code 201.14 (a)(c) Responsibility of Licensee 28 Pa. Code (b)(1) Management 28 Pa. Code 211.12 (c)(d)(5) Nursing Services

Based on clinical record reviews, and interviews with staff, it was determined the facility failed to implement interventions following prior elopement behavior and failed to revise the care plan to reflect newly identified elopement risk and escalating behavioral for one of one resident reviewed. (Resident R1) Findings include: Review of the facility's undated Leave of Absence (LOA) Policy indicated that a Leave of Absence is a temporary period when a resident leaves the facility with the expectation of returning. The policy requires staff to ensure the resident is clinically stable prior to departure, obtain a signed LOA form, document the date and time of departure, and provide any necessary instructions. Upon the resident's return, staff are required to document the time of return, complete a nursing assessment, and update the care plan if indicated. The policy also states that if a resident does not return as expected, staff must attempt to contact the responsible party and take additional steps, including notifying authorities if the resident's safety cannot be confirmed. Review of Resident R1's Minimum Data Set (MDS- a federally required assessment) dated January 10, 2026, revealed the resident was admitted on [DATE]. The resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment indicated the resident required partial to moderate assistance with sit-to-stand, chair-to-bed transfers, toilet transfers, and ambulation of 10 and 50 feet with turns, and was totally dependent for car transfers. Resident R1's diagnoses included coronary artery disease (narrowing of the arteries that supply blood to the heart), hypertension (high blood pressure), diabetes mellitus (a disorder affecting blood sugar regulation), cerebrovascular accident (CVA), also known as a stroke caused by interrupted blood flow to the brain, malnutrition (inadequate intake of nutrients needed for health), generalized weakness (reduced muscle strength affecting mobility), and a history of falls. The resident's medication regimen included antiplatelet medications (to prevent blood clots), hypoglycemic agents including insulin (to control blood glucose), and anticoagulant therapy (blood thinners used to prevent clot formation). Review of Resident R1's nursing notes revealed that on January 12, 2026 at 3:27 PM, Resident R1 was involved in a verbal altercation with another resident. During the incident, the other resident ran toward Resident R1 and punched the resident. No visible injuries were noted for either resident. The Director of Nursing (DON), physician, police, and the responsible party were notified of the incident. Continue review of nursing notes revealed that on January 13, 2026 at 9:52 AM, Resident R1 was transferred to room to another room. Within five minutes, the resident was involved in a verbal altercation with his new roommate. As a result, the resident was subsequently transferred to a different nursing unit. Nursing note dated January 20, 2026, at 9:23 AM, state that the facility contacted the emergency room (ER) and was informed that Resident had left the ER without being seen at 7:00 AM. The resident returned to the facility at 9:00 AM. A new elopement assessment was completed, and the resident was identified as a flight risk. The physician, Social Services, and Administration were notified, and a full body assessment was completed with no skin issues noted. Review of Resident R1's elopement risk evaluation dated January 20, 2026, revealed that the resident is at risk for elopement, with a score of 2.0. The evaluation was based on several factors, including a history of attempting to leave the facility without informing staff, wandering behavior, and behavior that could compromise the safety or well-being of self or others. Additionally, the resident had been recently admitted within the past 30 days and had not fully adjusted to the facility. According to facility protocol, a score greater than 1 indicates that the resident is considered at risk for elopement. Review of nursing note dated January 30, 2026 at 2:25 PM, revealed the resident was found smoking in his room. Social Services was notified, and the resident verbally threatened another resident , stating he would beat him up. Continued review of nursing notes revealed a note dated February 4/2026 at 11:36 PM, the resident remained on a Leave of Absence (LOA). A phone call was placed to follow up, but there was no answer. A message was left for the responsible party. Review of Resident R1's care plan revealed multiple identified risk areas beginning December 17, 2025, including risk for impaired skin integrity, self-care deficits with expected ADL decline, risk for adverse medication reactions related to medication use, and discharge planning needs. Discharge planning was initiated upon admission, with goals to provide community resource information and ensure appropriate support systems are in place prior to discharge. The care plan further identifies diabetes management goals to prevent complications, continued monitoring for medication-related adverse effects, and fall risk with interventions to anticipate and meet resident needs. Additional problem areas include potential oral/dental health issues and nutritional concerns related to abnormal labs, heart disease, diabetes, and a history of high added-sugar dietary patterns. Behavioral concerns were added to the care plan on January 12, 2026, following an incident in which the resident punched another resident. The care plan reflects potential for physical and verbal aggression, as well as smoking-related behaviors. On February 4, 2026, a self-determination focus was added addressing the resident's choice not to follow facility smoking rules, with a goal for the resident to discuss and understand the potential negative consequences of noncompliance. Continue review of Resident R1's care plan revealed that there was no care plan developed for wandering behaviors or elopement risk. Interview with Social Worker, Employee E3 on February 26, 2026 at 08:58 a.m. confirmed she was familiar with the resident and spoke with the resident on January 20, 2026 regarding the facility's Leave of Absence (LOA) policy. She informed the resident that he could not go out that day because the physician was not available to provide consent. Employee E3 described the resident as someone who frequently expressed a desire to leave the facility. At the time of that discussion, she stated she was unaware that the resident had been identified as an elopement risk. She further indicated she was not aware that the care plan had been updated to reflect elopement risk status. 28 Pa. Code 201.18(b) Management 28 Pa. Code 211.12(c)(d)(5) Nursing Services

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide residents with their requested foods of preferences for five of seven residents interviewed (Residents R3, R4, R5, R6 and R9). Findings include: Interview with Resident R3 on February 18, 2026, at 12:05 p.m. revealed that she often receives foods that she told them she does not like. Interview with Resident R4 on February 18, 2026, at 12:08 p.m. revealed that she often receives foods that she told them she does not like, but that she eats them because she is so hungry. Observation of her plate from lunch revealed that she had eaten everything on the plate. When asked if she got the ham, broccoli and mashed potatoes, she said that the did and that she really does not like ham. She said that she spoke to the dietitian and is supposed to be getting double portions but never does. She is concerned about losing weight. Further observation of her meal ticket revealed no items were listed as double portions. Interview with Resident R4 on February 18, 2026, at 12:11 p.m. revealed that she does not like the food served and is not eating well. She said that she had a recent diagnosis of cancer and is worried about losing weight. She said she is supposed to be getting a nutritional supplement with her meals but only got this once over a week ago. Interview with Resident R5 on February 18, 2026, at 12:15 p.m. revealed that he often receives foods that he cannot eat and showed a picture on his phone of a black square item on a plate. When asked, he said it was a burnt piece of pizza that was not edible, he said he sent it back and never got a replacement item. When he asked, he was told that the did not send anything, and he said he had to order out again. He said he has also received chicken that had blood in it and he refused to eat the rest fearing of getting worms. Again he said that the did not give him a substitution. Interview with Resident R9 on February 18, 2026, at 12:20 p.m. revealed that she is not getting enough to eat and is often hungry. She said she receives foods that she told them she does not eat, like scrambled eggs and they still send it. 28 Pa. Code 211.6(a) Dietary services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policies, documentation and clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure all allegations of suspected abuse were reported immediately, as required, to the Department of Health for two of three allegations reviewed (Resident R2 and R10). Findings include: Review of undated facility policy, Abuse, Neglect and Exploitation revealed that the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the grievance for Resident R10 submitted on February 7, 2026, for an ongoing alleged incident of verbal abuse happening most recently on February 6, 2026, by Employee E10. Employee E10 allegedly threatened Resident R10 to get him kicked out of the facility because he was accusing her of telling people about his mental health diagnosis. A review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS) revealed no reported events by the facility for Resident R10. Interview with the Administrator and Director of Nursing (DON) on February 18, 2026, at 1:30 p.m. confirmed that the February 7, 2026, allegation of an alleged incident of verbal abuse involving Employee E10 and Resident R10 which occurred on February 6, 2026, was not reported to DOH or entered into the ERS. Interview with the DON on February 18, 2026, at 1:20 p.m. revealed that she recalled a discussion with Resident R2 and her daughter about an allegation of verbal abuse that had happened on February 3, 2026. The DON recalled that Resident R2 alleged that a nurse aide who was wearing black scrubs had threatened her to stop ringing her call bell or she would end up dead. The DON recalled that she told the resident and her daughter that the black scrubs meant that the aide was likely from an agency. When asked if this allegation of verbal abuse was reported to the DOH or entered into the ERS she indicated that it was not. A review of the Pennsylvania DOH ERS revealed no reported events by the facility for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on clinical record review, review of information submitted by the facility, review of facility documents, and staff interview, it was determined the facility failed to ensure a resident was free of abuse for one of two residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1. Resident R1 was involved in a physical altercation with a staff member, during which the staff member punched Resident R1 in the face. A reasonable person would determine that a staff member striking a resident with moderate cognitive impairment caused actual harm. Due to the resident's cognitive limitations and dependence on staff for care and protection, the impact of the incident is magnified and places the resident at risk for ongoing psychological trauma. This deficiency was cited as past non-compliance. Findings include: Review of the facility policy, Freedom from Abuse Neglect and Exploitation, with a revision date of September 2025, indicated the facility must provide a safe resident environment and protect residents from abuse, and not use verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion. Review of Resident R1's clinical record revealed January 2026 physician orders included the following diagnosis: Epilepsy (brain condition that causes recurring seizures); Hypertension (high blood pressure); Chronic Obstructive Pulmonary Disease (COPD- a term for lung and airway diseases that restrict your breathing); Dementia (group of symptoms affecting memory, thinking and social abilities and interfere with a person's daily life), and unspecified Psychosis (term used for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). Review of Resident R1's Comprehensive Minimum Data Set Assessment (MDS-periodic assessment of a resident's needs) dated November 19, 2025, indicated the resident had moderate cognitive impairment. Review of information dated November 23, 2025, at approximately 7:00 p.m. submitted by the facility on November 23, 2025, it was reported that [Resident R1] was being physically aggressive towards staff and attacked and hit an employee. According to the report another employee attempted to de-escalate the situation by speaking to [Resident R1]. [Resident R1] attacked that employee and the employee allegedly took a swing at [Resident R1]. The facility substantiated the incident as resident abuse. Review of the facility investigation revealed dietary worker (Employee E3) reported being approached and punched in the face by the resident while they were in the elevator. Continued review of the facility investigation documentation revealed Employee E4, dietary supervisor (alleged perpetrator) was interviewed and stated he was notified the resident hit an employee in his department while the employee and the resident were both in the elevator. Employee E4 reported that he went to find out what happened and attempt to calm the resident down. Dietary supervisor reported the resident started to get aggressive with him and he asked (him/her) to stop multiple times. Dietary supervisor reported that he attempted to exit the situation, then the resident took a swing at him. The dietary supervisor reported that he swung back and hit the resident. Review of written statement by the dietary aide dated November 23, 2025, indicated the dietary aide was hit by the resident. Review of a second written statement by the dietary aide indicated the dietary aide was walking to get the truck and that a resident asked him to walk with them to see something. The dietary aide reported that when the lady came out, the resident grabbed a plate and then put it back. Dietary aide reported the resident asked him if he (the dietary aide) could hear (him/her) and he (dietary aide) stated that he could. The dietary aide reported the resident then started to approach him, so he (dietary aide) backed up and the resident swung at him and hit him in the face. During an interview with the dietary aide on January 7, 2026, at 3:23 p.m. the dietary aide reported, he was on the first floor, west wing getting the food truck. He stated a nurse was about to put a tray on the cart when (the resident) asked to check the tray. The dietary aide stated the resident asked him (dietary aide) if he could hear (him/her), he replied yes, then the resident started to approach him and hit him in the face. Dietary aide reported that he told the dietary supervisor what happened and called his mother. Dietary aide reported he wrote a statement about what occurred with the above-referenced resident. The dietary aide reported he saw the resident knocking on the double doors that lead to the kitchen but did not witness the dietary supervisor get hit by the resident and only heard about the incident. Review of statement obtained from the dietary supervisor dated November 23, 2025, revealed the dietary aide came to the dietary supervisor and told him what happened with Resident R1. The dietary supervisor reported he went to find out where resident was and went to the hallway where he found Resident R1. Dietary supervisor reported he saw the resident and told the resident that he needed to stop, and he said this a couple of times. Continued review of the dietary supervisor's statement indicated Resident R1 tried to swing at him and he (dietary supervisor) swung back and hit him. Review of a witness statement by a resident witness (Resident R3) dated November 23, 2025, revealed Resident R3 was sitting in front of the nursing office and saw Resident R1 walk towards the kitchen. Resident R3 witness statement revealed the dietary staff opened the doors and Resident R1 was trying to go by them. Resident witness reported that Resident R1 put (his/her) hands up to fight the staff and the dietary supervisor tried to talk with Resident R1 to find out what was wrong. Resident R3 witnessed Resident R1 hit the dietary supervisor and the dietary supervisor hit Resident R1 back. Resident witness (Resident R3) has been discharged from the facility since the incident on November 23, 2025, and was not interviewed regarding (his/her) statement that (he/she) provided to the facility. Review of witness statement by activity aide (Employee E5) dated November 23, 2025, revealed that around 7:00 p.m. on the date of the incident the dietary aide notified her that he was hit by Resident R1. The activity aide reported she notified the nursing supervisor (Employee E6). The activity aide reported, she was with the dietary aide and the dietary supervisor near the kitchen door where the resident was also. Activity aide reported Resident R1 was shaking and wobbling while throwing (his/her) hands up at the dietary supervisor and that the dietary supervisor reacted and hit the resident on the right side of the face. During interview with the activity aide on January 8, 2026, at 11:39 a.m. the activity aide reported that during the time of the incident on November 23, 2025, she was working as the front desk receptionist. The activity aide reported during the interview the dietary aide notified her that Resident R1 hit him on the elevator. Activity aide indicated that she notified the nursing supervisor who came down to speak with the dietary aide. The activity aide stated both she and the nursing supervisor went around to the kitchen area (the area near the double doors that lead to the kitchen area) and they notified the dietary supervisor about the incident. Activity aide revealed that Resident R1 walked around to the area where they were all standing and had his fist balled up. Activity aide reported the dietary supervisor was standing near the resident who had (his/her) fist balled up, and the dietary supervisor hit the resident on the side of (his/her) face. The activity aide reported that she did not witness the resident hit the dietary supervisor. Activity aide reported that she moved the resident out of the way and the nursing supervisor called someone and she (activity aide) went back to the front desk. Review of written statement from nursing supervisor (Employee E6) dated November 23, 2025, revealed that the nursing supervisor was called to the dietary department because it was reported to her that Resident R1 hit the dietary aide. Nursing supervisor reported that when she arrived at the kitchen she was met by Resident R1 who stated to the nursing supervisor, where is he? Nursing supervisor reported that she did not respond, and that she went into the kitchen and asked the dietary aide if the resident hit him. The nursing supervisor indicated in the statement that the dietary aide told her that the resident punched him. Nursing supervisor indicated that dietary supervisor then came from the kitchen, and the resident had his hands up as if (he/she) was going to fight. Nursing supervisor indicated the dietary supervisor asked the resident what happened, and what could he do for (him/her) since he was notified by the dietary aide that the resident hit him. Nursing supervisor reported that as the dietary supervisor approached the resident, the resident punched the dietary supervisor. Nursing supervisor indicated that the dietary supervisor then began hitting the resident, and stated to the resident, you messing with the wrong one, and then punched the resident in the face. Based on review of facility documents and interview with staff, a reasonable person would determine that a staff member striking a resident with moderate cognitive impairment caused actual harm. Due to the resident's cognitive limitations and dependence on staff for care and protection, the impact of the incident is magnified and places the resident at risk for ongoing psychological trauma. This action compromised the resident's right to be free from abuse and undermined the resident's sense of safety. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following information. Resident R1 was immediately removed from the area and assessed by the charge nurse. There were no signs of bruising or redness. Resident R1 was transferred to the hospital on 302 for psychiatric evaluation. The staff member involved immediately suspended immediately pending investigation. Staff member was terminated 11/24/2025. On 11/23/2025 the nursing supervisor and NHA interviewed residents and facility staff to [NAME] that there were no other incidents. On 11/23/2025 the nursing supervisor started education for Facility Staff regarding Abuse and de-escalation. The NHA, DON and/or designee continue De-escalation training for facility staff. An ad-hoc QAPI was held on 11/24/2025. The facility has engaged vendor provider to provide de-escalation training. Training will be conducted on February 2, 2026. NHA, DON and /or designee will conduct audits of allegation of staff-to-resident abuse allegations. Results of the audits will be reviewed at the QAPI meeting held monthly. The facility alleged a date of compliance with this plan of correction as November 24, 2025. Facility education records and subsequent audits were verified as complete. Staff were interviewed to confirm education on the facility's de-escalation policy for all staff. Staff interviews were also conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interviews, or observation. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on interviews and the review of clinical records, it was determined that the facility failed to ensure that one resident (Resident R2) was properly assessed by nursing staff and failed to ensure that 2 residents received medications according to physician orders (Resident R5 and R6). Findings include:Review of the January 2026 physician orders for Resident R2 included the following diagnosis: epilepsy (a brain condition that causes recurring seizures); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); post-traumatic stress disorder (PTSD- a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it); adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior); anxiety (frequent intense, excessive and persistent worry and fear about everyday situations, hypertension (high blood pressure), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high).During an interview with Resident R2 on January 4, 2025, at 1:15 p.m. the resident reported concerns that a drawer fell my right shoulder.my arm and reported that no one at the facility who spoke to her about it believed her. Resident R2 reported during the above referenced interview that her arm hurt. Review of the clinical record did not show any documentation that the alleged event occurred and/or that a nursing assessment was completed on the resident regarding the incident that she reported to ensure that the resident was properly assessed for any possible additional care, the physician was notified of her reported incident and could provide any necessary instructions and/or orders to the nursing staff, and that such assessment was complete and accurately documented in the clinical record. (e.g. no documentation in the clinical record that the resident's arm/shoulder area was assessed over a period of time, or that any vital signs.During an interview with Employee E10 (licensed nurse) on January 6, 2026 at 12:44 p.m. reported that the resident notified him that a dresser fell on her shoulder while she was sitting on her bed. Discussed with the licensed nurse that there was no documentation of the reported incident, no documentation of any assessment done on the resident to include assessment of the area where the dresser reportedly fell on, vital signs, . in the clinical record. The licensed nurse reported that he was told by the manger on duty, Human Resources Manager (Employee E9) to not document anything regarding event in the clinical record. Review of the January 2025 physician orders for Resident R5 included the following diagnosis: kidney failure (a condition in which one or both of your kidneys no longer work on their own); osteoporosis; psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it). Continued review of the resident's January 2025 physician orders included an order for the resident to be administered 1-2 milligram tablet of the medication Haloperidol in the morning for the treatment of psychosis and schizophrenia.During the medication administration observation, on January 6, 2026 at 10:11 a.m. Employee E11 (licensed nurse) could not locate the medication haloperidol on the medication cart, or in the medication room when she looked. During the above date and time, the license nurse reported that resident's above referenced medication could not be administered because the resident had no more left, and it had to be reordered from the pharmacy.Review of the January 2026 physician orders for Resident R6 included the following diagnosis: lumbago with sciatica (characterized by pain radiating from the lower back and into the legs and feet); hypertension (high blood pressure), and epilepsy (a brain disorder that causes repeated seizures).Continued review of the resident's January 2026 physician orders included a physician's order for the administration of 1-15 milligram tablet of the pain medication, oxycodone to be administered by mount every 10 hours. oxycodone HCI Oral Tablet 15mg (Oxycodone HCI) Give 1 tablet by mouth every 10 hours related to LUMBAGO WITH SCIATICA, LEFT SIDE.During a medication administration observation on January 6, 2026 at 10:38 a.m. Employee E12 (licensed nurse)went in to administer the medication for Resident R6 when R6 asked the licensed nurse do you have my pain medication? Licensed nurse reported that the oxycodone was not available for the resident to take because it had not been delivered by the pharmacy because a prescription from the physician is needed. During an interview with the resident during the above reference date and time, the resident reported I am in a lot of pain and I need my pain medication. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a safe, clean and homelike condition on two of four nursing units (1st floor [NAME] Unit and 4rth floor nursing unit). Findings: A review of the facility policy titled Policy Number: RR1.01 revised 09/2025 stated under bulletin 3. gg. Section p.8 F584 Safe/Clean/Comfortable/Homelike Environment- 1. Right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. 2. Housekeeping and maintenance services that maintain a sanitary, orderly, and comfortable interior 3. Clean bed and bath linens that are in good condition 4. Private closet space in each resident room [ROOM NUMBER]. Adequate and comfortable lighting levels in all areas, comfortable and safe temperatures levels (71F-81F), and maintenance of comfortable sound levels. On January 21, 2026, at 9:30 a.m., an observation on the first-floor [NAME] unit revealed that room [ROOM NUMBER] had a temperature of 52 degrees F, and the restroom light was not functioning. The sink water was turned off at the valve, and the Maintenance Director, Employee E7, had to turn it back on by opening the valves beneath the sink. Resident R7 was lying in bed wrapped in multiple blankets and reported that he/she was cold and that it had been cold for the past three months. Resident R7 refused a room change. room [ROOM NUMBER] had a temperature of 69 degrees F. The restroom showed rusted metal edges on the wall, with rust flaking off. [NAME] rust discoloration was observed around the toilet and toilet valves. The floor tile behind the toilet also had brown rust discoloration. On January 21, 2026, at approximately 9:40 a.m., an interview with Resident R8, who resided in room [ROOM NUMBER], revealed that he/she reported feeling cold in the room. Further observations during the same time screening revealed that room [ROOM NUMBER] had a temperature of 57 degrees F. Resident R9 reported feeling cold in the room. The [NAME] hallway unit had a total of two sanitizer dispensers, both of which were empty. It was further discovered that the left side of the first-floor [NAME] nursing unit heating system was not functioning. The following room temperatures were recorded: room [ROOM NUMBER] – 61 degrees F room [ROOM NUMBER] – 62 degrees F room [ROOM NUMBER] – 66.5 degrees F room [ROOM NUMBER] – 57 degrees F room [ROOM NUMBER] – 52 degrees F All rooms from 111-116 had a restroom light that was not functioning. These observation were confirmed by the maintenance director, Employee E7. On January 21, 2026, at 9:58 a.m., an observation in room [ROOM NUMBER] revealed a strong smell of cigarette smoke near Bed A. Resident R10 was interviewed and denied smoking; however, the Unit Manager, Employee E40, confirmed the strong smoking odor in the room and reported that the resident is a smoker who has a contract with the facility not to smoke but is noncompliant. They conducted a search and found a lighter. On January 21, 2026, at 10:18 a.m., an interview with Resident R10 revealed, It's freezing, but they did something and it got better. On January 21, 2026, at 11:27 a.m., an interview with the Administrator, Employee E1, and the Director of Nursing, Employee E2, revealed that there were heating issues on the left side of the first-floor [NAME] nursing unit. An invoice from a vendor indicated that on January 20, 2026, the vendor worked on the HVAC units and reported the following: We replaced the inducer motor on a rooftop unit, diagnosed another rooftop unit, and cleaned the limit switch. The unit also needs a rollout switch. In addition, the thermostat on one of the units needs to be replaced. Admin confirmed that thermostat was replaced and rollout switch was obtained by vendor. Everything was fixed as of January 20. 2026. The Administrator further reported that the facility would offer room changes and provide blankets to residents in room [ROOM NUMBER]-116. Frequent monitoring of room temperatures would be conducted if residents refused to change rooms. The Medical Director would be contacted to determine whether the room temperatures could affect residents' medical status. Residents' body temperatures would be checked every four hours for signs of hypothermia. A vendor was scheduled to return that day. The inducer motor was fixed the previous day. The facility had blankets on hand and placed an additional order for blankets the previous day in anticipation of worsening weather the following weekend. On January 21, 2026, at 1:26 p.m., the Maintenance Director, Employee E7, reported that the vendor shut down and reset the rooftop unit, after which the heat began functioning. All six rooms were back in compliance, with temperatures ranging from 72 degrees F to 79 degrees F. The Administrator reported that heat checks would be conducted every two hours for the next week to monitor room temperatures on the first-floor [NAME] unit. During a tour with the Nursing Home Administrator on January 5, 2026, at 1:20 p.m. room [ROOM NUMBER] where Resident R2 residents did not have any working cold water when the faucet in the bathroom was turned on. During an observation in room [ROOM NUMBER] during the above referenced time period, no working cold water was found when the faucet in the bathroom for room [ROOM NUMBER] was turned on. Resident R4 reported that she told them, about it, but could not recall who she told when she was asked. During an interview with the Director of Maintenance (Employee E7) on January 5, 2026, at 2:00 p.m. the Director of Maintenance reported that he was aware that room [ROOM NUMBER] did not have any working cold water when he went to fix the toilet in that room on December 10, 2025. The Director of Maintenance reported that he had known since this time and had not had time to fix it. In regard to room [ROOM NUMBER] not having any working cold water, the Director of Maintenance stated that he was notified of that after the above referenced observation in room [ROOM NUMBER]. 28 Pa. Code 201.18(e)(2.1) Management

