Every finding on record at Ivory Wellness Center

Based on interviews and the review of the clinical records, it was determined that the facility failed to ensure that a physician's order was clarified regarding the completion of an ultrasound study and failed to clarify an advanced directive for 2 out of 25 residents reviewed (Resident R1 and R12). Findings include: Review of the [DATE] physician orders for Resident R1 included the following diagnosis: diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high); hyperlipidemia (high cholesterol); hypertension (high blood pressure); acute respiratory failure ( occurs when the lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning. It also occurs if your lungs cannot remove carbon dioxide from your blood).Review of a physician's note dated [DATE] at 1:00 a.m. indicated that the resident was assessed by the facility physician, and complained about left calf pain.pt was seen in bed & is c/o a lot of L calf pain. Continued review of the physician's note indicated that physician ordered that a doppler ultra sound to rule out a deep vein thrombosis (DVT-a blood clot that forms in a deep vein, often in an individual's leg, and needs a quick diagnosis and treatment to prevent life-threatening complications). Review of the nursing notes indicated that the doppler ultra sound was completed by the facility's outside company on [DATE], and the results were provided to the facility on [DATE], 4 days after the initial request from the physician. During an interview with the unit manager on [DATE] at 12:50 p.m. it was confirmed that the doppler ultrasound was ordered on [DATE], but was not aware of the results of the doppler ultrasound until [DATE].Review of the August physician orders for Resident R12 arthritis; heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should that results in blood to back up often, and fluid can build up in the lungs, causing shortness of breath); hypertension (high blood pressure), and dementia (a group of symptoms affecting memory, thinking and social abilities).Continued review of the resident's physician orders included a physician order dated [DATE], and monthly thereafter, for the resident not be resuscitated by facility staff (DNR-a directive that states that an individual does not want to undergo life saving measures like cardiopulmonary resuscitation (CPR- an emergency treatment that's done when someone's breathing or heartbeat has stopped). Continued review of the clinical record also included a Portable Orders for Life Sustaining Treatment (POLST- a medical order completed by a healthcare professional that outlines a patient's preferences for emergency and ongoing medical care, particularly regarding life-sustaining treatments such as CPR, intubation, and hospitalization) completed [DATE], that indicated that the resident wanted CPR initiated should he stop breathing and no longer has a pulse.Continued review of the resident's clinical record did not include any other documentation as to why current physician orders were not updated to reflect the resident's wishes. During an interview with the Director of Nursing (DON) the discrepancy in the physician's orders were reviewed and discussed. 28 Pa. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, review of clinical records, observations and staff interviews it was determined that the facility failed to ensure a resident received nail care for one of 25 residents reviewed (Resident R7). Findings Include: Review of Resident R7's clinical record revealed the resident was admitted to the facility in April 2024 with diagnoses of cerebral infarction (stroke), Hemiplegia (one-sided weakness), and anxiety disorder (intense, excessive, persistent worry or fear). On August 12, 2026, at 10:30 a.m. the Resident R7 was observed with long, dirty fingernails with a brownish-red color substance underneath. Resident R7 was noted with small scab like marks on his/her face and hands. Resident R7 stated his/her significant other normally cut Resident R7's nails. Review of Resident R7's care plan revealed a self-care deficit that included checking the resident's nail length and keeping them trim and clean. Further review of Resident R7's care plan revealed the resident has behaviors of itching and uses anti-anxiety medication. Interview with the Director of Nursing on August 12, 2026, confirmed Resident R7's nails needed grooming. 28 Pa. Code 211.12 (d)(1) Nursing services 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for one of 12 residents reviewed (R100). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. Review of Facility Policy on admission Criteria, dated March 2019, indicated all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD. Continued review of facility policy revealed if the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. Per the facility policy, the admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. The social worker is responsible for making referrals to the appropriate state-designated authority. Review of Resident R100's clinical record revealed that the resident was admitted to the facility on [DATE], and has diagnoses of Major Depressive Disorder (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), anxiety disorder (intense, excessive, persistent worry or fear), Unspecified Psychosis (collection of symptoms that disrupt a person's thoughts and perceptions, making it difficult to distinguish what is real from what is not). Review of Resident R100's clinical record revealed that a Pennsylvania Preadmission Screening Resident Review Identification Level I (PASRR) Form was completed on September 9, 2022. In Section VII - Exceptional Admission, the item asking whether the individual meets the criteria for a PASRR Level II Evaluation by one of the Program Offices, is not a danger to self, and/or others and meets the criteria for Exceptional admission to a Nursing Facility, was left incomplete. The form did not indicate either Yes or No for this required field. Further review of R100's PASRR revealed that Section III A- List of Mental Health Diagnoses was left blank or left unrevised. It also indicated that Nursing Facility Field Operations stamp was not affixed, even though the PASRR form was written on September 9, 2022. Interview on August 13, 2026, at 1:14 p.m. with the Social Worker, E5, confirmed the above findings. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.16(a) Social services

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of residents who are trauma survivors, for one of two residents reviewed (R80).Findings include: Review of the facility policy and procedure on Trauma Informed Care and Culturally Competent Care, dated August 2022, indicated that Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of traumas. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.Review of facility policy and procedure on Trauma Informed Care and Culturally Competent Care revealed that the facility willDevelop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident.Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression).Develop individualized care plans that incorporate language needs, culture, cultural preferences, norms and values. Review of Resident R80's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD) [a mental health condition that can develop after an individual experience or witness a terrifying, shocking, or dangerous event]. Review of R80's Minimum Data Set (MDS - a standardized clinical assessment tool used to measure the physical, mental, and psychosocial status of nursing home residents) dated July 15, 2026, revealed that R80 has a diagnosis of Post Traumatic Stress Disorder. On August 14, 2026, at 12:09 p.m., review of clinical records for R80 discovered that there were no orders, and treatments offered for PTSD care. Review of the care plan for R80, initiated on October 25, 2019, or revised on May 25, 2026, discovered no focus, outcomes (goals), and interventions, care- planned for treating Post Traumatic Stress Disorder. On August 14, 2026, at 12:26 p.m., interview with the Director of Nursing confirmed the above findings. 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, interview with residents and staff and clinical record review, revealed that residents were not offered a scheduled rest period in their bed per resident's preference while their rooms were being remodel for four of five residents reviewed. (Residents R1, R2, R3 and R4) Findings include: Observation conducted on February 18, 2026, at approximately 9:23 a.m. revealed construction in resident rooms 123-127. Interview with Nursing Home Administrator, Employee E1 at the time of the observation revealed that the rooms were being remodeled. Residents assigned to the first floor were observed relocated to a second-floor lounge area due to the construction. Four of five residents (Residents R1, R2, R3 and R4) were observed seated in the 2nd Floor lounge). Residents R1, R2, R3 and R4 reported being required to remain in the lounge for extended periods, up to approximately 8-12 hours, without routine access to their rooms or beds. Continue interviews with above residents revealed they were told they could not remain in their rooms while work was being completed. Residents reported limited access to rest, privacy, and normal routines, including the ability to lie down. Residents stated they remained seated in wheelchairs for prolonged periods. Interview with the Director of Nursing, Employee E1 and Administrator, Employee E2 on February 18, 2026, at 1:55pm, confirmed Residents R1, R2, R3 and R4 were moved to the 2nd Floor due to concerns related to dust particles and construction safety. Administration, Employee E2 stated residents were advised in advance and that relocation was implemented for safety reasons. The Director of Nursing and Administrator further confirmed the construction was remodeling and not emergent. They stated residents were not offered alternative areas to rest upon request. Review of ResidentR1, R2, R3, and R4. clinical record review revealed no documented evidence that a scheduled rest period to rest in their bed were discussed pre resident's preference. 28 Pa. Code 201.18(b)(3) Management28 Pa. Code 211.12(c) Nursing services

