Every finding on record at Inglis House

Based on review of facility policy, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure resident call bells were answered in a timely manner and in accordance with resident needs for 3 of 12 residents reviewed (Resident R12, R10, and R6).Findings include: Review of facility policy titled Call bell response, dated June 3, 2025, revealed When activated, call bell system is to be answered immediately by any team member or assign staff. Interview with Resident R12 on August 18, 2026, at 11:45 a.m. revealed The call bell wait times are excessive, at times they get over 30 minutes. What if someone really needs something or if someone fell or is dying? They don't care. They don't answer. Interview with Resident R10 on August 18, 2026, at 12:05 p.m., revealed The call bells can sometimes take a while, like 20 minutes or more, and when they do help, they come in with an ear plug in their ear and they are talking to someone else and not really paying attention to you. Observation of nursing station on August 18, 2026, at 12:10 p.m., revealed nurse wearing an air pod in her right ear. Interview with Employee E2, Director of Nursing on August 18, 2026, at 2:00 p.m. confirmed that nurse was wearing air pod in her ear on the nursing unit and told to take it out. Interview with Resident R6 on August 18, 2026, at 12:12 p.m. revealed They have a real problem with people answering call bells, there is good staff that do their job and then really bad staff that don't even bother to help or answer calls. Review of facility call bell audit reports for nursing unit 3 south, dated August 10, 2026, through August 11, 2026, revealed the following: August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 2:12 a.m.; staff response time was 17 minutes 08 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 5:14 a.m.; staff response time was 18 minutes 42 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 5:55 a.m.; staff response time was 20 minutes 42 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 8:22 a.m.; staff response time was 53 minutes 21 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 10:49 a.m.; staff response time was 28 minutes 38 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 11:02 a.m.; staff response time was 28 minutes 50 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 11:21 a.m.; staff response time was 17 minutes 24 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 4:04 p.m.; staff response time was 17 minutes 06 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 4:21 p.m.; staff response time was 33 minutes 15 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 6:16 p.m.; staff response time was 22 minutes 09 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 6:38 p.m.; staff response time was 34 minutes 03 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 7:03 p.m.; staff response time was 24 minutes 13 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 7:35 p.m.; staff response time was 22 minutes 07 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 7:38 p.m.; staff response time was 35 minutes 12 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 7:56 p.m.; staff response time was 17 minutes 25 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 4:04 p.m.; staff response time was 19 minutes 33 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 4:04 p.m.; staff response time was 15 minutes 38 seconds. August 10, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 10:32 p.m.; staff response time was 16 minutes 13 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 12:26 a.m.; staff response time was 36 minutes 09 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 6:19 a.m.; staff response time was 19 minutes 32 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 10:01 a.m.; staff response time was 26 minutes 31 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 10:35 a.m.; staff response time was 16 minutes 12 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 10:40 a.m.; staff response time was 23 minutes 53 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 4:42 p.m.; staff response time was 19 minutes 45 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 6:28 p.m.; staff response time was 18 minutes 07 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 6:34 p.m.; staff response time was 18 minutes 00 seconds. August 11, 2026, room [ROOM NUMBER] S, Bed 1, call placed at 11:01 p.m.; staff response time was 24 minutes 16 seconds. Interview with Employee E1, Nursing Home Administrator on August 17, 2026, at approximately 2:00 p.m. revealed I would consider 30 minutes excessive for a resident to wait. Interview confirmed findings on call bell audits. 28 Pa. Code 211.12 (d) Nursing services

Based on review of facility policy, review of facility documentation, observations, and interviews with staff and residents it was determined that the facility failed to provide timely assistance with activities of daily living care for dependent residents for 3 of 10 residents reviewed (Resident R2, R9 and R6).Findings Include:Review of facility grievance records from January 2026 through June 2026 revealed ongoing concerns regarding staff responsiveness and timeliness of care. The monthly grievance logs documented repeated complaints involving delayed incontinence care, residents not awakened for care services, and delays in responding to resident requests.Review of Resident R2's Minimum Data Set (MDS- federally mandated resident assessment and care screening) dated March 22, 2026, revealed the resident is cognitively intact, able to communicate his/her needs and preferences, and has a suprapubic catheter (urinary drainage tube that is surgically inserted through the abdominal wall directly into the bladder to continuously drain urine).Further review of Resident R2's MDS revealed the resident has diagnoses of neurogenic bowel (loss of normal bail function due to neurological condition affecting the nerves that control the bail elimination), paraplegia (paralysis affecting the lower half of the body including both legs), and multiple sclerosis (a chronic progressive disease of the central nervous system that can impair movement sensation and bodily functions).Interview on June 16, 2026, at 8:20 a.m., with Resident R2 the resident reported his/her urinary catheter was leaking, and that nursing staff was informed. Resident R2 reported waiting for a nurse to address the issue.Interview June 16, 2026, at 8:20 a.m., with the Unit Manager, Employee E14, confirmed awareness of the leaking catheter but, was administering medications and would address the concern later.Observation on June 16, 2026, at 9:51 a.m. revealed Resident R2 received care, approximately 1.5-hours after assistance was requested.Observations on June 16, 2026, at 8:30 a.m. revealed Resident R9 and R6 were eating breakfast.Interview June 16, 2026, at 8:30 a.m. with Resident R9 revealed his/her brief was wet, and incontinence care had not been provided since the previous night. Subsequent interview with Resident R6, the resident also reported not receiving incontinence care since the night before. Resident R6 revealed this is a frequent occurrence, and he/she is often left in a soiled or wet brief for extended period of time.Interview on June 16, 2026, at 8:45 a.m. with Registered Nurse, Employee E13, confirmed that Resident R9 and R6 were eating breakfast and had not yet received morning incontinence care or brief changes.28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of personnel files and staff interviews it was determined that the facility failed to ensure licensed, direct-care staff maintained current certification in Cardiopulmonary Resuscitation (CPR) for one of four personnel files reviewed (Employee E15). Findings Include: Review of personnel file for Respiratory Therapist, Employee E15, revealed the employee had an expired CPR certification (Cardiopulmonary Resuscitation -lifesaving procedure that maintains blood flow and oxygen to the brain and heart when the heart or breathing stops). Interview on [DATE], with Respiratory Therapist, Employee E15, confirmed CPR training was not renewed. Interview on [DATE], with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed Respiratory Therapist, Employee E15, had an expired CPR certification. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to administer medications in accordance with physician orders for one of ten residents reviewed (Resident R4). Findings Include:Review of facility policy titled General Medication Procedures, revised September 3, 2025, revealed the purpose of the policy is to ensure residents receive medications in a timely manner, maintain continuity of prescribed therapeutic regimens, ensure prompt administration of initial medication doses, and provide medications in accordance with physician orders. The policy establishes that nursing staff are responsible for ensuring medications are available, accurately prepared, administered timely, and monitored to ensure residents receive prescribed medications without unnecessary delay or interruption. Observation on June 16, 2026, at 10:21a.m. revealed restorative aid, Employee E18, responded to Resident R4's activated call bell. When the call-bell was answered, Resident R4 reported he/she was still waiting to receive morning medications and requested that restorative aide, Employee E18, notify the nurse to administer his/her medications.Review of Resident R4's clinical record revealed a physician order for baclofen (muscle relaxant) 20 milligram one tablet three times daily scheduled for administration at 8:00 AM, 2:00 PM and 10:00 PM.Further review of Resident R4's clinical record revealed a physician order for gabapentin 800 milligram two tablets three times daily for pain scheduled for administration at 8:00 AM, 2:00 PM and 10:00 PM.Interview June 16, 2026, at 10:55 AM, with Licensed Nurse, Employee E19, confirmed Resident R4 had not yet received Baclofen and Gabapentin that were scheduled for administration at 8:00 a.m.28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of ten residents reviewed (Resident R1).Findings Include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], has a BIMS (brief interview for mental status) score of 15 (indicating intact cognitive function), and requires set-up assistance for eating.Review of Resident R1's clinical record revealed the resident has diagnoses of thyroid disorders (condition in which the thyroid has not produced hormones at proper levels affecting metabolism energy overall body function), paraplegia (often caused by spinal cord injury or disease resulting in the loss of movement and sensation), attention deficit hyperactivity disorder (ADHD- characterized by persistent patterns of inattention, hyperactivity, and impulsivity), and anxiety (fear or nervousness). Review of Resident R1's comprehensive care plan revealed the resident's diagnosis of hyperthyroidism and ADHD has the potential to affect the resident's nutritional status and weight.Further review of Resident R1's comprehensive care plan dated September 13, 2023, revealed the resident is at risk for nutritional problems with interventions in place to monitor weight status, adherence to prescribed diet, providing nutritional supplements as ordered, educating the resident regarding malnutrition risks, and having the Registered Dietitian evaluate the resident and make dietary recommendations as needed.Review of Resident R1's clinical record revealed the following weight history:03/18/2026 180.2-pounds04/02/2026 175.2-pounds04/22/2026 174.2-pounds05/09/2026 172.2-pounds05/21/2026 168.2-pounds06/02/2026 166.2-pounds.Review of resident R1's weight records revealed the resident's weight declined from 180.2 pounds on March 18, 2026, to 166.2 pounds on June 2, 2026, representing a 14-pound (7.8%) loss in approximately 76 days, meeting CMS (Centers for Medicare and Medicaid Services) criteria for significant weight loss within a 90-day period.Review of Resident R1's clinical record revealed a nutritional assessment completed on April 20, 2026. Resident R1 was assessed with a weight of 176.8-pounds and no significant weight changes were documented.Review of Resident R1's clinical record revealed the resident's weight continued to trend down to 166.2-pounds, sustaining another 10.6-pound significant weight loss since the last nutrition assessment completed April 20, 2026. Further review of resident R1's clinical record revealed no documented evidence the significant weight loss was reviewed or addressed.Interview on June 16, 2026, at 1:30 p.m. with Registered Dietitian, Employee E5, confirmed Resident R1 sustained a significant weight loss. Further interview with Registered Dietitian, Employee E5, revealed re-weights were ordered but not yet completed. 28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on staff interviews and observations, it was determined that the facility failed to ensure that resident call bells were within reach of them for 4 out of 5 residents observed (Resident R3, R4, R5, and R6). Findings include: During an observation on the 1 North nursing station, the following residents were observed in their rooms with call bells that were not within their reach. During an observation on May 14, 2026 at 3:17 p.m. Resident R3 was observed in the room lying in bed with the call bell hanging off the back of the bed where the resident could not reach the call bell. Licensed nurse (Employee E4) was present for this observation, picked the call bell up and placed it within the resident's reach. During an observation on May 14, 2026 at 3:20 p.m. Resident R4 was observed in their room lying in bed with the call bell on the floor, on the floor in the back of the bed. Licensed nurse (Employee E4) was present for this observation, picked the call bell up and placed it within the resident's reach. During an observation on May 14, 2026 at 3:25 p.m. Resident R5 was observed was observed in their room lying in bed with call bell hanging off the back of the bed, on the floor in the back of the bed. Licensed nurse (Employee E4) was present for this observation, picked the call bell up and placed it within the resident's reach. During an observation on May 14, 2026, at 3:26 p.m. Resident R6 was sitting in his wheelchair watching television. The resident's call bell was observed hanging from the right side of his bed (when walking in the room,) on the floor where the resident would not be able to retrieve it should had need to due to his physician impairments. During this time, the Nursing Home Administrator (NHA) was notified, and came into the resident room, picked the call bell up, and placed it within the resident's reach. During a discussion with the Nursing Home Administrator (NHA) on May 14, 2026, at 3:45 p.m. it was discussed concerns with the NHA regarding the residents not having their call bells within their reach during room observations on unit 1 north. 28 Pa. Code 211.12(d)(1) Nursing services

Based on staff interviews, review of clinical records, and the review of facility documentation, it was determined that the facility failed to ensure that a resident received incontinence care in a timely manner for 1 out of 2 residents reviewed (Resident R1). Findings include: Review of the May 2026 physician's orders included the following diagnosis: multiple sclerosis ( a neurological illness that can cause numbness, weakness, trouble walking, vision changes and other symptoms); cognitive communication deficit (occurs when a person struggles to communicate effectively due to underlying cognitive impairments such as attention, memory, executive function, or social cognition, rather than a primary language or speech disorder); intellectual disabilities (limitations in an individual's mental abilities that affect intelligence, learning and everyday life skills); muscle weakness; lack of coordination, and unsteadiness on feet. Review of the resident's person-centered plan of care with a revision date of May 25, 2026, included a plan of care for bowel and urine incontinence, and indicated that the resident needed disposable briefs, and needed to be changed prn (as needed). Continued review of the resident's person-centered plan of care indicated that the resident needed the assistance of 1 staff member to assist the resident with the activity of daily living related to toileting. Review of the resident's plan of care indicated that the resident required the use of a manual wheelchair. Review of the resident's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's need) dated February 24, 2026, indicated that the resident was awake, alert and oriented. Review of information submitted to the state survey agency on May 3, 2026, reported concerns with care and services that the resident needed during the 7:00 a.m. through the 3:00 p.m. nursing shift that were not provided by the facility in a timely manner on May 3, 2026. The concerns with care and services included concerns that the resident reported to a family member and was observed by the complainant during a video call with the resident sitting in urine-soaked clothing. The information submitted to the state survey agency also indicated that the above referenced incident was reported by resident/observed by the resident's member at 11:00 a.m. during their call, and at 11:45 a.m. both the complainant and the resident ended their video chat, and the complainant asked the resident to call her back once staff has changed her. Continued review of the information reported to the state survey agency indicated that the resident contacted the family member a 2nd time at 1:30 p.m. during her lunch meal and informed the complainant that she still had not been changed from when they spoke on the video chat earlier in the day. Review of the facility's investigation regarding the incident indicated that on May 4, 2025 at 1:20 p.m. the resident was interviewed by staff, but the interview documented indicated that (she/he) was not directly asked about the incident that occurred the day prior that was reported to the facility to rule out resident neglect. Review of the unsigned typed statement from the resident's friend (Resident R2) on May 6, 2026, at 1:00 p.m. documented that Resident R2 reported that the resident had an accident prior to or after arrival to (her/his) room, and that Resident R1 was at her doorway requesting assistance from staff for approximately 10-20 minutes. Resident R2 reported that staff eventually entered Resident R1's room Review of the undated statement regarding a complaint reported from the resident's assigned nurse aide (Employee E3) indicated that that resident was provided care to the resident in the morning, and that less than a half hour afterwards, the nurse aide stated that she received a message that the resident was wet. The nurse aide reported that she served the resident her lunch in her room, finished serving the other residents, collected resident trays after lunch, and then told Resident R1 that she was going to eat her lunch prior to changing her. Continued review of the nurse aide's statement documented that when the nurse aide was eating her lunch, a 2nd call came into the facility regarding concerns with Resident R1 needing assistance being changed. The nurse aide statement indicated that she stopped eating when she was notified of the 2nd call and went to provide incontinence care to the resident. During a discussion with the Nursing Home Administrator (NHA) and the Assistant Nursing at 12:01 p.m. the investigation was reviewed and it was discussed that the resident did not receive incontinence care in a timely manner It was discussed hat as the nurse aide was aware that the resident needed to be changed prior to the nurse aide serving the resident her lunch, prior to the nurse aide serving the other resident their lunch, prior to the nurse aide collecting lunch trays after the resident and other residents were done eating, and prior to the nurse aide eating her lunch. It was discussed that the nurse aide was notified again after a 2nd call came in when the nurse aide was eating her lunch, and that per the nurse aide's statement, it was not until this time that the nurse aide finally went to the resident's room to assist her with incontinence care. 28 Pa. Code 211.10( d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to maintain a homelike environment in one resident's room on one of five units. (Resident R22). Findings include: Review of Resident R22's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of hemiplegia and hemiparesis (one-sided weakness or loss of mobility) following a cerebral infarction (stroke) effecting the right dominate side and legally blind. Review of Resident R22's care plan revealed the resident required extensive assistance from staff for the resident's activities of daily living. Observations during interviews with Resident R22 on February 25,26, and 27, 2026 at approximately between 1:00pm-1:30 p.m. revealed the resident's bed was not made. The resident appeared upset by this and mentioned it often. This was confirmed with the Director of Nursing on February 27, 2027, at 1:30 p.m. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 PA Code 211.12(d)(1) Nursing services

Based on review of facility policy, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that a lateral transfer was carried out with two caregivers as required for one of 36 residents (Resident R9).Findings include: Review of facility policy titled Lifting and Transfer of Residents, most recently revised on June 1, 2025, revealed that At least two staff members are required to perform the transfer safely to minimize risk of injury and When a transfer requires two or more caregivers, both staff members should be actively involved throughout all elements of the transfer. Review of clinical documentation revealed that Resident R9 was admitted to the facility on [DATE], and had diagnoses including, parkinsonism (a neurological syndrome with symptoms that may include slow movement, stiffness, tremors while at rest, and unstable posture) contracture of muscle (a permanent tightening of muscles, ligaments or skin, which causes rigid and inflexible joints, limiting their movement), aphasia (difficulty or inability to speak), and dementia. Further review revealed a fall incident which happened on January 18, 2026. Review of the documentation submitted to the State Survey Agency stated that after she received a shower the resident returned to her room with the CNA (nurse aide) [and].slipped off the shower trolley on to the floor. The record noted that the resident sustained no obvious injury and displayed no signs or symptoms of pain.A witness statement from the nurse aide, Employee E5, stated that she put the trolley rail down [Resident R9] slipped out and fell off the trolley. It was never my intention to transfer her alone; I was just getting her ready in that way so when I called the other CNA she was ready to be transferred.An interview with Employee E2, the Director of Nursing, on February 27, 2026, at 12:10 p.m., she stated that prior to getting a second nurse aide to help her, the nurse aide had lowered the bedrail in preparation of positioning the shower trolley next to the bed, but that the resident had fallen before the trolley had been placed against the bed due to tremors from her Parkinsonism. Employee E2 confirmed that it is facility practice not to start the transfer process, including lowering bedrails, prior to the arrival of a second person. She also confirmed that Employee E5 had failed to follow that protocol, which resulted in Resident R9 falling. 28 Pa. Code 201.14. (a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing care services