Based on observations and interviews, it was determined that the facility failed to ensure complete and accurate clinical record regarding the consumption of a meal for 1 out of 3 residents observed (Resident R5).Findings include:Review of the January 2025 physician orders for Resident R5 included the following diagnosis: kidney failure (a condition in which one or both of your kidneys no longer work on their own); osteoporosis; psychosis (the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), and post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).Review of a physician's order for Resident R5 with an order date of August 25, 2022 and monthly thereafter included an order for the resident to have a fortified cereal one time a day during her breakfast meal for the additional calories and protein intake. Fortified Cereal one time a day for additional kcal and protein intake. With breakfast. During the medication administration observation, on January 6, 2026 at 10:11 a.m. Employee E11 was observed documenting in the clinical record with her initial indicating that the resident had at least received the fortified cereal/and or consumed it. When asked if she observed the resident with the cereal on her breakfast tray and/or if she consumed it, Employee E11 confirmed that she did not see her with it, and stated, they (referring to dietary) usually send it up.

Based on a review of facility policy, clinical record review, and interviews with resident and staff, it was determined that the facility failed to assist and initiate a discharge plan for a resident who requested to be discharge from the facility for one of three residents reviewed. (Resident R1) Findings include:Review of the facility policy title Discharges dated October 1, 2025, revealed that the residents may not be discharged unless specific criteria are met and at the facility must provide written notice, physician documentation, and coordinate discharge planning with social services, nursing, MDS (resident assessment of care needs), and therapy. The policy requires a discharge notice include the reason for discharge, effective date, appeal rights, and discharge location, and that a post discharge plan of care be developed. Review of Resident R1's admission MDS dated [DATE], revealed that this resident was admitted into the facility on October 8, 2025. Resident R1 was assessed with a BIMS (Brief interview for Mental Status score of 14, indicating that the resident was cognitively intact. The assessment documented that she was independent with indoor mobility and required supervision or partial assistance with walking and transfers. Resident R1's diagnosis included cellulitis (skin infection) of the lower limb. Review of Resident R1's admission agreement packet dated October 8, 2025, revealed that Resident R1 signed the admission documents, which included information regarding anticipated care services. The packet indicated that the resident was admitted for short-term rehabilitation, defined by the facility as goal-oriented, comprehensive inpatient care provided to individuals with an acute illness, injury, or exacerbation of a disease process. The admission packet further states that all resident transfers and discharges will be conducted in accordance with applicable state and federal laws. It specifies that a resident may be transferred or discharged if their condition has improved sufficiently so that facility-level services are no longer required, or if the resident voluntarily chooses to be transferred or discharged . In all cases, the facility is required to collaborate with the resident or legal representative to develop and implement a safe, timely, and appropriate discharge plan.The admission documents also included the Resident Rights section, affirming the resident's right to be informed of and participate in their treatment, care planning process, expected goals and outcomes, and the duration and effectiveness of the plan of care.Resident R1 signed and acknowledged receipt of all documents included in the admission agreement. Interview with Resident R1 completed November 18, 2025, at 9:50 a.m. revealed that (she/he) stated (she/he) was at the facility only for rehabilitation and is eager to go home. Resident R1 expressed this desire for several weeks to the former social worker, but no action has been taken. The resident stated that (she/he) has discussed plans with her family and intends to stay with (her/his) daughter upon discharge. Interview with the social worker on November 18, 2025, at 11:35 a.m. revealed that she was aware the resident wished to leave the facility, but she was not confident about the resident's planned living arrangement. The social worker confirmed that Resident R1 is (her/his) own representative and is cognitively capable of making her own decisions. Review of the resident's care plan revealed that there was no documentation or mention of a discharge plan.Review of the resident's nursing notes revealed that on November 12, the social worker documented an attempt to contact the resident's daughter. No other documentation was found indicating that the resident or facility had initiated discharge planning.Review of the resident's physical therapy notes revealed that the resident is expected to return to living at home with family, with home assistance and support provided as needed. The notes identified potential barriers to discharge, including multiple medication management requirements, the need for physical assistance to function safely at home, and likely caregiver support in the next setting. Therapy notes dated November 13, 2025, indicated that the resident was compliant and actively participated in skilled interventions.Interview with the nursing home administrator on November 19, 2024, at approximately 2:30 PM revealed that he was aware the resident had requested a discharge. He stated that the request had been discussed at a recent meeting and confirmed that there was no documentation indicating that a discharge plan had been initiated or that any steps had been taken to facilitate the resident's discharge.25 Pa Code 201.14(a) Responsibility of licensee

Based on observations, review of facility policy, and interview with residents and staff it was determined that the facility failed to ensure that residents were explained their resident rights for four of eleven residents reviewed. (R1, R76, R120, and R178). Findings Include:Review of the facility policy titled Resident Rights undated, reads Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Further review of the Resident Rights policy revealed, Policy Explanation and Compliance Guidelines: A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility.During resident council group meeting held on September 17, 2025 there were five of eleven residents that stated they did not know what their resident rights were or how they would call the Department of Health to file a complaint. Review of resident council minutes from the months of April, May, June, July, and August, 2025 revealed there were no indication that any of the resident rights were reviewed during resident council. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(d) Resident Rights

Based on observations, facility policy review, and staff interview, it was determined that the facility failed to provide residents with the ability to file grievances anonymously for four out of four nursing units reviewed.Findings Include: Review of the facility policy titled, Grievance Policy dated November 2016 states, The facilities established grievance policy includes: Notifying the resident individually or through posting of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of the grievance official, a reasonable expected time frame for completing review of the grievance, the right to obtain a written decision, the contact of independent entities to whom grievances may be filed (state agency, quality improvement or, state survey agency, state LTC ombudsman). Further review of the facility policy states, The facility Grievance Office is the Social Worker, and is responsible for: Overseeing the grievance process, receiving and tracking grievances to conclusion, leading any necessary investigations, maintaining the confidentially of all information associated with grievances, issuing written grievance decisions, coordinating with state and federal agencies as necessary in light of specific allegations.Observations conducted of the First, Second, Third, and Fourth floor nursing units with the Social Services Director, Employee E16, on September 16, 2025 at 1:49 p.m. revealed that there were no grievance forms accessible to residents, caregivers, or family members to have the ability to form anonymous grievances. When Employee E16 was asked where grievance forms were, she stated, I have the forms in the office, the nurses have them in their office, but residents usually come to if they have a concern. Further observation of the grievance process in the facility revealed there were two grievance mailboxes where residents could turn in their grievance, but the boxes were not locked for privacy. Further observation during the tour revealed that it did not have any posting on the second, third of fourth floor in a prominent location about the right to file grievances in writing anonymously. The posting also did not include the reasons why you would file a grievance at the facility. Review of the facility grievance form provided revealed there was no space to indicate that the grievance was being formed anonymously. Further review of the grievance form revealed there was also no space to check off regarding the right to obtain a copy of the written decision regarding his or her grievance. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(i) Resident rights