Based on observations, review of clinical documentation, review of facility policies, resident interview, and staff interview it was determined that the facility did not ensure a resident was treated with respect and dignity related to searches and drug use policy for one of seven residents reviewed. (Resident R1)Findings Include:Review of facility policy titled, Drug Screening/Searches for Residents with a created date of February 24, 2025. The policy states, Policy: It is a policy of Ivory Wellness Center to maintain a drug free environment to ensure the safety and well-being of all the residents living in the facility. Definition: Illegal Use of Drugs- The use of drugs, the possession or distribution of which is unlawful under the Controlled Substances Act. This does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act. Illicit drugs may include but are not limited to opiates, amphetamines, cannabis, hallucinogens, etc. Further review of the facility policy revealed, Procedure/Responsibilities/Actions:.7. The facility will have searches done randomly to identify residents that may be using or distributing illegal drugs.8. If a resident tested positive for illegal drugs or is found to have illegal drugs in their possession the attending MD will be notified.9. The IDC team will meet to provide counseling and discuss the possibility of being transferred to a more appropriate setting for possible rehabilitation or discharge. The resident may also be requested to sign a contract that stipulates that if there is any further violation of the facility policy or the law, it will not be tolerated and could result in discharge from the facility.10. Out On Pass privileges may be suspended for a certain period as deemed appropriate by the physician.11. The resident's substance abuse behavior will be addressed in the resident's plan of care that will include managing resident behavioral symptoms. It may also include discharge planning if necessary.Review of facility documentation provided by Employee E2 the Director of Nursing states, Drug Consent Policy states, As a Resident at Facility , I___________agree that during my stay at the facility, I will NOT bring in drugs of any kind, I will NOT take any drugs that are not prescribed by my Physician, and I will NOT give or sell drugs of any kind to any other resident, visitor or staff member. I understand and agree that if I am found in possession of drugs or observed taking or selling drugs of any kind, I will be discharged from the facility and not permitted readmission. I agree to be searched / have my room searched for the possessions of drugs*. My Physician as well as the Police department will be notified promptly. If suspected, but not observed taking illegal drugs, I agree to urine and blood drug screening ordered by my Physician. My signature indicates my acceptance and agreement with this Policy. Review of Resident R1's clinical record revealed the resident was re-admitted to the facility on [DATE]. The resident has the following diagnosis: Depression, Insomnia, Psychoactive Substance Abuse, Lower Back Pain, Nicotine Dependence and Anxiety. Interview held at 9:55 a.m. with Employee E4 the physician's assistant who has a history with the resident. Employee E4 stated that for her and physician Employee E6 they no longer care for Resident R1 due to her constant requests for narcotics. Employee E4 states that Resident R1 has done many things like receiving medications dispensed at that the facility and was found selling it to other residents here. When asked when this occurred, Employee E4 stated it occurred within the last few weeks. Employee E4 states that Resident R1 is a bully to other residents, even as of recently stole a women's credit card in her room and maxed them out. Resident R1 was interviewed at 10:21 a.m. and discussed the situation where she was found with an pill in her possession. The resident stated, one day, like they had done before they had drug sniffing dogs come here and they came into my room. When asked where it came she stated it came into my room by my bed and by my dresser. The resident stated, I then got upset and told them to get out of my room but then realized I was wrong to keep it so I handed it over to them. When asked where the resident got the pill from she stated, from here, one day I was sleeping and the nurse left the cup of pills on my tray stand and I know I shouldn't have hid it but I did and I admitted after it was wrong. Review of facility documentation shows a grievance filed by Resident R1 on October 12, 2025. The grievance states, .I'm harassed by the DON, ADON, NHA and others in the pursuit to locate drugs on location. The resolved date list October 14, 2025. The answer to What action was taken to resolve grievance concern-resident met with unit manager, DON. The answer to Results of action taken-DON conducted Medical Director to follow up Review of physician progress note from October 14, 2025 made by Employee E5 states, Nature of Presenting Illness: Asked to evaluate patient as medical director for substance abuse issues and other concerns. Patient has a history of substance abuse currently on Suboxone. It has been reported by staff and other residents that patient selling her Adderall. This has since been discontinued. Patient also with positive drug test for marijuana. Patient has violated controlled substance policy and was upset at current provider for refusing to continue to write Suboxone along with other controlled substances. During my examination today, both the director of nursing Employee E2 and unit manager Employee E7 were present for the entire conversation. Explained that I will be seeing the patient from here on out because she has refused to see the other providers in the practice. The facility has also reached out to the other physicians in the building who declined to bring the patient on service because of documented behaviors and ongoing substance abuse. Patient was recently found to have Adderall in her room and in her pocket on search by drug dog. I explain to the patient at length why the wean for Suboxone will be ordered. Given the fact that patient is abusing other drugs and found storing Adderall in her room reports from other residents that she is actively selling drug drugs in the facility. Upon me explaining Resident R1 became very agitated and aggressive. Yelling at me that I cannot do this I did offer her choice and did recommend a less restrictive environment as she is [AGE] years old and is able to perform all ADLs and does not need nursing level of care. She refused physical exam Told me to leave the room. She then began to chase me down the hallway, calling me a *ucking prick and that she would report me. The Director of Nursing was interviewed at 11:32 a.m. and asked if the resident ever signed a Drug Use Policy that would be enforceable by the facility and for Resident R1 to be knowledgeable of facility rules. The Director of Nursing Employee E2 stated that she was unsure but that she would check. Later, at 12:10 p.m. the Director of Nursing Employee E2 stated that she asked physician, Employee E5 and he stated that he did not have her sign one because she always refuses to sign anyway. The facility failed to ensure not to conduct searches of a resident or their personal belongings, unless the resident, or resident representative agrees to a voluntary search and understands the reason for the search. 28 Pa. Code: 201.18(b)(2) Management.28 Pa. Code: 201.29(j) Resident's rights.

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.Findings include: A tour of the Food Service Department was conducted on September 22, 2025, at 9:30 a.m. with Employee E3, Food Service Director (FSD), revealed the following concerns: Observation in the outdoor receiving area revealed 6 wooden pallets were leaning against the wall, and a large pile of black milk crates thrown to the left of the door. Observation of the convection oven revealed heavy build-up of black baked-on food particles on the inside surface of the oven. Observation of the reach in refrigerator in the kitchen revealed no internal thermometer to check temperature. Interview with the FSD on September 22, 2025, at 9:45 a.m. confirmed the above findings. Observation in the kitchen dish area during a follow up visit on September 23, 2025, at 1:30 p.m. revealed that the dishwasher wash temperature was 150 degrees and the rinse temperature was only 120 degrees. When asked why the rinse temperature was so low the FSD said that they just had their equipment and chemical company fixing the booster heater, but that it need another part. He said that they had been using the machine as a low temperature machine using a chlorine sanitizer, but it was disconnected when the booster heater was put in. Observation under the dish machine revealed clear plastic tubing laying on the floor next to a gallon jug of household bleach. The FSD removed the cap and put the tubing into the jug and ran the machine for a few minutes. After running several empty racks through the machine, he checked and the reading was still zero on chlorine as the bleach was not being pumped into the machine. An interview with the FSD on September 23, 2025, at 1:45 p.m. revealed that they had called the technician to come and check the machine. During this interview, the FSD confirmed that the chloring was not hooked up, that they should not be using household bleach and that they had not checked the chlorine level prior to washing the lunch dishes. An interview with the equipment and chemical company technician, Employee E13 on September 23, 2025, at 2:05 p.m. revealed that the sanitizer pump was not operating when he arrived and that he got the pump working and when tested, he got the minimum 50 ppm reading on chlorine. He also confirmed that the facility should not be using household bleach, but rather the sanitizer for commercial dish washing machines. An interview on September 23, 2025, at 2:20 pm with the Maintenance Director, Employee E12 revealed that he had been at the facility for thirty days and that he was aware that the dishwasher was being fixed and that it had been operating as a chemical sanitizer. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observations and resident interviews, it was determined that the facility failed to maintain the facility in a clean, safe, comfortable and homelike condition on both nursing floors. Findings include: Observations during the initial tour of the facility on September 22, 2025, revealed the following concerns: Observations on September 22, 2025, at 10:45 a.m., in room [ROOM NUMBER] in the bathroom revealed holes in the wall patched with a rough white substance and the bottom of the inside of the door had holes torn into the splintered wood door causing a hazardous condition. There was also flies buzzing around the room, Resident R23 said that he has seen the flies the last week or so. Observations on September 22, 2025, at 10:48 a.m., in room [ROOM NUMBER] revealed holes in the wall by the window patched with a rough white substance, and the ceiling tiles had dark brownish circular stains, some of which appeared to have been painted over with white paint. Observations on September 22, 2025, at 10:55 a.m., in room [ROOM NUMBER] revealed holes in the wall patched with a rough white substance. Observations on September 22, 2025, at 10:59 a.m., in room [ROOM NUMBER] revealed holes in the wall by the floor patched with a rough white substance and one entire wall covered with words and lyrics written in black marker. Observations on September 22, 2025, at 10:48 a.m., on September 22, 2025in room [ROOM NUMBER] revealed holes in the wall near the floor between the beds patched with a rough white substance. Observations of Second floor unit on Monday, September 22, 2025, room [ROOM NUMBER], revealed cracked walls in multiple areas, near the window and air conditioning unit. Further observations of Second floor unit revealed six trash and laundry bins stored in the shower room as well as a mechanical lift. A discussion with the Administrator at 10:15 a.m. on September 25, 2025, confirmed the above findings. 28 Pa. Code 207.2(a) Administrator's responsibility