Based on review of clinical records, facility documentation, review facility policy and interview with residents and staff, it was determined that the facility failed to provide appropriate pain management for one of 36 residents reviewed. (Resident R86) Findings include: Review of facility policy on Pain Management with effective date: December 1, 2006 and revision date: February 21,2022, revealed that under section purpose to establish the measurement and intervention to be applied for pain management under section policy number one the residence level of pain will be assessed routinely and is needed the assessment will use assessment tools and reforms approved by English house to measure and document the resident's pain. Under section definition pain intensity may be described using a number on a 10-point scale or by the terms mild moderate severe and excruciating. Numeric pain scale verbal residence or residents who can communicate via adapted technology will have the pain assessed using the numeric pain scale: 0 none. 1 to 3 mild, 4 to 6 moderate, 7 to 10 severe. Review of Resident R86's clinical record reveal that Resident R86 was admitted to the facility on [DATE], with diagnosis of Multiple Sclerosis (disease that cause breakdown of the protective covering of the nerve) and Chronic Pain Syndrome. Review of Resident R86's clinical record revealed a physician's order for: Acetaminophen tablet 325 milligrams (mg), give 650 mg by mouth every four hours as needed for pain- mild, not to exceed 3000 mg of Acetaminophen daily., with a start date of November 26, 2025. Further review of Resident R86's clinical record revealed a physician's order for: Oxycodone HCl capsules 5mg, give 2 tablets by mouth every 6 hours as needed for moderate to severe pain do not give within two hours of receiving Oxycodone extended-release tablet 10 mg with a start date of December 14, 2025. Review of Resident R86's medication administration record (MAR) revealed that on February 15, 2025, at 5:48PM, Resident R86 had a pain scale of 9 and was administered Acetaminophen tablet 650mg by mouth every four hours as needed for mild pain. Further, Resident R86 did not receive Oxycodone HCl capsules 5mg, give 2 tablets by mouth every 6 hours as needed for moderate to severe pain. Further review of Resident R86's MAR revealed that on February 16, 2025, at 5:36AM, Resident R86 had a pain scale of 7 and was administered Acetaminophen tablet 650mg by mouth every four hours as needed for mild pain. Further, Resident R86 did not receive Oxycodone HCl capsules 5mg, give 2 tablets by mouth every 6 hours as needed for moderate to severe pain. Interview with Resident R86 conducted on February 24, 2026, at 12:29PM revealed that the week before, Resident R86 was in pain and did not receive (her/his) oxycodone. Interview with Director of Nursing Employee E2 conducted on February 27, 2026, at 12:39 PM revealed that there was on issue with Resident R86's prescription on February 16, 2026. Further Employee E2 confirmed that on February 16, 2025, at 5:36AM, Resident R86 had a pain scale of 7 and was administered Acetaminophen tablet 650mg by mouth, which was ordered for mild pain instead of Oxycodone HCl capsules 5mg, give 2 tablets by mouth for moderate to severe pain. Further Employee E2 revealed that pain scale was as follow: Mild: 1-3, Moderate: 4-6, severe: 7-10. 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to ensure the use of outside resources for one of 36 residents reviewed (Resident R135).Findings Include: Review of Resident R135's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 29, 2026, revealed the resident was cognitively intact and had diagnosis of obstructive sleep apnea (sleep disorder where the airway repeatedly becomes blocked during sleep, causing pauses in breathing and disrupted sleep). Review of Resident R135's comprehensive care plan dated July 25, 2024, revealed the resident had altered respiratory status/difficulty breathing related to diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident R135's clinical record revealed an After Visit Summary dated October 9, 2026, that the resident was seen at the Sleep Disorder Center for sleep apnea. Discharge instructions included a scheduled follow-up on October 15, 2025, to perform a sleep study. Review of Resident R135's clinical record revealed a progress note dated October 14, 2025, that on October 13, 2025, the nursing supervisor and Director of Nursing, Employee E2, met with Resident R135 at bedside. Resident R135 complained of right ear pain and the resident was informed the sleep study would be put on hold pending an update from pulmonology. Continued review of the progress note dated October 14, 2025, revealed the facility had placed a call to the sleep center and made them aware Resident R135 required assistance for activities of daily-living help. The sleep center denied being able to help the resident for any transfer, and care. Interview on February 27, 2026, at 12:30 p.m. with Resident R135 revealed his/her sleep study appointment was cancelled and that the facility did not further coordinate to reschedule the appointment. Review of Resident R135's entire clinical record revealed no documented evidence that the facility coordinated nursing services to accommodate the resident during a sleep study. There was no evidence that the facility re-schedule Resident R135's sleep study with the center. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation an interview with staff it was determined that the facility failed to implement an effective infection control program related to handwashing and laundry services.Findings include: Review facility policy on handling linens with vision date of February 27, 2026, revealed at under section Purpose: To ensure the health and safety of [NAME] House staff and residents. All linen is handled, stored, transported, and processed in a manner that will prevent contamination and maintain a clean environment. [NAME] section Policy: This policy establishes the guideline for the proper handling and storage of clean and soiled linen. Under section Procedure: #12. Laundry service workers who collect, transport, and handle used linen/laundry must use personal protective equipment (PPE). Gowns, gloves and masks with eye shields will be kept in the laundry area for this purpose. Masks are only necessary if there is potential for being splashed with blood or body fluids. Observation of the soiled linen storage conducted on February 26, 2026, at 9:46AM with Director of Environmental Services Employee E3 and Employee E4 Environmental Services supervisor revealed that soiled linens were stored in an area where folded boxes and other items were also stored. Further observation of the area where the soiled linens were stored revealed that there were no hand-washing facilities, there was no hand sanitizers, there were no Personal protective equipment (PPE-gowns, gloves and masks), and no garbage bins for disposing PPE's observed in the area where the soiled linens were stored. Interview with Employee E3, Director Environmental Services and Employee E4, Environmental Services supervisor confirmed that There were no hand washing facilities no hand sanitizers no personal protective equipment (PPE-masks, gown, gloves) and no garbage bins for disposing used PP's in the area where the soiled linens were stored further employee and employee also confirmed that there were other items stored in the same area where the soiled linens were stored. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1) Nursing services

Based upon review of resident records and interview with staff determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of residents' transfers and/or discharges for two of 36 resident records reviewed (Resident R68, R181). Review of Resident R678's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of chronic kidney infection and heart failure. Continued review of the resident's clinical record revealed that the resident was transferred to the hospital on January 22, 2026 and February 13, 2026, due to unplanned emergencies. Interview with the Nursing Home Administrator on February 27, 2026, at,1:00 p.m. revealed the State Long-Term Care Ombudsman was not notified of Resident R68 transfers to the hospital. The NHA explained the staff member in charge of notifying the ombudsman no longer is employed at the facility. Furthermore, the NHA indicated that the notification letters have not been sent approximately since September 2025. Review of Resident R181's clinical record revealed that the resident was admitted to the facility on [DATE], and discharged to home on December 9, 2025. Interview with the Employee E1, the Nursing Home Administrator, on February 27, 2026, at,1:00 p.m. revealed the State Long-Term Care Ombudsman was not notified that Resident R68 transfer to the hospital, or that Resident R181 was discharged to home. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(2) Management