Based on interviews with staff, review of clinical records, and facility documentation, it was determined the facility failed to protect Resident R112 from Resident R46 who had a history of verbal aggression towards Resident R112. This failure resulted in actual harm to Resident R112 who sustained a closed head injury and a fractured right finger when Resident R46 became physically violent towards Resident R112 for two of 33 resident records reviewed. (Resident R112 and Resident R46) Findings include: Review of Resident R46's quarterly MDS assessment (Minimum Data Set, assessment tool used to evaluate the functional abilities and cognitive status of a resident) dated July 16, 2024, revealed the resident was alert and oriented, capable of making independent decisions, diagnosed with Epilepsy, (chronic brain disorder that causes seizures) and Hemiplegia (one sided weakness) affecting the right dominate side. The resident was assessed as independent in all activities of daily living (ADL), including walking, and transferring and was continent of bowel and bladder. Review of Resident R112's quarterly MDS assessment, dated August 15, 2024, assessed the resident with severe cognitive impairment, diagnosed with Schizophrenia (chronic mental disorder) and Dementia (progressive degenerative disease of the brain). The resident was occasionally incontinent of urine and frequently incontinent of bowel, used a walker for ambulating and needed supervision with activities of daily needs. Review of Resident R112 care plan dated May 11, 2021, revealed a care plan developed for incontinence care and Activities of Daily Living. The resident was care planned for requiring staff assistance when needed. Review of Resident R46's nurses' notes dated, May 2, 2024, indicated a verbal altercation occurred between Residents R46 and R112. Resident R46 was heard yelling from bathroom door to Resident R112, cursing and threatening the resident, saying he would, 'Beat you the f-k up,' and 'You don't know me.' Resident R46 was asked to close the door and calm down, and social services was notified. Review of written statement taken by Social Services during an interview with Resident R112 and Resident R46 dated May 2, 2024 revealed, Resident R112 said [he/she] called the resident the N word because [Resident 46] kept yelling about the toilet. Resident R46 said [he/she] got into an argument because [he/she] keeps leaving the toilet clogged. When Resident R46 told the resident about it, Resident R46 said [he/she] was called the N word. Review of weekly nursing note dated June 3, 2024, states, Resident R46 frequently screams and curses at roommate related to shared bathroom. Review of Resident R112's nursing note dated October 12, 2024 revealed the nurse aide called this nurse around 6:10 a.m. and reported the resident is bleeding from [his/her] head and resident stated that a black guy hit [resident] on [resident] head. This nurse immediately responded and found resident sitting in a chair in front of [his/her] room bleeding from [his/her] head. Nursing supervisor made aware. Upon assessment laceration noted on the top of the head, on the middle of the head and also a laceration noted on the back of [his/her] head with hematoma. Resident also both with a small cut and a swollen and bruised right pinky finger. Resident is alert and awake with some period of confusion, able to make need known with no loss of consciousness. The resident was asked if he/she fell and the resident denied falling. This writer asked resident what happened and resident stated that [he/she] was coming out of the bathroom and a black guy hit [him/her] on [his/her] head with a cane. The physician was notified and order to send resident to the emergency room for evaluation. Review of information dated October 12, 2024 submitted by the facility on October 12, 2024 to the State Agency, revealed Resident R112 was seen walking to [his/her] bedroom with blood on [his/her] face. Resident R112 was noted to have a hematoma on the back of the head, a laceration on top of head and finger. The resident attending physician was notified and Resident R112 was sent to the hospital for evaluation. Continue review of information dated and submitted by the facility on October 12, 2024 to the State Agency revealed Resident R112 was treated at the hospital for a closed non displaced fracture of the proximal phalanx of the right little finger and a closed head injury. Further review of information dated October 12, 2024 and submitted by the facility on October 12, 2024 to the State Agency revealed the Nursing Home Administrator interviewed Resident Resident R107 who was R112's roommate. Resident R107 witnessed next-door-neighbor (Resident R46), who they share a bathroom with, push Resident R112 and hit [Resident R112] with [his/her] cane. The investigation concluded that Resident R46 was identified as the perpetrator and the facility substantiated the resident-to-resident altercation as abuse. The facility failed to ensure that Resident R112 was free from physical abuse from Resident R46 with a history of verbal aggression towards Resident R112. This failure resulted in actual harm to Resident R112 who sustained a closed head injury and a right fractured finger when Resident R46 became physically violent towards Resident R112. 28 Pa. Code 201.29 (c)(3)(4) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement and failed to ensure that windows were secure on the unit. This failure resulted in an Immediate Jeopardy situation for Resident R1, who exited the building through a third floor window and sustained serious injuries, including bilateral lower extremity fractures and a fracture of the third lumbar spine vertebra for one of three residents. (Resident R1) Findings include: Review of the facility policy, Elopements and Wandering Residents, with a revision date of April 23, 2024, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Continued review of the policy indicated that residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The policy also indicated that adequate supervision will be provided to help prevent accidents or elopements. Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior). Review of an admission note dated March 27, 2024, at 6:37 p.m. written by Employee E3 (licensed nurse) indicated that the resident was admitted to the facility on the above referenced date from the local hospital after suffering a heart attack. Continued review of the above referenced admission note indicated resident is at risk of elopement, wandering or exit seeking behaviors. Review of the resident's discharge hospital records dated March 27, 2024, indicated that the resident did not have the capacity to make his medical decisions. Review of a court order dated March 19, 2024 stated that the resident was adjudicated on the above referenced date as a totally incapacitated person, and had an appointed Guardian (someone appointed by the court to manage the personal and financial affairs an individual who the court has determined lacks the capacity to make his/her own decisions). Review of the resident's Elopement assessment dated [DATE], indicated that the resident was at risk for elopement. The assessment indicated that resident Expresses desire to leave, Independently mobile, Adjustment difficulties, Desire to return home, in addition to a Psychiatric history. Review of Resident R1's March 2024 physician orders indicated a physician order dated March 28, 2024, and monthly thereafter, for the resident to have a wanderguard (an electronic device that is typically applied on an individual's ankle or wrist to alert his/her caregivers (with an alarm) when that individual is near an exit location (e.g. doors, elevators) applied to his left ankle. The order also indicated that on every nursing shift, staff is to ensure to check the placement and function of the wanderguard. Continued review of the March 28, 2024, physician orders also included a physician's order for the 11:00 p.m. -7:00 a.m. supervisor to check the function of the resident's wanderguard during his/her shift. Review of the resident's person-centered plan of care included a plan of care dated March 28, 2024, that indicated that the resident was at risk for injury related to elopement and wandering. The resident expressed intent to leave facility. The plan of care also included the resident's diagnosis of Schizophrenia. The interventions related to this care area included involving the resident in activities, reporting changes in behavior, provide activities of interest, in addition to the application of a wanderguard. Review of a nursing note dated March 28, 2024, at 6:17 a.m. indicated .wander guard placed to left ankle due to reports of wandering. Review of a nursing note on March 28, 2024, at 1:10 p.m. documented that the resident was at the nursing station asking, how do I get out of here? Review of a nursing note dated March 30, 2024, at 6:46 p.m. revealed Resident came to the nursing office asking if I could give him a day pass to go to 7-11 mini market. Resident is an elopement risk, but no attempts to leave out of the facility. Resident does have wanderguard applied to his left ankle. Plan of care is ongoing. Review of a nursing note on April 5, 2024, at 6:56 a.m. indicated that the resident was not wearing his wanderguard and that another one was placed on his ankle. Review of a nursing note dated April 11, 2024, at 5:06 p.m. indicated that the resident's wanderguard bracelet was found in his bedside drawer, and that the resident stated that he did not want to wear it. Continued review of the note indicated that the resident did not want the wanderguard on his ankle so nursing staff applied the wanderguard to his left wrist. Review of a nursing note dated April 12, 2024, at 2:37 a.m. the resident was found with the wanderguard bracelet inside the dresser next to his bed. The note documented that the resident reported that he did not want the wanderguard on him. Review of a nursing note dated April 13, 2024, at 3:10 p.m. documented Resident is alert and oriented x 3 Confusion noted. Exhibits anxiety, wanders Review of a nursing note on April 14, 2024, at 5:19 p.m. documented that the resident is an elopement risk and that he continues to remove his wanderguard. Review of a nursing note dated April 14, 2024, at 2:15 p.m. indicated that the resident was pacing back and forth throughout shift and needed to be redirected. Review of a nursing note dated April 15, 2024, indicated . resident continues refusing wanderguard. Review of a nursing note dated April 18, 2024, at 11:58 a.m. indicated that resident informed the social services director that he wanted to discharge home to his apartment. Review of a nursing not dated April 18, 2024, at 2:59 p.m. documented Resident received at front desk. Resident was assisted back upstairs by charge nurse. Review of information submitted to the State Survey Agency on April 24, 2024, indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement. Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024, 8:42 p.m. on the third floor walking to his room. A summary of interviews conducted with facility staff (licensed nurses and nursing assistants) who worked on the 3:00 p.m. through 11:00 p.m. shift that the resident was last seen on, indicated that the general time period that staff reported last seeing the resident on the third floor where his room was located between 8:00 p.m. through 9:00 p.m. Review of a statement from Employee E4 (licensed nurse assigned to Resident R1) dated April 23, 2024, reported that she last saw Resident R1 out of bed walking in the hallway around 9:00 p.m. on April 22, 2024. Employee E4 reported that she administered the resident his medication at approximately 8:30 p.m., asked him if he was ok, and reported that the resident nodded yes. Review of an interview conducted by the facility dated April 23, 2024, with the nurse aide, Employee E5 assigned to the resident on April 22, 2024 during the 3:00 p.m. through the 11:00 p.m. nursing shift indicated that she saw Resident R1 between 8:00 p.m. and 9:00 p.m. in his room. During an interview with Employee E5 on April 30, 2024 at 12:18 p.m. the employee confirmed the statement provided to the facility. Employee E5 reported that she went in to check on the resident during the above referenced time to see if he needed anything (e.g. wash towels, socks). Employee E5 reported that Resident R1 told her that he did not need anything. Employee E5 reported that the resident was sitting on the edge of his bed during her encounter with him. Review of an interview conducted by the facility dated April 23, 2024 with the nurse aide, Employee E6 assigned to Resident R1 on April 22, 2024 during the 11:00 p.m. through the 7:00 a.m. shift stated, I really didn't see [Resident R1] on 11-7 shift because I know he walks around the building. I know he usually does his own thing. During an interview on April 30, 2024 at 1:28 p.m. via telephone with Employee E6, confirmed that he was assigned to Resident R1 on the above referenced shift, and reported that he did not see the resident that he was assigned to at all during his 8 hour shift. Review of the investigation did not show evidence of the facility conducting an interview yet with Employee E7 (licensed nurse), who was assigned to Resident R1 on April 22, 2024, on the 11:00 p.m. through the 7:00 p.m. nursing shift. During a telephone interview with Employee E7 (licensed nurse) on April 30, 2024 at 1:32 p.m. Employee E7 confirmed that she was assigned to the resident on the above referenced shift. Employee E7 also reported that she did not remember seeing the resident at all during her shift. She stated, that the resident was always out. I work on the floor 3-4 times a week, so I always see him out in the hallway asking if he can get on the elevator or asking if he can have a shower. Employee E7 continued her statement and reported, He's always nice, polite, and easily directed, and paces the floor. I didn't bother him that night because I figured since I didn't see him like I usually do on the unit, then he is finally sleep for once, so I'll just let him sleep. Review of an interview conducted by the facility dated April 23, 2024, with nurse aide (Employee E8) who was assigned to Resident R1 on April 23, 2024 from 7:00 a.m. through 3:00 p.m. reported that she saw the resident at approximately 8:17 a.m. She reported that he was dressed and heading to the elevator. During an interview with the state surveyor on April 30, 2024, at 12:28 p.m. Employee E8 reported that she thought she saw the resident get on the elevator at 8:17 a.m. in the morning. Employee E8 also stated that she placed the resident's breakfast tray in his room and that the resident was not present at the time that she delivered the breakfast tray to him. Employee E8 reported that she came back around 12:00 p.m. and noticed that he did not eat it. Employee E8 reported that she contacted the unit manager to let her know that he did not eat his breakfast and that the name Dr. [NAME] was called throughout the facility, which is a code word used to notify staff that there was a resident whose presence in the facility cannot be accounted for. Review of an interview conducted by the facility with Resident R2 (Resident R1's roommate) on April 24, 2024, revealed that Resident R2 notified the facility that he did notice that the window was open because he felt a breeze. Resident R2 stated that when he felt the breeze he walked over to the window and noticed that the window was pulled out of its frame and was lying on the floor. Resident R2 stated that he picked the window up, and put the window back in the frame. During an interview with Resident R2 on April 30, 2024 at 10:27 a.m. Resident R2 reiterated his account of seeing the window on the floor, picking it up and inserting it back into the window frame. Review of an interview conducted by the facility dated April 23, 2024, with licensed nurse (Employee E9) assigned to Resident R1 on April 23, 2024, from 7:00 a.m. through 3:00 p.m. indicated that the employee stated that she attempted to provide the resident with his medications in the morning but was told by staff that the resident wanders in the building, and that it was his baseline behavior. Employee E9 reported that she looked for the resident in his room while administering medication to other residents, but she still did not see the resident. Review of the investigation indicated that when it was noted that the resident had not eaten his breakfast, and not had his medication administered to him, the Unit Manager was notified, and the facility initiated their elopement protocol to locate Resident R1. Review of an account from the Social Services Director (SSD, Employee E10) dated April 23, 2024 at 1:00 p.m. the SSD that both he and Employee E11 (Social services assistant) drove to the resident's old apartment, called the resident Guardian to see if she had working cell phone number for him. The Social services director reported that he was able to make contact with the resident at approximately 1:30 p.m. when the resident told the SSD that he was in the hospital because he climbed out of his window the previous evening an attempt to go home. Continued review of the investigation completed by the facility indicated that when the resident exited out of his third-floor window, he sustained injuries that caused him to call 911 (Emergency Medical services) for transportation to the hospital. During an interview with Resident R1 on May 2, 2024, at 9:15 a.m. Resident R1 reported that he wanted to leave the facility, so he jumped out of a window. Resident R1 reported that he lifted the window out of its frame. When asked if he used any tools (knife, pen, etc), Resident R1 stated, I only used my hands. I was surprised it came out that easy. Resident R1 reported that he moved a short distance of where he landed when he jumped and called 911 to pick him up because he could not walk. Review of the resident's History and Physical report dated April 23, 2024 at 3:39 p.m. indicated that the resident fractured both his right and left legs. Continued review of the report indicated that the resident also had a fracture of the third lumbar spine vertebra (L3). Review of the resident's clinical record and the facility investigation did not show evidence of any supervision or monitoring that were put in place for Resident R1 who was identified as an elopement risk upon admission and refused to wear his wanderguard. Resident R1 was last seen entering his room at 8:42 p.m. on April 22, 2024, and not noticed missing from the building until April 23, 2024, at approximately 12:00 p.m. 15 hours later. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on April 30, 2024, at 12:45 p.m. the facility determined that Resident R1 exited the facility through his window that the room rounds, and bed checks were not completed properly by nursing staff. The facility failed to adequately supervise a resident who was at risk for elopement and failed to secure windows on the unit. This failure to adequately supervise a resident at risk for elopement resulted in the resident exiting the building by jumping from his 3rd floor bedroom window and sustaining serious injuries resulting in an immediate jeopardy situation. Based on the above findings an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on April 30, 2024, at 2:34 p.m., for failure to adequately supervise a resident at risk for elopement, and failure to secure windows on the unit. The Immediate Jeopardy template was provided to the Administrator and an immediate action plan was requested. On April 30, 2024, at 8:59 p.m. the facility provided the following corrective action plan: 1. On April 23, 2024, an audit of all resident room windows were completed by the maintenance director. The maintenance director installed an additional bracket to all resident rooms to prevent the windows from being removed from the frame. 2. On April 23, 2024, the DON (Director of Nursing)/designee reviewed all resident care plans and reviewed and revised them to reflect elopement risk assessment findings. 3. On April 23, 2024, the DON/designee(s)re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool. 4. DON, designee(s) will complete elopement risk assessments that will assess residents on admission, quarterly, and in the event of a significant change. 5. On April 23, 2024, the DON/designee also in-serviced nurse aide staff on completing checks on the residents that they are assigned to every two hours during their shift to account for the resident's whereabouts. Licensed nurses were also serviced to ensure that head counts of residents are completed on their nursing shift. Interviews were conducted with facility staff on May 1, 2024, between 1:30 p.m.- 3:35 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the proper procedure for alerting management. Review was conducted of the education provided to facility staff related to resident elopement and the Immediate Jeopardy was lifted on May 1, 2024, at 4:16 p.m. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan

Based on a review of clinical records, review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect related to Resident R1 not receiving treatment and services to prevent new wound development, promote healing and prevent worsening of existing wounds. This failure resulted in actual harm to Resident R1 who developed two worsening of wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. Findings include: Review of an undated facility policy Abuse Policy and Procedure revealed that Neglect is defined at 483.5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The following definitions are intended to assist in the immediate identification and reporting of abuse and/or neglect. 2. Deprivation of Goods and Services: Abuse also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which results in care deficit to a resident(s). Review of an undated facility policy Wound Treatment Management revealed that 1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Review of an undated facility document Wound Management Program revealed that Based on the comprehensive assessment of a resident, 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 6, 2023, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living to include bed mobility, transfers, and toilet use. The resident's cognition was severely impaired, and the assessment indicated that the resident was unable to complete interview. Resident was at risk for developing pressure ulcers. MDS also indicated that the resident rarely/never makes self-understood and able to understand others. Review of Resident R1's care plan dated December 30, 2023, revealed that the resident was at risk for skin integrity with interventions included body check weekly and as needed, notify physician and family of changes and provide skin care as needed. Observation of tracheostomy care to Resident R1 on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5, was completed. During the observation a pack of gauze was observed on resident's right side of neck under his trach ties and the right neck area. Both employees did not know why the resident had gauze to the right side of the neck. Resident was observed with his neck towards right ride with his chin bone touching the area of the shoulder bone. A request was made to Employee E4 and E5 to open the gauze. Further observation after the gauze was removed from Resident R1's neck revealed that there were two new wounds under the gauze. There was a 2 x 2 boarder dressing on one of the wounds without any medications. There was no date on the dressing. The right clavicle wound appeared to be an area where resident's chin touching the clavicle bone and the neck wounds appeared to be an area where the trach tie touched the skin. It was observed that resident's neck tilted towards the right side and right side of the chin was touching the right clavicle bone. No offloading or pressure reducing measures were observed to the area. Interview with resident representative for Resident R1 On January 5, 2024, at 2:30 p.m. stated resident was not able hold his head straight for long period of time and his head would tilt to either side and touched his shoulder. Often trach ties and trach tubing were also touching the skin around neck. Interview with the Speech Therapist, Employee E6, on January 5, 2024, at 2:30 p.m. stated, Resident R1 could not hold his head straight for long time. She stated she placed a rolled towel to support his head during her therapy time and removed the towel after the therapy was over. Interview with Licensed Nurse, Employee E5 on January 5, 2023, stated she was not aware of resident's two wounds to the right side of the neck. There was no information provided to the shift-to-shift report. Employee E5 stated there was no physician order to provide treatment or check residents wound to the right neck. Review of physician orders for Resident R1 dated July 7, 2023, revealed an order to check for skin integrity around the neck related to trach collar. Review of nursing progress note dated December 21, 2023, revealed that the resident was identified with moisture associated dermatitis to left clavicle which measured 0.5-centimeter (cm) x 1.0 cm. X 0.1 cm. Review of progress note for Resident R1 dated December 26, 2023, revealed a skin documentation that a new skin impairment was observed on residents left chin area which measured 1.5-centimeter (cm) x 2.0 cm. Review of physician orders for Resident R1 dated December 27, 2023, revealed an order to complete full body skin assessment three times a week. New skin impairment should be documented; initiate a treatment document in the nurses' notes. Review of the clinical record revealed that the resident was transferred to the hospital on December 27, 2023, with a respiratory change in condition. The resident was readmitted to the facility on [DATE]. Review of hospital record for Resident R1 dated December 29, 2023, revealed under skin condition that the resident had Stage II pressure ulcer on right and left clavicle wound, right leg wound and a DTI (Deep Tissue Injury) to the right foot. Review of facility admission assessment dated [DATE], revealed no evidence that the resident's right clavicle wound was indicated on the assessment, or a treatment plan was initiated. Review of a readmission assessment of Resident R1 dated December 29, 2023, revealed that there was no negative finding noted on the skin assessment. Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated right clavicle's wound measuring 1 cm x 1.5 cm, and left clavicle's wound and left chin. All treatment in place. Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle, left clavicle and left chin. All treatment in place. Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound. Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin. Review of a skin assessment completed by Licensed nurse, Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment. Interview with Licensed nurse, Employee E4, on January 5, 2024, at 1:00 p.m. stated she was not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated Licensed nurse, Employee E4 did not conduct a proper skin assessment. Staff were expected to conduct skin assessment and document the findings in the medical record. Any changes to skin integrity should be addressed with the physician for treatment orders. Review of clinical record for Resident R1 revealed no documented evidence that the physician or wound care practitioner was notified about Resident R1's right clavicle wound when it was first documented on December 30, 2023, subsequently after. There were no interventions implemented to promote the wound healing or preventing further skin breakdown. A skin assessment completed on January 5, 2024, at 1:39 p.m., revealed that the right clavicle measured 1.5 cm x 2.3 cm. and right neck wound measured 0.7 cm. x 2 cm. A wound care consult report dated January 5, 2024, after the surveyor observation of the right clavicle and right neck wound revealed that resident had muscle weakness, reduced mobility and extreme contracture with right clavicle pressure ulcer and right lateral neck pressure ulcer. Right clavicle was an acute Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer and measured 1.3 cm x 2 cm. x 0.2 cm. Right lateral neck was an acute Stage 3 pressure ulcer and measured 0.9 cm. x 1.3 cm x 0.1 cm. Further review of the wound care consult report dated January 5, 2024, and progress note for Resident R1 dated December 30, 2023, confirmed that the right clavicle wound increased in size and a new wound was developed adjacent to the right clavicle wound. Review of Medication Administration Record for December 2023 and January 2024 revealed that the nursing staff did not administer any care to the right clavicle and right neck area including, wound treatment, wound prevention, and interventions to promote wound healing. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. confirmed that the staff did not notify physician when resident developed right clavicle wound and obtained treatment orders. Employee E2 also confirmed that the staff did not implement interventions for wound prevention and promote wound healing to Resident R1's right neck area. Employee E2 stated staff was expected to initiate an incident report and implement interventions when a new wound was identified which was not completed when Resident R1's wound was first identified with wounds to the right clavicle. Employee E2 also stated Licensed nurse, Employee E4 completed an inaccurate skin assessment on January 3, 2024, which resulted in facility not identifying the new pressure ulcers and resident not receiving treatment to the right neck pressure ulcer areas. The facility failed to develop and implement interventions to promote wound healing and prevent further development of wounds when Resident R1, who was at risk for developing wounds and history of impaired skin integrity, developed new and worsening wounds to his right clavicle which resulted in Resident R1's right clavicle wound worsening in size. Facility failed to provide an accurate skin assessment to identify and provide treatment of wounds which resulted in Resident R1 not receiving care and services to prevent new wound development, promote healing and prevent worsening of existing pressure sores. Immediate jeopardy was called on January 17, 2024 at 9:22 AM and the IJ template was provided to the facility. Facility developed the following approved action plan: 1. Resident (R1) was assessed by the Nurse Practitioner on 1/5/2024. The area identified on Resident (R1's) right clavicle and right lateral neck were determined to be moisture associated skin dermatitis (MASD). Resident (R1) does not have any pressure-related wounds. Treatment orders were obtained and followed per physician orders. 2. On 1/10/2024 the unit managers assessed all residents in the facility. Treatment orders are in place for all wounds. 3. The facility has implemented additional skin assessments for all residents, a minimum of 2 times per week to identify any new alteration of skin integrity. 4. On 1/17/2024 the facility reviewed its abuse/neglect prevention policy. On 1/17/2024 facility leadership started education for all staff on what constitutes neglect. Additional education was provided for nursing staff on residents that are at risk for developing pressure ulcers/pressure injuries remain free from neglect. Training includes notifying the practitioner of newly identified wounds for initiation of wound treatments. The facility will have 80% of the staff educated by 1/18/2024. The remaining staff will be educated prior to the start of their shift. 5. The DON, NHA and/or designee will complete weekly audits for residents at risk for developing pressure ulcers. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. Review of facility documentation revealed that the corrective action plan was immediately initiated on January 17, 2024. On January 18, 2024, wound treatment orders were reviewed for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 - treatment orders in place. Interviewed the following staff regarding PU/PI prevention policy and neglect related to prevention of skin wounds: 12 licensed nurses, employees E9, E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20 and five nurse aides, employees E21, E22, E23, E24, E25. Reviewed Abuse/Neglect prevention education provided for 96% of all staff. Reviewed Wound Management education provided for nursing staff - completed at 96%. Immediate Jeopardy was lifted on January 18, 2024 at 4:05 PM. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, review of facility policies, observations and staff interviews, it was determined that the facility failed to timely assess and consistently provide recommended and/or prescribed treatment and services, to prevent new wound development, promote healing and prevent worsening of existing wounds. This failure resulted in actual harm to Resident R1 who developed new and worsening wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. (Resident R1) Findings include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians [ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. Review of an undated facility policy Wound Treatment Management revealed that 1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Review of an undated facility document Wound Management Program revealed that Based on the comprehensive assessment of a resident, 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 6, 2023, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living to include bed mobility, transfers, and toilet use. The resident's cognition was severely impaired, and the assessment indicated that the resident was unable to complete interview. MDS also indicated that the resident rarely/never makes self-understood and able to understand others. Review of Resident R1's care plan dated December 30, 2023, revealed that the resident was at risk for skin integrity with interventions included body check weekly and as needed, notify physician and family of changes and provide skin care as needed. Observation of tracheostomy care to Resident R1 on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5, was completed. During the observation a pack of gauze was observed on resident's right side of neck under his trach ties and the right neck area. Both employees did not know why the resident had gauze to the right side of the neck. Resident was observed with his neck towards right ride with his chin bone touching the area of the shoulder bone. A request was made to Employee E4 and E5 to open the gauze. Further observation after the gauze was removed from Resident R1's neck revealed that there were two new wounds under the gauze. There was a 2 x 2 boarder dressing on one of the wounds without any medications. There was no date on the dressing. The right clavicle wound appeared to be an area where resident's chin touching the clavicle bone and the neck wounds appeared to be an area where the trach tie touched the skin. It was observed that resident's neck tilted towards the right side and right side of the chin was touching the right clavicle bone. No offloading or pressure reducing measures were observed to the area. Interview with Licensed Nurse, Employee E5 on January 5, 2023, stated she was not aware of resident's two wounds to the right side of the neck. There was no information provided to the shift-to-shift report. Employee E5 stated there was no physician order to provide treatment or check residents wound to the right neck. Review of physician orders for Resident R1 dated July 7, 2023, revealed an order to check for skin integrity around the neck related to trach collar. Review of nursing progress note dated December 21, 2023 revealed that the resident was identified with moisture associated dermatitis to left clavicle which measured 0.5 centimeter (cm) x 1.0 cm. X 0.1 cm. Review of progress note for Resident R1 dated December 26, 2023, revealed a skin documentation that a new skin impairment was observed on residents left chin area which measured 1.5 centimeter (cm) x 2.0 cm. Review of physician orders for Resident R1 dated December 27, 2023, revealed an order to complete full body skin assessment three times a week. New skin impairment should be documented; initiate a treatment document in the nurses' notes. Review of the clinical record revealed that the resident was transfered to the hospital on December 27, 2023, with a repiratory change in condition. The resident was readmitted to the facility on [DATE]. Review of hospital record for Resident R1 dated December 29, 2023, revealed under skin condition that the resident had Stage II pressure ulcer on right and left clavicle, right leg wound and a DTI (Deep Tissue Injury) to the right foot. Review of facility admission assessment dated [DATE], revealed no evidence that the resident's right clavicle wound was indicated on the assessment, or a treatment plan was initiated. Review of a readmission assessment of Resident R1 dated December 29, 2023, revealed that there was no negative finding noted on the skin assessment. Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated right clavicle's wound measuring 1 cm x 1.5 cm, and left clavicle's wound and left chin. All treatment in place. Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle, left clavicle and left chin. All treatment in place. Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound. Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin. Review of a skin assessment completed by Licensed nurse, Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment. Interview with Licensed nurse, Employee E4, on January 5, 2024, at 1:00 p.m. stated she was not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated Licensed nurse, Employee E4 did not conduct a proper skin assessment. Staff were expected to conduct skin assessment and document the findings in the medical record. Any changes to skin integrity should be addressed with the physician for treatment orders. Review of clinical record for Resident R1 revealed no documented evidence that the physician or wound care practitioner was notified about Resident R1's right clavicle wound when it was first documented on December 30, 2023, subsequently after. There were no interventions implemented to promote the wound healing or preventing further skin breakdown. A skin assessment completed on January 5, 2024, at 1:39 p.m., revealed that the right clavicle measured 1.5 cm x 2.3 cm. and right neck wound measured 0.7 cm. x 2 cm. A wound care consult report dated January 5, 2024, after the surveyor observation of the right clavicle and right neck wound revealed that resident had muscle weakness, reduced mobility and extreme contracture with right clavicle pressure ulcer and right lateral neck pressure ulcer. Right clavicle was an acute Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer and measured 1.3 cm x 2 cm. x 0.2 cm. Right lateral neck was an acute Stage 3 pressure ulcer and measured 0.9 cm. x 1.3 cm x 0.1 cm. Further review of the wound care consult report dated January 5, 2024, and progress note for Resident R1 dated December 30, 2023, confirmed that the right clavicle wound increased in size and a new wound was developed adjacent to the right clavicle wound. Review of Medication Administration Record for December 2023 and January 2024 revealed that the nursing staff did not administer any care to the right clavicle and right neck area including, wound treatment, wound prevention, and interventions to promote wound healing. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. confirmed that the staff did not notify physician when resident developed right clavicle wound and obtained treatment orders. Employee E2 also confirmed that the staff did not implement interventions for wound prevention and promote wound healing to Resident R1's right neck area. Employee E2 stated staff was expected to initiate an incident report and implement interventions when a new wound was identified which was not completed when Resident R1's wound was first identified with wounds to the right clavicle. Employee E2 also stated Licensed nurse, Employee E4 completed an inaccurate skin assessment on January 3, 2024, which resulted in facility not identifying the new pressure ulcers and resident not receiving treatment to the right neck pressure ulcer areas. The facility failed to identify, develop and implement interventions to promote wound healing and prevent wound development in accordance to the resident' plan of care, facility polices and professional standards of practice. Facility failed to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who developed new and worsening wounds on his right clavicle and neck. Immediate jeopardy was called on January 17, 2024 at 9:22 AM and the IJ Template was provided to the facility. Facility developed the following approved action plan: 1. Resident (R1) was assessed by the Nurse Practicioner on 1/5/2024. The area identified on Resident (R1's) right clavicle and right lateral neck were determined to be moisture associated skin dermatitis (MASD). Resident (R1) does not have any pressure-related wounds. Treatment orders were obtained and followed per physician orders. 2. On 1/10/2024 the unit managers assessed all residents in the facility. Treatment orders are in place for all wounds. 3. The facility has implemented additional skin assessments for all residents, a minimum of 2 times per week to identify any new alteration of skin integrity. 4. On 1/17/2024 Nurse management team started education for licensed nursing staff on the facility's pressure ulcer prevention policy and procedure including protocols for skin assessments and treatments for new and existing residents. The facility will have 80% of the staff educated by 1/18/2024. The remaining staff will be educated prior to the start of the shift. 5. The DON, NHA and/or designee will complete weekly audits for residents at risk for developing pressure ulcers. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. Review of facility documentation revealed that the corrective action plan was immediately initiated on January 17, 2024. On January 18, 2024, wound treatment orders were reviewed for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 - treatment orders in place. Interviewed the following staff regarding PU/PI prevention policy and neglect related to prevention of skin wounds: 12 licensed nurses, employees E9, E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20 and five nurse aides, employees E21, E22, E23, E24, E25. Reviewed Abuse/Neglect prevention education provided for 96% of all staff. Reviewed Wound Management education provided for nursing staff - completed at 96%. Immediate Jeopardy was lifted on January 18, 2024 at 4:05 PM. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R92 was free from neglect related to a significant medication error. This failure resulted in an Immediate Jeopardy situation for Resident R92 who received 10 units of a fast-acting insulin that was intended for another resident and without proper monitoring following the administration of the insulin for one of 40 residents reviewed. (Resident 92). Findings include: Review of the facility policy entitled, Freedom from Abuse Neglect & Exploitation implementation date November 28, 2017, revealed The purpose of this procedure is to comply with reporting of crimes that may occur at the facility in accordance with section 1150B of the elder Justice Act (EJA). To protect elders with diminished capacity while maximizing their autonomy and help elders recognize the right to be free of abuse, neglect and exploitation. Review of Resident 92's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit, delusional disorder. A review of Resident 92's clinical file confirmed that the resident is non-diabetic and does not have a physician order for insulin. Review of Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severely impaired, and had memory problems. A review of Resident 92's nursing notes dated September 20, 2023, at 7:23 p. m. revealed that License nurse, Supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u (units) of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime. Review of facility documentation submitted to the Department of Health on September 20, 2023, revealed a patient/resident neglect report submitted on September 20, 2023, revealed Resident R92 had a licensed charge nurse Employee E24 mistakenly given 10 units of Humalog. Resident R92 does not received insulin. Resident R92 does not have a diagnosis of diabetes. Resident R92 resides in room [ROOM NUMBER]B and was in room [ROOM NUMBER]A sitting in 320A chair. Licensed nurse, Employee E24 believed that Resident R92 was Resident R107. Employee E24 failed to properly identify Resident R92. Resident R92 was assessed by nursing supervisor Employee E23 no distress was noted. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s (signs and symptoms) of hypoglycemia and recheck her Resident R92 at bedtime Nurse Practitioner, Employee E27 evaluated Resided R92 and noted there was no ill effects noted. Facility determined the investigation to be unsubstantiated for neglect. Review of Resident R92's September 2023's physican orders revealed that on September 20, 2023, order for Accu check, one time only for Glucose (sugar). According to the Medication Administration Report (MAR) on September 20, 2023, at 11:53 p.m. the Accu-check reading was 153. Resident R92 also had a physician order to Monitor resident for s/s of hypoglycemia every shift for 3 days starting on September 20, 2023. Review of Resident R92's September 2023 Medication Administration Record revealed that Accu-check on September 20, 2023, at 10:53 p.m. reading of 153 blood sugar level and at 11:11 p.m. of 130 blood sugar reading. An attempt was made on September 21, 2023, at 4:20 a.m. and Resident R92 refused. Review of nursing notes revealed no documented evidence of continue monitoring of Resident R92 for signs and symptoms of hypoglycemia, and of what type of sugary drink and food was the resident provided with ordered by the physician. On October 18, 2023, at 11:31 a.m. an observation was made of Resident R92 sitting in her room without an identifying wristband. An interview was conducted with nursing supervisor, Employee E4 confirming that Resident R92 refused to wear identifying wristband. Further observation of another resident in the unit (Resident R157) revealed that the resident also did not have an identifying wristband. On October 18, 2023, at 11:39 a.m. an interview was held with Licensed agency nurse, Employee E22 who reported a resident would be identified based on the name sign in the room, census report or asking the supervisor. On October 18, 2023, between 3:40 p.m. and 4:03 p.m. about 19 residents were observed and/or interviewed on the 2nd floor and all of them had an identifying wristband on. On October 18, 2023, at approximately 2:00 p.m. an interview with the Director of Nursing (DON) confirmed that the facility unsubstantiated the neglect investigation related to Resident R92 as it was just a one time occurrence and that the agency nurse made an error. The neglect investigation only included two statements that the Nursing Supervisor, Employee E23 conducted. DON confirmed there was no evidence of proper monitoring following the administration of the insulin. There was no training conducted to all staff on medication administration, and/or identification of residents. An interview held with Nurse supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. revealed nurse Employee E24 failed to follow the five rights of medication administration which resulted in neglect of Resident R92. It further revealed most likely Licensed nurse, Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency to ensure competencies of medication administration. Nursing Supervisor, Employee E23 confirmed there was no evidence of proper monitoring following the administration of the insulin medication. Based on the above mentioned findings an immediate jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:47 p.m. The immediate jeopardy template was provided at the time to the Nursing Home Administrator and an immediate action plan was requested. On October 18, 2023 and 9:57 p.m. the facility provided the following corrective actions: 1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin. The employee responsible for the medication error no longer works in the facility. 2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON and there were no other occurrences of insulin administration to non-diabetic residents. 3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that the resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system. In the event of a medication error the facility will notify the physician and follow the physicians' order related to the type of medication error. The resident will be on 24-hour report and monitored based on the physician recommendation. The facility will obtain parameters for specific monitoring instructions for the medication error. The nurse will document monitoring in nursing notes. 4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Staff will be required to sing off on the training prior to their first shift worked in the facility. 5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. The implementation of the action plan was confirmed on October 18, 2023, at 10:12 p.m. Interviews were conducted with facility nursing staff on October 18, and 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. On October 19, 2023, at 4:57 p.m. the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free of medication errors for one of 40 residents reviewed (Resident R92). This failure resulted in an Immediate Jeopardy situation for Resident R92 who was administered 10 units of a fast- acting insulin medication that was intended for another resident. Findings include: Review of the facility policy entitled, Administering Medications date May 2016, revealed Medication are administered as prescribed in accordance with manufactures' specifications, good nursing principles and practices and only by person legally authorized to do so, Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. It further states under bulletin 10. Resident are identified before medication is administered using at least two resident identifiers. Methods of identification may include a. check identification band 2. Check photograph attached to medication record 3. Verify resident identification with other nursing care center personnel note: the resident's room number or physical location is not used as an identifier. Review of Resident R92's clinical record revealed an admitted [DATE], with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit and delusional disorder. Review of the Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severe cognitive impairment. A BIMS (Brief Interview of Mental Status) score was not documented due to resident being rarely/never understood. A review of Resident R92's September 2023 physician orders did not list the resident with a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and no orders for insulin. A review of a nursing note dated September 20, 2023, at 7:23 p.m. revealed that License nurse supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical administration record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime. Review of facility documentation revealed a witness statement, dated September 20, 2023, by License nurse supervisor, Employee E23 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. noted that she was asked by 3 East charge nurse, Employee E25 to come to the floor and assess an issue. Upon arrival was told by staff that 3 south nurse had accidentally given resident 10 units of Humalog. When asked what happened, 3 south nurse, Employee E24 stated she saw resident sitting in 320 A chair and thought that was her room. Employee E24 stated the resident didn't property answer, aide/CNA (nurse aide), Employee E26 nearby didn't say anything and that the resident in 320 B (Resident 108) just said resident takes meds whole .(Resident R92) noted w/Alzheimer + confusion and wonders and sits in different rooms. When asked did the 3 South charge nurse, Employee E24 check resident's armband or picture on the EMAR, she stated no and was just going by the census sheet. MD made aware and ordered resident be given sugary snacks + drinks, monitor for s/s of hypoglycemia + accu-checks at bedtime. RP made aware and just wants to be updated with any changes. Resident given snacks and drinks. Review of facility documentation revealed a witness statement, dated September 20, 2023, completed by License nurse supervisor, Employee E23 regarding license nurse, Employee E24 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed charge nurse gave Resident R92 10 units of Humalog accidentally stating that because Resident R92 was sitting in 320A chair & room, she thought it was Resident R107. License nurse, Employee E24 then said that while she was talking to Resident R92, nurse aide, Employee E26, who was nearby did not say she was talking to the wrong resident and that Resident R108 said Resident R92 takes her meds whole. Resident R92 has Alzheimer and confusion and wonders from room and wouldn't be aware enough to say anything. When nursing supervisor, Employee E23 told the charge nurse, Employee E24, she became irritable stating that at other facilities, residents are not allowed to sit in other resident's room. When asked did she check the resident's armband or picture on the EMAR she said no, she was just getting off the census sheet. She then tried to accuse/put blame on Employee E26, nurse aide for not saying anything and of Resident R108. License Nurse, Employee E24 came to the supervisor office and dropped the keys off and stating she wasn't and isn't in the right mental status to work . and then left the facility. An interview held with Nurse Supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. confirmed the above-mentioned statements. Nursing Supervisor, Employee E23 stated that she received a call approximately at 4:30 p.m. on September 20, 2023, from charge nurse, Employee E25 making her aware that there was issue with Resident R92. Upon arrival Employee E23 learned that Employee E24 who was an agency license nurse assigned to Resident's 92's accidentally administered 10 units of Humalog to Resident R92 who was non-diabetic resident which should have been administered to Resident R107. Resident R92 was sitting in room [ROOM NUMBER]A chair which belong to Resident R107. Employee E24 failed to check resident's armband, Electronic Medical Administration Record (EMAR) or picture and depended on census report to identify the Resident R92. Nurse Supervisor, Employee E23 further revealed mostly likely was Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency. Nursing Supervisor, Employee E24 told Employee E25 make sugary nourishment to keep Resident R92's sugar elevated and notified the physician. Physician gave an order to give juices, snacks and monitor her blood sugar. Nursing Supervisor, Employee E23 assessed the Resident R92 there was no signs of hyperglycemia or distress. Nurse Practitioner, Employee E27 evaluated Resident R92 this same night at approximately 9:00 p.m. Employee E23 did not write a witness statement nor made herself available after the incident to be part of the investigation. Nursing Supervisor, Employee E23 wrote the above witness statement regarding his encounter with Employee E24. A telephone interview was held with License nurse, Employee E25 on October 18, 2023, at 6:16 p.m. who worked on September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed that nurse aide, Employee E26 approached her approximately 4:15 p.m. on October 20, 2023, and notified her that license nurse, Employee E24 accidently gave insulin to Resident R92 who is non-diabetic. Licensed nurse, Employee 25 immediately notified supervisor Employee E26 and went to assess the situation. Upon her arrival Resident R92 was as her normal self, sitting with her hands crossed her chest with no distress. Licensed nurse, Employee E24 notified Licensed nurse, Employee E25 that she measures her blood sugar before she gave an insulin, and it was 144. Licensed nurse, Employee E24 further reported that she did not verify Resident's R92 identity per the medication policy but only used her census sheet. Licensed nurse, Employee E25 checked Resident's R92's blood sugar level and to her best memory it was 80. Resident R92 had dinner that night and sugary snacks and drinks were provided such as orange juice and peanut butter sandwich to elevate her sugar level. Resident R92 at any point was not in any distress during the night. At approximately 6:00 p.m. Licensed nurse, Employee E24 left her shift and supervisor was notified. A telephone interview was held with nurse aide, Employee E26 on October 18, 2023, at 8:56 p.m. who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed she was not in the room when insulin was administered to Resident R92. Employee E26 walked into room [ROOM NUMBER] and observed Resident R92 sitting in a 320A room's chair and License nurse, Employee E24 with a needle in her hand. Nurse aide, Employee E26, questioned if Licensed nurse, Employee E24 gave an insulin to Resident R92. Licensed nurse, Employee E24, responded, no I gave it to Resident 107. Nurse aide, Employee E26, then told Licensed nurse, Employee E24 that was not Resident R107 but Resident R92. Employee E26, immediately went to another nurse, Employee E25 who was covering 3rd floor South Unit and reported that Resident R92 was given insulin and Resident R92 was a non-diabetic resident. Licensed Nurse, Employee E25 immediately notified the nursing supervisor Employee E23 who came to assess the situation. On October 18, 2023, at 7:25 p.m. an attempt was made to conduct a phone interview with license nurse, Employee E24 whose number was not working. This same time an interview with Director of Nursing revealed that a staffing agency for whom nurse, Employee E24 was employed at was notified and Employee E24 was placed on the do not return list and not permitted at the facility moving forward. Review of Resident R92's clinical record revealed that physician orders obtained on October 20, 2023 for a one time Accu-Check for glucose level and to monitor the resident for signs and symptoms of hypoglycemia every shift for 3 days starting on September 20, 2023. Review of Resident R92's September 2022, Medication Administration Record revealed that on September 20, 2023, at 11:53 p.m. the one-time Accu-check reading was 153 blood glucose (sugar) reading. Based on the above mentioned findings, an Immediate Jeopardy was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:45 p.m. The Immediate Jeopardy template was provided to the Nursing Home Administrator and an immediate action plan was requested at the time noted above. On October 19, 2023, at 9:57 p.m. the facility provided the following corrective action plan: 1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin. 2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON (Director of Nursing) and there were no other occurrences of insulin administration to non-diabetic residents. 3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that they resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system. 4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Agency staff will be required to sign off on the training prior to their first shift worked in the facility. 5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. The implementation of the action plan was verified on October 18, 2023 at 10:12 p.m. Interviews were conducted with nursing staff on October 18, 2023 and October 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The Immediate Jeopardy was lifted on October 19, 2023, at 4:57 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing Services