Based upon interviews with residents and staff and review of facility resident council minutes determined the facility failed to serve meals that were palatable, and at an appetizing temperature for nine of nine residents attending residents' group meeting (Resident R38, R39, R52, R68, R71, R77, R78, and R79), and one of 23 resident records reviewed (Resident R6).Findings include: On September 22, 2025, at approximately 1:00 p.m. during an interview with an alert and oriented resident, Resident R6 complained that the food during meals is Always served room temperature. Review of resident council minutes dated May 14, June 11, July 9, August 20, and September 10, 2025, revealed the residents voiced wanting more variety of meal alternatives, and concerns that during mealtime the food temperatures were not hot. Council minutes revealed the residents spoke to the facility administration and the food director regarding these food concerns. On May 14, 2025, it was documented that the Dietary Director expressed getting the food carts out sooner to keep the food hot. On July 9, 2025, the resident council minutes continued to note Multiple complaints of food being served cold and continued with the same complaint during the August 20, 2025, council meeting. On September 24, 2025, at 10:15 a.m. during an interview with nine alert and oriented residents from the facility's Resident council group, the residents all agreed the food continues to be served cold, and there is still no variety. These concerns were confirmed with the Director of Nursing on September 24, 2025, at 1:25 p.m. Interview with Resident R23 on September 22, 2025, at 10:34 a.m. revealed that he thinks that food is not good, too much chicken and rice is too thick, not always hot. Interview with Resident R28 on September 22, 2025, at 10:37 a.m. revealed that the food is not good, too much rice, small portions, not always warm. Interview with Resident R7 on September 22, 2025, at 10:40 a.m. revealed that food is not good, it is never warm, the hot water for tea is cold, will not make tea. Interview with Resident R73 on September 22, 2025, at 10:44 a.m. revealed that the food is really bad, the burgers are like rock, not always warm. Interview with Resident R89 on September 22, 2025, at 2:30 p.m. revealed that he stated I don't trust the food. It does not look good or smell good, I think they put something in it. I did not touch the lunch tray. Observations during a test tray conducted on September 24, 2025, revealed that the salad was served on the same plate as the spaghetti tray, causing the salad temperature to be 93 degrees and the spaghetti with meat sauce to be 118 degrees. The milk was at 52 degrees, and the fruit cup was at 70 degrees. Temperatures were taken by the Food Service Director (FSD), Employee E3, who confirmed that these foods were all outside the acceptable temperature range for palatability. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management

Based on clinical record review, a review of facility policy and documentation and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers and discharges for four of 26 clinical records reviewed (Residents R41, R115, R1 and R3).Findings include: A review of the Transfer or Discharge, Facility-Initiated policy, updated October 2022, revealed that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of Resident R3's clinical record revealed that on June 18, 2025, the resident was sent out to hospital for evaluation due to low oxygen levels, low heart rate and high temperature.Further review of Resident R3's clinical record revealed the resident was hospitalized for 10 days and was re-admitted to facility on June 27, 2025.Review of facility provided documentation revealed no evidence that facility-initiated discharge for Resident R3 was communicate with long term care state ombudsman. Clinical record review for Resident R41 revealed that resident was admitted to the facility on [DATE], with diagnoses including end stage renal disease (kidneys can no longer function adequately to meet the body's needs, requiring dialysis or a kidney transplant for survival). Continued record review for Resident R41 revealed that the resident was sent to the hospital on July 27, 2025, with complications of refusing dialysis and was readmitted to the facility on [DATE]. A review of the list of residents sent to the Ombudsman for facility-initiated emergency discharged for July or August 2025 did not reveal Resident R41 was included in this notification. Closed clinical record review for Resident R115 revealed that resident was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood). Continued record review for Resident R115 revealed that the resident was admitted to the hospital on [DATE], with hypoglycemia (when the level of sugar in your blood drops below the healthy range). A review of the list of residents sent to the Ombudsman for facility initiated emergency discharged for July or August 2025 did not reveal Resident R115 was included in this notification. An interview on September 25, 2025, at 12:40 p.m. with the Administrator, confirmed that, the Long-Term Care Ombudsman was not informed of these particular transfers and discharges for these four residents. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation and employee interviews, it was determined that the facility failed to maintain the dish washing machine in the main kitchen and the med storage refrigerator on the second-floor medication room in an operating condition.Findings include: Observation on September 23, 2025, at 1:30 p.m. during a follow-up tour of the dietary department with the Food Service Director (FSD), Employee E3, revealed that the dish washing machine had a final rinse temperature of 120 degrees. When asked about this the FSD indicated that the booster heater had recently been worked on but was still waiting for parts and they were to be using it as a low temperature chemical sanitizing machine. When asked to check the chlorine ppm, the FSD got no reading on his test strips. It was noted that the plastic tubing was laying on the floor next to a closed gallon jug of household bleach. The FSD removed the cap and put the tubing into the jug of bleach and ran the machine for several minutes. After allowing the machine to run for a few minutes with empty dish racks going through he tested the chlorine level again and still got no reading on the test strips. The FSD stated that they were waiting for the technician from the equipment and chemical company who was in route to check the machine. At 2:05 pm the technician, Employee E13 arrived and adjusted the sanitizer pump and got a mild reading of about 50 ppm, the minimum level of chlorine for sanitizing dishware. The technician confirmed that the facility should not be using household bleach, but rather the chlorine sanitizer designed for commercial dish washing machines. Interview with the Maintenance Director, Employee E12 on September 23, 2025, at 1:45 p.m. confirmed that he was aware that the facility was waiting for parts for the dish washing machine and that they should be using an approved sanitizer which they would borrow from their sister facility across the street. Interview with the FSD conducted on September 23, 2025, at 2:15 p.m. confirmed the above findings and revealed that he did now know why the sanitizer was not hooked up and operating and that they had not checked the chloring level prior to washing the lunch dishes. 28 Pa Code 201.14(a) Responsibility of licensee

Based on observations, review of clinical records, and review of facility policy, it was determined that the facility did not ensure to develop a care plan related to resident's right-hand contracture for one of six residents reviewed (Resident R3)Findings include:Review of facility policy 'Care Plans, Comprehensive Person-Centered,' revised March 2022, indicates that 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: e. reflects currently recognized standards of practice for problem areas and conditions.Review of Resident R3's clinical record revealed medical diagnosis of contracture of right hand.Review of nursing notes, dated June 2, 2025, indicates patient with a history of spasticity in the right handReview of nursing note, dated July 7, 2025, indicates Resident R3 had contracture, right wrist.Observations of Resident R3 on Monday, September 22, 2025, revealed the resident had a right hand/ wrist contracture.Review of resident's care plan revealed no evidence that a care plan was developed to address Resident R3's right hand/wrist contractures.28 Pa Code 211.12(d)(5) Nursing services