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that pain management was provided consistent with professional standards of practice, for one of 6 sampled residents (Resident R1).Findings include:A clinical record review revealed Resident R1 was admitted to the facility on [DATE], with diagnoses that include polyneuropathy ( condition damaged to multiple peripheral nerves leading to pain, weakness and sensory loss), trigeminal neuralgia (condition causes intense pain similar to an electric shock on the side of the face), paraplegia (form of paralysis affects the lower body) and chronic pain.Resident R1's care plan, initiated on May 24, 2024, identified a goal for the resident to verbalize pain adequate relief of pain or ability to cope with incompletely relieved pain. The care plan included an intervention to administer routine pain medication regime as order. A physician's order for Resident R1 to be administered Lyrica 75 mg give 1 capsule by mouth two times a day for neuropathy hold for confusion or lethargy initiated on August 27, 2025 and discharged on September 9, 2025.On October 15, 2025 at 10:49 a.m. Resident R1 was interviewed and reported she had severe pain during in her upper body the evening shift on September 9, 2025. The doctor wanted to increase her Lyrica dose from 75 mg to 100 mg. The doctor stopped the 75 mg dose at 4:39 p.m. on September 9 and gave a new order for 100 mg at 9:00 a.m. the next day. Because of this, Resident R1 did not get her usual 5 p.m. Lyrica dose on September 9.On October 15, 2025, at 12:35 p.m., an interview with the Director of Nursing, Employee E1, revealed information from the September 2025 Medication Administration Report (MAR). The facility physician increases Resident R1's Lyrica dose from 75 mg to 100 mg. The physician discontinued the 75 mg order at 4:39 p.m. on September 9 and wrote a new order for 100 mg at 9:00 a.m. the next day. As a result, Resident R1 did not have a routine Lyrica order for the evening of September 9, 2025.It was further revealed, based on a written statement from the evening licensed nurse, Employee E7, dated September 9, 2025, that she reported this concern to the evening supervisor during medication administration, which took place between approximately 4 p.m. and 6 p.m. The statement further outlined: At around 9 p.m., Resident R1 approached me again and asked about her medication, expressing that she was in severe pain. I checked to see if the order was ready so I could administer it, but this time the order was not showing up at all. I then called the supervisor's office to speak.According to the Medication Administration Record (MAR), a Lyrica order for 100 mg was initiated on September 9, 2025, at 9:30 p.m. and was administered at 10:12 p.m.In the same interview, the Director of Nursing, Employee E1, confirmed that the Lyrica order was not administered on time.28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to provide pressure ulcer treatment consistent with standards of professional practice for one of three residents reviewed (Resident R1).Findings Include:Review of facility policy Skin Integrity: Wound Monitoring revised September 22, 2016, revealed when a new wound is identified the licensed nurse will measure the wound and document findings in the electronic medical record (EMR), and notify the Registered Nurse, and Physician. The physician's order for wound care treatments should include cleansing agent, frequency, and dressings as indicated. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body). Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear. Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day. Instructions specified to cleanse the areas with normal saline solution, apply skin prep, and leave open to air. Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium. Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Licensed Nurse, Employee E3, aware of a new wound on his/her right ankle. Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's booties to assess the area and observed a foam dressing applied to the right heel. Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on. Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area. Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth). Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Review of Resident R1's entire clinical record revealed no documented evidence that licensed nurse, Employee E5, measured the wound and documented findings of the assessment in the EMR. Further review of Resident R1's clinical record revealed no documented evidence that the Registered nurse or Physician were notified of the new skin impairment or obtained treatment orders for the area. Interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift when this employee went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage on the back of his/her ankle because it was bleeding. Licensed Nurse, Employee E5, subsequently applied a foam dressing to the back of Resident R1's right ankle. Review of Resident R1's June 2025 Physician orders and Treatment Administration Record revealed no treatment orders were obtained to the resident's right ankle. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a pressure ulcer for one of three residents reviewed (Resident R1). Findings Include:Review of facility policy Abuse, Neglect and Exploitation revised August 19, 2025, revealed the facility will thoroughly investigate all reports of suspected or alleged abuse, and neglect; as well as all injuries of unknown origin to rule out potential abuse. Documentation pertinent to the investigation shall consist of written signed statements from the resident and witnesses. Interviews should be inclusive of employees (on all shifts) having contact with the resident during the period of the alleged incident. Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body). Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear.Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day. Instructions specified to cleanse with normal saline solution, apply skin prep, and leave open to air.Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium.Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Wound Nurse, Employee E3, aware of a new wound on his/her right ankle. Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's booties to assess the area and observed a foam dressing applied to the right heel. Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on. Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area. Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth). Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Further review of employee statement by nurse aide, Employee E4, revealed Resident R1 informed nurse aide, Employee E4, that when the nurse aide from 7:00 a.m. to 3:00 p.m. shift (identified as nurse aide, Employee E7) was putting his/her shoes on a scab on the foot must have fallen off causing the skin impairment.Review of facility documentation and facility investigation revealed no documented evidence that the facility obtained a statement by licensed nurse, Employee E5 or nurse aide, Employee E7.Interview on August 25, 2025, at 12:30 p.m. with licensed nurse, Employee E3, confirmed it was Resident R1 who made this employee aware of new skin impairment to the right ankle. Licensed nurse, Employee E3, was unsure who applied the foam dressing to Resident R1's ankle and was further unsure when the area had opened. Interview on August 25, 2025, at 2:15 p.m. with Director of Nursing, Employee E2, confirmed no statement was obtained by licensed nurse, Employee E5, or nurse aide, Employee E7. 28 Pa. Code 211.12 (d)(1) Nursing services.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to timely notify the physician of a new skin impairment for one of three residents reviewed (Resident R1).Findings Include:Review of facility policy Notification of Change in Resident Status/Condition revised October 15, 2016, revealed the nurse will contact the physician to report nursing assessment/observations involving incidents, accidents, and significant changes in physical status. The nurse will obtain new orders as warranted from the physician, and these orders will be documented in the electronic medical record.Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 27, 2025, revealed the resident was cognitively intact and had a diagnosis of paraplegia (paralysis of the legs and lower body).Continued review of Resident R1's MDS revealed the resident was at risk of developing pressure ulcers/injuries (localized damage to the skin and underlying tissue caused by prolonged pressure, shear, or friction) and was dependent (helper does all the effort) on staff for putting on/taking off footwear.Review of Resident R1's clinical record revealed a physician order dated July 6, 2024, and July 10, 2024, for skin prep to right medial ankle and right heel every day. Instructions specified to cleanse with normal saline solution, apply skin prep, and leave open to air.Review of Resident R1's wound evaluation dated June 24, 2025, revealed the resident had a Stage 3 (full thickness tissue loss in which the skin injury has gone through the skin into the fat tissue) Pressure Ulcer to the mid back inferior and Stage 4 (the most severe stage of a pressure sore, with damage to all layers of the skin, exposing muscle, tendon and bone and has a high risk of infection) Pressure Ulcer to the left ischium.Review of Resident R1's clinical record revealed a nursing note dated June 29, 2025, by Licensed Nurse, Employee E3, that indicated while this nurse was providing wound care for Resident R1's previously documented wounds (mid back and left ischium) Resident R1 made the Licensed Nurse, Employee E3, aware of a new wound on his/her right ankle. Continued review of the nursing note dated June 29, 2025, revealed Licensed Nurse, Employee E3, subsequently removed Resident R1's heel boots (specialized footwear designed to prevent pressure ulcers on the heels of patients confined to bed or chairs for extended periods) to assess the area and observed a foam dressing applied to the right heel. Resident R1 reported to the Licensed Nurse, Employee E3, that he/she noticed the heel bleeding a lot during his/her shower and that his/her shoes were difficult to put on. Review of facility incident/accident investigation summary dated June 29, 2025, written up by Registered Nurse, Employee E6, revealed on June 29, 2025, while Licensed Nurse, Employee E3, was providing wound care for Resident R1, the resident stated he/she had a new wound to the right heel/ankle area. Licensed nurse, Employee E3, subsequently notified the unit manager who further assessed the new skin impairment as a stage 3 pressure wound measuring 3.5 centimeters (cm) (length) by 4.0 cm (width) by 0.3 cm (depth). Continued review of facility investigation revealed an employee statement by nurse aide, Employee E4, dated July 1, 2025, which revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift while nurse aide, Employee E4, was giving Resident R1 a shower the employee noticed the resident's heel bleeding and subsequently reported it to the licensed nurse, identified as Employee E5. Review of Resident R1's entire clinical record revealed no documented evidence that licensed nurse, Employee E5, documented a wound assessment, notified the physician of the new skin impairment or obtained treatment orders for the area. Interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, revealed on June 27, 2025, during the 3:00 p.m. to 11:00 p.m. shift when this employee went to Resident R1's room, the resident had asked Licensed Nurse, Employee E5, to put a bandage on the back of his/her ankle because it was bleeding. Licensed Nurse, Employee E5, subsequently applied a foam dressing to the back of Resident R1's right ankle.Further interview on August 25, 2025, at 3:23 p.m. with Licensed Nurse, Employee E5, confirmed the physician was not notified regarding the skin impairment and further confirmed a description of the wound (including measurements) was not documented in Resident R1's clinical record. Licensed Nurse, Employee E5, reported Resident R1 stated that the skin impairment was not new so the employee assumed the physician was already aware. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of clinical record, facility policies, facility documentation, and interviews with staff, it was determined the facility failed to adequately supervise one of five residents reviewed (Resident R1). This failure resulted in Resident R1 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 was missing for a period of approximately four hours after the fall. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. This deficiency was identified as Immediate Jeopardy Past Noncompliance. (Resident R1) Findings include:Review of facility policy titled, Elopement dated February 15, 2000, revealed the facility's protocol and guidelines to follow when a resident cannot be located. Continued review revealed, Residents who have been assessed, determined not to be safe in the community alone, and have been identified as a risk for elopement are not permitted to leave the campus alone. This policy outlines procedures to be implemented when it is determined that a Resident: identified as an elopement risk has attempted to elope or is missing from [NAME]. An elopement risk assessment is conducted upon admission, quarterly, upon identification of a possible risk, and after an attempted or actual elopement. Resident assessed as an elopement risk will have an appropriate care plan implemented. Elopement is a term used to describe an incident when a Resident, who has been assessed to be unsafe in the community alone, physically leaves the campus, or is observed attempting to leave the campus, or has not returned from an unauthorized leave or trip. Elopement can be intentional or unintentional. Roam Alert is a system that provides protection to wandering-prone residents by controlling exit doors. When the resident approaches a door, the system alerts Security to act. The Roam Alert System provides freedom of mobility to Residents in Long Term Care Facilities, while ensuring that they remain safe.Review of Resident R1's admission documentation revealed the resident was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels, cycling between periods of high and low and can significantly impacting a person's ability to function in daily life), and Dementia (group of symptoms affecting memory, thinking and social abilities.)Review of Resident R1's Elopement Evaluation, dated July 22, 2022, revealed that the resident was assessed by the facility to be at risk for elopement.Review of Resident R1's Quarterly MDS (Minimum Data Set - mandatory periodic resident assessment tool), dated May 14, 2025, revealed the resident was admitted to the facility on [DATE], and with a diagnosis of Multiple sclerosis (chronic, often disabling disease that attacks the central nervous system-brain and spinal cord. It's an autoimmune disease, meaning the body's immune system mistakenly attacks its own tissues). Continued review revealed the resident had a BIMS (Brief Interview for Mental Status) score of five, which indicated the resident was severely cognitively impairment. Further review of the MDS revealed that the resident required Extensive Assistance for transfer.Review of Resident R1's care plan, initiated June 8, 2023, revealed that Resident R1 was an elopement risk related to disorientation to place, and due to impaired safety awareness; with interventions of Wander Alert, (safety device placed on resident which alarms/lock doors to the outside of the building), check for placement as per orders, air tag (tracking device designed to act as a key finder, which helps people find personal objects), monitoring when out of bed; and education to staff on ensuring resident does not enter restricted area ([NAME] Building, staff rooms, medical supply rooms, maintenance rooms, mechanical rooms, kitchen/food services areas, corporate offices). Revision date as July 3, 2025.Review of Risk Elopement Evaluations dated January 15, 2025, and May 11, 2025, for Resident R1 revealed Resident R1 was at risk of elopement.Review of clinical notes for Resident R1 revealed a hospice care note, dated July 18, 2025, at 6:53 a.m., indicated Resident in bed, slept well through the night, no apparent distress, no complaint of pain or discomfort, will monitor.Review of clinical notes for Resident R1 revealed a nursing note, dated July 18, 2025, at 3: 19 p.m., indicated Resident out of bed to wheelchair at this time.Review of clinical progress notes for Resident R1 revealed a nursing note, dated July 19, 2025, at 12:13 a.m., indicated at 10:22pm, NHA (Nursing Home Administrator) and DON (Director of Nursing) called and spoke to resident's wife RP (Responsible Party) about resident missing after dinner, and facility staff search each room and facility ground. Wife stated that she came in visit him today in the afternoon, left him in the room at 3:30 pm.Review of documentation submitted to the State Survey Agency on July 19, 2025, revealed that on July 18, 2025, [Resident R1] was admitted to [NAME] House on June 7, 2023 with a BIMS of 7, alert to name only. Resident is able to communicate needs. [Resident R1] non ambulatory, is able to use (his/hers) upper extremities, utilizes (his/her) power wheelchair for mobility, and is independent with locomotion. (He/She) was found in stairwell, . around 11pm. [ Resident R1] finished a visit with (his/her spouse) around 3:30, (spouse) left (him/her) in (his/her) room to watch TV. (He/She) finished dinner around 5:45pm, video indicated that (he/she) was seen going down the hallway of 3 North towards the therapy side of the building. (He/She) continued through the double doors, to the next set of doors leading to the stairwell. Stat 555 was called to the [NAME] side of the building, resident was observed on the floor with (his/her) head in an upward position, and (his/her) wheelchair positioned behind (him/her). Resident was alert, seatbelt fastened, and from the knee up (he/she) was positioned on the landing of the staircase. Several male staff members including the RN supervisor, lifted (him/her) and chair in the upright position. Resident was sent out to Hospital for further evaluation. (Spouse) was made aware. Physician and hospice were notified. [Resident R1] returned on Monday July 21st with a diagnosis of fall: Pneumothorax on the right, rib fractures 2-3-4, fracture of the right clavicle and subdural hematoma. Resident is negative for shortness of breath, chest pain, nausea and vomiting and Per family and (spouse) no medical or surgical interventions required. Resident is at baseline for mental status and resumed Hospice upon re-admission. (He/She) was re-admitting to a new room on the first floor across from the nursing station, and when out of bed (he/she) will be using a manual wheelchair.During an interview on July 30, 2025, at 1:16 p.m., Employee E3, a Registered Nurse, who was the Nurse Supervisor for 1st, 2nd, and 3rd Floor North Side, at the time of the incident happened confirmed that on July 18, 2025, Resident R1 was in the dining room between 5:30 p.m.- 5:45 p.m. After dinner, before 8:00 p.m., Resident R1 was seen over 3 South, at the end of the hall and was instructed to return to (his/her) unit 3 North. At 8:00 p.m. Nurse Supervisor, Employee E3 was on the unit and staff informed Employee E3 that Resident R1 was nowhere to be found. Resident R1 is known to wander to different rooms, and the staff started to look on 3 North in all the rooms for Resident R1. Staff were not able to find Resident R1 on the 3rd North. Employee E3, called Security to overhead page for Resident R1 to return to (his/her) room. At 9:00 p.m. Employee E3 called the other supervisor to notify her that the staff could not find Resident R1, and to have her units look in all their rooms, elevators, shower rooms for the resident.At 9:45 p.m. Registered nurse, Employee E3 called the Nursing Home Administrator (NHA) and Director of Nursing (DON) to notify them Resident R1 was nowhere to be found in the facility. Resident R1 had a Roam alert and Security stated that it did not go off or show that he/she had exited externally from the building. The search for Resident R1 continued to the internal portion of the courtyard and other areas of the building. At 10:28 p.m. the DON arrived, and staff had completed the check of all common areas, parking lot, courtyard, elevators, stairwells, and accessible areas of the business office that would be accessible for Resident R1. At 10:30 p.m. staff went to the business office side to check areas that Resident R1 would not normally be accessible to. A code was entered to go into the internal business office area on the third floor. Staff looked in the area and continued to the back stairwell of that area. At 10:45 p.m. Resident R1 was found by the , Environmental Service Director, Employee E14, on the landing at the bottom of the first set of steps.Interview with the DON on July 30, 2025, at 1:30 p.m. also confirmed the above information with date and times. On July 30, 2025, at 11:41 a.m., interviewed the Director of Engineering Services, Employee E4, along with Assistant Nursing Home Administrator (ANHA), Employee E1, and Director of Nursing (DON) , Employee E2, showed the route the resident took on July 18, 2025 starting from the Third Floor Therapy Area hallway leading to [NAME] Hall Vestibule; at the beginning of [NAME] Hall office there is a door; which was left open accidently; there was no wanderguard detector (alarm mechanism which locks/alarms) on the door, as it was not part of resident area. ANHA, Employee E1, and DON, Employee E2 reasoned that Resident R1 moved forward in his/her wheelchair, pushed open the door at the fire stairway entrance door; and fell with his/her wheelchair below approximately eight small steps.Interview conducted on July 30, 2025, at 12:27 p.m., with Resident R1, revealed Resident R1 was in his/her bed, with pleasant expressions. Resident R1 stated did not remember the accident that he/she sustained. On August 1, 2025, at 11:24 a.m., interviewed Employee E14, Environmental Service Director, who found Resident R1, on July 18, 2025, at 10:45 p.m. Employee E14 stated that he found Resident R1 on the floor with (his/her) head in an upward position, and resident's wheelchair positioned behind him/her. Resident was alert, seatbelt fastened, and from the knee up resident was positioned on the landing of the staircase.Reviewed of Resident R1's hospital records revealed the resident was admitted on [DATE], from Nursing Home for fall on July 18, 2025, down flight of stairs who at baseline uses wheelchair due to right sided paralysis. Multiple injuries, including PTX (pneumothorax, a condition where air leaks into the space between the lung and chest wall, causing the lung to potentially collapse) with rib fractures 2-4, SDH (Subdural Hematoma- a condition where blood collects between the dura mater and arachnoid layers of the brain's protective coverings), right clavicular (the collarbone) fracture, left fourth digit (finger) dislocation, scalp hematoma (a collection of blood under the skin of the scalp, often appearing as a bump on the head), and multiple abrasions (a superficial skin injury caused by rubbing or scraping against a surface) .admitted to trauma floor.Review of facility nursing progress note dated July 22, 2025, indicated the resident was readmitted to the facility at 12:30 p.m. Resident was awake and responsive, verbalizing needs without problems. The admitting diagnoses included Trauma, closed dislocation of left finger, multiple rib fractures, Fracture of right clavicle, subdural hematoma . 5 stitches to (right) top of head, bruise to (R) shoulder, red bruise to (left) side scalp, bruise to (R) side face, swelling to (R) hand, scab to (R) and (L) shin, chest tube puncture site to (R) side, abrasion to (L) shoulder, intact blister to (L) upper arm, scab to (R) outer ankle, splint to (R) finger, dressing intact.Based on the above findings, an Immediate Jeopardy for the safety of the resident was identified for failure to provide adequate supervision of resident with dementia who was known to be at risk for elopement. The resident went missing on July 18, 2025, at 5:55 p.m. and was not located until July 18, 2025, at 10:45 p.m., a period of almost more than four hours. 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) and Director of Nursing (DON) on July 31, 2025, at 10:22 a.m.On July 31, 2025, at 5:10 p.m. the facility's action plan was accepted. The action plan included the following:1. Assess the safety of residents utilizing power wheelchairs. Facility assessment for resident safety with use of power wheelchairs was completed on July 21, 2025. Facility identified five residents that are at potential at risk based on the completed audit. (Completed on July 21, 2025) Resident R1 was assessed upon his return from hospitalization by rehabilitation services, based on assessment Resident R1 was set up for manual wheelchair for safety as of July 23, 2025.2. Ensure all doors are locked to non-resident areas. As part of this facility investigation, identified doors to non-residential areas have been secured. Facility completed the following measures to ensure resident safety. Set up of keypad lock to [NAME] Building to limit resident access to non-residential area. (Completed on July 19, 2025) Education of staff that was responsible for non-compliant with security door process. (Completed on July 19, 2025) Updated security process to monitor and audit identified doors to non-residential areas to ensure resident safety (Process effective July 26, 2025).3. Revise/ review resident safety policies to include power wheelchairs, locked doors, stairwells, and elopements. Facility review of resident safety policy initiated on July 26, 2025. 4. Ensure development of care plan interventions to prevent residents from entering non-resident areas. Care plan for identified residents at risk were updated based on facility audit on July 21, 2025. Resident R1's care plan was updated upon return from hospitalization on July 23, 2025. 5. Ensure doors are functioning properly and staff are in-serviced on areas in the building where residents are restricted related to resident safety. Ongoing security department monitoring and audit of identified doors to ensure that the doors are secured and functioning properly (Process effective as of July 26, 2025).6. Provide staff training on ensuring residents don't enter areas of the building where residents are restricted from being related to resident safety. [NAME] House staff training on ensuring residents don't enter areas of the building where residents are restricted from related to resident safety started as of July 26, 2025, and is ongoing. Facility has completed approximately 50 percent of the training and is expected to complete 100 percent compliance by August 6, 2025.On August 1, 2025, the implementation of the action plan was verified. Interviewed 24 staff from various units, and departments. Staff was able to verbalize what they would in ensuring that residents don't enter areas of the building where residents are restricted from related to resident safety. Observed the setup of keypad lock to [NAME] Building to non-residential area in the presence of Employee E3. Reviewed the documents showing staff education completed as mentioned in the Action Plan. Reviewed the revised care plan for Resident R1.Review of residents' care plans confirmed that resident's care plans were updated to include that a resident was not to be left unattended.Following the verification of the immediate action plan the Immediate Jeopardy was lifted on August 1, 2025, at 2:53 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(a) Management 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(3) Management 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical record, review of job's descriptions and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that adequate supervision was provided to on one of one resident reviewed (Resident R1) at risk for elopement. This failure resulted in Resident R1 wandering in the hallways of the facility on an electric wheelchair, and accessing the fire stairway entrance door, falling down a flight of stairs while strapped to the wheelchair. Resident R1 required transfer to the hospital and diagnosed with rib fractures, a fracture of the right clavicle, a subdural hematoma and closed dislocation of left finger and five stiches to the right top of the head. This deficiency was identified as Immediate Jeopardy Past Noncompliance. (Resident R1) Findings include:Review of the Nursing Home Administrator's (NHA) job description revealed that the Administrator is responsible for directing the day-to-day operations of the facility in accordance with current federal, state, and local standards and to ensure the highest degree of resident care and services are delivered and maintained. The Administrator serves as a member of the [NAME] Senior Leadership Team, and in that capacity, provides input and support to the organization-wide strategic development, quality evaluation, communications, and culture building initiatives. Ensure facility is a safe, clean, comfortable, and appealing environment for residents, families, volunteers, visitors, and staff in accordance with company and regulatory guidelines. Continuously monitor to ensure that a safe and sanitary physical environment is maintained throughout the facility; that all equipment is maintained and functioning properly, and adequate, appropriate inventory levels of all supplies are available and used correctly.Finally, the [NAME] House Executive Director & Administrator is accountable for high-level oversight of Clinical Services for the [NAME] House facility to support and maintain an ongoing quality assurance program based on clinical indicators, and to enable residents to reach optimal health and maximal function to achieve their goals and live full lives.Review of the Director of Nursing's job description revealed that the primary purpose of the Director of Nursing position is to utilize nursing knowledge and assessment skills in the development and implementation of individualized nursing care plans to ensure that customer needs and all applicable regulations are met. The Director of Nursing will also assist in the orientation and supervision of staff, attend to the daily operations of the Neighborhood and assume a leadership role. It is essential that all duties are performed with the highest level of integrity, while supporting [NAME] Values and Standards of Excellence, ensuring the achievement of competencies and compliance with regulatory agencies. Job responsibilities included: Ensure resident safety by ensuring complete and accurate documentation of incidents and initiate investigations and interventions as indicated and maintains the confidentiality of all resident care information. Partners with the Neighborhood leaders to create a culture of learning, integrity, service and teamwork and supports safety and maintains clean facilities for residents and staff.Review of Resident R1's admission documentation revealed the resident was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels, cycling between periods of high and low and can significantly impacting a person's ability to function in daily life), and Dementia (group of symptoms affecting memory, thinking and social abilities.)Review of Resident R1's Quarterly MDS (Minimum Data Set - mandatory periodic resident assessment tool), dated May 14, 2025, revealed the resident was admitted to the facility on [DATE], and with a diagnosis of Multiple sclerosis (chronic, often disabling disease that attacks the central nervous system-brain and spinal cord. It's an autoimmune disease, meaning the body's immune system mistakenly attacks its own tissues). Continued review revealed the resident had a BIMS (Brief Interview for Mental Status) score of five, which indicated the resident was severely cognitively impairment. Further review of the MDS revealed that the resident required Extensive Assistance for transfer.Review of Resident R1's care plan, initiated June 8, 2023, revealed that Resident R1 was an elopement risk related to disorientation to place, and due to impaired safety awareness; with interventions of Wander Alert, (safety device placed on resident which alarms/lock doors to the outside of the building), check for placement as per orders, air tag (tracking device designed to act as a key finder, which helps people find personal objects), monitoring when out of bed; and education to staff on ensuring resident does not enter restricted area ([NAME] Building, staff rooms, medical supply rooms, maintenance rooms, mechanical rooms, kitchen/food services areas, corporate offices). Revision date as July 3, 2025.Review of Risk Elopement Evaluations dated January 15, 2025, and May 11, 2025, for Resident R1 revealed Resident R1 was at risk of elopement.Review of clinical notes for Resident R1 revealed a nursing note, dated July 18, 2025, at 3:19 p.m., indicated Resident out of bed to wheelchair at this time.Review of clinical progress notes for Resident R1 revealed a nursing note, dated July 19, 2025, at 12:13 a.m., indicated at 10:22pm, NHA (Nursing Home Administrator) and DON (Director of Nursing) called and spoke to resident's wife RP (Responsible Party) about resident missing after dinner, and facility staff search each room and facility ground. Wife stated that she came in visit him today in the afternoon, left him in the room at 3:30 pm.Review of documentation submitted to the State Survey Agency on July 19, 2025, revealed that on July 18, 2025, [Resident R1] was admitted to [NAME] House on June 7, 2023 with a BIMS of 7, alert to name only. Resident is able to communicate needs. [Resident R1] non ambulatory, is able to use (his/hers) upper extremities, utilizes (his/her) power wheelchair for mobility, and is independent with locomotion. (He/She) was found in stairwell, . around 11pm. [ Resident R1] finished a visit with (his/her spouse) around 3:30, (spouse) left (him/her) in (his/her) room to watch TV. (He/She) finished dinner around 5:45pm, video indicated that (he/she) was seen going down the hallway of 3 North towards the therapy side of the building. (He/She) continued through the double doors, to the next set of doors leading to the stairwell. Stat 555 was called to the [NAME] side of the building, resident was observed on the floor with (his/her) head in an upward position, and (his/her) wheelchair positioned behind (him/her). Resident was alert, seatbelt fastened, and from the knee up (he/she) was positioned on the landing of the staircase. Several male staff members including the RN supervisor, lifted (him/her) and chair in the upright position. Resident was sent out to Hospital for further evaluation. (Spouse) was made aware. Physician and hospice were notified . [Resident R1] returned on Monday July 21st with a diagnosis of fall: Pneumothorax on the right, rib fractures 2-3-4, fracture of the right clavicle and subdural hematoma. Resident is negative for shortness of breath, chest pain, nausea and vomiting and Per family and (spouse) no medical or surgical interventions required. Resident is at baseline for mental status and resumed Hospice upon re-admission. (He/She) was re-admitting to a new room on the first floor across from the nursing station, and when out of bed (he/she) will be using a manual wheelchair. During an interview on July 30, 2025, at 1:16 p.m., Employee E3, a Registered Nurse, who was the Nurse Supervisor for 1st, 2nd, and 3rd Floor North Side, at the time of the incident happened confirmed that on July 18, 2025, Resident R1 was in the dining room between 5:30 p.m.- 5:45 p.m. After dinner, before 8:00 p.m., Resident R1 was seen over 3 South, at the end of the hall and was instructed to return to (his/her) unit 3 North. At 8:00 p.m. Nurse Supervisor, Employee E3 was on the unit and staff informed Employee E3 that Resident R1 was nowhere to be found. Resident R1 is known to wander to different rooms, and the staff started to look on 3 North in all the rooms for Resident R1. Staff were not able to find Resident R1 on the 3rd North. Employee E3, called Security to overhead page for Resident R1 to return to (his/her) room. At 9:00 p.m. Employee E3 called the other supervisor to notify her that the staff could not find Resident R1, and to have her units look in all their rooms, elevators, shower rooms for the resident.At 9:45 p.m. Registered nurse, Employee E3 called the Nursing Home Administrator (NHA) and Director of Nursing (DON) to notify them Resident R1 was nowhere to be found in the facility. Resident R1 had a Roam alert and Security stated that it did not go off or show that he/she had exited externally from the building. The search for Resident R1 continued to the internal portion of the courtyard and other areas of the building. At 10:28 p.m. the DON arrived, and staff had completed the check of all common areas, parking lot, courtyard, elevators, stairwells, and accessible areas of the business office that would be accessible for Resident R1. At 10:30 p.m. staff went to the business office side to check areas that Resident R1 would not normally be accessible to. A code was entered to go into the internal business office area on the third floor. Staff looked in the area and continued to the back stairwell of that area. At 10:45 p.m. Resident R1 was found by the , Environmental Service Director, Employee E14, on the landing at the bottom of the first set of steps.On July 30, 2025, at 11:41 a.m., interviewed the Director of Engineering Services, Employee E4, along with Assistant Nursing Home Administrator (ANHA), Employee E1, and Director of Nursing (DON) , Employee E2, showed the route the resident took on July 18, 2025 starting from the Third Floor Therapy Area hallway leading to [NAME] Hall Vestibule; at the beginning of [NAME] Hall office there is a door; which was left open accidently; there was no wanderguard detector (alarm mechanism which locks/alarms) on the door, as it was not part of resident area. ANHA, Employee E1, and DON, Employee E2 reasoned that Resident R1 moved forward in his/her wheelchair, pushed open the door at the fire stairway entrance door; and fell with his/her wheelchair below approximately eight small stepsOn August 1, 2025, at 11:24 a.m., interviewed Employee E14, Environmental Service Director, who found Resident R1, on July 18, 2025, at 10:45 p.m. Employee E14 stated that he found Resident R1 on the floor with (his/her) head in an upward position, and resident's wheelchair positioned behind him/her. Resident was alert, seatbelt fastened, and from the knee up resident was positioned on the landing of the staircase.Reviewed of Resident R1's hospital records revealed the resident was admitted on [DATE], from Nursing Home for fall on July 18, 2025, down flight of stairs who at baseline uses wheelchair due to right sided paralysis. Multiple injuries, including PTX (pneumothorax, a condition where air leaks into the space between the lung and chest wall, causing the lung to potentially collapse) with rib fractures 2-4, SDH (Subdural Hematoma- a condition where blood collects between the dura mater and arachnoid layers of the brain's protective coverings), right clavicular (the collarbone) fracture, left fourth digit (finger) dislocation, scalp hematoma (a collection of blood under the skin of the scalp, often appearing as a bump on the head), and multiple abrasions (a superficial skin injury caused by rubbing or scraping against a surface) .admitted to trauma floor.Review of facility nursing progress note dated July 22, 2025, indicated the resident was readmitted to the facility at 12:30 p.m. Resident was awake and responsive, verbalizing needs without problems. The admitting diagnoses included Trauma, closed dislocation of left finger, multiple rib fractures, Fracture of right clavicle, subdural hematoma . 5 stitches to (right) top of head, bruise to (R) shoulder, red bruise to (left) side scalp, bruise to (R) side face, swelling to (R) hand, scab to (R) and (L) shin, chest tube puncture site to (R) side, abrasion to (L) shoulder, intact blister to (L) upper arm, scab to (R) outer ankle, splint to (R) finger, dressing intact.Based on the deficiencies identified in this report, the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and Regulations were followed, contributing to the Immediate Jeopardy situation.Refer to F68928 Pa. Code: 201.18(b)(1) Management28 Pa. Code: 201.18(b)(3) Management