Based on observations, review of clinical record, review of hospital record, resident and staff interviews and policy review, it was determined that the facility failed to monitor residents for the possession of unprescribed substances and provide behavioral health services including the development of behavioral contracts for two of 38 residents reviewed with substance abuse disorder (Resident R141 and Resident R154). This failure resulted in Resident R154 obtaining and providing an unprescribed narcotic medication to Resident R141 and both residents receiving emergency medical care for narcotic overdosing at the facility. This failure placed Residents R141 and R154 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: A review of the policy titled Safety for Residents with Substance Use Disorder dated October 2022, revealed that it was the intent of this policy to create an environment free of accident hazards for residents with a history of substance use disorder. The policy indicated that a resident with substance use disorder would be assessed for leaving the facility and using illegal or unprescribed drugs during the leave. A resident with substance use disorder would have a care plan implemented to include increased monitoring and supervision to include any visitors the resident may have. Continued review of the facility's policy stated that staff were expected to assess the resident for substance use (illegal drugs, unprescribed medication or alcohol use/abuse). The staff were to recognize if the resident was leaving the facility frequently with or without facility knowledge. In accordance with this policy the facility was responsible for preventing substance use for each resident by providing behavioral health substance use treatment services, medication-assistance treatment, alcoholic/narcotics anonymous meetings for the resident and family, increase monitoring and supervision of the resident and address goals related to discharge planning as needed. Review of the policy titled Behavioral Health Services dated October 2022, revealed the purpose of this policy was to ensure that all residents received necessary behavioral health services to assist residents to attain and maintain their highest level of mental and psychosocial functioning. This policy indicated that the facility was to ensure behavioral health care services were person centered and reflected the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. A review of the policy titled Behavioral Contracts dated October 2022, revealed that the purpose of this policy was to identify residents who exhibit behaviors which could endanger themselves, others or staff and to develop a behavioral health contract to ensure that the resident was receiving appropriate services and interventions to meet their needs. In accordance with this policy, residents with substance use disorder would have a contract to address inspections of the resident's possessions if there was reasonable suspicion of illegal, unprescribed drugs, alcohol, weapons or unauthorized items that could endanger the resident or others. This policy also indicated that drug testing would be considered if suspension of illegal drug use could adversely affect the resident's condition, restricted or supervised visiting would be necessary if the visits were deemed dangerous to the resident, other residents or staff, increased monitoring and supervision in the facility would be appropriate to maintain the health and safety of the resident suspected of substance use and the protection of the other residents from the substance user/abuser. Review of Resident R141's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of substance abuse disorder. Review of Resident R141's Minimum Data Set (MDS- assessment of resident's care needs) dated January 23, 2023, revealed that the resident was cognitively intact. This assessment also indicated that this resident was independent with locomotion in the bedroom and on the nursing unit; with no upper or lower body extremity impairments. Review of Resident R141's nursing note dated January 23, 2023, at 2:59 p.m, revealed Resident noted to be more sleepier than normal. Resident unable to be woken up easily. Resident admitted to taking medication. Resident states she brought a Percocet 30 mg (milligrams). Resident was able to be woken up after hard sternum rubs. Resident was encourage to go to the hospital. Resident refused to go to the hospital. Review of nursing note dated January 23, 2023, at 3:28 p.m. noted that the resident assisted back to bed for comfort. Resident R141's vital signs were elevated with a blood pressure of 155/85 (normal blood pressure is 120/80) and heart rate was 112 (normal pulse rate is 60-100). Review of Resident R141's care plan revealed that there was no care plan developed for substance abuse or a behavioral contract as indicated in the facility's policy. Interviews conducted with Nursing Home Administrator and Director of Nursing on March 28, 2023, at 1:00 p.m. confirmed that there was no investigation conducted by the facility related to how the resident was able to obtain the narcotic medication Percocet. Further, it was confirmed during interview that there was no person centered care planning or behavioral contract established with Resident R141 to protect the resident from substance use and abuse. Review of Resident R141's nursing documentation dated March 16, 2023, at 7:30 p.m. by Licensed nurse, Employee E31 revealed that approximately at 6:40 p.m. Employee E31 was called to assess Resident R141. The nursing supervisor was informed by the charge nurse that Resident R154 had told the charge nurse that Resident R141 was in his room and had overdose on something he gave her. Upon assessing resident, resident was noted with slow shallow breathing, cold and clammy skin and slow pulse. When asking [Resident R154] what happened, he stated she came to him because she was in pain and according to [Resident R154] gave her some narcotics including Percocet 30 mg and then began to become unresponsive. 2 doses of Narcan given to resident via alternating nostrils. 911 (Emergency Medical Services) called for transportation to ER (emergency room ) for evaluation. DON/MD (medical doctor) made aware. Resident became more alert and responsive appx. 5-10 minutes after Narcan administration. Continued review of nursing documentation revealed a nursing note dated March 16, 2023, at 9:02 p.m. which noted that Resident R154 came to the nurse to report that Resident R141 overdose in his room. Resident R154 was asked what Resident R141 had taken and how did she get it. Resident R154 said she asked him to get her some Heroin and Oxycodone which he did when he went out on a leave of absence. A review of Resident R141's hospital record dated March 16, 2023, revealed that this resident was treated for an opioid overdose. The hospital record indicated that Resident R141 was evaluated after opioid overdose and that emergency care with Narcan was administered to Resident R141. The hospital emergency department staff discharged Resident R141 on March 16, 2023; to return to the nursing facility for further observation and monitoring. Review of Resident R141's nursing documentation dated March 17, 2023, revealed that the nursing staff witnessed Resident R141 demanding Resident R154 to give her that black plastic bag. The nursing staff member asked to see what was in the black plastic bag however, Residents R141 and Resident R154 would not allow the licensed nurse to visualize the contents of this bag. Review of Resident R141's nursing note dated March 22, 2023, revealed that during the 11-7 shift a licensed nurse found Resident R141 vaping. When the licensed nurse questioned the resident about what was happening, Resident R141 denied using the vape. The nursing assistant found the vaping devise on the floor in front of Resident R141's bed. The nursing documentation indicated that the drug paraphernalia was turned into the supervisor on March 22, 2023. Interview with the Director of Nursing, on March 28, 2023 at 1:30 p.m. confirmed that there was no investigation into how the resident was able to have access to this vaping device. The Director of Nursing also confirmed that there was no investigation of the vaping device that was turned in to the supervisor on March 22, 2023. Observation and interview with Resident R141 on March 28, 2023, at 11:00 a.m. revealed that the resident utilized a wheelchair for mobility. Resident R141 confirmed during interview using a vaping device and that she prefers to use marijuana with the device, when she can get a hold of this drug. Interview with the Director of Nursing on March 28, 2023, at 2:00 p.m., confirmed the event that took place on March 16, 2023, between Resident R154 and Resident R141. The Director of Nursing reported that both of these residents have a significant history for substance use disorder. The Director of Nursing also reported that since Resident R141 and Resident R154 have been associating with each other both residents have relapsed into using unprescribed medications and other narcotics. Further interview with the Director of Nursing revealed that Resident R154 had been obtaining unprescribed medications from individuals at the outside treatment clinic that he attended daily. According to the Director of Nursing, Resident R154 was being supplied with unprescribed drugs from friends that take him out on outings as well. Review of clinical record revealed that R154 was admitted to the facility on [DATE], with diagnoses of Psychoactive Substance Abuse, Alcohol Abuse, Major Depressive Disorder, Rhabdomyolysis, Osteoarthritis, Hypertension. Review of Resident R154's quarterly MDS dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 15 suggesting that Resident R154 was cognitively intact. Review of Resident R154's May 2022 physician orders revealed an order dated May 31, 2022, may have therapeutic leave of absence. Review of Resident R154's substance abuse care plan initiated on February 9, 2022, revealed that the resident will not be under the influence of alcohol or illicit substances. The care plan interventions included to encourage expression of feelings, assist the resident to recognize what triggers behaviors and develop constructive ways of dealing with these behaviors, provide diversional activities as needed, provide factual information about substance abuse and correct misinterpretations. provide information/access to groups (nursing assistants/activity assistants) as needed, provide therapeutic sessions that address addiction and associated behaviors, and teach stress management techniques and coping strategies. Review of Resident R154's care plan initiated on February 9, 2022, for potential for alteration in activities indicated that Resident R154 attends NA/AA (Narcotics Anonymous/Alcoholic Anonymous) meetings weekly. Review of Resident R154's nursing notes dated December 21, 2022, revealed that Resident R154 tested positive for marijuana. Further, due to the positive test for marijuana, Resident R154 was no longer allowed to have his methadone administered in the facility. Resident R154 had to go to the methadone clinic every day to receive his daily methadone dose with an escort for three months (until March 21, 2023). Review of Resident R154's nursing note dated January 24, 2023, at 12:03 a.m. revealed that at approximately 5:45 p.m. nurse was alerted by CNA (nurse aide) that resident was slumped over on his wheelchair and has not touched dinner tray. This nurse came into room to assess resident, HR (heart rate) 50 RR (respirations) 16 Sp02 (oxygen level) 94% at room air. Nurse was unable to obtain B/P (blood pressure). Resident R154 unable to be aroused. made UM (unit manager) aware. UM attempted to arouse resident also noted ineffective. Nursing supv. (supervisor) made aware, resident responding briefly to nsg (nursing) supv. Resident appeared to be suffering from overdose recommended that Narcan be admin (administered). 2 doses of Narcan adm. 3 minutes apart 1 in each nostril. Resident R154 was sent to local hospital via 911 (Emergency Medical Services). Resident R154 returned to the facility on [DATE]. Review of hospital emergency department discharge notes dated January 23, 2023, revealed a diagnosis of Opioid dependence, Opioid withdrawal, and Opioid overdose. Further review of Resident R154's documentation dated January 24, 2023 at 7:55 p.m. revealed that Nursing Home Administrator (NHA) and Director of Nursing (DON) interviewed Resident R154 and Resident R154 admitted to NHA and DON that he bought a pill from someone outside of the clinic while getting his methadone treatment. Review of Resident R154's nursing note dated March 16, 2023, at 8:35 p.m. confirmed that Resident R154 admitted that he gave Resident R141 30 milligrams of Percocet because Resident R141 kept asking him for it. Continued review of Resident R154's nursing notes dated March 16, 2023, revealed that at 9:46 p.m. the resident was observed with signs and symptoms of overdose. Resident R154 was observed to be very lethargic and sleeping (nodding) while wheeling himself in the hallway. Resident R154 was observed to periodically stop and sleep off and required hard tapping to get him up. Resident R154 appeared to be breathing normally with vital signs as follow: Blood pressure-142/90, Pulse-85, Respiration-20. Resident R154 was offered a dose of Naloxone (Narcan), but he refused. Further, on March 17, 2023, at 4:41 a.m., Resident R154 was observed giving Resident R141 items in black plastic bag that he would not allow nurse to see. Resident R154 was agitated during the shift and was cursing at CNA (nurse aide) assigned to him. Resident R154 was observed to be very lethargic and sleeping very deeply slumped over in wheelchair in room. Every two hourly checks were performed. Resident R154 continued to require hard tapping to arouse. Review of Social Services note dated March 17, 2023, at 12:56 p.m. revealed that Social Service Director, Employee E14 met with resident at 7:00 a.m. to educate him on the dangers of brining drugs into the facility and giving them to other residents. Resident understands and agrees. SSD (Social Service Director) and Unit Manager asked resident if they could perform room search. Resident agrees. SSD and Unit Manger searched resident's room. Marijuana vape pen found. No other drug paraphernalia found . SSD called 911 (Emergency Medical Services) to report drug overdose. Further review of Resident R154's nursing notes revealed that on March 17, 2023, at 3:00 p.m. NHA and DON spoke to Resident R154 regarding bringing in drugs to the facility and giving them to Resident R141 causing Resident R141 to overdose which resulted in hospitalization . Resident R154 refused to get help for drug rehabilitation. DON informed Resident R154 that he will not be going to the methadone clinic daily and his bottles will be picked up and administered at facility. Further, Resident R154 was informed that the clinic was reducing his methadone daily dose from 180 milligrams to 162 milligrams. Review of Resident R154's physician's orders dated March 17, 2023, revealed an order for Resident cannot go out on leave of absence. Review of Resident R154's care plan revealed that a care plan for the potential for opioid overdose was not initiated until March 17, 2023. Further, Resident R154's behavior of supplying drug to another resident was not addressed in the care plan until on March 29, 2023 Review of the NA/AA (Narcotics Anonymous/Alcoholic Anonymous) meeting (via zoom meeting) list revealed that there was only one meeting in February 2023 and two meetings in March 2023. Further, Resident R154 did not attend the meeting dated February 8, 2023, attended only half of the meeting on March 22, 2023, and did not attend the meeting on March 29, 2023. Further review of Resident R154's clinical record revealed that there was no documented evidence that resident R154 was monitored after returning from a methadone clinic for the pocession of unprescribed medications. Further, there was no evidence that toxicology tests were offered/conducted on Resident R154 after he was observed exhibiting signs and symptoms of drug use on January 23, 2023, February 9, 2023, and March 16, 2023. Interview with Resident R154 conducted on March 29, 2023, at 1:28 p.m. confirmed that he got the pills outside of the methadone clinical but did not provide details regarding the incident. Review of Facility transportation log for January, February and March revealed that on January 2, 2023, January 14, 2023, January 15, 2023, January 29, 2023, February 12, 2023, February 18, 2023, February 26, 2023, February 28, 2023, and March 12, 2023, Resident R154 went to the methadone clinic without an escort. Interviews with Facility Administrator and Director of Nursing conducted on March 28, 2023, at 1:00 p.m. confirmed that resident admitted to them that he purchased the pills from someone at the methadone clinic. Further interview with NHA and DON also confirmed that there was no behavioral contract established with Resident R154 to address both his substance use and giving unprescribed narcotic to Resident R141. Further interview with DON confirmed that the substance abuse care plan for Resident R154 was not updated and did not have new interventions to address Resident R154's positive for marijuana on December 21, 2022, and his bringing unprescribed medication into the facility and using it on January 23, 2023. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator on March 28, 2023, at 3:41 p.m. for the failure to identify and intervene with care and services to meet the needs of two residents with a history of substance abuse disorder. The two residents received emergency care for narcotic overdosing at the facility. The facility also failed to prevent access to unprescribed narcotics for these residents and other residents of the facility. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on March 28, 2023, at 3:41 p.m. On March 28, 2023, at 7:45 p.m., the facility's action plan was accepted. The action plan included the following: - On March 17, 2023, [Resident R154] was moved to the 4th floor and [Resident R141] was moved closer to the nursing station on the West wing. The reason for the move was to separate and to increase the visibility of [Resident 141]. -On March 21, 2023, Cheltenham Nursing and Rehab reviewed all resident's electronic health record and identified a list of residents with a diagnosis of substance use disorder. -On December 21, 2022, Cheltenham Nursing and Rehab conducted education for the facility on CMS's implementation of Phase 3, dealing with Behavioral Health and Substance Use Disorder. -On January 26, 2023, during QAPI (Quality Assurance Improvement Plan), Cheltenham Nursing and Rehab reviewed and approved new policies and procedures for residents with mental health diagnosis and substance use disorder. -Cheltenham Nursing and Rehab Center has implemented various interventions to prevent access to unprescribed medications. These interventions include, with resident permission a search of belongings brought into the facility after an outing or delivery, search of the resident's room, non-approval of leave of absence request, securing windows of resident rooms with ground level access. The facility sends and escorts on trips to the methadone clinic to limit access to narcotics. The facility has also implemented NA (Narcotic Anonymous) and AA (Alcoholic Anonymous) meetings for identified residents. -Interventions specific to [Resident R154] include January 24, 2023, facility spoke with the Methadone clinic to inform the clinic of the drug transaction that occurred at their location. On January 24, 2023, Maintenance team secured the window outside of [Resident R154's] room to eliminate the possibility of narcotics being supplied through his window. On January 24, 2023, Resident agreed to allow the staff to search his belongings when he returns from an outing or has a delivery sent to the facility. On January 24, 2023, [Resident R154] informed the NHA that he wanted to start attending NA meetings again. On March 17, 2023, NHA and DON spoke with the Medical Director of the Methadone Clinic and got approval for a facility staff member to pick-up take home bottles of Methadone in order to limit his ability to have access to obtain narcotics. On March 17, 2023, the Medical Director of Cheltenham wrote an order to restrict [Resident R154] from going on leave of absence and outings. The Medical Director deemed [Resident R154] unsafe to go into the community alone. On March 20, 2023, the facility sent a referral to [Alcohol and Drug Rehabilitation Facility] -On March 28, 2023, the facility started training facility staff on identifying residents with possible drug abuse history and developing interventions to prevent residents access to unprescribed drugs. The facility will have 80% of the staff educated within 24 hours. The remaining staff will be educated prior to the start of their shift. Staff will be required to sign the education material acknowledging the understanding of the training provided to them. -The DON, NHA and/or designee will complete weekly audits of new admissions and current residents with a history of substance use for three months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. Interviews were conducted with facility staff on March 29, 2023, between 8:00 a.m. and 4:30 p.m., to verify the implementation of the Action Plan. Facility staff were able to verbalize how they would identify residents with substance abuse disorder and implement interventions to prevent these residents from access to unprescribed drugs. A review was conducted of the education provided to the facility staff related to behavioral health care and services for residents with substance abuse disorder and the prevention of these residents from accessing unprescribed drugs. A review of resident's care plans confirmed that residents care plans were updated to include that close monitoring and supervision was added to prevent access to unprescribed medications and promote a safe environment free of accident hazards. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on March 29, 2023 at 5:27 p.m. 28 Pa Code 201.14 (a) Responsibility of licensee 28 Pa Code 201.18 (a) Management 28 Pa Code 201.18 (b) (1) Management 28 Pa Code 201.18 (b) (3) Management 28 Pa Code 201.18 (d) Management 28 Pa Code 211.10 (a) Resident Care policies 28 Pa Code 211.10 (d) Resident Care Policies 28 Pa Code 211.12.(c) Nursing Services 28 Pa Code 211.12 (d) (3) Nursing Services 28 Pa Code 211.12 (d) (5) Nursing Services

Based on clinical record review, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to adequately supervise one of ten residents reviewed (Resident R1), resulting in Resident R1 eloping from a medical appointment. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled, Elopement Management Program, revealed that elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and /or other medical complications, drowning, or being struck by a motor vehicle. Further review revealed, The facility will provide care and services to identify risk factors for elopement, implement appropriate care plan interventions, conduct elopement drills, and follow a missing resident action plan, should an elopement occur. We will provide a safe environment for our residents and attempt to prevent elopements of those residents identified as being at risk. Review of Resident R1's admission documentation revealed that the resident was admitted to the facility on [DATE]. Review of Resident R1's admission MDS (Minimum Data Set- a mandatory periodic resident assessment tool) dated December 26, 2022, revealed that the resident was admitted to the facility with the diagnoses of schizophrenia (mental disease characterized by loss of reality contact, delusions, hallucinations and /or feelings of persecution), seizure disorder (neurological disorder that cause brief episodes of spasm, unresponsiveness), hypertension (elevated/high blood pressure), hepatitis C (a viral infection that causes liver inflammation, sometimes leading to serious liver damage), bipolar disorder (is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), alcohol use disorder, acute kidney disease, altered mental status, and traumatic brain injury. Continued review revealed that the resident had a BIMS (Brief Interview for mental status) score of three, which indicated that the resident was severely cognitively impaired. Review of Resident R1's care plan, initiated on January 7, 2023, revealed Resident R1 was at risk for injury related to elopement/wandering behaviors, expresses intent to leave facility and impaired cognition. Review of Resident R1's nursing notes dated December 28, 2022, at 2:19 p.m. indicated that the nurse was informed by the admission director that resident was noted waiting by the front door twice and constantly wandering the 1st floor unit. Social service director made aware and redirected resident to come back to the first floor. Resident refused to wear a wander guard (device place on either the resident's wrist or the ankle which then electronically locks outside doors when the resident approaches the door). Will continue to monitor. Review of the incident documentation dated February 8, 2023, revealed that on February 7, 2023, Resident was transferred with escort for Neurology appointment. Unit Manager was notified by escort that resident left the medical office while escort had gone for less than five minutes to use bathroom. Escort went to front desk at appointment when they arrived and asked for key to bathroom and asked two receptionists to watch resident for he is a flight risk and the two at the desk said okay. Upon return he was not in waiting room. Escort asked where he was and they said he walked out. She stated you were supposed to be watching him. Escort ran to front lobby and asked security if they saw resident leave and she showed a picture of resident. They said he walked out a couple minutes ago. She asked which way he went and they didn't' know. She called facility and was instructed to call 911, which she did . Escort called family and they said he has done this previously and he will go to his bank to withdraw money. Escort walked to [bank] and she showed a picture and he was there and he withdrew money. The security at the bank said what direction he left and escort walked that way and went to [supermarket] that she came upon because they sell alcohol. It was confirmed that he was in there. We received address from his previous apartment and NHA (Nursing Home Administrator) and one of the search cars drove there and resident was not there at 4:30 p.m. police officer arrived at [facility] .Admission was called by residents old landlord stating he was at apartment. Continued review of the incident documentation stated that the Nursing Home Administrator went back to the resident's apartment but 9-1-1 (Emergency Medical Services) never arrived. The Nursing Home Administrator called the Mobile Crisis Intervention unit. Upon assessment by the mobile crisis team the resident was 302 (involuntary commitment into a mental health institution). Interview on February 21, 2023, at 12:10 p.m. with Employee E3, unit clerk, revealed that the staff escorted [Resident R1] to Neurology Appointment on February 7, 2023. Employee E3 stated, I checked resident in on a kiosk at 9:41 a.m. and asked two receptionists if I could use the bathroom. I also asked if they could watch the resident because he is a flight risk. I was given a key for bathroom located just outside of the office. I was gone less than five minutes. I asked the receptionists 'Where is the resident?' they stated that he just walked out. Employee E3 continued, I have worked here almost ten years. I schedule the appointments for residents. I go out on appointments almost daily. I don't usually use the restroom but I did that day. I ran down the steps and showed security guard resident's picture and asked security if they saw this person. Security guard stated that resident just left. I searched the perimeter of the outside of the office building and continued my search down [an avenue located in the center of a major city]. Security guard stated the surveillance video showed resident exiting the building at 9:51 a.m. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator on February 21, 2023, at 1:57 p.m. for failure to provide adequate supervision to a resident assessed as elopement risk during a medical appointment. The resident was missing from February 7, 2023. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on February 21, 2023 at 1:57 p.m. On February 21, 2022, at 6:31 p.m. the facility's action plan was accepted. The action plan included the following: 1. On 2/21/2023 the facility revised its elopement policy related to the supervision of residents during appointments outside of the facility. The revision reads as follows: Resident's going on outside appointments that require an escort. The facility will provide adequate supervision of the Resident(s) during appointments outside of the facility. If a Resident is going out for an appointment and accompanied by an Escort, the Escort is not to leave the Resident at any time unless the provider asks the Escort to leave. 2. On 2/21/2023 Nurse management staff reviewed and audited all resident care plans of Residents at risk for elopement. Care plans for Residents identified as elopement risks were revised to include the need for constant supervision while attending an outside medical appointment. 3. On 2/21/2023, the Staff Development Coordinator began education for present staff. The education included the revision made to the facility's elopement policy, related to supervision of residents during outside appointments. Remaining staff will be educated prior to the start of their next shift until we reach 100%. Education for 40% of staff will be completed within 24 hours and 85% of staff will be completed within 48 hours. Staff will be required to sign the educational material presented acknowledging that they understand the information provided to them. The Facility's revised elopement policy will be provided to each contracted agency employee prior to receiving an assignment. A signed copy of the facility's revised elopement policy will be maintained in employees files. 4. The Director of Nursing, NHA and /or Designee will perform weekly audits on all new admissions and Residents identified as elopement risks for three months. The results of the audits will be reviewed and revised by the QAPI committee which meets monthly. Interviews were conducted with facility staff on February 22, 2023, between 2:30 p.m. and 4:00 p.m. to verify the implementation of the Action Plan. Facility staff were able to verbalize what they would do if they were assigned to accompany a resident to a medical appointment and what their responsibilities were in case they themselves had an emergent situation. A review was conducted of the education provided to facility related to resident elopement. A review of resident's care plans confirmed that resident's care plans were updated to include that a resident was not to be left unattended during appointments. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on February 22, 2023, at 5:00 p.m. 28 Pa Code 201.14 (a) Responsibility of licensee 28 Pa Code 201.18 (a) Management 28 Pa Code 201.18 (b) (1) Management 28 Pa Code 201.18 (b) (3) Management 28 Pa Code 201.18 (d) Management 28 Pa Code 211.10 (a) Resident Care policies 28 Pa Code 211.10 (d) Resident Care Policies 28 Pa Code 211.12.(c) Nursing Services 28 Pa Code 211.12 (d) (3) Nursing Services 28 Pa Code 211.12 (d) (5) Nursing Services