Based on review of resident council minutes and facility policy, interviews with the resident council, and the preferences of the residents, determined that the facility failed to provide an ongoing program to support residents choice of daily fresh air activities, and failed to facilitate a facility-sponsored trip as a group activities, to support the residents' interests in interacting with the outside community for nine of nine residents interviewed (Resident R18, R38, R39, R52, R68, R71, R77, R78, and R79). Review of facility policy 'Activity Evaluation,' revised February 2023, indicates that in order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities.Further review of policy indicates that 6. The activity evaluation is used to develop individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest.Interview with facility's activities director, Employee E4, on Monday, September 22, 2025, at 10:00 am, revealed that residents were escorted outside to gazebo for fresh air break on Tuesday and Thursdays, at either at 2:00 pm or 3:00 pm - depending on the weather.Observations of first floor and second floor units revealed no evidence of posted schedule for fresh air break.Interview with Resident R77 on Monday, September 22, 2025, at 9:45 am, revealed that she is allowed for fresh air break only if it's during scheduled smoking times - on patio of second floor dining room.Interview with Resident R18, on Monday, September 22, 2025, at 10:40 am, revealed that he is not offered an option for fresh air break.On September 24, 2025, at 10:15 a.m. during an interview with nine alert and oriented residents (Resident R18, R38, R39, R52, R68, R71, R77, R78, and R79) from the facility's Resident council group, the residents revealed the non-smokers were not offered by staff to go outside for daily fresh air but the residents who smoke were offered cigarette breaks, four times a day. Review of the previous resident council minutes from May 2025 to September 2025 revealed the residents were requesting outings and more time outdoors. Further review of the council minutes revealed on June 11, 2025, the response from the activity department discussed Several fundraisers to cut cost of transportation. During the July 9, 2025 meeting indicated that the old business previously discussed were resolved, and the activity department informed the residents they were starting, Monthly outings starting in August 2025. Further interview revealed the residents stated there were no scheduled outings in September and no further conversation regarding future day trips and/or fundraisers. These concerns were confirmed with the Director of Nursing on September 24, 2025, at 1:25 p.m. 28 Pa Code 201.18(b)(3) Management

Based on observation and staff interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with professional standards, and to discard expired medications in accordance with professional standards, for one of one medication storage room. (Second Floor).Findings include:Observation of the Medication Storage Room of the Second Floor, on September 24, 2025, at 2:04 p.m., revealed the temperature of the medication storage refrigerator was 54 degrees Fahrenheit. The refrigerator was cluttered with various items, and eight Influenza vaccine (syringes form) with expiration date June 30, 2025.Interview with a Roistered Nurse, Employee E14, at the time of the finding, confirmed that the Influenza vaccine (syringes form) should have been discarded.28 Pa Code 211.9(g)(h) Pharmacy services28 Pa Code 211.12(c) Nursing services

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 32 residents reviewed (Resident R83).Findings include:Review of Resident R83's physician order dated June 20, 2024, revealed an order for Prozac Oral Capsule (Fluoxetine HCl), give 20 milligrams (mg) by mouth one time a day related to Major Depressive Disorder, Anxiety Disorder; give with 10mg to equal 30 mg.On September 23, 2025, at 9:55 a.m., during review of medication administration, it was observed that a Licensed Practical Nurse, Employee E15, administered to Resident R83 one tablet of Fluoxetine 20 mg capsule.On September 23, 2025, at 10:01 a.m., during an interview, Employee E15, clarified that Resident R83 was on gradual dose reduction for Prozac Oral Capsule (Fluoxetine HCl); hence the actual dosage of Prozac Oral Capsule (Fluoxetine HCl) to administer to R83 was only 20 mg by mouth; but the same was not displayed in the electronic physician order; at the time of the finding.An interview with the Director of Nursing, on September 23, 2025, at 1:21p.m., confirmed the finding. 28 Pa Code: 211.5(b)(i) Clinical Records

Based on review of clinical records and interview with staff, it was determined that facility did not ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza and, as applicable, the pneumococcal immunization for 18 out of 100 residents reviewed ( Resident R66, R105, R32, R15, R118, R54, R102, R55, R51, R100, R93, R109, R62, R83, R69, R94, R99, R76)Findings include:Review of facility policy 'Pneumococcal Vaccine,' revised March 2023, indicates that before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the resident's medical record.Review of facility policy 'Influenza Vaccine.' Revised August 29, 2025, indicates that prior to vaccination , the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's /employee's medical record.Review of Resident R66's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R105's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R32's clinical record revealed pneumococcal vaccine was administered on January 26, 2024; there was no documented evidence that education was provided.Review of Resident R15's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R15's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R118's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R54's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R102's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R55's clinical record revealed influenza vaccine was administered on October 1, 2024; there was no documented evidence that education was provided.Review of Resident R51's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R51's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R100's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R100's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R93's clinical record revealed pneumococcal vaccine was administered on October 22, 2024; there was no documented evidence that education was provided.Review of Resident R109's clinical record revealed pneumococcal vaccine was administered on October 25, 2024; there was no documented evidence that education was provided.Review of Resident R62's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R83's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R69's clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R94s clinical record revealed influenza vaccine was administered on October 7, 2024; there was no documented evidence that education was provided.Review of Resident R99's clinical record revealed pneumococcal vaccine was administered on October 23, 2024; there was no documented evidence that education was provided.Review of Resident R76's clinical record revealed pneumococcal vaccine was administered on October 22, 2024; there was no documented evidence that education was provided.Interview with facility's director of nursing, employee E1, on Wednesday, September 24, 2025, at 11:20 am, confirmed that education was not provided prior to administering vaccinations.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1) management28 Pa Code 211.15(f) clinical records

Based on review of clinical records and interview with staff, it was determined that facility did not ensure to provide pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for two out of 100 residents reviewed (Resident R116 and R29)Findings include:Review of Resident R116's clinical record indicates covid-19 immunization was administered on November 8, 2024; there was no documented evidence that education was provided.Review of Resident R29's clinical record indicates covid-19 immunization was administered on December 3, 2024; there was no documented evidence that education was provided.Interview with facility's director of nursing, employee E1, on Wednesday, September 24, 2025, at 11:20 am, confirmed that education was not provided prior to administering vaccinations.28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(b)(1) Management28 Pa Code 211.15(f) Clinical records