Based on the review of facility documentation, clinical records, hospital records, and interviews with resident and staff, it was determined the facility failed to provide appropriate staff supervision for Resident R1. This failure resulted in actual harm to Resident R1 who was found with a vertical laceration beginning at the midline of the forehead extending towards the scalp for one of 7 residents reviewed. (Resident R1) Findings include: Review of the facility policy titled Resident Safety revised on September 22, 2016, revealed nurse aides will make safety/hygiene rounds on all resident to ensure that the environment is safe and that resident hygiene needs are met. It is recommended that rounds be made every 2-3 hours. Continued review of policy revealed under bullet number 8 indicates Provide two or more person assist when necessary during transfer to ensure staff and resident safety. Further review of facility policy revealed under Care Plan Documentation section indicated, Assistive devices, safety measures, amount of assistance required by the resident to be documented in the approach/interventions section of the plan of care. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of laceration without foresight body of unspecified part of head, Epilepsy (seizures), Neurogenic Bowel (dysfunctional of the bowel), Neuromuscular Dysfunction of bladder, restless legs syndrome, legal blindness, Paraplegia (paralysis that effects lower held of the body). Review of Resident R1's quarterly Minimum Data Set assessment (MDS- periodic assessment of resident care needs) dated February 11, 2025, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 13, indicating the resident was cognitively intact. Continued review of the MDS assessment revealed the resident's functional abilities for self-care task such as toileting hygiene, shower/bathe, dressing, personal hygiene, bed mobility is dependent. Dependent definition based on the MDS coding indicates Helper does all the effort. Resident does none of the effort to complete the ability. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of the comprehensive care plan dated, March 1, 2025, identified a goal and intervention of February 2, 2025, for bed mobility - resident requires assistance by (2) staff to turn and reposition in bed frequently and for dressing- the resident requires assistance by (2) staff to dress. Review of information submitted to the State Survey Office on March 19, 2025, revealed Resident R1 was care planned for 1 assist for bed personal hygiene. When the nurse aide was providing morning care, while bathing the resident in bed Resident R1 was holding onto the bed rail to assist the nurse aide with washing the resident's back. The bed rail fell (disengaged) then Resident R1 fell from the bed to the floor. Resident R1 was assessed with laceration to the forehead, the resident was transferred to ER (emergency room ) by 911 (Emergency Medical Services). The physician and resident's spouse were both notified. Bed rails were immediately checked by the engineer, both rails were found functioning. Review of the facility's investigation completed March 19, 2025, revealed a written statement from Nurse Aide, Employee E10, which indicated, I went into resident's room approximately 8:00 a.m. I washed the front of the resident. I was standing on the left, side rail were up locked on the right side of the bed. I then dressed [resident] and put the brief halfway on. I then pulled the side rails on left side up and I heard the rails click (locked) I went to [his/her] right side locked the bed and turned resident to the left (toward the sink) as I was pulling out brief, I hear a click, and the rails went down, and the resident fell to the floor on [his/her] stomach. I immediately yelled for help multiple staff members came in to assist. Review of Resident R1's nursing documentation dated March 19, 2025 revealed called to resident room at 8:15 am, resident found on the floor lying on abdomen . talking and crying, opening to mid forehead with large amount of bleeding noted. Resident stated 'my arm hurts,' airway secure, non labored breathing, head stabilized, pressure applied to open area on forehead MD (physician) called order to send to [hospital] for evaluation given, 911 (Emergency Medical Services) called. Resident remains in position on floor until 911 arrived, [resident] continued to talk, no cognitive decline noted, charged nurse and respiratory therapist remained with resident . 911 arrived at 8:43 am wish (with) 2 attendants, resident let facility via stretcher at 8:46am. Review of Resident R1's hospital after-visit summary, dated March 19, 2025, revealed Large left scalp hematoma. Assessment further revealed, a 10cm (centimeters) vertical laceration beginning at the midline of the forehead extending towards the scalp resulting in exposure of the front bone face showing no fractures of the calvarium or skull base. Review of Resident R1's nursing progress note dated March 19, 2025, revealed, Resident R1 returned to the facility at 9:30 p.m. from the medical center. Resident presented with 35-40 stitches from the scalp to her forehead and covered with gauze, no drainage noted, resident denies pain at this time, slight bruising noted. Resident mode was stable and pleasant, alert to person, time and place. Review of Resident R1's therapy progress notes, dated March 20, 2025, revealed Occupational Therapy (OT) evaluation provided following return from hospital s/p (status post) fall from bed. Resident is currently in hill-rom (hospital) bed with bilateral (b/l) full rails and meridian low air loss mattress. Rails are used both for bed mobility and for safety secondary to diagnoses of MS (multiple sclerosis) paraplegia, and seizure disorder. OT reviewed event with resident. (She/he) reports that (she/he) was turned on her/his side and received care and does not recall what happened when (she/he) accidentally fell . Reviewed bed positioning and mobility with resident. (She/he) is agreeable to a wide bed which would allow for more space for lateral turning and repositioning. Currently discussing potential room change to a large room with ceiling lift that would better accommodate a wide bed. Review of Resident R1's wound progress notes dated March 20, 2025, revealed, Resident was assessed for injury to forehead extending to front portion of scalp. Area is fully approximately with about 39 stitches. Observation conducted on April 3, 2025, at 9:41 a.m., of Resident R1, who was lying in a hospital gown in bed, ready to receive morning care from nurse aide, Employee E4. No other staff were accompanying Employee E4 at that time. At 9:48 a.m., Employee E4 exited the room after providing care and reported needing a second nurse aide to assist with a Hoyer lift (mechanical device used for transfer of resident from one surface to another) transfer, meaning the resident needed to be transferred from the bed to a wheelchair, requiring an additional person. Employee E4 then returned to the room to hook up the Hoyer pad to the lift, which had already been placed under the resident's back. Continued observation on April 3, 2025 at 9:57 a.m., revealed a second nurse aide, Employee E5, entered the room to assist nurse aide, Employee E4 in transferring Resident R1. At 10:00 a.m., Employees E4 and E5 came out and was interviewed. Employee E5 confirmed the aides strapped, guided, and transferred Resident R1 from the bed into the wheelchair. Employee E4 confirmed, they did not provide support with dressing, turning, changing, or washing Resident R1, and further clarified, I only strapped, guided, and transferred R1 over into [his/her] wheelchair. Once Employee E4 completed providing care to Resident R1, interview was conducted at 10:01 a.m. on the same day. During the interview, it was revealed that Employee E4, working alone, had changed the resident by turning [him/her] from right side to left, cleaning resident's right-side buttock, placing a brief, and then repeating the procedure on the left side. Employee E4 asked Resident R1 to hold onto the railing while turning resident to each side to clean the buttock, place a brief and placed a Hoyer lift pad under Resident R1. When asked if Employee E4 was aware of how many people were needed to assist with turning and repositioning, Employee E4 confirmed, 2 people assist, but we're short right now, and further revealed, he was the only one providing morning care to Resident R1 before transferring resident to [his/her] wheelchair with the assistance of Employee E5. Interview conducted On April 3, 2025, at 10:16 a.m., with Resident R1, who was observed with a laceration on his/her forehead and hair shaved. Resident R1 reported that after the incident, there was a lot of blood in my hair, and they had to shave my hair, and I ended up with 38 stitches. Resident R1 further revealed, today, he/she received care from Employee E4, who asked Resident R1 to hold onto the railing while turning resident to provide care. Interview attempted on April 2, 2025, at 10:45 a.m. with nurse aide, Employee E10 who was on medical and family leave as of April 1, 2025, but was not able to be contacted. Interview conducted on April 2, 2025, at 11:03 a.m., with the Rehabilitation Director, Employee E6. Employee E6 confirmed that Resident R1 was in an appropriate bed with bilateral railings, which were assessed based on the resident's weight. The railings were re-assessed and found to be functioning properly. Additionally, Resident R1 was re-assessed, and interventions, such as providing a larger bed to offer more space, were implemented. A bed mobility assessment was conducted, which recommended, 2 person assistance with bed mobility, dressing, turning, and repositioning. A request was made to provide the rehabilitation assessment conducted prior to the fall. On April 2, 2025, at 11:56 an interview was conducted with nursing assistant, Employee E7 who reported the way she would know which resident requires 1 or 2-person assist is based on the assignment sheet. Reviewed assignment sheets but failed to identify notation that South 1 Nursing unit had anyone requiring 2 person assistance. On April 2, 2025, at 12:32 p.m., an interview was conducted with the Assistant Director of Nursing, Employee E2. Employee E2 confirmed, the comprehensive care plan, last updated on March 1, 2025, which was prior to the fall, identified an intervention from February 2, 2025. The care plan indicated for bed mobility, Resident R1 requires assistance from 2 staff members to turn and reposition frequently, and for dressing, the resident requires assistance from 2 staff members to dress. On April 2, 2025, at 12:59 p.m., an interview was conducted with the Administrator, Employee E1, and the Assistant Director of Nursing, Employee E2. Staff confirmed, according to the comprehensive care plan and MDS assessment dated [DATE], Resident R1 requires 2-person assistance for bed mobility, turning, repositioning, and dressing. However, it was also reported that staff continued to provide only 1-person assistance, as observed during today's evaluation. On April 2, 2025, at 2:00 p.m., the Rehabilitation Director, Employee E6, presented documentation that included two Rehab Screenings, which were conducted every 90 days. It was noted that during the February 14, 2025, screening for Resident R1, the assessment indicated, 1 person assist was required for dressing, but no documentation was made regarding the number of people needed for bed mobility, which is a required detail. A previous Rehab Screening, conducted on November 1, 2024, documented 1-person assistance was needed for both bed mobility and dressing. However, this information was not reflected in Resident R1's care plan and contradicted the MDS assessment dated [DATE]. Employee E6 acknowledged, she signs off on care plan revisions but was unable to provide an explanation as to why Resident R1's care plan was not updated accordingly. On April 2, 2025, at 2:15 p.m., an interview was conducted with the Assistant Director of Nursing, Employee E2, regarding nurse aides' knowledge of which residents require a 1-person assist versus a 2-person assist. Employee E2 reported that, according to the nurse aides' task documentation, it was revealed the nurse aides had been documenting providing 1-person assist to Resident R1 both before and after the incident. The facility failed to provide appropriate staff assistance during morning care to Resident R1 which resulted in actual harm to Resident R1 who sustained a fall and was found with a vertical laceration beginning at the midline of the forehead and extending toward the scalp. This injury exposed the frontal bone and required 35-40 stitches to close the wound. 28 Pa. Code 201.18(e)(1) Management 28 Pa Code 211.10(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1) Nursing Services