Based on clinical record review and staff interview, it was determined that the facility did not ensure that physician's orders were followed or clarified regarding a diet order which was improperly transcribed as a regular texture which resulted in actual harm to one out of four residents reviewed (Resident R1), who after a choking incident requiring CPR (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating) and intubation (the insertion of a tube into a patient's body allowing air into the lungs) was transferred to the hospital with admission to the intensive care unit on a ventilator (device used medically to support breathing) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Review of the clinical record for Resident R1 revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for Resident R1 revealed that she was sent out to the hospital on [DATE], for a change in mental status. A review of active orders as of [DATE], revealed a [DATE], order for a regular diet, pureed texture. Further review revealed that Resident R1 returned from the hospital on [DATE], with a physician's order for a No Added Salt, Regular Texture Diet. Review of Resident R1's hospital discharge clinical summary dated [DATE], revealed Diet Instructions for a pureed house diet with aspiration precautions, feed, and maximum assistance with meals. Review of information submitted by the facility on [DATE] related to a choking incident which occurred at 5:30 p.m. on [DATE], revealed that Resident R1 had returned from a hospital stay on Friday, [DATE]. Her orders were entered into the electronic medical record by the nursing supervisor who entered an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1 ate a regular diet for breakfast and lunch on Saturday, [DATE]. Her supper tray was brought to her room and placed on a bedside table next to her bed. At 5:30 p.m. the CNA was with Resident R1's roommate and the LPN came in to administer medication when they both noticed Resident R1 reaching over putting food into her mouth and she began to have trouble breathing. They sat the resident up and began to do the [MEDICATION(S)] maneuver with no success. The resident was gasping for breath making raspy sounds. They called for the nursing supervisor. They attempted to suction the resident with no success. The supervisor came, called a code, and called 911. The resident was turning blue with a weak pulse, and CPR was started with an AED (automated external defibrillator - a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, to help the heart re-establish an effective rhythm) on the resident which indicated no shock, continue CPR. The ambulance arrived at 6:12 p.m. and when attempting intubation extracted a one-inch piece of meat. EMS intubated the resident, placed an IV line, administered [MEDICATION(S)] and transported the resident to the emergency department at 6:29 p.m. The [DATE], update to the submitted information stated that the resident was presently in the ICU on a ventilator with a poor prognosis. An interview was conducted with Employee E7, LPN, on [DATE], at approximately 1:00 p.m. confirmed the above account of the [DATE], choking incident with Resident R1. And also revealed that she did not know who brought the meal tray to Resident R1's bedside. She said the tray was put at the bedside and not in front of the resident. When asked if she questioned why the resident was receiving a regular diet when the resident had been on a pureed diet before going out to the hospital, she said that the tray was left at bedside, and that if they had presented the tray to the resident they may have noticed the discrepancy. A review of the menu for the supper meal on [DATE], revealed that beef stroganoff was on the menu. An interview with Employee E6, Dietary Supervisor, on [DATE], at approximately 12:00 p.m. confirmed that the regular diets received beef stroganoff for supper on [DATE], and that he had cooked this meal. When asked about the beef stroganoff he said the regular diets got the chunks of beef. A review of the incident report for the [DATE], choking incident revealed witness statements from staff who were present during the event. Review of an interview conducted by the DON and NHA, revealed that Employee E10, the nursing supervisor, admitted that she hit the wrong order when she renewed an old order for a regular house diet, and when asked further, she said she did not pay attention to detail. Review of statements from both CNAs and both LPNs present during the incident confirm the events outlined in the event report. A review of Employee E10's employee file revealed a document, Nursing Supervisors Duties and Responsibilities which she had signed on [DATE]. The document stated that as supervisor, she was to check orders from physicians or consultants in the facility that day, and check on any new or readmissions from previous shift to see that all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 1:15 p.m. confirmed that the nursing supervisor, Employee E10, had entered the wrong diet order when Resident R1 was readmitted from a hospital stay on [DATE], and that this had led to the resident receiving regular beef stroganoff which had caused the resident to choke during supper on [DATE]. The facility failed to verify that the correct diet order was entered into the electronic medical record for one resident who suffered a choking incident which caused her to be dependent on a ventilator in the ICU with a poor prognosis. 42 CFR 483.25 Provide Care/Services for Highest Well Being 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policies, facility documentation and clinical records, and interviews with staff, it was determined that the facility failed to ensure that two of four residents identified as an elopement risk received adequate supervision, assessment and monitoring by staff. The facility's failure to appropriately supervise, assess and monitor the residents resulted in both residents eloping from the facility and resulted in an immediate jeopardy situation (Residents R1 and R2). Findings include: Review of facility policy, Accidents and Incidents-Investigation Reporting, dated effective 12-11-20, indicated that all accidents/ incidents occurring on our premises must be investigated and reported to the administrator. The policy further indicated that the charge nurse registered nurse will examine all accident/incident victims and an accident/incident report form must be completed on the shift that the accident or incident occurred. Continued review of the policy indicated that the occurrences that were outlined that warranted an incident report included: falls, resident to resident altercations, fractures, and elopements. Review of an undated facility policy, Elopement Management Program, indicated that if a resident triggers as an elopement risk per the assessment, the following interventions may be implemented (1) elopement risk care plan (2) a wander-guard bracelet (device that triggers an alarm and can lock doors to prevent the resident from leaving unattended) or similar device will be placed on the resident (3) a copy of residents determined to be an elopement risk will be kept at the nursing stations as well as the front reception areas. Further review of the policy indicated that should an employee discover that a resident is missing from the facility, several steps should be taken which included alerting staff, notifying the administrative staff and the attending physician. Upon the resident's return to the facility from an elopement, the DON or a licensed professional nurse should examine the resident for injuries, contact the attending physician and the responsible party, and report the findings and the condition of the resident. Review of Resident R1's physician orders dated 6/2021, indicated that the resident had diagnoses that included: [CONDITION(S)] (mental disorder that affects a person's ability to think, feel, and behave clearly), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and [CONDITION(S)] (a mental disorder characterized by a disconnection from reality). Review of Resident R1's Quarterly Minimum Data Set (MDS-an assessment of the resident's needs) dated 5/28/ 2021, indicated that the resident was moderately cognitively impaired. Further review of the MDS indicated that the resident was able to walk in his room and the corridors without any physical assistance from staff. Review of Resident R1's person-centered plan of care date initiated 6/10/21, indicated that Resident R1 was at risk for injury related to elopement/wandering behaviors, [CONDITION(S)], with goals that included the goals of the resident not eloping from the facility, and a goal of wandering safely within his/her environment. Interventions included monitoring and reporting changes in the resident's behaviors and applying a Wanderguard to the resident's left ankle. Review of Resident R1's Elopement Risk Data and Collection Assessment, completed on 6/10/21, revealed that the resident had not been identifed as an elopement risk. Further review of the elopment assessment revealed that the form was incomplete and that multiple questions listed on the assessment form were left blank and unanswered. Review of 6/ 2021 physician orders for Resident R1 revealed no physician order for a Wanderguard to be applied to the resident. Review of Resident R1's clinical record revealed a Behavior Note, dated 6/27/21 at 1:03 a.m., which revealed . Later in shift resident began pacing hallway. Resident kept going in and out of other residents rooms and seeking exit. Redirection unsuccessful. Continued review of the clinical record for Resident R1 revealed an Incident Note, dated 6/27/21, at 9:53 a.m. which revealed . Around 9:50 AM, heard DR Walker (coded announcement to notify staff that a resident is missing) immediately respond, resident noted coming from back side to front car parking lot, redirected resident to inside the facility. charge nurse notified. Message to psych consult for elopement behavior and agitation, will monitor. Review of surveillance video footage and information provided by the Nursing Home Administrator revealed that Resident R1 was seen being retrieved from this area at 9:44 a.m., 12 minutes after the resident was seen sitting in the courtyard. Employee E7, Registered Nurse/Supervisor reported that when questioned, nursing staff indicated that they did not know how the resident left the building. Interview with the Nursing Home Administrator (NHA) on 7/10/21, at 9:30 a.m., revealed that Resident R1 was seen on the facility's surveillance video system sitting in the courtyard at 9:32 a.m Resident R1 was then seen placing his foot on a window screen and using the support from the window screen to climb over the white gate that surrounded the outer part of the courtyard at approximately 9:34 a.m The distance from the courtyard that Resident R1 exited from on 6/27/21, to where the resident was found after the first elopement was confirmed to be 392.7 feet on 7/10/21, at 11:00 a.m. when measured by the NHA and the Director of Maintenance. Interview with Employee E5, nursing assistant, on 7/8/21, at 2:36 p.m., confirmed that on 6/27/21, the employee saw Resident R1 go out the west wing dining room and heard the door alarm sound. Employee E5 further indicated that it was the resident's pattern to go in and out the west wing dining room door all day. Interview with Employee E7, R.N./Supervisor, on 7/10/21, at 3:00 p.m., confirmed that on 6/27/21, that she and Employee E10, Director of Maintenance, went outside and retrieved the resident from the sidewalk next to the parking lot area closest to the front door of the building. Review of information submitted by the facility revealed that Resident R1 had eloped from the facility twice on 6/27/21, by exiting out the same west wing dining room doors that are alarmed to notify staff when someone is trying to exit the door. Further review of the clinical record for Resident R1 revealed a Health Status Note dated 6/27/21, at 11:05 a.m. which indicated This nurse heard a page from the receptionist stating that resident eloped and is on . Avenue. Staff ran out to the street, apprehended resident and escorted him back to the building. Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 7/10/21, at 9:30 a.m., related to the resident's second elopement, revealed that based upon surveillance video the resident was seen entering the courtyard and sitting down at 10:49 a.m At 10:52 a.m. the resident was seen climbing the courtyard gate. The NHA further indicated that the resident was retrieved by Employee E7, R.N./Supervisor, at 11:04 a.m., 15 minutes after Resident R1 entered the courtyard. Continued interview with Employee E7, RN/Supervisor, on 7/10/21, at 3:00 p.m., regarding Resident R1's second elopement indicated that she heard the Dr. Walker, page and went to the receptionist desk where she was notified that Resident R1 was across the street. Employee E7 reported that she saw Resident R1 across the street, in front of a house. Observation during the investigation revealed that Resident R1 had crossed four lanes of traffic to get to the opposite side of the street to the location where Employee E7 retrieved the resident. The distance from the courtyard where Resident R1 exited from to where the resident was found after the second elopement was confirmed to be 556.3 feet as measured by the NHA and the Director of Maintenance on 7/10/21 at 11:00 a.m Interview with the Director of Nursing (DON) on 7/7/21, at 4:45 p.m., revealed that there was no documented evidence that Resident R1 had a Wanderguard device applied at the time of the elopements, as documented in the resident's plan of care. Review of the Resident R1's clinical record revealed no documented evidence that facility staff had implemented any additional monitoring or taken any further measures to ensure Resident' R1's safety following the first elopement on 6/27/21. Continued review of Resident R1's clinical record revealed no documented evidence that the resident had been assessed by licensed nursing staff after both elopements, as required by facility policy. Interview with Employee E7, R.N./Supervisor, on 7/10/21, at 3:00 p.m. confirmed that there was no documented evidence that Resident R1 had been assessed by licensed nursing staff following both elopements on 6/27/21, as per facility policy. Review of the clinical record for Resident R2 revealed physician orders dated 7/2021, which indicated that the resident had diagnoses of: depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and [CONDITION(S)] (a mental disorder characterized by a disconnection from reality), history of falls and severe intellectual disabilities. Further review of the clinical record for Resident R2 revealed a quarterly Minimum Data Set (MDS- assessment of needs) dated 4/2/21, which indicated that Resident R2 was moderately cognitively impaired. Review of the Resident R2's Elopement Risk Data and Collection Assessment, completed on 5/8/21, indicated that the resident had a history of elopement, expressed desire to leave the facility, was independently mobile, had adjustment difficulties, had a desire to return home, had a psychiatric history, was restless, irritable and had a history of wandering. The results of the assessment indicated that the resident was at risk for elopement. Review of the resident's person-centered plan of care dated revised on 5/4/21, indicated that the resident was at risk of injury related to the resident's elopement/wandering expresses intent to leave the building. The goals related to this plan of care included that the resident not elope from the facility, and wandering safety in his/her environment. Interventions included monitoring and reporting changes in the resident's behaviors. Review of Resident R2's clinical record revealed a physician order dated 5/2021, and continuing monthly thereafter, for Wander Guard Bracelet. Check placement, function, and skin integrity every shift. every shift wander guard on RT wrist. Review of the resident's interdisciplinary notes and interview with the NHA on 7/8/21, indicated that Resident R2 had eloped from the facility on May 9, 2021, during the 3:00 p.m. to 11:00 p.m. nursing shift. Interview with Employee E13, licensed practical nurse, on 7/10/21 at 6:35 p.m., revealed that when the employee went to administer Resident R2 her evening medications she did not see the resident. Employee E13 reported that she continued to administer medications to the other residents and that when she went back to the resident's room to administer her medication, the resident was not in her room. Employee E13 indicated that the resident's dinner meal tray was still on the resident's bedside table in the resident's room. Employee E13 reported that the resident had a physician's order for a Wanderguard and that Resident R2 always has it on. Interview with the Nursing Home Administrator (NHA) on 7/10/21, at 9:30 a.m., revealed that the resident was last seen at 3:40 p.m. At 4:15 p.m., Resident R2 was seen near the front desk receptionist area. At 4:24 p.m. surveillance footage recorded Resident R2 leaving via the facility's main entrance with visitors. Review of facility documentation revealed that Resident R2's uncle contacted the facility at approximately 10:00 p.m. (approximately 5-1/2 hours after the resident exited out of the facility's front door) and informed them that the resident was at his address. The resident was subsequently brought back to the facility at approximately 11:50 p.m. on 5/9/21, by the NHA. The NHA indicated that the resident had used public transportation to get to her brother's home. The distance from the facility to where the resident was located was approximately 16.2 miles when calculated using a GPS. Interview with the Employee E11, former Director of Nursing, on 7/10/21, at 2:40 p.m., revealed that she was notified by Employee E12, registered nurse supervisor, on 5/9/21, at approximately 9:10 p.m. that Resident R2 could not be located. Employee E11 reported that the surveillance video showed that Resident R2 left the facility with a group of five-six visitors. Continued interview with Employee E11 confirmed that the door in which Resident R2 exited was equipped with a Wanderguard alarm. Employee E11 further reported that she did not believe that Resident R2 had a Wanderguard on at the time that of the elopement. Further interview with Employee E11 indicated that there were some residents who needed Wanderguards at the time but did not have them because the system that the facility had at the time of Resident R2's elopement was no longer being used, and that a new wander guard system needed to be purchased by the facility so that a new one could be installed. E11 reported that the elevators in the facility were not equipped with a wander guard alarm system, and the elevators also do not lock. Employee E11 reported the door in which Resident R2 exited out of is alarmed for residents who have wander guards and the door would have set the wander guard alarm off if the system was working properly. Interview with Employee E14, front desk receptionist, on 7/10/21 at 7:31 p.m., confirmed that the employee had worked on the 3:00 to 11:30 p.m. shift on May 9, 2021, the evening that Resident R2 had eloped from the facility. Employee E14 reported that if a resident with a Wanderguard is within the vicinity of the facility's front door she would hear the door alarm. Employee E14 reported that she did not hear the facility's front door alarm that would have alerted her that someone with a Wanderguard was near the door. Interview with the NHA on 7/10/21, at 11:00 a.m. confirmed that the employee had brought the resident back to the facility, and that he was unsure if the main entrance door alarmed when the resident walked through the door upon her return. Interview with Resident R2's uncle on 7/12/21, at 3:41 p.m., revealed that Resident R2 informed him that the resident took the bus from the facility to his home. The uncle further reported that the resident stated that she walked from the facility to his home. The resident's uncle reported that the resident showed up to his home at approximately 11:00 p.m Further interview with Resident R2's uncle revealed that when the resident arrived at his home, his wife changed Resident R2's clothing because Resident R2 sneakers were falling off her feet, and the resident had urinated on herself. Continued interview with the resident's uncle indicated that once the resident arrived at his home, he contacted the facility regarding the resident's location and that the NHA picked the resident up to transport him/her back to the facility. Review of Resident R2's clinical records revealed no documented evidence that any assessments had been completed by licensed nursing staff following the resident's return, as required by facility policy. The facility failed to ensure that two cognitively impaired residents identifed as at risk for elopement were provided with the appropriate monitoring and supervision to prevent them from eloping from the facility. Additionally, the facility failed to complete physical assessments on these residents following their elopements, as required per facility policy, to ensure that they were free from injury and harm. Based on the above findings an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on 7/8/21, at 3:52 p.m., for failure to ensure that appropriate monitoring and assessments were completed on residents at risk for elopement. The Immediate Jeopardy template was provided to the Administrator and an immediate action plan was requested. On 7/ 8/21, at 8:45 p.m., the facility provided the following corrective action plan: 1. Reassessing all residents identified as an elopement risk. 2. Updating the care plans of residents identified as elopement risk. 3. Creating an elopement form which included the resident's name, room number, floor, device lot number and picture to be placed on all nursing units, and the front desk reception area. 4. Educating all contracted and non-contracted nursing staff, nursing assistants prior to the start of their shift and non-nursing staff employed by the facility on the elopement policy, code name for elopement, Dr. Walker, the new wander guard system, and the daily assessment/documentation of wander guards of identified residents for elopement. The completion of a post competency test to demonstrate understanding of the information presented. 5. Requiring licensed nursing staff to complete a visual check every shift to ensure that the wander guard device is on the resident who has been identified as an elopement risk. 6. Requiring the night shift nursing supervisor to conduct rounds on every resident identified as an elopement risk, in addition to scanning the residents' transmitters with the Wander Guard Blue detector for functionality. Documentation of these tasks will be recorded in the residents' electronic medical record. 7. Requiring the Maintenance Director and/or designee to audit the facility's wander guard system and doors daily for functionality. This audit will be documented on a log sheet and reviewed at the monthly QAPI meeting (Quality Assessment Performance Improvement meeting-a meeting/documented plan that guides the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance, and continually improved) Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on 7/10/21 at 12:59 p.m. 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan

Based on an investigation into two reportable events related to two suicide attempts by a resident, it was determined that the facility failed to ensure appropriate treatment and services to attain the highest practicable physical, mental health and psychosocial well-being were provided for one of two residents reviewed (Resident R1, R2) resulting in actual harm, unresponsiveness, transfer to the hospital and death for one resident, (Resident R1). The investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services placing residents in an Immediate Jeopardy situation. Findings include: Resident R1 was admitted to the facility on (MONTH) 2, (YEAR), after a hospital stay where he was admitted for a change in mental status and a possible suicide attempt. A review of his hospital records revealed that the resident had a history of [REDACTED]. The resident was seen by psychiatry while in the hospital. The hospital recommendations from (MONTH) 22, (YEAR), stated the resident would benefit from placement at a skilled nursing facility and remained in need of care by a psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of [REDACTED]. A review of the resident's facility clinical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. in which symptoms characteristic of a [MEDICAL CONDITION] that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the [MEDICAL CONDITION]), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified convulsions, (an abnormal, involuntary contraction of the muscles most typically seen with certain [MEDICAL CONDITION] disorders. The term convulsion is sometimes used as a synonym for [MEDICAL CONDITION], but not all [MEDICAL CONDITION] are characterized by convulsions. A person having convulsions appears to be shaking rapidly and without control), altered mental status unspecified, high blood pressure and liver failure. Review of Resident R1's physician's orders [REDACTED]. On (MONTH) 8, (YEAR), an order for [REDACTED]. A review of the resident's care plan from (MONTH) 2, (YEAR), to (MONTH) 21, (YEAR), revealed that the resident's history of suicide attempts was not reflected on the care plan. A problem area was added on (MONTH) 21, (YEAR), that addressed the resident as being at risk related to acute behavioral episode of self-harm: resident slit his wrist. No additional documentation with regard to the resident's history of suicidal behavior was added to the care plan. A nursing progress note written by Employee E4, Licensed Practical Nurse (LPN) and the Unit Manager, dated (MONTH) 16, (YEAR), stated that the resident was observed to be sad today, refusing to associate with anyone; just staying by himself; denies pain or discomfort; denies pain or discomfort but still looks sad and angry. Message left for CRNP (Certified Registered Nurse Practitioner) to re-evaluate resident. Will continue to monitor. A review of two sections of the clinical record, one titled Consults and one titled Mental Health, showed no evidence of a completed evaluation by the CRNP as requested by nursing staff on (MONTH) 16, (YEAR). In an interview with the Director of Nursing (DON) on (MONTH) 9, (YEAR), at approximately 1:30 p.m. she verified that no documentation was in the medical record nor could any be found in the facility to demonstrate the consult had been completed. A progress note written by Employee E5, LPN, dated (MONTH) 7, (YEAR), stated that a nurse was notified by a nurse aide that the resident was bleeding on his right wrist. The resident was found with an approximate 3.2 cm (centimeters -a metric unit of measurement) x (by) 5 x 4 cm cut on right wrist. The right hand was bloody. The resident was asked if he did that to hurt himself and he nodded yes. An order was given to send the resident to the hospital for an evaluation. A progress note dated (MONTH) 7, (YEAR), stated the resident was admitted to the hospital with [REDACTED]. A nursing progress note dated (MONTH) 20, (YEAR), stated the resident was readmitted to the facility. A physician's orders [REDACTED]. The progress notes dated (MONTH) 27 and (MONTH) 31, (YEAR), noted that the resident refused his morning medications, the physician was notified and no new orders were noted. A progress note dated (MONTH) 2, (YEAR), stated the Social Services Director (SSD) sent a psychology referral to behavioral health services because the resident can benefit from additional supportive services. In an interview with the SSD on (MONTH) 9, (YEAR), at 1:40 p.m. she verified that the resident was not, to date, seen by behavioral health services. A nursing progress note dated (MONTH) 24, (YEAR), stated, no [MEDICAL CONDITION] activity noted, out of bed to wheelchair only to go to the bathroom and back. Refused dinner. When questioned, how are you? he just shook his head side to side. Evening snacks left on overbed table. There was no evidence to demonstrate that any additional follow up was completed to see why the resident indicated he was not okay as shown by his head shaking from side to side. A nursing progress note written by Employee E6, LPN, dated (MONTH) 5, (YEAR), stated that at 8:05 p.m. the resident came back to the third floor from the first-floor reception room where he had been last seen at 6:40 p.m., and was given his evening medication. At around 8:20 p.m., the nurse aide called the nurse to the third-floor shower room. The nurse saw the resident was hanging from a piece of a bedsheet from the shower pole in the shower room. The resident's feet were noted to be touching the floor and his face was blue in color. The nurse cut the piece of cloth around his neck and lowered the resident to the floor. The resident was noted with a nose bleed, was non-responsive with no pulse. The resident was a full code (indicating if the resident suffers cardiac or respiratory arrest, the resident wishes CPR will be provided), and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated immediately and 911 was called. The resident was transported to the emergency department at 8:40 p.m. The resident remained in the hospital on a ventilator (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently) as of (MONTH) 10, (YEAR). A verbal update from the facility on (MONTH) 12, (YEAR), indicated the resident expired on (MONTH) 12, (YEAR). A review of the documentation in the mental health section of the resident's clinical record revealed the dates that the resident was seen by psychiatry as follows: [DATE], (YEAR)- no mention of resident's history of suicide attempts noted in the documentation. [DATE], (YEAR), follow up visit. [DATE], (YEAR), a [MEDICAL CONDITION] medication review with a recommendation to discontinue [MEDICATION NAME]. [DATE], (YEAR), a consultation report from pharmacy to evaluate the resident's medications in relation to falls. CRNP noted resident is post suicide attempt and no medication changes were made. [DATE], (YEAR), which was one day after the resident hanged himself. The note stated that the resident was now even a higher risk with this second attempt. During an interview on (MONTH) 9, (YEAR), at 1:00 p.m. the DON was asked how prn orders for psych consults were interpreted, and she stated once a resident was seen by psych, they determined the frequency of the follow up visits. When asked how the facility knew if the services were provided, she stated it was assumed that professionals did their job. During an interview (MONTH) 9, (YEAR), at 2:00 p.m. with the SSD, the DON, and the Nursing Home Administrator (NHA), they were asked what the facility procedure was to ensure that psychological or behavioral care and services were provided to residents in need of these services. SSD stated that if a need was identified, a referral was sent to the provider and it was assumed professionals do their job. When asked how the facility determined the consult was completed, the SSD responded there was no mechanism in place to accurately determine care and services for mental and behavioral health are provided to meet the individual needs of residents. An immediate jeopardy situation was identified to the NHA on (MONTH) 9, (YEAR), at 2:25 p.m. related to the findings on (MONTH) 9, (YEAR), when it was revealed that the facility failed to provide needed care or services resulting in one resident's failure to improve and/or attain their highest practicable physical, mental, and/or psychosocial well-being. Resident R1 had multiple suicide attempts which resulted in harm and the resident subsequently expired on (MONTH) 12, (YEAR). The immediate corrective action plan included the following interventions: 1. Resident R1 was admitted to the hospital where he remains. 2. On (MONTH) 9, (YEAR), residents seen by the psychiatric team with a similar [DIAGNOSES REDACTED]. This will be completed by (MONTH) 10, (YEAR). On (MONTH) 10, (YEAR), their records will be reviewed for psychiatric visits/follow up and any residents not seen in the last 30 days will be identified to the psychiatrist, Nurse Practitioner and licensed Social Worker by (MONTH) 11, (YEAR). 3. The administrator, assistant administrator, DON, unit managers, and Social Workers have been educated on the process of coordinating with the social services department on any consults requested of the psychiatry/psychology vendors. Unit managers and social services will validate receipt of documentation from the vendors prior to their departing the premises on the date of service. All staff will be immediately educated, as they arrive on shift, on recognizing the signs and symptoms of depression and suicidal ideation not later than (MONTH) 12, (YEAR). 4. The Director of Social Service and/or designee will perform weekly audits on psychiatric visits for two months. The results of the audits will be reviewed by the Quality Assurance and Performance Improvement Plan, (QAPI) committee for revisions as needed. The Immediate Jeopardy was removed on (MONTH) 12, (YEAR), at 2:30 p.m. after it was verified that the corrective action plan was implemented. On (MONTH) 10, (YEAR), the progress of the facility plan of correction was reviewed. The SSD provided documentation to show that on the evening of (MONTH) 9, (YEAR), all residents were interviewed/assessed by either the SSD or the Assistant Director of Nursing to see if they were in need of psychiatric or behavioral health services. Resident R2, who was interviewed/assessed by the SSD, stated she was suicidal and she had a plan to carry out her suicide. The SSD stated that after discussion among the medical staff, it was decided to send the resident out to the hospital for evaluation. The resident was transferred to the hospital and was admitted for psychiatric evaluation and treatment. The resident was still in the hospital at the time the Immediate Jeopardy was lifted. The facility failed to ensure appropriate treatment and services to attain the highest practicable mental health and psychosocial well-being were provided for one resident (Resident R1) resulting in harm and eventual death. The facility failed to have a system in place to ensure that the other residents in the facility with similar needs were receiving the appropriate mental health services, placing residents in an immediate jeopardy situation. Quality of Care CFR(s): 483.25 - Previously cited [DATE], [DATE] 28 Pa. Code 201.14 (a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(a) Management Previously cited [DATE] 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.11(c) Resident care plan Previously cited [DATE], [DATE] 28 Pa. Code 211.11(d) Resident care plan Previously cited [DATE] 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]

Based on an investigation of two reportable events related to two suicide attempts by a resident, it was determined that the facility failed to ensure that the residents received appropriate treatment and services to correct assessed problems for one of two residents reviewed (Resident R1, R2) resulting in actual harm, unresponsiveness, transfer to the hospital and death for (Resident R1); and the investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, resulting in an Immediate Jeopardy situation. Findings include: Resident R1 was admitted to the facility on (MONTH) 2, (YEAR), after a hospital stay where he was admitted for a change in mental status and a possible suicide attempt. A review of his hospital records revealed the resident had a history of [REDACTED]. The resident was seen by psychiatry while in the hospital. The hospital recommendations (MONTH) 22, (YEAR), stated the resident would benefit from placement at a skilled nursing facility, and remains in need of care by psychiatrist, (a physician who specializes in the branch of medicine devoted to the diagnosis, prevention, study, and treatment of [REDACTED]. A review of the resident's facility clinical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. in which symptoms characteristic of a [MEDICAL CONDITION] that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the [MEDICAL CONDITION]), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified convulsions, (an abnormal, involuntary contraction of the muscles most typically seen with certain [MEDICAL CONDITION] disorders. The term convulsion is sometimes used as a synonym for [MEDICAL CONDITION], but not all [MEDICAL CONDITION] are characterized by convulsions. A person having convulsions appears to be shaking rapidly and without control), altered mental status unspecified, high blood pressure and liver failure. physician's orders [REDACTED]. On (MONTH) 8, (YEAR), an order for [REDACTED]. A review of the resident's care plan from (MONTH) 2, (YEAR), to (MONTH) 21, (YEAR), revealed that the resident's history of suicide attempts was not reflected on the care plan. A problem area was added on (MONTH) 21, (YEAR), that addressed the resident being at risk related to acute behavioral episode of self-harm: resident slit his wrist. No additional documentation with regard to the resident's history of suicidal behavior was added to the care plan. A nursing progress note dated (MONTH) 7, (YEAR), stated the resident was seen and evaluated by the physician and a psych consult was ordered. A note dated (MONTH) 8, (YEAR), stated the resident was seen by Certified Registered Nurse Practitioner (CRNP) and a new order was written for [MEDICATION NAME] 5 mg for depression. A progress note, dated (MONTH) 16, (YEAR), stated the resident was observed to be sad today; refusing to associate with anyone; just staying by himself; denies pain or discomfort. Denies pain or discomfort at this time but still looks sad and angry. Message left for CRNP to re-evaluate resident. Will continue to monitor. A review of two sections of the clinical record, one titled Consults and one titled Mental Health, showed no evidence of a completed evaluation by the CRNP as requested by nursing staff on (MONTH) 16, (YEAR). In an interview with the Director of Nursing (DON) on (MONTH) 9, (YEAR), at approximately 1:30 p.m. she verified that no documentation was in the medical record, nor could any be found in the facility to demonstrate the consult had been completed. A progress note, dated (MONTH) 7, (YEAR), stated that a nurse was notified by a nurse aide that the resident was bleeding on his right wrist. The resident found with an approximate 3.2 cm x. 5 x. 4 cm cut on right wrist. Right hand was bloody. Resident was asked if he did that to hurt himself, he nodded yes. An order was given to send the resident to the hospital for evaluation. A progress note, dated (MONTH) 7, (YEAR), stated the resident was admitted to the hospital with [REDACTED]. A progress note, dated (MONTH) 20, (YEAR), stated the resident was readmitted to the facility. A physician order [REDACTED]. Progress notes dated (MONTH) 27 and (MONTH) 31, (YEAR), noted that the resident refused his morning medications, physician was notified and no new orders noted. A progress note, dated (MONTH) 2, (YEAR), stated the Social Services Director (SSD) sent a psychology referral to behavioral health services because the resident can benefit from additional supportive services. In an interview with the SSD on (MONTH) 9, (YEAR), she verified that the resident was not, to date, seen by behavioral health services. A progress note, dated (MONTH) 24, (YEAR), stated no [MEDICAL CONDITION] activity noted, out of bed to wheelchair only to go to the bathroom and back. Refused dinner. When questioned, how are you? he just shook his head side to side. Evening snacks left on overbed table. A nursing progress note written by Employee E6, LPN, dated (MONTH) 5, (YEAR), stated that at 8:05 p.m. the resident came back to the third floor from the first-floor reception room where he had been last seen at 6:40 p.m., and was given his evening medication. At around 8:20 p.m., the nurse aide called the nurse to the third-floor shower room. The nurse saw the resident was hanging from a piece of a bedsheet from the shower pole in the shower room. The resident's feet were noted to be touching the floor and his face was blue in color. The nurse cut the piece of cloth around his neck and lowered the resident to the floor. The resident was noted with a nose bleed, was non-responsive with no pulse. The resident was a full code (indicating if the resident suffers cardiac or respiratory arrest, the resident wishes CPR will be provided), and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated immediately and 911 was called. The resident was transported to the emergency department at 8:40 p.m. The resident remained in the hospital on a ventilator, (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently), as of (MONTH) 10, (YEAR). A verbal update from the facility on (MONTH) 12, (YEAR) indicated the resident expired on (MONTH) 12, (YEAR). A review of the documentation in the mental health section of the resident's clinical record revealed the dates that the resident was seen by psychiatry as follows: [DATE], (YEAR)- no mention of resident's history of suicide attempts noted in the documentation. [DATE], (YEAR)- follow up visit. [DATE], (YEAR)- a [MEDICAL CONDITION] medication review with a recommendation to discontinue [MEDICATION NAME]. [DATE], (YEAR) - a consultation report from pharmacy to evaluate the resident's medications in relation to falls. CRNP noted resident is post suicide attempt and no medication changes were made. [DATE], (YEAR) - which was one day after the resident hanged himself. The note stated that the resident was now even a higher risk with this second attempt. In an interview with the DON on (MONTH) 9, (YEAR), 1:00 p.m. the DON was asked how prn orders for psych were interpreted, and she stated once a resident was seen by psych they determined the frequency of the follow up visits. When asked how the facility knew if the services were provided she stated it was assumed that professionals did their job. During an interview on (MONTH) 9, (YEAR), at 2:00 p.m. with the SSD, the DON, and the Nursing Home Administrator (NHA), they were asked what the facility procedure was to ensure that psychological or behavioral care and services were provided to residents in need of these services. SSD stated that if a need was identified, a referral was sent to the provider and it was assumed professionals do their job. When asked how the facility determined the consult was completed, the SSD responded there was no mechanism in place to accurately determine care and services for mental and behavioral health are provided to meet the individual needs of residents. An immediate jeopardy situation was identified to the NHA on (MONTH) 9, (YEAR), at 2:25 p.m. related to the findings on (MONTH) 9, (YEAR), when it was revealed that the facility failed to ensure appropriate treatment and services to attain the highest practicable mental health and psychosocial well-being were provided for Resident R1, resulting in harm and had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services. The immediate corrective action plan included the following interventions: 1. Resident R1 was admitted to the hospital where he remains. 2. On (MONTH) 9, (YEAR), residents seen by the psychiatric team with a similar [DIAGNOSES REDACTED]. This will be completed by (MONTH) 10, (YEAR). On (MONTH) 10, (YEAR), their records will be reviewed for psychiatric visits/follow up and any residents not seen in the last 30 days will be identified to the psychiatrist, Nurse Practitioner and licensed Social Worker by (MONTH) 11, (YEAR). 3. The administrator, assistant administrator, DON, unit managers, and Social Workers have been educated on the process of coordinating with the social services department on any consults requested of the psychiatry/psychology vendors. Unit managers and social services will validate receipt of documentation from the vendors prior to their departing the premises on the date of service. All staff will be immediately educated, as they arrive on shift, on recognizing the signs and symptoms of depression and suicidal ideation not later than (MONTH) 12, (YEAR). 4. The Director of Social Service and/or designee will perform weekly audits on psychiatric visits for two months. The results of the audits will be reviewed by the Quality Assurance and Performance Improvement Plan, (QAPI) committee for revisions as needed. The Immediate Jeopardy was removed on (MONTH) 12, (YEAR), at 2:30 p.m. after it was verified that the corrective action plan was implemented. On (MONTH) 10, (YEAR), the progress of the facility plan of correction was reviewed. The SSD provided documentation to show that on the evening of (MONTH) 9, (YEAR), all residents were interviewed/assessed by either the SSD or the Assistant Director of Nursing to see if they were in need of psychiatric or behavioral health services. Resident R2, who was interviewed/assessed by the SSD, stated she was suicidal and she had a plan to carry out her suicide. The SSD stated that after discussion among the medical staff, it was decided to send the resident out to the hospital for evaluation. The resident was transferred to the hospital and was admitted for psychiatric evaluation and treatment. The resident was still in the hospital at the time the Immediate Jeopardy was lifted. The facility failed to ensure appropriate treatment and services to attain the highest practicable mental health and psychosocial well-being were provided for one resident (Resident R1), resulting in harm and eventual death. The facility failed to have a system in place to ensure that the other residents in the facility with similar needs were receiving the appropriate mental health services, placing residents in an Immediate Jeopardy situation. 28 Pa. Code 201.14 (a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(a) Management Previously cited [DATE] 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.11(c) Resident care plan Previously cited [DATE], [DATE] 28 Pa. Code 211.11(d) Resident care plan Previously cited [DATE] 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services Previously cited [DATE], [DATE] 28 Pa. Code 211.16(a) Social services