Based on review of facility policy, observations in the food and nutrition department, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings Include: Review of facility policy Food Storage dated August 2024, revealed food items will be stored, thawed, and prepared in accordance with good sanitary practice. All products shall be dated upon receipt or when they are prepared. Further review of facility policy revealed meat should be dated when taken out of the freezer. Dented cans should be placed on damaged good shelf and returned for credit. Any opened products shall be placed in containers with tight-fitting lids or Ziploc bags. All foods shall be stored off the floor. A tour of the main kitchen was conducted with the Food Service Director, Employee E21, on October 28, 2024, at 8:45 a.m. revealed the following: Interview with the Food Service Director, Employee E21, revealed a food order was received in the morning around 6:30 a.m. that was unable to be put away yet. Observations revealed a box of frozen French fries, frozen waffles, tomatoes, and apple juice cups were stored directly on the kitchen floor. Observations in dry storage revealed a reach-in refrigerator. Observations inside the reach-in refrigerator revealed 4 sheet cakes with no dates, a moldy cucumber, a box of individual cream cheese portions on the bottom shelf with a dark, liquid dripping all over the box, 7 heads of lettuce with no date and was starting brown/[NAME]. Further observations revealed two large pork loins and a box of chicken thighs with no dates. Per the food service director, the meats were previously frozen and put in the fridge to thaw. Continued observations in dry storage revealed a box of bananas stored on top of a plastic milk crate. Further observations revealed the bananas were extremely overripe and deteriorating. The food service director picked up the box of bananas to remove from the dry storage room and a swarm of fruit flies scattered throughout the dry storage room. On the shelving in dry storage there was a bag of sugar that was open to air and not put in a sealed, air-tight container. Further observations in dry storage revealed two cans of dented sweet potato cans that were not in a designated damaged goods area. Observations of the reach-in freezer revealed the freezer was tightly packed, limiting adequate circulation of air around the food. Further observations of the reach-in freeze revealed an open, and undated container of hot dogs. The bottom of the reach-in freezer had significant food and debris build up that required cleaning. Observations of the walk-in refrigerator revealed pineapples in a plastic storage container with no date. Observations above the prep sink revealed a long shelf along the wall storing condiments. Observations revealed a container of teriyaki sauce with drippings on the outside of the container making it sticky to touch. Behind the wall of the shelf were dark, dried liquid drippings down the wall. The shelf had a significant build-up of grease, food, and debris. Fruit flies were present and flying above the prep sink. The microwave was greasy to touch. Observations revealed the condiment cart used to store condiments to utilize during tray line was missing a wheel and was being held up by a small bin. Observations were confirmed by the Food Service Director, Employee E21, throughout the duration of the kitchen tour. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to ensure medication regimen reviews were completed monthly by a licensed pharmacist and failed to ensure recommendations were reviewed timely by the physician for 4 of 5 residents reviewed (Resident R88, R28, R6, and R40). Findings Include: Review of facility policy, Medication Regimen Review dated September 2023, revealed The Medication Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. Continued review revealed, The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. Continued review revealed, Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug and the irregularity the pharmacist identified. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. Further review revealed, Any written communications provided to the facility will be filed and any attachments in a readily retrievable area. During an interview with the Director of Nursing, Employee E2, on October 29, 2024, at approximately 3:30 p.m., surveyors requested six months of medication regimen reviews completed by a licensed pharmacist for the following residents: Resident R88, R28, R6, and R40. Review of documentation provided by the Director of Nursing, Employee E2, and review of Resident R88's entire clinical record revealed no documented evidence a licensed pharmacist conducted a complete medication regimen review for Resident R88 for June or July 2024. Review of documentation provided by the Director of Nursing, Employee E2, and review of Resident R6's entire clinical record revealed no documented evidence a licensed pharmacist conducted a complete medication regimen review for Resident R6 for June or July 2024. Review of documentation provided by the Director of Nursing, Employee E2, and review of Resident R40's entire clinical record revealed no documented evidence a licensed pharmacist conducted a complete medication regimen review for Resident R40 for July 2024. Review of Resident R40's Consultant Pharmacist Medication Regimen Review, dated June 29, 2024, revealed recommendations to review the resident's antidepressant medication for a possible dose reduction. The physician did not sign that the recommendation was reviewed until August 26, 2024. Review of Resident R28's monthly pharmacy review provided by Employee E2 on October 30, 2024, at 9:19am revealed that there were pharmacy reviews for May 22, 2024, July 28, 2024, August 25, 2024, and September 24, 2024. Interview with Employee E2 conducted on October 30, 2024, at 9:19 a.m. revealed that there was no pharmacy review for April 2024, June 2024 and October 2024 for Resident R28. Continued interview with the Director of Nursing, Employee E2, on October 20, 2024, at 9:36 a.m. revealed that she was hired by the facility in August 2024, and that she was unable to retrieve any data from the consultant pharmacist prior to September 2024. 28 Pa Code 211.2(d)(3) Medical director 28 Pa Code 211.9(k) Pharmacy services 28 Pa Code 211.12(d)(1) Nursing services 48347 Based on review of facility policy, clinical record review, and review of facility documentation, it was determined that the facility failed act upon pharmacist recommendation and provide a rationale for continued use of medication. (resident R21) Findings include: Review of facility policy titled Medication Regimen Review dated September 2023, revealed that the medication regime review is a thorough evaluation of the medication regime of a resident with the goal of promoting positive outcomes and minimalizing adverse consequences associated with medication. The review includes preventing identifying reporting and resolving medication related problems medication errors and other irregularities and collaborating with other members of the inner disciplinary team. Any irregularities noted by the pharmacist during this review must be documented on a written report and is sent to the attending physician. The attending physician must document in the residence medical record the identified irregularity has been reviewed and if any action has been taken to address it there is if there is to be no change in the medication the attending physician should document his or her rationale in the residence medical records. Review of manufacture [NAME] medication Amitriptyline Hydrochloride insert revealed that this medication is an antidepressant with sedation effects, used to relieve symptoms of depression. Patients with major depressive disorder may experience worsening of the depression and or the emergence of suicide ideation and behavior unusual changes. Patients being treated with antidepressants for any indication should be monitored appropriately and observe closely for clinical worsening. Side effects of this medication may include symptoms of anxiety, agitation, panic attack, insomnia, irritability, hostility, aggressiveness, impulsiveness, hypomania, and mania. Patients being treated with antidepressants for major depressive disorder as well as other indications consideration should be given to changing therapeutic regime including possibility of discontinuing the medication. Review of resident r 21 clinical record revealed resident R 21 was admitted into the facility October 16, 2023 with diagnosis including unspecified psychosis, major depressed disorder, and alcohol abuse. Review of residence clinical record revealed the resident was admitted to the facility and had diagnosis including. Review of facility documentation of pharmacy review dated July 28, 2024, revealed an evaluation of resident R 21's medication regime consisting of the antidepressant drug Amitriptyline. The pharmacist recommendation of this evaluation requested a rationale of risk verses benefits of continuation of the drug. Continued review of this documentation revealed that the physician referred the recommendation to psychology for further review. This document was signed by the physician and faxed on August 26, 2024. Review of resident R21 clinical record psychology, and psychiatry notes revealed the last notation in resident 21' chart was dated June 14, 2024. Continued review of resident R 21's clinical record revealed note response or notation addressing pharmacist recommendation. Review of resident R 21's physician orders revealed resident an order for medication Amitriptyline oral tablet 10 mg instructed to give 30 mg by mouth dated September 16, 2024. 28 Pa code 211.2(a) Physician Services 28 Pa Code 211.9(K) Pharmacy services

Based on observations, and staff and resident interviews it was determined that the facility failed to maintain a clean, comfortable, and home-like environment for one of two nursing units observed (room [ROOM NUMBER]-B). Findings Include: Observations on October 29, 2024, at 10:28 a.m., revealed in the closet for Resident R15, room [ROOM NUMBER]-B, clothes were thrown in a messy pile in the closet. Observations revealed the rod in the closet had fallen, so staff were unable to hang the resident's clothes as intended. Interview on October 29, 2024, at 10:30 a.m. with alert and oriented Resident's R17 and R69 revealed the closet rod had been broken for a while. Observations on October 29, 2024, at 10:35 a.m. with the Director of Nursing, Employee E2, confirmed the closet rod in room [ROOM NUMBER]-B was broken and the resident's clothes were thrown in a pile. 201.14 (a) Responsibility of licensee.