Based on a review of facility policy, clinical records, staff training records, information submitted by the facility, and staff and resident interviews, it was determined the facility failed to ensure the resident environment remained free of accident hazards resulting in actual harm to Resident R127 who sustained a second degree burn on the left knee when an employee's personal hot beverage spilled on the resident for one of 35 residents reviewed (Resident R127). This deficiency is cited as past non-compliance. Findings include: Review of facility policy Hours of Work revised October 24, 2020, revealed employees are not permitted to leave the facility's campus during break periods. Breaks must be taken in the cafeteria; employees lounge, or in similarly designated non-work areas. No food or beverage is permitted in direct service delivery work areas. Review of Resident R127's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Quadriplegia (paralysis of all four limbs). Review of Resident R127's quarterly Minimum Data Set assessment (MDS- periodic assessment of resident's care needs) completed January 27, 2025, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 13, which indicates the resident did not have cognitive impairment. The resident was assessed with upper and lower extremity impairments. Review of facility investigation initiated February 23, 2025, revealed Resident R127 was calling the aide while she was walking past the resident's room, to the staff lounge with her personal hot tea in her hand. Resident R127 was sitting in the wheelchair with the overbed table in front of the resident. The resident asked nurse aide, Employee E5 to empty the urinal that was place on the overbed table. Nurse aide, Employee E5 placed her personal hot tea cup with the lid on top on the resident's overbed table, then took took the resident's urinal to the bathroom located inside the room. She emptied the urinal in the toilet. When she opened the bathroom door, the door accidentally hit the overbed table, which knocked the tea cup over, and onto Resident R127's left knee and floor. The nurse aide Employee E5 called the charge nurse immediately. Review of Resident R127's nursing note dated February 23, 2025 revealed the resident sustained a burn to the left knee due to a tea cup on the table was accidentally knocked over and spilled on (his/her) left knee. On assessment left knee noted red and warm to touch, three peeling areas were noted. Resident complained of little pain upon touch. Ice applied to the area. All staff were educated on not to bring any hot beverages or personal items into resident's room. Review of statement by nursing aide, Employee E5 dated February 23, 2025, revealed I was on way down to the breakroom around 9:30 am with my own personal cup in my hand. On my way down [Resident R127] was calling my name. I stopped in to help him/her. (He/she) wanted me to do a couple things for (him/her). Employee E5 stated that she went to empty the resident's urinal, I put my cup on (his/her) table and opened the bathroom door and the door hit (his/her) table, then the cup fell on (his/her) leg and the floor. I called the supervisor. Employee E5 stated that at the time Resident R127 had long pants. When the nurse came into the room the resident's pants were wet. After the resident was assessment resident was changed to shorts. Review of statement by charge nurse, Employee E6 dated February 23, 2025, revealed charge nurse was called to resident room by care nurse. Upon entering room, care nurse stated that her cup with tea had accidentally been knocked over and spilled onto [Resident R127] left foot. Vital signs obtain Nurse Supervisor and charge nurse in to assess. Review of statement by Resident R127 completed by Director of Nursing, Employee E2, dated February 24, 2025, revealed, Resident R27 was alert and orientated x3 (oriented to person, place and time). Resident stated that yesterday February 23, 2025, the resident was sitting up in the wheelchair and bedside table in front of the resident. Resident R127 heard the aide passing by the room. Resident R127 called her to come in. This nurse aide, Employee E5, had her tea cup, when the resident asked her to empty the urinal, she placed her tea on the table. The table moved and accidentally spilled the tea on the resident's left knee. (Resident) stated it was accident. (Resident) wants to maintain the same nurse aide, Employee E5 for his/her care. Interview with Resident R127 on March 18, 2025, at 10:03 am, revealed and confirmed, on February 23, 2025, the aide helped with few tasks and placed her hot drink on the overbed table and it accidentally spilled on his/her knee and the floor. Resident R127 stated, as of right now everything is healed and did not hurt. Interview with the Nursing aide, Employee E5 on March 18, 2025, at 10:09 a.m. revealed, she was on her way down to the breakroom with her own personal hot tea on her hand. On her way down Resident R127 was calling her name. She stopped in to help the resident. The resident wanted her to do a couple things for (him/her). She went to empty the resident's urinal, I put my cup on [resident] overbed table and opened the bathroom door and the door hit (his/her) table, and the cup accidentally fell on (his/her) leg and the floor. I called the supervisor. Review of physician orders dated February 23, 2025 revealed an order was obtained for Triple Antibiotic External Ointment, with instructions to apply to left knee topically two times a day for peeling skin secondary to burn for 10 days, cleansed left knee with normal saline solution prior to administration. Review of physician documentation dated February 26, 2025, revealed, the resident skin was assessed with a second degree burn with partial thickness of the left knee. The wound team was scheduled for February 27, 2025. Review skin/wound documentation date on March 14, 2025, confirmed that Resident R127 was followed by the wound team and confirmed Wound 2 partial thickness radiation dermatitis/burn to left knee, status resolved. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R127's environment remain safe which resulted in actual harm to Resident R127 when a staff's personal hot beverage spilled on the resident's left knee causing a second degree burn. On March 20, 2205, the Nursing Home Administrator presented documentation, indicating, the facility initiated a plan of correction on February 23, 2205, related to ensuring no personal drinks were brought into a resident's area. Review of facility Action plan/Follow up documentation revealed the following information. 1. The resident was immediately changed to shorts, and comforted by the DON and nursing lead, he remained on nursing report for close monitoring. Wound treatment initiated by the wound care nurse, on February 23, 2025, for triple antibiotic external ointment applied twice daily. Consult was for wound consultants on February 27, 2025, primary care physician saw him on February 25, 2025. 2. Visual audit of each floor was conducted to see if drinks were noted out of place. 3. Staff will be educated on the importance of not having drinks in resident areas. Employee received a counseling from the DON on February 23. 2025. The mother and resident R127 understood it was an accident and wanted to keep the staff member assigned to the resident. 4. Audits will be conducted weekly x 4 monthly x 2. The facility alleges compliance with their plan of correction as of March 17, 2025. Facility education record and competency record verified for completion. Staff were interviewed to verify education of facility policy on hot beverages or personal items. Random resident records reviewed to verify compliance with the facility policy on hot beverages and personal items. This deficiency was cited as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical record, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to test the temperature of a hot water beverage provided to one of five residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who spilled the hot water beverage on her chin and chest resulting in second degree thermal [CONDITION(S)]. This deficiency was identified as past non-compliance. Findings include: Review of Resident R1's significant change MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 26, 2021, revealed that the resident was admitted to the facility January 15, 2015 with the diagnoses of [CONDITION(S)] (paralysis of all four limbs), [CONDITION(S)] (damage to the brain from interruption of its blood supply), and dysphagia (difficulty swallowing). Continued review of the MDS assessment revealed that the resident was cognitively intact and that she was totally dependent for eating requiring the assistance of one staff person. Review of occupational therapy notes for Resident R1 revealed a note, dated January 4, 2022, which indicated that the resident was assessed to use a mounting system on her bedside table with a cup holder to provide hands-free access to warmed beverages. The occupational therapist indicated that the resident demonstrated accessing the beverage as well as satisfaction with beverages heated to 135 degrees Fahrenheit with no indication of safety issues. The occupational therapist indicated that nurse aide staff were provided education and that signage and photographs were posted to direct staff on proper setup, placement, temperature checks and need for use of both towels and chux (disposable water resistant towels) on her chest as a precaution. Continued review of occupational therapy notes revealed a note, dated February 10, 2022, which indicated that Resident R1 was discovered with blisters on her chin and chest wall. The resident reported to the therapist that the adaptive mug was set-up as prescribed, however, the straw may not have been tilted up as prescribed. The therapist noted that she was unable to determine if the spillage occurred as a result of the straw position or as a result of the resident's impaired ability to fully close her mouth around the straw. Review of nursing notes for Resident R1 revealed a note, dated February 10, 2022, that indicated the resident was assessed by the wound care team. Upon assessment the resident was noted with a partial thickness 2nd degree burn under her chin. The wound measures were 7.0 cm (centimeters) by 6.0 cm. by 0.1 cm. Further review of the nursing note revealed Wound base was fluid filled serous blister which sloughed (separation of dead tissue from living tissue) off leaving 60% pink epithelial (a type of body tissue that forms the covering on all internal and external surfaces of the body), and 40% red intact red skin. No drainage noted, peri wound intact. No weeping or swelling noted. Resident denied any pain or discomfort. Cleansed with nss (normal saline solution) and [MEDICATION(S)] and oil emulsion applied and non adherent gauze applied. Continued review of the nursing note revealed that a partial thickness 2nd degree burn to upper chest, measuring 15.0 cm. by 12.0 cm. by 0.1 cm. was identified. Wound base which had small area of fluid filled blister sloughed leaving 30% pink epithelial, and 70% red intact skin. No drainage, peri wound intact. No weeping or swelling noted. Resident denied any pain or discomfort. Wound cleansed with nss and [MEDICATION(S)], oil emulsion, and gauze applied. Review of facility documentation, dated February 11, 2022, indicated that on February 10, 2022, at 12:08 p.m. a nurse aide served Resident R1 a reheated beverage per resident's request. Continued review revealed that the nurse aide did not take the temperature of the beverage before giving it to Resident R1 and that she did not place a chux over the folded towel on Resident R1's chest area. Continued review of facility documentation revealed a written statement from Employee E14, nurse aide, who stated that I heated up the water for 20 seconds as usually requested. I put a towel over chest before giving resident water. I asked the resident to sip the water to see if it was to her liking and not too hot. She said it was fine before I left her room . about five minutes later she rang her call bell to let me know she had spilled water on herself. Interview conducted on February 22, 2022, at 9:10 a.m. with Resident R1 confirmed that she sustained a burn to her chin and chest related to spilling a hot water beverage. The resident stated that not enough towels were placed under her chin and that the spilled water seeped through to her chin and chest. Interview on February 22, 2022, at 12:30 p.m. with Employee E15, occupational therapist, stated that prior to the incident, materials were prominently posted by Resident R1's bed and on her cup instructing staff to check beverage temperatures before serving to the resident and that chux and towels must be placed on the resident's chest for safety. Employee E15 stated that staff were expected to follow safety precautions as posted for residents. On February 10, 2022, following the incident, the facility immediately implemented the following corrective actions: - Nursing assistant, Employee E14, was suspended from employment on February 10, 2022, related to the burn incident sustained by Resident R1. The facility immediately began an investigation into the burn sustained by Resident R1. - Resident R1 was assessed by the wound care team on February 10, 2022, and treatments were initiated related to her [CONDITION(S)]. - Resident R1's equipment was removed on February 10, 2022, until it could be reassessed by occupational therapy. Residents R1's equipment status was changed from set-up to supervised. Resident R1 and staff were re-educated regarding set-up and monitoring during meals. - Audits were initiated February 10, 2022, for all residents adaptive equipment used for eating/drinking. Audits were completed February 14, 2022. -Resident R1's care plan was updated on February 11, 2022 related to impairment in skin integrity as a result of a burn to the chin and chest with interventions developed. - Facility policy regarding Food and Beverage Temperature Requirements was revised February 14, 2022. Key changes included that nurse aide staff and licensed practical nurse staff are no longer permitted to heat or reheat any food or beverages. All heating/reheating of foods must be done by and temperature checked by staff from the kitchen/dietary department. After hours the RN Supervisor is responsible for heating and temperature checking any food or beverages. - Education for all staff was initiated February 10, 2022, and included Food and Beverage Temperature Requirements policy and competency training. Education was completed February 19, 2022. - Occupational Therapy provided specific training to staff regarding staff supervision with meals, beverages should not exceed 130 degrees Fahrenheit, resident positioning and resident safety. - Ongoing audits to ensure compliance were initiated February 10, 2022, and include adaptive equipment function, use of microwaves to ensure policy posted and thermometers available and rounding by therapy and administrative staff during meals to assess ongoing safety of residents. Interviews conducted with nursing and dietary staff on February 22, 2022, confirmed that they had all been in-serviced on policy and procedures regarding heating or reheating of resident beverages and foods. Interviewed staff were knowledgeable of proper serving temperatures for residents and newly implemented safety requirements. This deficiency was identified as past non-compliance. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on the review of facility policies, clinical records, observations, review of facility documentation, review of surveillance video footages, and resident and staff interviews, it was determined the facility failed to supervise one Resident R1 who punched Resident R4 on the head and ran his wheelchair over Resident R4's foot. This failure resulted in actual harm to Resident R4 who sustained a fractured right foot. Further, the facility failed to provide appropriate staff supervision to Resident R1 who allegedly sexually assaulted two female residents and with a history of physically aggressive behavior. The facility's failure to provide appropriate staff supervision for Resident R1 placed 20 residents on one of five nursing units at risk of physical or sexual harm and resulted in an Immediate Jeopardy Situation. (3rd floor South) Findings include: Review of the facility policy titled, One on one supervision, dated December 20, 2018, revealed that, 1:1 supervision is a potential part of a safety plan to ensure the resident's physical and psychological well-being and safety. This policy is to provide guidelines for a consistent approach for 1:1 supervision of a resident who is, or-potentially is, a risk to themselves or others or who is at risk for impaired decision making based on cognitive deficits, as well as document the need and ongoing review of 1:1 supervision. Review of the admission record for Resident R1 revealed that the resident was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] (loss of muscle function in the lower half of the body, including both legs) and mild intellectual disabilities. Review of a quarterly Minimum Data Set assessment (MDS-assessment of resident care needs) dated August 1, 2021, revealed that the resident had a BIMS score (Brief Interview of Mental Status-A screen used to assess resident's cognition) of 15 which indicated that the resident's cognitive ability for decision making was intact. The MDS also revealed that the resident was independent for locomotion on and off the unit in a wheelchair and he was at supervision level for transfer. Review of Resident R1's nursing note dated October 16, 2021, revealed that Resident R1 had an altercation with another resident while outside in the courtyard on the south side of the building. Review of the facility investigation dated October 16, 2021, revealed a statement from the Nurse Supervisor, Employee E12, which stated that Resident R1 was asked what happened out in the courtyard. Resident R1 responded that Resident R4 called him an [*!#*] so he hit him. The Nurse Supervisor, Employee E12, asked how did Resident R1 hit the other resident. Resident R1 stated, with my fists in his head. He put his hands together raised his arms and swung his arm in a forward motion stating (this how I did it). Resident R1 also stated, I rammed my chair into him and he started to bleed. There was blood all over . [Resident R1] also stated he was glad that the other resident got hurt. Review of a security incident report dated October 16, 2021, revealed that security was notified by the dietary staff that there was a blood trail outside by the canopy smoking area in the courtyard leading all the way to the elevator. Dietary staff informed the security that it came from Resident R4. Resident R4 reported to the security staff that Resident R1 intentionally ran his wheelchair into Resident R4. Medical Emergency Services arrived at the facility at 4:00 p.m. and Resident R4 was transfer to the hospital at 4:08 p.m. Further review of the facility documentation revealed that Resident R4 sustained a fracture of the right foot. Review of a psychotherapy consult report dated October 16, 2021, revealed that at the start of the consultation Resident R1 was very angry, and the therapist had to redirect him several times to talk about the incident. The resident had difficulty accepting his role in it, resistant to accepting blame and unrealistic about the seriousness of what took place. The therapist communicated that Resident R1's action were serious since it had caused an injury and that his peer had been sent out in an ambulance. The therapist reviewed other ways that the resident could have handled his anger including leaving the scene and stressed that physical violence is never accepted. Resident R1 was assessed by the therapist to have a flat affect and did not appear to cognitively understand the seriousness of his actions. The facility failed to ensure the proper supervision of Resident R1 resulting in Resident R1 hitting Resident R4 on the head and running his wheelchair over Resident R4. This failure resulted in actual harm to Resident R4 who sustained a fractured right foot. Further review of the facility investigation dated October 16, 2021, revealed that Resident R4 reported to the facility staff that Resident R1 sexually assaults female residents. Resident R4 suggested that staff speak with Resident R2. Resident R2 and Resident R3 stated that they were sexually assaulted by Resident R1. Review of a statement provided by Resident R2 dated October 20, 2021, stated Resident R1 tried to touch her and kiss her. She stated she told him not to do that, she was married. Review of psychotherapy consult report for Resident R2 dated October 21, 2021, revealed that, therapist met with Resident R2 for weekly session and as a follow up to the incident that took place last week with Resident R1. Resident R2 stated inappropriate touching began approximately one and a half year ago. Review of a copy of a text message sent to the facility staff by Resident R4 dated October 20, 2021, stated Resident R1 had a history of entering female resident's room and touching their private parts. He stated his nursing assistant saw Resident R1 engaging in criminal activity. Review of a statement provided by Resident R3 dated October 20, 2021, stated Resident R1 touched her breast and down below. Resident R3 also stated it happened every time Resident R1 came to her room. Review of psychotherapy consult report for Resident R3 dated October 21, 2021, revealed that the Resident R3 cried briefly as she spoke about the incident but became animated and excited as she talked about her high school experiences. She stated several times that she felt hurt by what he did to me. Review of facility documentation submitted to the Department on October 27, 2021 revealed that the facility substantiated the allegation of sexual abuse based on review of a video footage of Resident R1 going into resident's rooms and closing the door. Resident R1 was advised that he should not go to the 1S (south) unit anymore. He was also explained that the staff may ask him to leave the neighborhood if he was there. Review of facility document, Security incident report dated, October 25, 2021, confirmed a camera footage report on Resident R2's room and Resident R3's room from October 10, 2021 to October 20, 2021. Camera 29 (located at 1st floor south wing exit) and Camera 64 (located at 1st floor south 1) were utilized for the investigation. The following timeline of events were documented in the report: On October 10, 2021 at 4:14 p. m. to 4:17 p.m. -Resident R1 was observed leaving Resident R2's room. On October 10, 2021 at 5:00 p. m. to 5:46 p.m. -Resident R1 entered Resident R2's room at 5:29 p.m. and left the room at 5:42 p.m. On October 10, 2021 at 6:14 p. m. to 7:30 p.m.- Resident R1 entered Resident R3's room at 6:55 p.m. It appeared Resident R1 closed the door. Resident R1 left the room at 7:30 p.m. On October 12, 2021 at 3:56 p. m. to 4:57 p.m.- Resident R1 entered Resident R2's room at 3:59 p.m. Resident R1 left the room at 4:28 p.m. On October 12, 2021 at 5:56 p. m. to 6:38 p.m.- Resident R1 entered Resident R2's room at 5:58 p.m. Resident R1 left neighborhood at 6:38 p.m. On October 13, 2021 at 4:21 p. m. to 5:20 p.m.- Resident R1 entered Resident R2's room at 5:20 p.m. and closed her door. Resident R1 and Resident R3 left the neighborhood at 6:00 p.m. On October 13, 2021 at 7:29 p. m. to 8:11 p.m.- Resident R1 entered Resident R2's room at 7:55 p.m. Resident R1 left the room at 8:11 p.m. On October 14, 2021 at 4:03 p. m. to 5:25 p.m.- Resident R1 entered Resident R2's room at 5:26 p.m. At 5:33 he closed the door. At 5:35 an unknown LPN (Licensed Practical Nurse) entered and exited Resident R2's room while Resident R1 was inside the room, she closed the door after she left the room. On October 14, 2021 at 6:30 p. m. to 7:17 p.m.- Resident R1 entered Resident R2's room at 6:32 p.m. when Resident R2 opened the door. Resident R1 left the room at 7:15 p.m. On October 15, 2021 at 6:00 p. m. to 6:49 p.m.- Resident R1 entered Resident R2's room at 6:34 p.m. and closed the door. Resident R1 left the room at 6:48 p.m. On October 15, 2021 at 6:49 p. m. to 8:04 p.m.- Resident R1 entered Resident R2's room at 7:08 p.m. and closed the door. Resident R1 left the neighborhood at 8:04 p.m. On October 16, 2021 at 5:21 p. m. to 5:41 p.m.- Resident R1 entered Resident R3's room at 5:33 p.m. Resident R1 left the room at 5:41 p.m. Review of psychiatric consult report dated October 22, 2021, for Resident R1 revealed Resident R1 was anxious, loud pressured speech and angry, with impaired judgement. The staff reported Resident R1 with recent hypersexual behaviors, unpredictable and aggressive behaviors. Potential for further risk of injury to self or others, not able to self-regulate, despite plan as demonstrated by easily triggered to verbal aggression. [Resident R1] was restricted to his room. Discussed with [Employee E4, Assistant Director of Nursing] would likely not benefit from in-patient psych at this time, has not exhibited any physically violent behaviors since the weekend, although is potential for further harm due to his inability to self-regulate. Further review of the consult report revealed that, Threat statement: Patient is currently a potential threat to self or others. Threat communicated to: [Employee E4]. Review of psychiatric assessment report dated October 28, 2021, revealed that resident and therapist met with physician for a psychiatric assessment. The doctor's finding include: Resident has significant intellectual disability. There is limited understanding. Resident will have a minute of remorse and then it's gone, and later forgets that he has shared remorse. There is no understanding of consequences. Resident is unable to separate issues. There is capacity for the sexual inappropriateness to happen again. Therapist shared an incident of a physical altercation between resident and his peer (Resident R4) and the injury that was sustained, and that furthered the doctor's recommendations that it would be best if the resident did not remain at the facility. Interview conducted on October 29, 2021, at 2:17 p.m. with psychotherapist, Employee E6, (who provided psychotherapy to Resident R1 on October 21, 2021) revealed that she agreed with the psychiatrist findings that Resident R1 has the potential for harm towards self or others. Observation of Resident R1 on October 29, 2021, at 10:36 a.m. revealed that the resident was sitting in his wheelchair near the door in his room. There was no staff present near him providing supervision. Interview with nursing assistant, Employee E7, on October 29, 2021, at 2:30 p.m. stated Resident R1 left his room approximately at 10:00 a.m. for shower. She saw him in the hallway. He stated he was going to take a shower. Employee E7 stated that Resident R1 did not ask staff permission before he left his room. Employee E7 also stated that the resident was mostly independent for his Activities of Daily Living and he only needed set up or supervision. Review of a surveillance video footage with Employee E8, Security Supervisor, on November 1, 2021, revealed that the resident left his room on October 29, 2021, at 9:22:16 a.m. Resident disposed the linen through the chute at 9.22.35 a.m. and proceeded towards the nurse's station at 9.22.53 a.m. It was observed in the surveillance video footage that a staff exited from resident room 309 (4th room from Resident R1's room) and spoke to the resident. There was no evidence in the video footage that staff closely monitored the resident when he exited his room, or the resident asked staff before he exited his room. Further observation revealed that the resident reached at the nurse's station at 9.24.00 am. Employee E8, confirmed that it took one minute and 7 seconds for Resident R1 to reach in front of nurse's station. Observation of third floor south side nursing hallway revealed that there were 20 resident rooms from Resident R1's room to the 3rd floor south hall nurses' station. There were 12 female resident rooms in between Resident R1's room and 3rd floor south hall nurses' station. Interview with Assistant Nursing Home Administrator, Employee E2, on October 29, 2021, at 2:30 p.m. stated the security staff was closely monitored Resident R1 for the night after the incident on October 16, 2021. He stated the close supervision by the security staff stopped on the next day. Interview with Security Supervisor, Employee E8, on October 29, 2021, at 7:43 p.m. stated security staff did not provide close supervision to Resident R1. She also stated the resident was also not monitored consistently. Observation of the video surveillance footage at the security desk revealed that the camera focused Resident R1's room was not displayed as a primary screen. Interview with the Nursing Home Administrator and Assistant Administrator, Employee E2 on October 29, 2021, at 6:30 p.m. stated, Resident R1 was quarantined to his room due to his behavior and the facility was in the process of finding an alternative placement for Resident R1 due to his risk of harm to self or others. During an interview with Assistant Director of Nursing, Employee E4, on October 29, 2021, at 6:30 p.m. confirmed that the facility did not provide close staff supervision for Resident R1 but stated staff monitored the resident throughout the shift. Review of entire clinical record for Resident R1 revealed no documented evidence that the facility evaluated the risk possessed by Resident R1 towards other residents as documented in his psychiatric assessments dated October 22, 2021 and October 28, 2021 and implemented close staff supervision. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on October 29, 2021, at 6:05 p.m. for the facility's failure to provide appropriate supervision and monitoring to Resident R1 who sexually assaulted two female residents, including a history of aggressive physical behavior towards Resident R4 and with the capacity to be at risk of injury to himself or others. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Assistant Nursing Home Administrator, Employee E2, on October 29, 2021 at 6:14 p.m. The facility submitted a written plan of action on October 29, 2021, at approximately 9:50 p.m. and implemented the plan of action which included: 1. Facility has provided 1:1 supervision effective 10/29/2021 at 6:25 p.m. to ensure the supervision of Resident R1 and the safety of other residents. 2. Staff members will be educated at the start of their shift that Resident R1 is on 1:1 supervision and will remain on 1:1 until further notice. 95% of staff will receive this training by 11/03/2021, 100% by 11/05/2021. 3. Resident R1 may be in other parts of the building and participate in activities with 1:1 supervision. If Resident R1 is uncooperative in any way with 1:1 supervision, Security and Nursing Supervisor should be notified immediately. 4. Reevaluation of 1:1 supervision will be done by the Psychiatric Group by 11/12/2021. 5. Audits will be conducted each shift by the Nursing Supervisor and Security to ensure that 1:1 supervision is in place for Resident R1. Results of these audits will be reported at the monthly QAPI meeting. 6. Education for staff about prevention and identification of abusive behavior and relationships among residents will occur by 11/08/2021 by the Behavioral Therapist and/or Psychology Provider. 7. A safety survey will be conducted by facility Social Workers and/or Neighborhood Life Leaders which will include questions about inappropriate behavior and/or unwanted sexual advances by anyone including other residents. This safety survey will begin on 10/30/21 at 10:00 a.m. and will be completed by 11/2/2021. On November 1, 2021 at 11:00 12:00 a.m. the action plan was reviewed, observations made of Resident R1's room confirmed that Resident R1 was placed on 1:1 supervision. Interviews conducted with licensed and non licensed nursing staff staff confirm that they were in-service on of abusive behavior and relationships among residents. The Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on November 1, 2021, at 4:03 p.m. Refer to F600 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services