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to implement interventions to maintain a safe and accident, hazard free environment and failed to ensure that for one of two residents reviewed (Resident R1, Resident R2), the resident received adequate supervision related to [MEDICAL CONDITION] which caused actual harm, unresponsiveness, transfer to the hospital and eventual death for (Resident R1). The investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, placing residents in the facility in an Immediate Jeopardy situation. Resident R1 was admitted to the facility on (MONTH) 2, (YEAR), after a hospital stay where he was admitted for a change in mental status and a possible suicide attempt. A review of his hospital records revealed the resident had a history of [REDACTED]. The resident was seen by psychiatry while in the hospital. The hospital recommendations dated (MONTH) 22, (YEAR), stated the resident would benefit from placement at a skilled nursing facility, and remains in need of care by psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of [REDACTED]. A review of the Resident R1 facility clinical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. in which symptoms characteristic of a [MEDICAL CONDITION] that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the [MEDICAL CONDITION]), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified convulsions, (an abnormal, involuntary contraction of the muscles most typically seen with certain [MEDICAL CONDITION] disorders. The term convulsion is sometimes used as a synonym for [MEDICAL CONDITION], but not all [MEDICAL CONDITION] are characterized by convulsions. A person having convulsions appears to be shaking rapidly and without control), altered mental status unspecified, high blood pressure and liver failure. Review of Resident R1's physician's orders [REDACTED]. On (MONTH) 8, (YEAR), an order for [REDACTED]. Review of Resident R1's care plan from (MONTH) 2, (YEAR), to (MONTH) 21, (YEAR), revealed that the resident's history of suicide attempts was not reflected on the care plan. A problem area was added on (MONTH) 21, (YEAR), that addressed the resident as being at risk related to acute behavioral episode of self-harm: resident slit his wrist. No additional documentation with regard to the resident's history of suicidal behavior was added to the care plan. A nursing progress note dated (MONTH) 7, (YEAR), stated the resident was seen and evaluated by the physician and a psych consult was ordered. A note dated (MONTH) 8, (YEAR), stated the resident was seen by Certified Registered Nurse Practitioner (CRNP) and a new order was written for [MEDICATION NAME] 5 mg for depression. A nursing progress note, written by Employee E4, Licensed Practical Nurse (LPN) and the Unit Manager, dated (MONTH) 16, (YEAR), stated the resident was observed to be sad today; refusing to associate with anyone; just staying by himself; denies pain or discomfort. Denies pain or discomfort but still looks sad and angry. Message left for CRNP to re-evaluate resident. Will continue to monitor. A review of two sections of the clinical record, one titled Consults and one titled Mental Health, showed no evidence of a completed evaluation by the CRNP as requested by the nursing staff on (MONTH) 16, (YEAR). In an interview with the Director of Nursing (DON) on (MONTH) 9, (YEAR), at approximately 1:30 p.m. she verified that no documentation was in the medical record nor could any be found in the facility to demonstrate the consult had been completed. A nursing progress note written by Employee E5, LPN, dated (MONTH) 7, (YEAR), stated that a nurse was notified by a nurse aide that the resident was bleeding on his right wrist. The resident found with an approximate 3.2 cm (centimeters - a metric unit of measurement) x (by) 5 x 4 cm cut on right wrist. The right hand was bloody. The resident was asked if he did that to hurt himself and he nodded yes. An order was given to send the resident to the hospital for evaluation. A nursing progress note dated (MONTH) 7, (YEAR), stated the resident was admitted to the hospital with [REDACTED]. A nursing progress note dated (MONTH) 20, (YEAR), stated the resident was readmitted to the facility. A physician's orders [REDACTED]. Progress notes dated (MONTH) 27 and (MONTH) 31, (YEAR), noted that the resident refused his morning medications, the physician was notified and no new orders noted. A review of the resident's care plan from (MONTH) 2, (YEAR), to (MONTH) 21, (YEAR), revealed that the resident's history of suicide attempts was not reflected on the care plan. A problem area was added on (MONTH) 21, (YEAR), that addressed the resident as being at risk related to acute behavioral episode of self-harm: resident slit his wrist. This was 14 days after the resident slit his wrist. No additional documentation with regard to the resident's history of suicidal behavior was added to the care plan. A progress note dated (MONTH) 2, (YEAR), stated the Social Services Director (SSD) sent a psychology referral to behavioral health services because the resident can benefit from additional supportive services. In an interview with the SSD on (MONTH) 9, (YEAR) at 1:40 p.m., she verified that the resident was not, to date, seen by behavioral health services. A nursing progress note dated (MONTH) 24, (YEAR), stated, no [MEDICAL CONDITION] activity noted, out of bed to wheelchair only to go to the bathroom and back. Refused dinner. When questioned, how are you? he just shook his head side to side. Evening snacks left on overbed table. There was no evidence to demonstrate that any follow up was conducted to find out why the resident indicated he was not okay by shaking his head side to side. A nursing progress note written by Employee E6, LPN, dated (MONTH) 5, (YEAR), stated that at 8:05 p.m. the resident came back to the third floor from the first-floor reception room where he had been last seen at 6:40 p.m., and was given his evening medication. At around 8:20 p.m., the nurse aide called the nurse to the third-floor shower room. The nurse saw the resident was hanging from a piece of a bedsheet from the shower pole in the shower room. The resident's feet were noted to be touching the floor and his face was blue in color. The nurse cut the piece of cloth around his neck and lowered the resident to the floor. The resident was noted with a nose bleed, was non-responsive with no pulse. The resident was a full code (indicating if the resident suffers cardiac or respiratory arrest, the resident wishes CPR will be provided) and CPR (Cardio [MEDICAL CONDITION] Resuscitation) was initiated immediately and 911 was called. The resident was transported to the emergency department at 8:40 p.m. The resident remained in the hospital on a ventilator (a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently) as of (MONTH) 10, (YEAR). A verbal update from the facility on (MONTH) 12, (YEAR), indicated the resident expired on (MONTH) 12, (YEAR). A review of the documentation in the mental health section of the resident's clinical record revealed the dates that the resident was seen by psychiatry as follows: [DATE], (YEAR)- no mention of resident's history of suicide attempts noted in the documentation. [DATE], (YEAR), follow up visit. [DATE], (YEAR), a [MEDICAL CONDITION] medication review with a recommendation to discontinue [MEDICATION NAME]. [DATE], (YEAR), a consultation report from pharmacy to evaluate the resident's medications in relation to falls. CRNP noted resident is post suicide attempt and no medication changes were made. [DATE], (YEAR), which was one day after the resident hanged himself. The note stated that the resident was now even a higher risk with this second attempt. In an interview on (MONTH) 9, (YEAR), at 1:00 p.m. the DON was asked how prn orders for psych were interpreted, and she stated once a resident was seen by psych, they determined the frequency of the follow up visits. When asked how the facility knew if the services were provided ,she stated it was assumed that professionals did their job. During an interview on (MONTH) 9, (YEAR), at 2:00 p.m. with the SSD, the DON, and the Nursing Home Administrator (NHA), they were asked what the facility procedure was to ensure that psychological or behavioral care and services were provided to residents in need of these services. SSD stated that if a need was identified, a referral was sent to the provider and it was assumed professionals do their job. When asked how the facility determined the consult was completed, the SSD responded there was no mechanism in place to accurately determine care and services for mental and behavioral health are provided to meet the individual needs of residents. An immediate jeopardy situation was identified to the NHA on (MONTH) 9, (YEAR), at 2:25 p.m. related to the findings on (MONTH) 9, (YEAR), when it was revealed that the facility failed to provide needed care, services and supervision resulting in one resident's failure to improve and/or attain their highest practicable physical, mental, and/or psychosocial well-being. Resident R1 had multiple suicide attempts which resulted in harm by hanging on (MONTH) 5, (YEAR), and the resident subsequently expired on (MONTH) 12, (YEAR). The immediate corrective action plan included the following interventions: 1. Resident R1 was admitted to the hospital where he remains. 2. On (MONTH) 9, (YEAR), residents seen by the psychiatric team with a similar [DIAGNOSES REDACTED]. This will be completed by (MONTH) 10, (YEAR). On (MONTH) 10, (YEAR), their records will be reviewed for psychiatric visits/follow up and any residents not seen in the last 30 days will be identified to the psychiatrist, Nurse Practitioner and licensed Social Worker by (MONTH) 11, (YEAR). 3. The administrator, assistant administrator, DON, unit managers, and Social Workers have been educated on the process of coordinating with the social services department on any consults requested of the psychiatry/psychology vendors. Unit managers and social services will validate receipt of documentation from the vendors prior to their departing the premises on the date of service. All staff will be immediately educated, as they arrive on shift, on recognizing the signs and symptoms of depression and suicidal ideation not later than (MONTH) 12, (YEAR). 4. The Director of Social Service and/or designee will perform weekly audits on psychiatric visits for two months. The results of the audits will be reviewed by the Quality Assurance and Performance Improvement Plan, (QAPI) committee for revisions as needed. The Immediate Jeopardy was removed on (MONTH) 12, (YEAR), at 2:30 p.m. after it was verified that the corrective action plan was implemented. On (MONTH) 10, (YEAR), the progress of the facility plan of correction was reviewed. The SSD provided documentation to show that on the evening of (MONTH) 9, (YEAR), all residents were interviewed/assessed by either the SSD or the Assistant Director of Nursing to see if they were in need of psychiatric or behavioral health services. Resident R2, who was interviewed/assessed by the SSD, stated she was suicidal and she had a plan to carry out her suicide. The SSD stated that after discussion among the medical staff, it was decided to send the resident out to the hospital for evaluation. The resident was transferred to the hospital and was admitted for psychiatric evaluation and treatment. The resident was still in the hospital at the time the Immediate Jeopardy was lifted. The facility failed to implement interventions to maintain a safe and accident hazard free environment and failed to ensure that Resident R1 received adequate supervision related to a active [MEDICAL CONDITION] which caused actual harm, unresponsiveness, and transfer to the hospital for Resident R1, who expired on (MONTH) 12, (YEAR), and placed the residents at the facility in an Immediate Jeopardy situation. Quality of Care CFR(s): 483.25(d)(1)(2) - Previously cited [DATE] 28 Pa. Code 201.14 (a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(a) Management Previously cited [DATE] 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE] 28 Pa. Code 211.5(h) Clinical records 28 Pa. Code 211.11(c) Resident care plan Previously cited [DATE], [DATE] 28 Pa. Code 211.11(d) Resident care plan Previously cited [DATE] 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to maintain a safe and hazard free environment related to oxygen and medication storage, and failed to ensure that one of 30 residents reviewed received adequate supervision related to the previous removal of a tracheostomy which caused actual harm to the resident when the tracheostomy was removed for the second time and resulted in the residents death (Resident CL). Findings include: A review of the closed clinical record of Resident CL1 on [DATE], revealed that the resident was admitted to the facility on [DATE], after spending three months in an acute care hospital and an acute care rehabilitation center following a massive subarachnoid bleed (refers to bleeding within the subarachnoid space, which is the area between your brain and the tissues). Review of the admission nursing note dated February 16, 2017 revealed that Resident CL1 was non-verbal but could communicate by nodding her head yes or no. A review of the clinical record revealed that Resident CL1 had [DIAGNOSES REDACTED]., a ventricular-peritoneal shunt (a surgical procedure that treats [DIAGNOSES REDACTED] which occurs when excess cerebrospinal fluid (CSF) collects in the brain's ventricles), S/P ventilator dependent respiratory failure (a condition when a patient cannot breathe on his/her own. A ventilator is a breathing machine that is used to support the breathing and provide the lungs with oxygen and remove carbon dioxide from the body), dysphagia (difficulty breathing), S/P pe[DEVICE] insertion (Percutaneous Endoscopic Gastrostomy (PEG) is a medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) and neurogenic bladder (a bladder dysfunction, flaccid or spastic, caused by neurologic damage). Review of the progress note on February 17, 2017, at 1:57 a.m. revealed .Upon rounds, resident appeared agitated, seen attempting to pull out her trach (the tube into the windpipe) . On February 17, 2017, an order was obtained for bilateral hand mittens (thick mittens on both hands than can restrict movement of the fingers) at bedtime (6:00 p.m. to 6:00 a.m.). Further review of the progress note of February 19, 2017, at 12:10 a.m. revealed that at 11:00 p.m. on February 18, 2017, the charge nurse responded to the call by an incoming nursing assistant (NA). The resident was noted to be in bed with her trach completely out, staff immediately had to hyperextend (extend the neck beyond its normal limits to open the resident's airway) the resident's neck and reinserted the trach back into place. A small amount of blood was was noted around the insertion site. The resident was noted to be in respiratory distress. The physician was made aware and an order was given to send the resident to the Emergency Department for further evaluation. An interview on [DATE], at 1:00 p.m. with Employee E2, the Director of Nursing confirmed that the only new interventions added to the resident's plan of care upon her return from the Emergency Department were: (1) close supervision, and (2) hand mittens to prevent the resident from pulling the trach/peg out. The physician ordered Trazodone 50 mg (antidepressant used to treat depression and anxiety disorders) to be given at HS (hour of sleep). A review of the progress note on February 19, 2017, at 6:19 a.m. revealed that the .(resident) continues with periodic episodes of agitation and attempts to hold on to the trach. A review of the progress note on February 20, 2017, at 6:19 a.m. revealed .still continues with periodic episodes of agitation and have made several attempts to take the trach out . A review of a progress note on February 20, 2017, at 2:48 p.m. revealed that the, .resident trying to pull out her trach . A review of the progress note on February 20, 2017, at 10:54 p.m. revealed the, . Resident was also seen at about 6:30 p.m. for breathing treatment. Resident still had trach in and one mitten was off and mitten was replaced .at about 7:45 p.m., staff checked on resident. Resident was not responding and on thorough examination, staff noted that the resident's trach was out. CPR (Cardio-Pulmonary Resuscitation - an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart) was initiated. Resident was pronounced at 8:33 p.m. The facility failed to implement interventions and supervision to prevent a resident from harming herself, following the removal of a tracheostomy that caused actual harm to the resident when the tracheostomy was removed for the second time, and resulted in the residents death (Resident CL). The initial tour of the loading dock with Employee E8, the Dietary Director, on [DATE], at approximately 9:30 a.m. revealed the presence of two storage cabinets located behind the loading dock and adjacent to the trash compactor. Signage posted above each storage cabinet indicated that one cabinet contained oxygen tanks which were full and the second cabinet contained oxygen cabinets which were empty. Continued observation of the area located around the oxygen storage cabinets and the trash compactor revealed the presence of multiple cigarette butts on the ground. In addition, there was no posted signage present for No Smoking due to the presence of oxygen storage tanks. An interview with Employee E3, at the time of the observation, confirmed that the facility does have a designated smoking area for employees which is located on the other side of the facility. Further interview with the employee confirmed that no one should be smoking in this area. Further observation of the loading dock area on [DATE], at 11:30 a.m. with Employee E1, the Nursing Home Administrator, and Employee E9, the Medical Supply Director, revealed the presence of 30 full oxygen tanks in the storage cabinet labeled full and 11 full oxygen tanks present in the storage cabinet labeled empty. An interview with Employee E9 revealed that the facility received a delivery of oxygen tanks at approximately 9:30 a.m. and they didn't have enough room for the 41 full tanks in the full oxygen storage cabinet. Observation of the B Wing Nursing Station on [DATE], at 11:00 a.m. revealed the presence of one box of five Ben Gay patches and four Icy Hot patches (over the counter patches used for pain relief) present on the counter of the nurses station which was unattended by facility staff. The medications remained on the counter for approximately thirty minutes, unattended by staff, before Employee E3 removed the patches and placed them in a locked medication room for storage. Observation of one of two medication carts on the B Wing Nurses' Station on Friday, [DATE], at 12:30 p.m. revealed that the medication cart for resident rooms A1-B9, was left unlocked and unsupervised by the Licensed Nurse that was assigned to the medication cart. At the time of the observation, ambulatory residents and facility staff members and visitors were observed walking past the unlocked medication cart. At the time of the observation, an interview with Employee E17, a Licensed Nurse, confirmed that the medication cart was left unlocked and further indicated that the medication cart should never be left unlocked when unsupervised. A second observation of the same medication cart on Monday, [DATE], at 11:00 a.m. revealed that the Licensed Nurse assigned to the medication cart left it unlocked and residents, facility staff members and visitors were observed walking past the unlocked medication cart. At the time of the observation an interview with Employee E18, a Licensed Nurse, confirmed that the medication cart was left unlocked and further indicated that the medication cart should never be left unlocked when unsupervised. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE]

Based on observation, review of clinical records, and interview with facility staff, it was determined that the facility failed to implement interventions that are consistent with resident needs, monitor and evaluate the impact of the interventions, provide interventions necessary to prevent and worsening of a pressure ulcer for one of thirty resident, (Resident R22) resulting in actual harm. Findings include: Review of the clinical record for Resident R22 revealed a significant change MDS (Minimum Data Set assessment- a periodic assessment of resident care needs) assessment dated [DATE], which revealed a [DIAGNOSES REDACTED].), and a Gastrostomy (feeding tube). The MDS revealed Resident R22 was severely cognitively impaired (never/rarely unable to make decisions). The MDS revealed that Resident R22 was always incontinent of bowel and bladder and had functional limitations with impairment to the upper and lower side of her body. Furthermore, the same MDS stated Resident R22 was at risk for developing a pressure ulcer (a wound involving loss of the top layers of skin that may progress to loss of skin layers, exposing muscle and bone). Nursing documentation dated October 29, 2015 stated, during a.m. care CNA (certified nursing assistant) called and reported a skin issue. New orders for LAL (low air loss ) mattress . On assessment it was noted as a moist associated skin damage on Resident R22's sacrum. Resident (R22) noted with a ulceration to her sacrum measured 0.5 x 0.5 x 0.1 cm. Nursing documentation dated October 31, 2015 stated, resident is P/I (post incident) for M.A.S.D. (moisture associated skin damage, skin erosion cased by prolonged exposure to moisture such as urine and stool). Also on bed rest for 7 days. Wound care report dated November 9, 2015 documented a facility acquired wound on Resident R22 sacrum, measured 2.0 cm. x 1.5 cm. x 0.1 centimeters with drainage and measured 3.3 cm. x 2.5 cm x 1.2 cm on November 30, 2015. Wound care report dated December 7, 2015 documented the wound measured 4.0 cm. x 2.5 cm. x 1.2 centimeters with drainage. Wound care report dated January 18, 2016 documented the sacral wound as now a Stage IV pressure ulcer measuring 6.0 cm. x 5.0 cm x 1.0 centimeters with serosanguineous (blood and watery fluid) drainage. Resident R22 was seen by Wound Consultant for wound management. Documentation from the wound consultant dated January 28, 2016, stated, patient returned from the hospital with sacral wound debrided in the hospital. Stage IV pressure ulcer (previously unstageable). Contributing diagnosis : urinary/fecal incontinence, poor mobility. Stage IV pressure ulcer measured 5.5 cm x 4.5 cm. x 1.0 centimeters with undermining noted from 6-12 o'clock by 7.2 centimeters. Interventions in place: Low air loss mattress Resident R22 Care plan effective dated April 1, 2011 to current stated , Potential for skin breakdown, related to incontinence. Keep skin clean and dry; provide peri care after each incontinent episode. Observe skin condition daily; weekly skin assessment by licensed nurse. Resident R22 care plan effective dated November 20, 2015 to current stated, impaired skin integrity related to pressure ulcer to sacrum, preventive interventions as delineated on the pressure ulcer prevention care plan (low air loss mattress, gel cushion and heel lift boots). Physician treatment order's dated December 1, 2015 to December 31, 2015 stated, pressure relieving mattress to bed every shift. There was no documented evidence of completion or signature for December 19, for first and second shift, and December 25th. for third shift as being completed. Physician treatment order's dated January 1, 2016 to January 31, 2016 stated, Apply LAL mattress to bed every shift. Check placement/inflation every shift. No documentation,evidence of completion or signature for January 16 th and 31 st. On February 5, 2016 at 11:00 a. m. copies of the above were presented to the DON Employee E2. Employee E2 stated, I am aware of the problem, it is in black and white that they were not done. On February 2, 2016 at 09:45 a.m., during the initial tour of the 4th floor, it was observed with the unit manager, Employee E19 that Resident R22's low air loss mattress was alarming. Employee E19 stated, it should be not be turned off, and was not aware of how long it was off. On February 3, 2016 at 9:55 a.m., it was observed with Resident R22's nurse, Employee E9, that Resident R22 mattress was on standby and not working properly. Employee E9 stated, Someone giving care never put it back on. I don't know how long it has been off. On February 3, 2016 at 12:25 wound care was observed on Resident R22, done by Employee E8 licensed nurse). Sacral wound measured approximately 6.5 cm x 5.0 cm x 1.5 cm with noted large amounts of serosanguineous drainage. Observed tunneling (enlargement/undermining of the wound) on sacral area approximately 9 o'clock. Employee E8 stated, Two and a half months ago family wanted her out of bed. The moisture on her sacral area turned into a non-stageable pressure ulcer. She ( Resident R22) went to get it debrided (surgical procedure to cut away dead tissue) 2-3 weeks ago and came back with a Sacral Stage IV. The facility failed to implement interventions, monitor current interventions and failed to prevent the worsening of a pressure ulcer for one of thirty residents, Resident R22 resulting in actual harm to the Resident. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/13/15 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/13/15 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 3/13/15 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 3/13/15 and 10/19/15