Based on review of clinical records, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 received adequate assistance during bed mobility which resulted in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures on the forehead. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed related to activities of daily living (adl)/self care, performance deficient due to hemiplegia and limited mobility. An intervention developed on May 23, 2024, stated that the resident needed pair care and assist of 2 people for all care related to bed mobility. Resident R1's nursing note dated July 12, 2024, revealed that the resident fell from his bed during care by staff (Nursing assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead. Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell . I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall. During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position. The facility failed to ensure that Resident R1 was assisted by two staff members during adl care which resulted in actual harm to Resident R1 who fell out of bed and sustained a laceration on the forehead requiring five sutures. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure that a resident was free of neglect resulting in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures to the forehead for one of four resident reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes), morbidly obesity and weakness. Review of Resident R1's admission Minimum Data Set (MDS-an assessment of resident's needs) dated May 2, 2024, indicated that the resident was cognitively intact. The resident was assessed with one sided upper and both sides lower body impairment. Continued review of the MDS revealed that the resident required substantial/maximum assistance to roll left and right. The resident was assessed as dependent (helper does all the effort) when lying to sitting on the side of the bed. Review of Resident R1's care plan dated May 8, 2024 revealed that a care plan was developed due to the resident's left sided weakness and limited mobility. The resident's care plan inidcated that the resident required the total assistant of one staff member for personal hygiene, and dressing and the use a mechanical aid requiring two staff members for transfers. Resident R1's nursing note dated July 12, 2024 revealed that the resident fell from his bed during care by staff (Nursing Assistant, Employee E3). The resident was observed laying on the floor and bleeding from his forehead. The resident was sent 911 (Emergency Medical Services) to the hospital for further evaluation. The resident received five sutures on his forehead. Interview with Resident R1 on July 29, 2024, at 3:00 p.m. stated, I fell out of my bed onto the floor when I was being washed. The aide just rolled me, and I had nothing to hold onto and fell . I got 5 stitches (pointing to his forehead) and cuts and bruising. My body is still sore and I have had headaches ever since my fall. During an interview on July 30, 2024, at 4:00 p.m. with Nurse aide, Employee E3 confirmed that while providing Resident R1 with morning care, she went to roll him onto his side to wash him, and he rolled off the bed, adding that the bed was also in the highest position. The NA stated she was re-educated and in-serviced because of the way she rolled him. The NA explained, I rolled Resident R1 away from me, not towards me, like I was taught to do. Interview with the Director of Nursing and the Assistant Director of Nursing confirmed Nurse aide, Employee E3 was re-educated for using the incorrect technique while giving care to Resident R1. 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to ensure that resident's environments were free of accident hazards, and failed to ensure that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within ,d+[DATE] feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury and resulted in immediate jeopardy situation for one of 25 residents reviewed. (Resident R27). Findings Include: Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested d. Educate resident/resident representatives about reviewing new personal items with staff upon receipt in facility. When the resident has been deemed safe and enhanced monitoring is no longer required; if the resident is ambulatory, regardless of the mode of ambulation, throughout the facility, the following prevention activities shall occur: a. Educate staff to continue to confirm location and well-being during routine care rounds, b. Educate staff regarding security of sharps, medications, hazardous chemicals, or other potentially dangerous objects in the facility, c. Educate staff regarding the locking of storage closets, monitoring and removing any hazardous objects on carts in patient care areas, shower rooms, or other rooms utilized by residents, and d. Management rounds to observe for compliance to prevention activities. Review of Resident R27's clinical record revealed that the resident was admitted to the facility with diagnoses including schizoaffective disorder, severe intellectual disabilities, suicidal ideations, and auditory hallucinations. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R27 dated [DATE], revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 which indicated that the cognitive status of the resident was moderately impaired. MDS mood assessment indicated that the resident sometimes had social isolation. Review of care plan for Resident R27 dated [DATE], revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times. Review of hospital record for Resident R27 dated [DATE], revealed that the resident was hospitalized for homicidal ideation and resident was on 1:1 monitoring and followed by video monitoring in the hospital. Resident was admitted as involuntary 305 admission (A 305 hearing also requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days). Resident had been hospitalized 24 times for 302 admissions (An involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) since 1999 and have ongoing suicidal ideation and homicidal ideation. Review of a psychiatric progress note dated [DATE] revealed that Patient referred for assessment of mood, adjustment; patient is a recent skilled nursing facility admission with a history of schizoaffective disorder, bipolar disorder, seizure disorder and intellectual disability. Per staff, patient has been restless, indicating periods of confusion since her admission, has made statements about not having regular silverware so she won't hurt herself. Facility is giving pt plastic silverware as a precaution. Patient is on paired care as a precaution. Staff describe other unusual behavior such as dancing about the hall. Currently pt presents as hypomanic, somewhat disorganized, difficulty articulating/word-find during interview; has difficulty giving information related to psychosocial history. Patient denies depression, states she was previously in a psych hospital stay but was unable to provide details. Denies suicidal ideation currently. States she is anxious because I don't have my belongings-I don't have any clothes. Reports auditory hallucinations I hear my mother talking to me from outside the window Does not answer questions about the nature of hallucinations or whether the voices are giving her instructions or if they cause her to feel distressed. Focus of encounter on fostering therapeutic rapport and setting goals. Plan included, Suggest staff maintain high degree of routine and structure as able while patient adjusts to skilled nursing facility placement; redirect when anxious or irritable; continue to use plastic silverware and paired care as precautionary measures; maintain supportive and encouraging response. Review of a psychiatric progress note dated [DATE]. revealed that History of threating statements, history of multiple suicidal ideation and homicidal ideation and attempts of oral ingestions, running into traffic, behaviors of placing knives to throat. Resident had auditory hallucinations and history of visual hallucinations. Plan included Monitor/document changes in mood/behavior to assist with psychotropic medication management. Monitor for signs and symptoms of threatening or suicidal behaviors or actions. Plastic silverware for precaution. Review of a psychiatric progress note dated [DATE], revealed that Currently patient presents as disorganized, mildly anxious. States I been hearing and seeing things in my mind- I see my father and he talks to me and he is dead- it's scary sometimes and I see my mother too- she holds a scary doll- I want some rubber snakes and a plastic knife with blood on it for Halloween to scare everybody- I need some guy-ish clothes and some girlish clothes. Focus of encounter on concrete coping strategies to deal with anxiety of seeing her deceased parents. Patient denies thoughts of self-harm. Review of a psychiatric progress note dated [DATE], revealed that Currently engages, endorses anxious thoughts, confusion, possible delusions; is perseverating about weapons, knives, using forks as weapons and Halloween. Is repetitive I turned in all my weapons my knives I hid in my pockets, I turned it in- I would never hurt anybody - I like Halloween. States He called my mother a bitch- my mother died - I went to the funeral but I couldn't send her off at the cemetery- the cemetery gives me the creeps- I am scared of that Focus of encounter on concrete strategies to reduce anxiety and fear; pt encouraged to focus on the positivity and safety that is around her and encouraged to know she does not have to think about things that frighten her. Review of a psychiatric progress note