Based on review of clinical records, facility policies and procedures, facility documentation and staff interview, it was determined that the facility failed to ensure that residents were free from physical abuse (Resident R4) and sexual abuse. This failure resulted in actual harm to two of five female residents (Resident R2 and Resident R3) who were sexually assaulted by Resident R1. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Reporting and Investigation dated, December 20, 2018 revealed, Physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, involuntary seclusion, deprivation of goods and/or services by staff, exploitation, and misappropriation of property will be prohibited. Residents will be free from physical abuse, mental abuse, verbal abuse, sexual abuse, neglect, corporal punishment, involuntary seclusion, deprivation of goods and/or services by staff, exploitation, and misappropriation of property. Residents will not be subjected to abuse by anyone, including, but not limited to, employees, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, family members or legal guardians, friends, or other individuals. Sexual abuse is nonconsensual sexual contact of any type with a resident includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. Further review of the policy revealed that, Investigation of abuse: vii: While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. Review of the admission record for Resident R1 revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment (MDS-an assessment of resident care needs) dated August 1, 2021, revealed that the resident had a BIMS score (Brief Interview of Mental Status-A screen used to assess the resident's cognition) of 15 which indicated that the resident's cognitive ability for decision making was intact. The MDS also revealed that the resident was independent for locomotion on and off the unit in a wheelchair and he was at supervision level for transfer. Review of the facility investigation dated October 16, 2021, revealed a statement from the Nurse Supervisor, Employee E12, which stated that Resident R1 was asked what happened out in the courtyard. Resident R1 responded that Resident R4 called him an [*!#*] so he hit him. The Nurse Supervisor, Employee E12, asked how did Resident R1 hit the other resident. Resident R1 stated, with my fists in his head. He put his hands together raised his arms and swung his arm in a forward motion stating (this how I did it). Resident R1 also stated, I rammed my chair into him and he started to bleed. There was blood all over . [Resident R1] also stated he was glad that the other resident got hurt. Review of a security incident report dated October 16, 2021, revealed that security was notified by the dietary staff that there was a blood trail outside by the canopy smoking area in the courtyard leading all the way to the elevator. Dietary staff informed the security that it came from Resident R4. Resident R4 reported to the security staff that Resident R1 intentionally ran his wheelchair into his wheelchair. Review of a quarterly Minimum Data Set assessment (MDS-an assessment of resident care needs) for Resident R4 dated September 20, 2021, revealed that the resident had a BIMS (Brief Interview of Mental Status-A screen used to assess the resident's cognition) score of 15 which indicated that the resident's cognitive ability for decision making was intact. Review of the facility investigation dated October 20, 2021, related to the incident that occurred on October 16, 2021 between Resident R1 and Resident R4, revealed that Resident R4 reported to the facility staff that Resident R1 sexually assaults female residents. Resident R4 suggested that staff speak with Resident R2. Review of a copy of a text message sent to the facility staff by Resident R4 dated October 20, 2021, stated Resident R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS for Resident R2 dated August 11, 2021, revealed that the resident had a BIMS score of 15 which indicated that the resident's cognitive ability for decision making was intact. Review of a statement provided by Resident R2 dated October 20, 2021, stated Resident R1 tried to touch her and kiss her. She stated she told him not to do that, she was married. Review of a psychotherapy consult report for Resident R2 dated October 21, 2021, revealed that the therapist met with Resident R2 for weekly session and as a follow up to the incident that took place last week with Resident R1. Resident R2 stated inappropriate touching began approximately one and a half years ago. Review of a statement provided by Resident R3 dated October 20, 2021, stated, Resident R1 touched her breast and down below. Resident R3 also stated it happened every time Resident R1 came to her room. Review of a quarterly MDS for Resident R3 dated September 5, 2021, revealed that the resident had a BIMS score of 14 which indicated that the resident's cognitive ability for decision making was intact. Review of a psychotherapy consult report for Resident R3 dated October 21, 2021, revealed that the Resident R3 cried briefly as she spoke about the incident but became animated and excited as she talked about her high school experiences. She stated several times that she felt hurt by what he did to me. Review of the facility documentation submitted to the Department of Health on October 27, 2021, revealed that Resident R2 and Resident R3 stated during the interview that Resident R1 touched them inappropriately in their private areas. The video footage from the hallway surveillance review by the faciity staff revealed that Resident R1 did enter and exit Resident R2 and Resident R3's rooms. The facility substantiated allegation of sexual abuse based on review of a video footage of Resident R1 going into residents' rooms and closing the door. Review of facility documentation submitted to the Department on October 27, 2021 revealed that the facility substantiated the allegation of sexual abuse based on review of a video footage of Resident R1 going into resident's rooms and closing the door. Resident R1 was advised that he should not go to the 1S (south) unit anymore. He was also explained that the staff may ask him to leave the neighborhood if he was there. Review of facility document, Security incident report dated, October 25, 2021, confirmed a camera footage report on Resident R2' s room and Resident R3' s room from October 10, 2021 to October 20, 2021. Camera 29 (located at 1st floor south wing exit) and Camera 64 (located at 1st floor south 1) were utilized for the investigation. The following timeline of events were documented in the report: On October 10, 2021 at 4:14 p. m. to 4:17 p.m. -Resident R1 was observed leaving Resident R2's room. On October 10, 2021 at 5:00 p. m. to 5:46 p.m. -Resident R1 entered Resident R2's room at 5:29 p.m. and left the room at 5:42 p.m. On October 10, 2021 at 6:14 p. m. to 7:30 p.m.- Resident R1 entered Resident R3's room at 6:55 p.m. It appeared Resident R1 closed the door. Resident R1 left the room at 7:30 p.m. On October 12, 2021 at 3:56 p. m. to 4:57 p.m.- Resident R1 entered Resident R2's room at 3:59 p.m. Resident R1 left the room at 4:28 p.m. On October 12, 2021 at 5:56 p. m. to 6:38 p.m.- Resident R1 entered Resident R2's room at 5:58 p.m. Resident R1 left neighborhood at 6:38 p.m. On October 13, 2021 at 4:21 p. m. to 5:20 p.m.- Resident R1 entered Resident R2's room at 5:20 p.m. and closed her door. Resident R1 and Resident R3 left the neighborhood at 6:00 p.m. On October 13, 2021 at 7:29 p. m. to 8:11 p.m.- Resident R1 entered Resident R2's room at 7:55 p.m. Resident R1 left the room at 8:11 p.m. On October 14, 2021 at 4:03 p. m. to 5:25 p.m.- Resident R1 entered Resident R2's room at 5:26 p.m. At 5:33 he closed the door. At 5:35 an unknown LPN (Licensed Practical Nurse) entered and exited Resident R2's room while Resident R1 was inside the room, she closed the door after she left the room. On October 14, 2021 at 6:30 p. m. to 7:17 p.m.- Resident R1 entered Resident R2's room at 6:32 p.m. when Resident R2 opened the door. Resident R1 left the room at 7:15 p.m. On October 15, 2021 at 6:00 p. m. to 6:49 p.m.- Resident R1 entered Resident R2's room at 6:34 p.m. and closed the door. Resident R1 left the room at 6:48 p.m. On October 15, 2021 at 6:49 p. m. to 8:04 p.m.- Resident R1 entered Resident R2's room at 7:08 p.m. and closed the door. Resident R1 left the neighborhood at 8:04 p.m. On October 16, 2021 at 5:21 p. m. to 5:41 p.m.- Resident R1 entered Resident R3's room at 5:33 p.m. Resident R1 left the room at 5:41 p.m. Further, a safety survey was conducted by the facility on October 30, 2021. Review of the interviews conducted as a result of the safety survey revealed that Resident R5 stated that Resident R1 sexually touched her inappropriately. Review of an annual Minimum Data Set assessment for Resident R5 dated September 20, 2021, revealed that the resident had a BIMS score of 15 which indicated that the resident's cognitive ability for decision making was intact. Interview with Resident R5 on November 1, 2021, at 2:17 p.m. confirmed that she experienced sexually inappropriate behavior in the elevator from Resident R1 when she first admitted to the facility. She stated while on the elevator Resident R1 kissed her breasts. Resident R5 added to her statement that she told Resident R1 to stop and he did. Resident R5 further stated that Resident R1's act was not consensual at the time. Interview with the Assistant Nursing Home Administrator, Employee E2, on October 31, 2021, at 3:00 p.m. revealed no prior awareness that Resident R5 was touched inappropriately. The facility failed to ensure that residents were free from sexual abuse, which resulted in Resident R2 and Resident R3 been sexually assaulted by Resident R1. Refer to F689 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services

Based on review of facility policy, clinical record review, review of facility documentation, and interviews with the resident and staff, it was determined that the facility failed to test the temperature of a hot water beverage provided to one of two residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who spilled the hot water beverage on her abdomen and right upper thigh resulting in a third- degree thermal burn. This deficiency was identified as past non-compliance. Findings include: Review of the facility policy, Food and Beverage Serving Temperature Requirements, revised on December 3, 2020, indicated the purpose is to ensure food safety practices and general requirements for keeping food at specified temperatures for service to residents are maintained. Temperatures will be taken during the serving process to make sure time and temperature standards are met to ensure safety. The kitchen dining rooms/solariums will have calibrated thermometers, log forms to check the temperature of food and liquid. The policy further stated that all hot beverages will be served to residents at a temperature of 130-145 degrees hot beverages at a higher temperature . must be allowed to cool before serving. Review of Resident R1's medical diagnosis list included the diagnoses of [CONDITION(S)] (paralysis of all four limbs) and dysarthria (difficult or unclear articulation of speech). Review of Resident R1's quarterly Minimum Data Set (MDS- a periodic assessment of the resident's needs) dated October 23, 2020, revealed that the resident was cognitively intact. Further review of the MDS revealed that the resident had functional limitations on both sides of her upper and lower extremities, used an electric wheelchair for mobility and needed extensive assistance with eating. Review of Resident R1's care plan revised dated October 30, 2020, revealed that the resident needed assistance with eating. The interventions included, feed resident and help with set up of her special drinking cup. Review of nursing note dated January 12, 2021, at 1:57 p.m. stated, Resident noted with burn at right size of abdomen, right lateral hip, right lateral pubic area. Skin presents with large open blisters at abdomen and right lateral hip along with multiple intact blisters diffusing throughout. Per CNA (nursing assistant) statement, resident asked for some hot water, staff grabbed resident's own water cup, filled cup from pitcher in solarium labeled hot water and gave it to resident- about 10 minutes later, same CNA (nurse assistant) went to check on resident because of some noise coming from her room and water was noted on the bed and on resident. Review of Resident R1's January 2021 physician's orders revealed an order obtained on January 12, 2021, for the topical cream [MEDICATION(S)] 1% apply to abdomen and right groin area. Review of the Skin/Wound note dated January 13, 2021, at 12:05 p.m. from the wound nurse, Employee E9 stated, partial burn to mid to right abdomen, right upper thigh, and pubic assessed by wound care team. Wound measures 35-centimeter (cm) x 30. Wound base to right hip noted with scatter clear fluid filled blisters. Abdomen to right abdomen noted also with scattered clear fluid filled blisters, as well as dead skin that remained after fluid drained. Review of the exam from the wound specialist dated January 15, 2021, described the wound as, Full-thickness ulceration of the right abdomen to right thigh 20.0 x 39.0 x 0.1 cm. Wound base 40% intact serous blister (water filled) 40 % reabsorbed serous blister, 20% slough (moist yellowish-white dead tissue) with moderate nonodorous serous drainage, 20% slough. Patient demonstrating evidence of pain during the wound assessment process. Diagnosis: full thickness (3rd degree) burn of right abdomen to thigh. Observation of the resident's burn to the right abdomen was conducted on February 17, 2021, at 1:30 p.m. with wound care nurses, Employees E8 and E9. An interview with Resident R1 was also conducted at the time of the observation in relation to the burn. The resident was awake, alert, and oriented, non-verbal with contracted bilateral hands. Resident R1 grimaced when asked about the pain where she was burned. The abdominal burn area covered the right side of her stomach, down to the tip of her right upper thigh/hip area and appeared to be covered with 80% slough. The wound care nurses indicated at the time of the observation that the wound measured 17 x 21 x 0.1 cm with large amounts serous fluid (clear watery fluid) and 70% slough. Review of the facility's documentation dated January 12, 2021, completed by the Assistant Director of Nursing, Employee E10, noted the nursing assistant, Employee E13 stated, resident asked for some hot water, staff grabbed resident's own water cup, filled cup from the pitcher in solarium labeled 'hot water' and gave it to the resident. Ten minutes later the same NA (nursing assistant) went to check on the resident because of some noise coming from her room. Water was noted on the bed and on the resident. Resident R1 is non-verbal and nodded yes when asked if the water spilled. When asked if she was in pain 'some grimacing noted.' The Assistant Director of Nursing noted, I went to check the temperature of the water in the carafe used for the resident in question the temperature in water carafe read 149.5 degrees (Fahrenheit). Further review of the facility investigation confirmed that, hot water was being held in a carafe in the resident dining room when a dietary worker left the room. The water temperature had been taken by a dietary employee and was found to be above safe serving temperature per facility policy and was being left to cool. Nursing assistant (Employee E13), came into the dining room to fill the resident's cup with warm water and took it from the carafe, as the dietary worker had stepped out of the dining room. The carafe was being held in an area behind a counter where only dietary workers are supposed to go. The water was measured to be at 149 degrees F (Fahrenheit) at 11:45 (a.m.) when checked by the dietary worker and was at 149 degrees at approximately 12:30-45 (p.m.) when checked by nursing staff following the incident. Review of written statement related to the interview with Resident R1 revealed that the resident described that, the cup was on my belly. When took a sip, it was very hot. She didn't realize the whole lid was not secure. She tried to move the cup but got tipped over. The hot water came out quickly. She got burn on her belly. Review of nursing assistant, Employee E13, written statement revealed that the resident wanted hot water from the solarium. I gave her water that kitchen staff brings up for tea, she has a temperature safe cup that I put the water in and gave it to her I checked cup to make sure that the lid was closed tight I heard the snap on the cup. I was walking pass her room maybe 10 min later I heard her moaning I went into her room where it was water on the floor I checked her skin and it was red in her abdominal are I immediately reported to the supervisor. An interview was conducted with Assistant Director of Nursing, Employee E10, on February 18, 2021, at 11:30 a.m. indicated, In general, to get hot water, we go to the solarium and have a dietary staff pour and check the temperature of the water for us. The facility reviewed the security cameras and saw nurse aide walking into the solarium. She then walks and fills the cup with a pitcher that was sitting on the counter from dietary. Even though it was accessible for her to grab she still needs the dietary staff to pour it and take the temperature for her. An interview on February 18, 2021, at 12:40 p.m. with nurse assistant, Employee E13, confirmed the following, At approximately 12:30 -1:00 p.m. I went to the solarium to heat water for Resident R1 in the microwave, but I used the pitcher of water sitting on the counter. I knew those pitchers are poured at 6:30 (a.m.) in the morning, and only brought up (from the kitchen) once so I didn't need to check the temperature. I securely placed the cup in Resident R1 hands and left the room. I went to feed another resident and when I was walking past her room, I heard her moaning. I saw water on the floor, the bed was wet, and the cup was still closed. An interview on February 18, 2021, at 12:25 p.m. with dietary assistant Employee E12, revealed, I bring the carafe to the solarium and put it on the counter, behind the steam tables. I'll pour the hot water, or a CNA (nurse assistant) will, but then I will test the water. The thermometer sits next to the carafe. On January 12, 2020, following the incident, the facility immediately implemented the following corrective actions: -Nursing Assistant, Employee E13, was suspended from employment on January 12, 2021, related to the burn incident sustained by Resident R1. -The facility immediately began an investigation into the burn sustained by Resident R1. -The occupational therapist re-assessed Resident R1 on January 12, 2021, for management of hot liquids. The insulated mug used by the resident was further adapted to prevent any leakage from the straw opening. A new insulated mug was also ordered per Resident R1's preference. Nursing staff was re-educated on the revised equipment and set-up in relation to Resident R1's management and handling of hot beverages. -On January 12, 2021, the facility began facility wide staff training on the facility policy on, Serving Food and Beverage Safely. -On January 15, 2021, the dietary staff received inservice by leaders of the dining services on, Beverage Pots containing hot beverages in dining rooms. The policy included that at the completion of the meal service the food cart will be brought to the dietary department. All beverage pots containing hot fluids like coffee and hot water are to be brought back to the department until the next meal service. Hot beverage pots were not to be left on the counter unattended. The homemaker (dietary) is to empty the hot liquids in pots before returning to the dietary department with the meal cart. -The residents that receive hot beverages on the floor where Resident R1 resides have their own mugs that nursing brings to the dining room. The hot beverage is then placed in their mug. When a hot beverages is found to be above 145 degrees the staff is to add ice or creamers to the cup to lower the temperature. Each creamer drops the temperature approximately 5 degrees. Interviews conducted with nursing and dietary staff on February 17 and 18, 2021, confirmed they had all been in-serviced on the policy and procedures to be taken before serving hot beverages to the residents. The interviewed staff voiced understanding of the implemented safety requirements before serving hot beverages to the residents. This deficiency was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa.Code 211.12(d)(5) Nursing services \

Based on review of facility policy, clinical record review, review of facility documentation, and interviews with the resident and staff, it was determined that the facility failed to ensure that Resident R4 was served hot water in a lid cup and to properly check the temperature of the hot water provided to the resident which resulted in actual harm to Resident R4, spilling a hot water cup on her right thigh, developing blisters on the right thigh and diagnosed with [REDACTED]. Findings include: Review of the facility policy title, Microwave Use, dated (MONTH) 17, (YEAR), indicated that the purpose of the policy was to ensure the Microwaves are to be safely stored and operated by staff only. Proper procedure are to be used when reheating food and beverages to provide palatable food and beverages without risk of causing a burn. It further stated, Employees are educated on proper use of microwaves for heating/reheating food and beverages. Under the subtitle Microwave Safety-Beverages it indicated that Beverages are to be heated initially for thirty (30) seconds, stirred and the temperature checked. If the temperature is below safety standards, beverage will be heated in fifteen (15) second intervals, following this procedure until found to be at an acceptable temperature. Allow heated beverage to sit for thrifty (30) seconds before moving, stirring or adding ingredient. Review of the facility policy, Food and Beverage Serving Temperature Requirements, revised on August, (YEAR), indicated that the purpose is to ensure food safety practices are maintained for keeping food at specific temperatures when being served to the residents. The policy further stated that the temperatures will be taken with a thermometer before being served and all hot beverages will be served to residents at a temperature of 130-145 degrees. Review of Resident R4's quarterly Minimum Data Set (MDS is a periodic assessment of the resident's needs) dated (MONTH) 17, 2019, indicated that the resident was cognitively intact, with [DIAGNOSES REDACTED]. Further review of the MDS revealed that the resident had functional limitations on both sides of her upper and lower extremities, used an electric wheelchair for mobility and needed extensive assistance with eating. Review of Resident R4's care plan dated (MONTH) 2, 2019, identified the resident with activities of daily living deficit related to [DIAGNOSES REDACTED]. Review of the facility's documentation dated (MONTH) 8, 2019, noted the nursing assistant Employee E4 called licensed nursing staff, Employee E5 to show Employee E5 open blisters to Resident R4's left buttocks/hip area. Upon observation Employee E5, notified the nursing supervisor and Resident R4's physician. A physican's order was obtained to wash the area with normal saline, pat dry and apply [MEDICATION NAME] (antibiotic ointment) and cover with dressing. The resident denied having any pain. Review of the facility's investigation, into the blisters identified on the resident left hip, dated (MONTH) 10, 2019, revealed that the resident stated that she spilled water on the area. The resident further explained that she had the water for a while and accidently dropped it on herself and that she sat in it for awhile. An interview was conducted with Resident R4 on (MONTH) 3, 2020, at 2:25 p.m. related to the incident revealed that she spilled the water on herself something did not feel right. I must have gotten someone else's water. I only wanted to take the chill out of mine. The resident pointed to a cup without a lid sitting in her room to show what type of cup was used. The resident indicated that if she is given hot liquids it goes in a cup with a lid and then she pointed to her lidded mug sitting in her cup holder on her wheelchair. The resident confirmed that she had full sensation on her legs. The resident stated that something did not feel right but she did not say anything things happen . it really does not hurt. Review of statement obtained on (MONTH) 10, 2019, from nursing assistant, Employee E4 revealed resident asked me to heat her drinking water for 2 min. I refused and heated it for 1 min. When I took the water out of microwave I tested the water by pouring it on the back of my hand before giving it to her. Interview conducted with Employee E4 on (MONTH) 17, 2020, at 10:15 a.m. revealed that Employee E4 provided drinking water to Resident R4 in a styrofoam cup. Employee E4 stated during interview that she did not notify the licensed nurse that the resident had reported spilling the water on her because when I turned her over I did not see any redness. Further during the interview, Employee E4 indicated that she tested the water with the back of her hand to be sure it was not too hot for her Employee E4 acknowledged that she was aware that there was a thermometer behind the microwave. Review of the statement obtained on (MONTH) 8, 2019, from nursing assistant, Employee E6 revealed that on a routine round at 5:30 I found couple blister on the resident left upper thigh. I reported to the charge. Interview conducted with licensed staff, Employee E5 on (MONTH) 17, 2020, at 12:30 p.m. confirmed that the resident was observed with two blisters in the morning approximately at 6:30 a.m. on (MONTH) 8, 2019, on Resident R4's left buttock. Review of the statement obtained from Registered Nurse, Employee E7 dated (MONTH) 14, 2019, noted that an open and a closed blister was observed on the resident's left lateral upper thigh. The open blister was assessed with [REDACTED]. x 5.0cm. x .01cm., elongated. A closed blister was assessed above the open blister. Review of the progress notes from the wound consult dated (MONTH) 11, 2019, (three days after the incident) identified the wound as a third degree thermal (related to heat) burn measuring 10.8 centimeters (cm) X 12.2 cm X 0.1 cm. The wound base had 50% intact skin, 10% intact serous (clear fluid) blister and 40% slough (dead skin tissue with yellowish white appearance). Interview with the Nursing Home Administrator (NHA) on (MONTH) 3, 2020, at 3:15 p.m. confirmed nursing assistant, Employee E4 did not follow the facility's microwave policy, did not use the correct equipment to test the water temperature and did not use a mug with a lid on it. The Nursing Home Administrator further indicated that all nursing staff were provided education on microwave use and food and beverage serving temperatures in accordance with the facility policy. The facility failed to ensure Resident R4 was served hot water in a lidded mug and to properly check the temperature of the hot water which resulted in actual harm to Resident R4, spilling a hot water mug on her right thigh, developing blisters on the right thigh and subsequently diagnosed with [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 10/18/18, 5/16/19 28 Pa. Code 201.18(b)(3) Management Previously cited 10/18/18, 5/16/19 28 Pa. Code 211.10(d) Resident care policies Previously cited 8/19/19 28 Pa. Code 211.11(b) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 8/19/19 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 8/19/19

Based on review of clinical records, facility documentation, hospital records, facility policy and procedure and staff interviews, it was determined that the facility failed to obtain clarification of a physician's order regarding an anti-[MEDICAL CONDITION] medication and failed to consistently monitor and assess a resident with a known history of [MEDICAL CONDITION] which resulted in actual harm to the resident who did not receive their [MEDICAL CONDITION] medication resulting in [MEDICAL CONDITION] which ultimately lead to the resident being transferred to the hospital, intubated and placed on a mechanical ventilator for one of three residents reviewed (Resident CL1). Findings include: Review of the facility policy titled, General Medication Procedures, with an effective date of October 12, 2006, and a revision date of September 22, 2016, stated, to assure that medications are provided to residents according to State and Federal Regulations. It further stated that the purpose was, to provide an adequate supply of medication in order to avoid interruption of the resident's regime. Review of Resident CL1's clinical record revealed physician's orders dated November 2016, which indicated [DIAGNOSES REDACTED].(a device that is inserted into the stomach through the abdomen to supply nutrition). Review of a Minimum Data Set assessment (MDS - a comprehensive assessment of care needs) dated November 4, 2016, indicated a Brief Interview of Mental Status (BIMS - a tool used to assess a residents cognitive status - a score ranging from 0 to 15, where 0-7 =severely impaired cognition, 8-12= moderately impaired cognition, and 13-15 = intact cognition) for daily decision making were documented as 3 indicating that they were severely impaired and the resident never/rarely made decisions. The resident had total dependence on two plus staff members for bed mobility, transfers and bathing, had impairment on both sides of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot), and was incontinent of bowel and had an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Review of physician's orders dated October 2016 revealed that the resident was to receive 1 tablet [MEDICATION NAME] (a medication used to prevent [MEDICAL CONDITION]) 1000 milligrams by mouth at 9:00 a.m. and 9:00 p.m. A nursing note on November 8, 2016, at 12:07 a.m. stated that Resident CL1 had returned from the hospital, that the resident had been admitted to the hospital for dysphagia (difficulty swallowing) and aspiration pneumonia (a lung infection caused by inhaling food or liquids) and that a feeding tube had been placed on November 4, 2016. In addition, the physician's readmission orders [REDACTED]. Nursing documentation dated December 29, 2016, at 8:21 p.m. stated that Resident CL1 had been transferred to the hospital because the feeding tube had clogged. The resident returned to the facility on [DATE], and the readmission physician's orders, received at that time, instructed staff to administer 5 milliliters (approximately one teaspoon) of [MEDICATION NAME] solution (100 milligrams per milliters) via the feeding tube at 9:00 a.m. and 9:00 p.m. for 37 days. A physician's progress note dated January 3, 2017, at 12:56 p.m. stated that the resident was diagnosed with [REDACTED]. A dietary note dated February 7, 2017, at 10:30 a.m. stated that the resident was receiving medications that included [MEDICATION NAME]. A nursing progress note on February 7, 2017, at 2:47 p.m. noted that Resident CL 1 was biting her tongue in the morning, had a blood pressure of 140/74, a heart rate of 80 beats per minute, respirations of 20 breaths per minute and the physician was notified who directed the staff to monitor the behavior. There was no further description of the behavior, how long it lasted or other observations of the resident at that time. A facility discharge note dated February 8, 2017, at 12:51 a.m. stated that the nursing supervisor had been called to Resident CL1's room at about 12:00 a.m. and the resident had been, having [MEDICAL CONDITION] intermittently, that the first [MEDICAL CONDITION] observed lasted for about 45 seconds to 1 minute and that thereafter the activities had been on and off, that left facial twitching was observed, had blood pressure of 158/78, heart rate of 98 beats per minute, respirations of 18 breaths per minute. The physician was notified and directed the staff to call 911 and send Resident CL1 to the hospital. There was no further information describing the [MEDICAL CONDITION] or assessing the resident. The hospital Emergency Department documentation on February 8, 2017, noted that Resident CL1 arrived at 1:27 a.m., that the EMTs (Emergency Medical Technicians) reported the resident had one hour of [MEDICAL CONDITION] activity at the facility, that en-route to the hospital the resident had another [MEDICAL CONDITION] and was medicated with Versed (a medication for sedation), and the staff in the emergency department administered [MEDICATION NAME] (a sedative used to treat [MEDICAL CONDITION]) 2 milligrams IV (intravenously, directly in a vein.) An Emergency Department nursing note on February 8, 2017, at 2:00 a.m. stated that the nurse from the facility had called and stated, as per her records the resident has not been on [MEDICATION NAME] since February 5, 2017. The Emergency Department physician documented on February 8, 2017, at 2:00 a.m. that, the resident had been on [MEDICATION NAME] until February 5 when the [MEDICATION NAME] order was cancelled, no one is sure why she was taken off her [MEDICATION NAME]. Further review of the Emergency Department documentation dated February 8, 2017, stated that at 2:10 a.m. the resident received Etomidate (a medication used for anesthesia) 10 milligrams via IV, Rocuronium 50 milligrams (a medication used for anesthesia) via IV, Propofol 50 milligrams (a medication used for sedation) via IV, [MEDICATION NAME] 1000 milligrams via IV, and was intubated (a breathing tube was placed into the trachea (the windpipe)) orally (through the mouth) and placed on mechanical ventilation (a device to assist with breathing.) The Emergency Department physician documented on February 8, 2017, at 2:39 a.m., [AGE] year old female with known [MEDICAL CONDITION] history had 1.5 hours of intermittent tonic clonic [MEDICAL CONDITION] (generalized whole brain [MEDICAL CONDITION] usually [MEDICATION NAME] 1-2 minutes with loss of consciousness and muscle stiffening and body convulsing) with no return to baseline after being discontinued from [MEDICATION NAME]. It stated further, [MEDICAL CONDITION] was most likely secondary to discontinuation of the anticonvulsant (the [MEDICATION NAME]). It also stated that the resident was to be transferred to a second hospital with appropriate neurosurgical (a medical specialty related to brain/spinal cord surgery or treatment) services, that the physician had spoken with the critical care physician at the hospital where the resident was to be admitted who agreed that the [MEDICAL CONDITION] were related to the discontinuation of the [MEDICATION NAME]. A nursing note dated February 8, 2017, at 4:00 a.m. stated that the resident had been transferred to the second hospital. A written transcript of a telephone interview by Employee E2, the Director of Nursing, with Employee E3, the Director of Nursing Clinical Operations and Nursing Excellence, dated February 8, 2017, at 1:00 p.m. stated that Employee E6, a Licensed Nurse, caring for the resident on February 7, 2017, did not know if the [MEDICATION NAME] had been administered, the resident had been blinking her eyes and bitting her tongue, and stated that if it was a [MEDICAL CONDITION], she would have had a blank stare. Employee E3 stated in an interview on February 22, 2017, at 11:45 a.m. that the [MEDICATION NAME] had been discontinued on February 5, 2017, due to an automatic stop date which was attached to the facility readmission physician's orders when the resident was returned to the facility in November 2016, but it had not been noticed; a consultant pharmacist reviewed the physcian's orders monthly and had not noted the automatic stop date; the physician signed the orders and had not noted the automatic stop date for the [MEDICATION NAME] and the nursing staff had not noted the automatic stop date. Additionally, Employee E3 stated that the resident was still in the Critical Care Unit at the hospital; the resident was still on a ventilator; several attempts to remove the resident from the ventilator had failed; the resident was probably not going to be returning to the facility; and the resident would need placement in a LTAC (Long Term Acute Care - a facility that delivers higher level of care for residents with complex medical needs). The facility failed to obtain clarification of a stop date attached to a physcian's order for a anticonvulsant medication and failed to consistently monitor and assess a resident who had a known history of prior [MEDICAL CONDITION] causing the resident actual harm. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited 10/08/15, 11/11/16 28 Pa. Code 201.18(b)(1) Management Previously cited 10/08/15, 11/11/16, 01/23/17 28 Pa. Code 211.5(f)(g)Clinical records Previously cited 11/11/16 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 11/11/16 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 11/11/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/08/15, 11/11/16, 01/23/17 28 Pa. Code 211.12(d)(2)(3) Nursing services Previously cited 11/11/16

Based on review of clinical records, facility policy and procedures and facility documentation and interviews with the staff, it was determined that the facility failed to provide pharmaceutical services that included the accurate administration of medications and failed to ensure that all aspects of the pharmacy services were accurately reviewed by a licensed pharmacist resulting in the incorrect administration of medication for a resident with a history of seizures which resulted in actual harm to the resident who did not receive their antiseizure medication resulting in seizures which ultimately lead to the resident being transferred to the hospital, intubated and placed on a mechanical ventilator for one of 3 residents reviewed (Resident CL1). Findings include: Review of the facility policy titled, General Medication Procedures, with an effective date of October 12, 2006, and a revision date of September 22, 2016, stated, Upon admission a copy of the new resident's initial orders and relevant medication information will be sent to the pharmacy. Review of the physcian's orders dated October 2016 revealed that the resident was to receive 1 tablet of Keppra (a medication to prevent seizures) 1000 milligrams by mouth at 9:00 a.m. and 9:00 p.m. Review of Resident CL1's clinical record revealed physician's orders dated November 2016 which included [DIAGNOSES REDACTED]. that is inserted into the stomach through the abdomen to supply nutrition). A nursing note on November 8, 2016, at 12:07 a.m. stated that Resident CL1 had returned from the hospital, the resident had been admitted to the hospital for dysphagia (difficulty swallowing) and aspiration pneumonia (a lung infection caused by inhaling food or liquids) and that a feeding tube had been placed on November 4, 2016. In addition, the physician's readmission orders [REDACTED]. Nursing documentation dated December 29, 2016, at 8:21 p.m. stated that Resident CL1 had been transferred to the hospital because the feeding tube had clogged. The resident returned to the facility on [DATE], and the readmission physician's orders, received at that time, instructed staff to administer 5 milliliters (approximately one teaspoon) of Keppra solution (100 milligrams per milliters) via the feeding tube at 9:00 a.m. and 9:00 p.m. for 37 days. A physician's progress note dated January 3, 2017, at 12:56 p.m. stated that the resident was diagnosed with [REDACTED]. A nursing progress note on February 7, 2017, at 2:47 p.m. stated that Resident CL 1 had been biting her tongue in the morning, had a blood pressure of 140/74, a heart rate of 80 beats per minute, respirations of 20 breaths per minute and notified the physician who directed the staff to monitor the behavior. A discharge note dated February 8, 2017, at 12:51 a.m. stated that the nursing supervisor had been called to Resident CL1's room and the resident had been, having seizures intermittently, and the first seizure observed lasted for about 45 seconds to 1 minute and that thereafter the activities had been on and off, that left facial twitching was observed, had blood pressure of 158/78, heart rate of 98 beats per minute, respirations of 18 breaths per minute. The physician was notified and directed the staff to call 911 and send Resident CL1 to the hospital. The hospital Emergency Department documentation on February 8, 2017, noted that Resident CL1 arrived at 1:27 a.m. and the EMTs (Emergency Medical Technicians) reported that the resident had a one hour seizure at the facility. While en-route to the hospital the resident had another seizure and was medicated with Versed (a medication for sedation), and the staff in the emergency department administered Ativan (a sedative used to treat seizures) 2 milligrams IV (intravenously, directly in a vein.). An Emergency Department nursing note on February 8, 2017, at 2:00 a.m. stated that the nurse from the facility had called and stated, as per her records the resident has not been on Keppra since February 5, 2017. Further review of the Emergency Department documentation dated February 8, 2017, stated that at 2:10 a.m. the resident received 1000 milligrams of Keppra via IV, and was intubated (a breathing tube placed into trachea (the windpipe)) orally (through the mouth) and placed on mechanical ventilation (a device to assist with breathing). The Emergency Department physician documented on February 8, 2017, at 2:00 a.m. that the resident had been on Keppra until February 5 when the Keppra order was cancelled, no one is sure why she was taken off his/her Keppra. In addition, the Emergency Department physician documented at 2:39 a.m., [AGE] year old female with known seizure history had 1.5 hours of intermittent tonic clonic seizures (generalized whole brain seizures usually lasting 1-2 minutes with loss of consciousness and muscle stiffening and body convulsing) with no return to baseline after being discontinued from Keppra. The facility's Director of Clinical Operations and Nursing Excellence, Employee E3, stated in an interview on February 22, 2017, at 11:45 a.m. that the Keppra had been discontinued on February 5, 2017, due to an automatic stop date that had been attached to the physcian's order when the resident was readmitted to the facility in November 2016, but it had not been noticed; a consultant pharmacist had reviewed the physcian's orders monthly and had not noted the automatic stop date; the physcian had signed the orders and had not noted the automatic stop date for Keppra; and the nursing staff had not noted the automatic stop date. A review of Pharmacy Consultation Reports for December 2016 stated no new irregularities in the resident's medication regime. The Pharmacy Consultation Report dated January 16, 2017, noted a repeated recommendation originally from November 18, 2016, for clarification of the proper dosage form of medications, some medications had been ordered by mouth and some medications were to be given via the feeding tube and the feeding tube had recent issues with clogging. During an interview on February 22, 2017, at 1:10 p.m. Employee E3 stated that when the pharmacist was interviewed, she stated that she looked at the order in November 2016. The pharmacist stated she had not noticed the stop date, the computer software system was not a true interface with the pharmacy and the pharmacy received the name of the medication but not the physician's order. In addition, the Employee E3 stated that the resident was still in the Critical Care Unit at the hospital; the resident was still on a ventilator; several attempts to remove the resident from the ventilator had failed; the resident was probably not going to be returning to the facility; and the resident would need placement in a LTAC (Long Term Acute Care - a facility that delivers higher level of care for residents with complex medical needs). The facility failed to assure the accurate administration of medications and failed to ensure that all aspects of the pharmacy services were accurately reviewed by a licensed pharmacist regarding an anticonvulsant medication that had a stop date attached to the order, which had been previously administered daily, causing actual harm to the resident. 42 CFR 483.45(a) Pharmaceutical Services - Accurate Procedures, RPH Previously cited 11/11/16 28 Pa. Code 211.9(a)(1) Pharmacy services Previously cited 11/11/16 28 Pa. Code 211.9(d) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/08/15, 11/11/16, 01/23/17 28 Pa. Code 211.12(d)(2)(3) Nursing services Previously cited 11/11/16

Based on observations, review of clinical records, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who was blind and independently used a manual wheelchair to navigate the facility, which resulted in harm to the resident when he propelled himself through a gate that had been left open and fell down nine steps. The resident sustained [REDACTED]. Findings include: A review of Resident R2's clinical record revealed physician's orders [REDACTED]. Review of Resident R2's clinical record revealed a significant change Minimum Data Set assessment (MDS - a periodic assessment of resident needs) dated December 26, 2016, which indicated that Resident R2's vision was severely impaired (no vision or sees only light, colors or shapes, eyes do not appear to follow objects). Further review of the significant change MDS, revealed that Resident R2 was completely alert and oriented and able to make their own decisions. Continued review of the significant change MDS indicated that Resident R2 required supervision (oversight, encouragement or cueing) and one person physical assist with locomotion in their wheelchair on the nursing unit. Resident R2's functional limitation was indicated to be an impairment on one side of the body with both the upper extremities (shoulder, elbow, wrist, hand) and the lower extremities (hip, knee, ankle, foot). Resident R2 was dependent on a manual wheelchair for mobility. Resident R2 was occasionally incontinent of bladder and always continent of bowel. Review of Resident R2's care plan revealed a Visual Impairment related to blindness care plan initially developed on April 11, 2013, and continued to present date, which indicated that Resident R2 will negotiate the facility environment safely and remain free from injury. The approach indicated in the care plan was that Safety Precautions will be maintained at all times. Review of Resident R2's fall risk assessment dated [DATE], indicated the resdient was a high risk for falls and further indicated that all safety measures needed to be maintained at all times for Resident R2 to prevent any types of falls. Review of the information dated January 16, 2017, submitted by the facility, revealed that Resident R2 was transferred to a local hospital for evaluation and treatment after sustaining a fall down nine cement steps while in the wheelchair. An interview with Resident R2 on January 21, 2017, at approximately 10:00 a.m. in the presence of Employee E4, a Licensed Nurse, revealed that he had been completely blind in the right eye and could see only shadows with the left eye for the last [AGE] years, and has complete impairment on the right side of the body (both upper and lower extremities) as a result of a motor vehicle accident. Resident R2 revealed that he used the handrail on the left hand side of the hallway to guide himself to the bathroom as he always has done. Another resident was in the bathroom, so he wanted to use the other bathroom on the other side of an alcove. The doors on the bathroom are double saloon style doors. Resident R2 explained that he pushes the bathroom doors open by using his knees. During this interview with Resident R2, at approximately 10:00 a.m. the residenmt revealed that, I thought I was at the bathroom door because it felt like the width of the door at the bathroom, so I pushed thru as I always do and then, I was upside down in my wheelchair. Resident R2 explained during the interview that he sustained an injury to his forehead as a result of the fall down nine steps. The injury required four stitches, the shaving of his hair line, and that he was completely bruised and sore on the right side of his body (the side of his body that is affected by complete weakness) and he was told that his right eye was black and blue. Resident R2 indicated that when he came out of the first set of bathroom doors, he headed toward what he thought was the other bathroom. He did not realize that he had gotten himself to the other side of the hallway. He thought he was at the bathroom door and he pushed through the door, by using his lower body. Resident R2 indicated that he landed at the bottom of the steps, upside down, with his head resting on the right lower corner of the door and with the manual wheelchair on top of him. Resident R2 indicated that he believes the wheelchair saved his life. At the end of the individual interview with Resident R2, in the presence of Employee E4, Resident R2 demonstrated how he can maneuver to the bathroom and the gate that leads to nine concrete steps. During the observation, Resident R2 made his way to the bathroom. Resident R2 used the handrail on the left hand side of the hallway to make his way to the bathroom by using the manual wheelchair. Resident R2 revealed that Velcro strips were placed on both sides of the gate on January 18, 2017, one day after the resident fell down the nine concrete steps. Resident R2 then crossed the hall to the other side, where the bathroom was located and used his lower body to push through the double saloon style doors to enter the bathroom. Resident R2 then pushed himself through the saloon style doors to leave the bathroom and was observed maneuvering himself back towards his room. An interview with Employee E7, a Licensed Nurse, on January 21, 2017, at 11:30 a.m. confirmed that the care plan developed for Resident R2 related to Visual Impairment was not effective. An interview with Employee's E10 and Ell, both from the Therapy Department, confirmed that on January 17, 2017, (one day after Resident R2 fell down the nine steps) the Therapy Department added Velcro strips to both sides of the wall by the metal gate. Resident R2 can feel the Velcro pieces, making him aware of the gate to the steps. Employees E10 and Ell further indicated that they did re-education with Resident R2 regarding the area around the gate. Further observation of the gate area with Employees E8 and E9 maintenance enginers, confirmed a sign affixed to the gate that read, Stop Exit is only to be used when Fire Alarm is Activated. Observation of the door at the bottom of the nine steps revealed two signs, one read, Fire Exit Please Keep door Closed, and the second sign read, Watch your step, Floors, Steps and Walking may be slippery when wet. During the continued observation of the gate area, Employees E8 and E9 indicated that on the other side of the door is a courtyard area that is used by the staff when on break and was a gathering area for the residents. Employees E8 and E9 revealed that staff do incorrectly use the door to access the outside courtyard area and further indicated that the gate and the door should only be used in an emergency situation. On January 21, 2017, at 11:20 a.m. in the presence of Employee E7, Licensed Nurse, Director of Clinical Operations, a surveillance video recording from January 16, 2017, was reviewed. The recording started at 10:04 a.m., Resident R2 was observed on the video near the gate at 10:06 a.m. and various staff members were observed walking past Resident R2 while he was near the gate. Further into the video recording at 10:07 a.m., Employee E13, a Nurse Aide, was observed coming out of the central supply closet, across from the steps, and seeing Resident R2 at the bottom of the steps. Employee E13 was then observed on the video, going down the steps to attend to Resident R2. Employee E14, a Nurse Aide, was observed on the video coming out of the bathroom and putting both hands to her face upon seeing Resident R2 at the bottom of the steps. At the time of the video observation, Employee E7 confirmed that the staff were in the area during the time Resident R2 was near the gate and did not offer any redirection. An interview with Employee E7, the Director of Clinical Operations, on January 21, 2017, confirmed that the gate was not latched and was left ajar at the time Resident R2 fell down the nine steps. Employee E7 further indicated that 911 was called. Resident R2's neck was stabilized by 911 personnel and the resident was transferred to the local hospital for evaluation and treatment. A review of the facility incident report dated January 16, 2017, indicated during an interview with Resident R2 by Employee E6, Licensed Nurse, upon the resident's return from the hospital revealed that He got turned around and because the gate was unlocked, he thought he was at the other bathroom door and pushed his way thru and ended up at the bottom of the steps. Review of a witness statement by Employee E6, a Licensed Nurse, dated January 16, 2017, indicated hearing, A sound of metal crashing coming from the area of the residents' bathroom, carts in the bathroom falling. Further review of Employee E6's statement indicated, There was no human voice or sounds during the noise before silence. Employee E6 indicated in the statement, Ran towards bathroom but did not see any equipment down and as she turned she saw Resident R2 at the bottom of the stairs. Further review of Employee E6's statement revealed that during the interview with Resident R2 on January 16, 2017, Resident R2 had indicated to Employee E6 that, the gate should have been latched. An interview with Employee E6 on January 21, 2017, at 12:15 p.m. confirmed that a pressure dressing had to be applied to Resident R2's head to control the bleeding. Resident R2 was unstrapped from the seatbelt which was holding him into the wheelchair and blankets were placed over the resident to keep him warm. Employee E6 also indicated that she instructed a staff member to call 911. Review of Resident R2's clinical record revealed that on January 16, 2017, at approximately 6:00 p.m. Resident R2 returned to the facility with four stitches to his forehead area as a result of the fall down the nine steps, a black and blue right eye and bruising down the right side of his body. A review of the hospital records dated January 16, 2017, the date of the fall, did not document any indications that Resident R2 was having any kind of medical condition at the time of the fall or during the evaluation and treatment at the hospital. Review of the last physician's progress note dated January 20, 2017, which was four days after Resident R2 fell down the nine steps, indicated that the resident was seen after a recent fall down the steps in the wheelchair, the patient is legally blind, and indicated to physician that, the gate was left open and he thought he was going into the bathroom. The physician's note did not indicate any new medical condition or concerns since last physician's visit on December 7, 2016. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 23, 2017, at 3:45 p.m. related to an event that occurred on January 16, 2017, at 10:00 a.m. when Resident R2, who had blindness in both eyes, was not provided with adequate and safe supervision while maneuvering in a manual wheelchair, which resulted in Resident R2 falling down nine concrete steps, resulting in actual harm. The Immediate Jeopardy was removed on January 23, 2017, at 5:18 p.m. after the facility submitted an acceptable corrective action plan and it was verified that the action plan had been implemented. The corrective action plan included the following interventions: 1. Checking that the gate is latched each shift by nursing. 2. Velcro strips have been added to sides of gate entrance for resident orientation. 3. In-servicing to all staff to ensure the gate is always latched and the emergency exit plan for the stairway. 4. A plan to install a magnetic lock on the gate that will be tied into the fire system. The facility failed to provide adequate and safe supervision for one resident with blindness who maneuvered in a manual wheelchair and resulted in Resident R2 falling down nine cement steps in the wheelchair, and required transportation to the hospital for evaluation and treatment for [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/08/15, 11/11/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 10/08/15, 11/11/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 10/08/15, 11/11/16 28 Pa. Code 201.18(a)(b)(2) Management Previously cited 11/11/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 10/08/15, 11/11/16

Based on review of the clinical record and facility policy and procedure and interviews with staff, it was determined that the facility failed to adequately assess, monitor and implement appropriate interventions to prevent a decline in skin integrity for one of 30 residents reviewed resulting in harm (Resident R147). Findings include: Review of facility policy, 927.04 Skin Integrity Documentation, dated as revised September 22, 2016, revealed Purpose: To provide for timely and standardized skin and wound documentation in the resident's clinical record. A formal observation of the resident's skin will be completed weekly and recorded on the electronic treatment administration record . A review of facility policy, 927.02 Skin Integrity: Assessment, dated as revised September 22, 2016, revealed, To provide a risk assessment process to identify those residents at risk for impaired skin integrity. 2. Weekly risk assessments will be completed for the first four weeks after admission and re-admission to continue to monitor for potential risk factors associated with skin breakdown. The Modified Braden (a tool used to identify an individual's risk of skin breakdown) assessment tool will be used to document these assessments. Review of the clinical record for Resident R147 revealed that the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED].S.-a progressive [MEDICAL CONDITION] disorder of the central nervous system) and [MEDICAL CONDITION] (paralysis of the lower half of the body). An initial Minimum Data Set assessment (MDS-assessment of resident needs) dated September 28, 2016, indicated that the resident was totally dependent on two or more staff for transferring (moving from one area to another) and required extensive assistance from one or more staff for dressing, eating, bathing and personal hygiene. Further review of the initial MDS indicated that the resident was non-ambulatory (unable to walk) and had identified care needs in the areas of pressure ulcers (the breakdown in the skin due to continued pressure on that area). A nursing progress note dated September 22, 2016, indicated that Resident R147 had arrived at the facility at approximately 12:00 p.m. The note further indicated that the resident was wearing a brace to the right leg at the time of admission into the facility. physician's orders [REDACTED]. Further review of the clinical record and the comprehensive care plan for Resident R147 revealed that no wearing schedule had been developed for the use of the right foot and leg brace. An interview with Employee E7, the Unit Manager, on October 31, 2016, at 1:00 p.m. revealed that the employee was unaware of any established wearing schedule for Resident R147's right foot and leg brace. Further interview with Employee E7 confirmed that the employee was unable to determine the length of time Resident R147 had utilized the right foot and leg brace while in the facility. Further review of the clinical record for Resident R147 revealed a Braden Scale dated October 7, 2016. Resident R147's Braden Scale yielded a total severity score of 14 which identified the resident at moderate risk for skin breakdown. Further review of Resident R147's clinical record revealed no further completed Braden Scale scores. Continued review of Resident R147's clinical record revealed nursing documentation dated October 19, 2016, at 7:59 p.m. which indicated that the staff had noted a new area of skin breakdown on the ball of the resident's right foot. The area was noted as 6.0 centimeters (cm) long by 4.5 cm wide. The area of skin breakdown was described as a pressure ulcer and noted that the staff suspected the pressure ulcer was the result of a deep tissue injury (skin wound due to localized trauma). Nursing documentation further indicated that the wound had not been present at the time of the resident's admission into the facility and that the foot rests on the resident's wheelchair had only metal (lacked additional padding) on them. An interview with Employee E9, a Physical Therapist, on November 1, 2016, at 9:30 a.m. revealed that per facility protocol, all residents are seen following their admission into the facility for a physical therapy evaluation. Review of the, Physical Therapy Plan of Care - Initial Assessment, form dated September 22, 2016, revealed no documentation and/or assessment of the resident's right foot and leg brace. Further interview with Employee E9 confirmed that Resident R147 had been wearing a Maffo (a hard plastic fitted brace) splint on the right foot and leg at the time of admission into the facility. Employee E9 indicated during the interview that the physical therapy department is responsible for developing a wearing schedule for the use of braces and splints. The employee was unable to explain why a wearing schedule had not been developed for Resident R147's right foot and leg brace. Review of Resident R147's, Electronic Treatment Administration Record, (ETAR) dated September 2016 revealed no documentation that the nursing staff had assessed the condition of Resident R147's skin. Review of the October 2016 ETAR revealed no documentation of the condition of the resident's skin until October 20, 2016, the day after the resident's pressure ulcer had first been noted. An interview with Employee E7, the Unit Manager, on October 31, 2016, at 1:00 p.m. confirmed there was no documentation in Resident R147's clinical record that nursing staff had been monitoring the use of a brace to Resident R147's right leg and foot, no documentation of completed Braden Scale scores and no documentation that staff had been assessing Resident R147's skin condition weekly as per their policy. The facility failed to ensure that one resident, identified at increased risk for skin breakdown, was adequately monitored and assessed to prevent the development of pressure ulcers. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/06/14, 10/08/15 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 201.18(b)(1) Management Previously cited 11/06/14, 10/08/15 28 Pa. Code 211.10(c)(d) Resident care policies

Based on clinical record review, review of facility policy and procedure, staff interviews and a review of facility documentation, it was determined that the facility failed to ensure that assessed safety interventions and supervision to prevent accidents were in place for two out of thirty residents reviewed (Residents R159 and R75) which resulted in actual harm to one resident (Resident 159). Findings include: A review of the facility policy and procedure for the lifting and transfer of residents stated that all transfers to and from a shower trolley are to be done via lateral transfer or with an overhead mechanical lift witha minimum of two staff personnel. Clinical record review revealed that Resident R159 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident R159 was alert, oriented and able to make his/her needs known. Facility documentation dated February 2, 2016, documented a resident fall at 9:50 a.m., while the resident was being transferred/repositioned on the shower trolley to be returned to her wheelchair via a mechanical lift. Facility documentation indicated only one staff member was present at the time of the incident. The documentation failed to reveal whether the wheels on the shower trolley were locked. The details of the incident report revealed that the shower trolley was pushed up against the shower room wall as the nursing assistant prepared the sling for the mechanical lift to place it under the resident. The resident rolled on her side and grasped the side rail of the shower trolley, which disengaged and began to lower. The resident began to move forward and the shower trolley moved away from the wall and the resident ultimately fell and landed on her buttocks. The resident complained of pain and was treated for [REDACTED]. Nursing progress notes from February 2, 2016, through February 6, 2016, noted that Resident R159 continued to be monitored for pain related to the fall on February 2, 2016. Nursing progress notes from February 8, 2016, documented from 5:55 p.m. through 10:20 p.m. indicated that the resident had pain, described as an ache, in the right leg and hip area ranging from a pain level of 5 out 10 to 8 out of 10, on a 1 to 10 scale with 10 being the worst pain. A progress note documented at 10:29 p.m. on February 8, 2016, noted that the resident's right leg was found to be adducted (drawn inward toward the midline of the body) and bigger than the left leg. The resident grimaced when the right hip was touched and had limited range of motion. The resident reported at that time that she had a fall on the Tuesday of last week (February 2, 2016). The physician was then notified and an X-ray of the hip was ordered. On February 9, 2016, at 3:44 a.m. a nursing progress note entry revealed to transfer the resident to the hospital due to the X-ray confirming a fractured right femur (a break in the thigh bone). Information included in the progress note indicated that the reason for the transfer to the hospital was due to a fall related major injury. Facility documentation revealed that only one staff member was present at the time of the incident on February 2, 2016. In an interview on October 31, 2016, at 2:00 p.m. the Director of Nursing verified that only one staff member was present at the time of the incident, instead of the required two staff members, to ensure the safe transfer of the resident to and from the shower trolley. The absence of safety interventions appropriate for transfer to and from the shower trolley resulted in actual harm to Resident R159. The facility failed to ensure that assessed safety interventions and supervision to prevent accidents were in place and resulted in actual harm to one resident. Observations of the One South Solarium (a resident dinning area for all of the residents on the One South Nursing Unit, where typically 15 residents attend for meals) at 11:15 a.m. on October 28, 2016, revealed that Resident R75 was seated at one of six tables, in a motorized wheelchair watching television. Ten feet from where Resident R75 was sitting, there were two tables set up with table cloths and five metal racks with trays/pans. Underneath the serving racks and trays were ten burning/ignited Sternos (canned heat; a cooking fuel). An interview with the Director of Dietary Services, Employee E10, at this time, revealed that the essential dietary equipment (steam table) used to hold hot foods was not operable and was removed from the One South Resident Dining Area on Monday October 24, 2016. There were no staff assigned to supervise the area while Resident R75 was watching television and waiting for the noon meal service to begin in the One South Resident Dinning Area. The Director of Dietary Services, Employee E10, reported at the time, that the dietary department had placed a work order to have the steam table repaired or replaced. The facility failed to ensure that assessed safety interventions and supervision to prevent accidents were in place. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 11/06/14, 10/08/15 28 Pa. Code 201.14(a) Responsibility of licensee previously cited 11/06/14, 10/08/15 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 11/06/14, 10/08/15 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/06/14, 10/08/15