dated [DATE], revealed that Currently patient presents as concrete and repetitive. Related to the altercation, patient states There was a dog and cat fight to describe the incident. They was talking about me and I don't like it- there was a dog and cat fight- I threw a bottle of soda on her Focus of encounter on emphasizing concrete, simple coping strategies; pt encouraged to back away from confrontations and ask for help from staff nearby if she feels that she might get into an argument with a peer. Review of progress note for Resident R27 dated [DATE], revealed that the resident threw a bottle of soda at a female resident when the other resident asked her to move from the table. Review of progress note for Resident R27 dated [DATE], at 8:51 p.m. revealed that the resident was wheeling up and down the hallway, very angry, resident then started banging her head and hand on the fire extinguisher door. Staff was able to calm the resident down. Resident then went to the dining area and started throwing the glass vases on the floor. Review of progress note for Resident R27 dated [DATE], at 9:55 p.m. revealed that the resident continued with destructive behaviors. After breaking the glass vases, she flipped over the treatment cart. Review of progress note for Resident R27 dated [DATE], revealed that the resident threw a plastic bag with items in it at another female resident. Resident was separated and placed on 1:1 supervision. Resident stated she heard voices from her mother and threw the plastic bag in the air. Review of a psychiatric progress note dated [DATE], revealed that the resident was Patient seen today for suicidal ideation statements. She is seen sitting in her wheelchair. Patient reports [male resident] and everyone else gets more attention than me, I want more attention, I am going to commit suicide. When asked if she had a plan, she said no. She was calm, pleasant and cooperative for exam, she was jovial and said her moods have been okay since last visit. She denies auditory hallucinations, but can be heard having conversations with herself sometimes. She states, I just talk to myself and talk to the sky. She has disorganized thinking, labile moods. No delusions or paranoia. Does not appear to be a threat to self or others at this time. Emotional support provided. Followed by Psychology. Plan included, - Monitor for worsening behaviors or self-harm behaviors. -Does not appear to be a threat to self or others at this time. -Monitor/document changes in mood/behavior to assist with psychotropic med management. -Monitor for s/s of threatening or suicidal behaviors or actions. -Plastic silverware for precaution. -No long cords in room. -Offer emotional support. -Continue to utilize nonpharmacologic interventions, supportive care when needed. -Redirect and reorient as needed. -Encourage socializing and activities to support mood and cognition. Review of progress note for Resident R27 dated [DATE], revealed that the nursing assistant asked the resident to go back to her room, resident got mad at the nursing assistant and threw a bag at her and threw the Christmas tree down. Resident stated I am mad at her. Review of progress note for Resident R27 dated [DATE], revealed that the resident was seen in the dining area waving a razor around hollering. Staff removed the razor from the resident's hand and redirected her. A search of the resident's belonging were completed to see if resident had anymore weapons no other weapons observed. Observation of the resident on [DATE], at 11:25 a.m. on the second-floor dining room revealed that Resident R27 was screaming and swinging a blue razor at surrounding residents. It was observed that there were other residents within ,d+[DATE] feet of the resident while she was swinging the razor. There were approximately 10 residents nearby resident. Interview with Employee E23, Nursing assistant, on [DATE], at 11:25 a.m. stated that the resident should not be having a razor and that she must have taken it off the cart. Employee E23 stated sometimes she holds utensils in her hands says I got weapons. Employee E23 stated the razors were kept in the medication cart or in the locked supply room. Interview with Employee E24, Licensed Practical Nurse, on [DATE], at 11:45 a.m. stated resident steals a lot, and she did not know how resident got hold of that razor. Employee E24 stated resident should only get plasticware for meals. Observation of second floor medication cart 2 revealed that there was unopened twin blade razor, similar razor, Resident R27 observed swinging, in the cart. Observation of the second-floor supply room revealed that the room was unlocked with a broken keypad lock. There were resident care supplies inside the room. Interview with Employee E2, Director of Nursing, on [DATE], at 1:44 p.m. stated resident had a history of hoarding, she clutches all kind of items, such as spoons. She had a history of suicidal ideation. Employee E2 stated resident shows the items and says she uses as a weapon; she swings the fork and anything she gets. An interview with Resident R27 was attempted on [DATE], at 12:00 p.m., resident was observed visibly upset and was saying things to herself. It was not clear what she was saying but could hear repeatedly saying weapon, that is my weapon. Interview with Employee E2, Director of Nursing, on [DATE], at 3:19 p.m. stated resident was swinging an unused razor which should have kept in the locked treatment cart. When asked Resident R27 was saying she got it off the cart. Resident R27 also stated she feels she has a right to hold it. Employee E2 stated possibly she got it off the cart. Employee E2 also facility did not know how resident got the razor and Resident R27 should not have anything sharp or hazardous materials due to her behavior and history. Review of facility audit report dated [DATE] revealed that the facility found 3 razors and 2 nail clippers unsecured from second floor resident rooms which were removed to securely label and store. Interview with Director of Nursing and Administrator on [DATE], at 3:39 p.m. stated residents with diagnosis of dementia, behavioral aggression or suicidal ideation should not have access to hazardous material such as razors or sharp objects. Review of facility record revealed that there were 30 residents with diagnosis of dementia on second floor. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on [DATE], at 5:35 p.m. for the facility's failure to ensure resident's environment were free of accident hazards and failed to ensure that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within ,d+[DATE] feet close to the resident. The facility's failure placed Resident R27 who had a history of suicidal ideation and behavioral issues as well as other residents on the second floor at risk for serious injury. An IJ Template was presented to the facility on [DATE] at 5:35 p.m The facility submitted a written plan of action on [DATE], at 9:00 p.m. and implemented the plan of action which included: 1. Staff removed the razor from Resident R27 and was immediately placed on 1:1 supervision. Staff performing 1:1 supervision will be trained by the Administrator or designee regarding their / responsibilities and documentation requirements prior to starting their 1:1 assignment. The Interdisciplinary care plan team will review the care plan for R27 and update to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals and other potentially dangerous objects. This update will include any additional recommendations from the Behavioral Health Services Consultant. Facility wide sweep was completed by 6pm on [DATE] and all hazardous material was removed. All medication carts, housekeeping locks check, and medication rooms were checked and secured effective today [DATE] Date of completion will be [DATE]. 2. The Interdisciplinary care plan team will audit the diagnosis, care plans, incident reports, admission records, and behavior health notes to identify any resident at risk: Any identified resident will have their care plan updated to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous objects. Initial audit today, then weekly x4, then monthly x 4. Date of completion will be [DATE]. 3. Administrator or designee will educate staff about the care plan interventions to prevent residents from obtaining sharp objects, medications, hazardous, chemicals, and other potentially dangerous objects. 4. Administrator, DON, and designee will conduct an inspection of the facility medication rooms, storage rooms, all carts, and remote storage rooms to identify any carts or storage areas that are not secured or have potentially hazardous materials not secured. Any room or cart identified as not being secure will be corrected immediately Initial audit today, then weekly x4, then monthly x 4. Date of completion with 90% done by ,d+[DATE] and 100% by [DATE]. 5. Administrator and DON will update the Facility Policy regarding the securing of sharp objects medications, hazardous chemicals, and other potentially dangerous objects. All staff will be educated on the new policies and procedures. Date of completion with 90% done by ,d+[DATE] and 100% by [DATE]. On [DATE], at 5:40 p.m. the action plan was reviewed, observation was made of all nursing units, janitors closet and housekeeping carts, medication and treatment carts, interviews were conducted with staff to confirm that the in-service education was completed. The NHA was notified that the I.J. was lifted on [DATE], at 5:40 p.m. The Immediate Jeopardy was abated, and the scope/severity was lowered to an E. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management

Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R27 with documented history of behavioral issues and suicidal ideation to prevent resident access to potentially hazardous materials. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident which placed Resident R27 and the other residents at risk for serious harm and resulted in immediate jeopardy situation. One of 25 residents reviewed. (Resident R27). Findings Include: Review of a facility policy Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated September 2023, revealed that The facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Managing risk factors to the extent possible or indicating the limits of such interventions. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. Applying current standards of practice in the care planning process. Evaluating treatment of measurable objectives, timetables and outcomes of care. Respecting the resident's right to choose to decline treatment, request treatment or discontinue treatment. Review of an undated facility policy Suicidal Ideation Identification and Guidance revealed that Evaluate resident environment for safety; remove and store objects which could be used for self-harm. Objects to consider for removal may include but not be limited to: a. Ligatures - belts, neckties, call light cords, shower hose, oxygen tubing, tube feeding tubing, IV tubing, cables to the TV or other electronics, wire coat hangers etc. b. Sharp objects such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. c. Personal care supplies that may be poisonous if ingested d. Educate resident/resident representatives about reviewing new personal items with staff upon receipt in facility. When the resident has been deemed safe and enhanced monitoring is no longer required; if the resident is ambulatory, regardless of the mode of ambulation, throughout the facility, the following prevention activities shall occur: a. Educate staff to continue to confirm location and well-being during routine care rounds, b. Educate staff regarding security of sharps, medications, hazardous chemicals, or other potentially dangerous objects in the facility, c. Educate staff regarding the locking of storage closets, monitoring and removing any hazardous objects on carts in patient care areas, shower rooms, or other rooms utilized by residents, and d. Management rounds to observe for compliance to prevention activities. When the resident has been deemed safe and enhanced monitoring is no longer required, if the resident is non-ambulatory, the following prevention activities shall occur: a. Care plan interventions updated and implemented, b. Management rounds to observe for compliance to prevention activities. Emergency Services or inpatient psychiatric stay should be utilized as appropriate. Contact the National Suicide Prevention Lifeline for additional assistance, if indicated. Review PASRR for accuracy and submit for review if required for changes. Update care plan and Kardex if needed, communicate changes to staff. Review of Resident R27's clinical record revealed that the resident was admitted to the facility with diagnosis including schizoaffective disorder, severe intellectual disabilities, suicidal ideations, and auditory hallucinations. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R27 dated November 27, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9 which indicated that the cognitive status of the resident was moderately impaired. MDS mood assessment indicated that the resident sometimes had social isolation. Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times, Review of hospital record for Resident R27 dated August 5, 2023, revealed that the resident was hospitalized for homicidal ideation and resident was on 1:1 monitoring and followed by video monitoring in the hospital. Resident was admitted as involuntary 305 admission (A 305 hearing also requires the treating psychiatrist to testify about the consumer's mental health status, at which time the mental health review officer can order treatment for a period not to exceed an additional 180 days). Resident had been hospitalized 24 times for 302 admissions (An involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) since 1999 and have ongoing suicidal ideation and homicidal ideation. Review of a psychiatric progress note dated October 9, 2023, revealed that Currently patient presents as concrete and repetitive. Related to the altercation, patient states There was a dog and cat fight to describe the incident. They was talking about me and I don't like it- there was a dog and cat fight- I threw a bottle of soda on her Focus of encounter on emphasizing concrete, simple coping strategies; pt encouraged to back away from confrontations and ask for help from staff nearby if she feels that she might get into an argument with a peer. Review of progress note for Resident R27 dated October 9, 2023, revealed that the resident threw a bottle of soda at a female resident when the other resident asked her to move from the table. Review of progress note for Resident R27 dated October 28, 2023, at 8:51 p.m. revealed that the resident was wheeling up and down the hallway, very angry, resident then started banging her head and hand on the fire extinguisher door. Staff was able to calm the resident down. Resident then went to the dining area and started throwing the glass vases on the floor. Review of progress note for Resident R27 dated October 28, 2023, at 9:55 p.m. revealed that the resident continued with destructive behaviors. After breaking the glass vases, she flipped over the treatment cart. Review of progress note for Resident R27 dated November 29, 2023, revealed that the resident threw a plastic bag with items in it at another female resident. Resident was separated and placed on 1:1 supervision. Resident stated she heard voices from her mother and threw the plastic bag in the air. Review of a psychiatric progress note dated December 7, 2023, revealed that the resident was Patient seen today for suicidal ideation statements. She is seen sitting in her wheelchair. Patient reports [a male resident] and everyone else gets more attention than me, I want more attention, I am going to commit suicide. When asked if she had a plan, she said no. She was calm, pleasant and cooperative for exam, she was jovial and said her moods have been okay since last visit. She denies auditory hallucinations but can be heard having conversations with herself sometimes. She states, I just talk to myself and talk to the sky. She has disorganized thinking, labile moods. No delusions or paranoia. Does not appear to be a threat to self or others at this time. Emotional support provided. Followed by Psychology. Plan included, - Monitor for worsening behaviors or self-harm behaviors. -Does not appear to be a threat to self or others at this time. -Monitor/document changes in mood/behavior to assist with psychotropic med management. -Monitor for s/s of threatening or suicidal behaviors or actions. -Plastic silverware for precaution. -No long cords in room. -Offer emotional support. -Continue to utilize nonpharmacologic interventions, supportive care when needed. -Redirect and reorient. Observation of the resident on January 17, 2024, at 11:25 a.m. on the second-floor dining room revealed that Resident R27 was screaming and swinging a blue razor at surround residents. It was observed that there were other residents within 2-3 feet of the resident while she was swinging the resident. There were approximately 10 residents nearby resident. Interview with Employee E23, Nursing assistant, on January 17, 2024, at 11:25 a.m. stated that the resident should not be having a razor and that she must have taken it off the cart. Employee E23 stated sometimes she holds utensils in her hands says I got weapons. Employee E23 stated the razors were kept in the medication cart or in the locked supply room. Interview with Employee E24, Licensed Practical Nurse, on January 17, 2024, at 11:45 a.m. stated resident steals a lot, and she did not know [NAME] resident got hold of that razor. Employee E24 stated resident should only get plasticware for meals. Observation of second floor medication cart 2 revealed that there was unopened twin blade razor, similar razor, Resident R27 observed swinging, in the cart. Observation of the second-floor supply room revealed that the room was unlocked with a broken keypad lock. There were resident care supplies inside the room. Interview with Employee E2, Director of Nursing, on January 17, 2024, at 1:44 p.m. stated resident had a history of hoarding, she clutches all kind of items, such as spoons. She had a history of suicidal ideation. Employee E2 stated resident shows the items and says she uses as a weapon; she swings the fork and anything she gets. An interview with Resident R27 was attempted on January 17, 2024, at 12:00 p.m., resident was observed visibly upset and was saying things to herself. It was not clear what she was saying but could hear repeatedly saying weapon, that is my weapon. Review of care plan for Resident R27 dated August 25, 2023, revealed that The resident is noted with the following behaviors: Is not capable of understanding the risk, altered mental status. She have been sexually abused numerous times in childhood by her parents and teachers, and she have had recurrent behavioral issues since childhood. She have had numerous prior suicidal attempts via ingestion, knife threats to put to throat, and running into traffic. Will bite staff. She will say things over and over again that may sound current to the listener. She threw a bag of items across the table in the dining room because She was angry. With interventions including provide plastic utensils with meals at all times. Further review of resident care plan revealed no evidence that the resident's care plan interventions included measures such as evaluation of resident environment for safety and removal of objects which could be used for self-harm. Care plan interventions did not include psychiatric recommendation of no long cord in the room. Continued review of resident's care plan revealed that the care plan did not include interventions to prevent resident access to hazardous materials such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. Review of Resident R27's care plan also revealed that the care plan interventions did not include interventions to prevent resident-to-resident altercations including physical aggression towards other residents. Interview with Employee E2, Director of Nursing, on January 17, 2024, at 3:19 p.m. stated resident was swinging an unused razor which should have kept in the locked treatment cart. When asked Resident R27 was saying she got it off the cart. Employee E2 also facility did not know how resident got the razor and Resident R27 should not have anything sharp or hazardous materials due to her behavior and history. Employee E2 confirmed that resident's care plan interventions for suicidal ideation and aggressive behavior only included providing plastic utensils and did not include interventions to prevent resident access to hazardous materials such as pens, pencils, knives, scissors, utensils for eating, razor blades, etc. Interview with Director of Nursing and Administrator on January 17, 2024, at 3:39 p.m. stated residents with diagnosis of dementia, behavioral aggression or suicidal ideation should not have access to hazardous material such as razors or sharp objects and residents plan of care should reflect such interventions. Review of facility record revealed that there were 30 residents with diagnosis of dementia on second floor. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 17, 2024, at 5:35 p.m. for the facility's failure to develop and implement a comprehensive person-centered care plan for Resident R27 with documented history of behavioral issues and suicidal ideation to prevent resident access to potentially hazardous materials. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident which placed Resident R27 and the other residents at risk for serious harm, An IJ Template was presented to the facility on [DATE] at 5:35 p.m The facility submitted a written plan of action on January 17, 2024, at 9:00 p.m. and implemented the plan of action which included: 1. Staff removed the razor from Resident R27 and was immediately placed on 1:1 supervision. Staff performing 1:1 supervision will be trained by the Administrator or designee regarding their responsibilities and documentation requirements prior to: starting their 1:1 assignment. The Interdisciplinary care plan team will review the care plan for R27 and update to ensure interventions to prevent. the resident from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous objects. This update will include any additional recommendations from the Behavioral Health Services Consultant. Date of completion will be 1/17/2024. 2. The Interdisciplinary care plan team will audit the diagnosis, care plans, incident reports, admission records, and behavior health notes to identify any resident at risk. Any identified resident will have their care plan updated to ensure interventions to prevent the resident from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous objects. Completion Date 1/18/2024. 3. Administrator or designee will educate staff about the care plan interventions to prevent residents from obtaining sharp objects, medications, hazardous, chemicals, and other potentially dangerous objects. Staff will be educated before the start of their shift. Date of completion with 90% done by 1/18 and 100% by 1/24/2024. 4. IDT Team will conduct an audit of resident care plans who were identified as suicidal ideation and behavioral concerns to ensure care plans are updated and interventions are implemented to prevent the residents from obtaining sharp objects, medications, hazardous chemicals, and other potentially dangerous materials. Initial audit today, then weekly x 4, then monthly x 4. On January 18, 2024, at 5:40 p.m. the action plan was reviewed, observation was made of all nursing units, janitors closet and housekeeping carts, medication and treatment carts, interviews were conducted with staff to confirm that the in-service education was completed. Resident records and facility audits were reviewed to ensure care plan was updated. The NHA was notified that the I.J. was lifted on January 18, 2024, at 5:40 p.m. The Immediate Jeopardy was abated, and the scope/severity was lowered to an E. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management

Based on the review of clinical records, facility documentations, interviews with staff and resident, it was determined that the facility failed to ensure that patient care equipment was in a safe and operating condition related to shower chairs. This failure resulted in actual harm to Resident R87, who fell from the a shower chair which collapsed while the resident was taking a shower and sustaining an avulsion fracture of medial malleolus (the small prominent bone on the inner side of the ankle at the end of the tibia) and severe sprain of left ankle for one of 25 residents reviewed. (Resident R87) Findings Include: Review of a facility policy Physical Environment, dated September 2023, revealed that A safe, clean, comfortable, and home-life environment is provided for each resident/patient, allowing the use of personal belongings to the greatest extent possible. All essential mechanical, electrical, and resident/patient care equipment is maintained in safe operating condition through the facility's Preventative Maintenance Program. Review of Shower Chair manufactures recommendation dated December 29, 2022, revealed that Periodic visual inspection of this shower chair is recommended to ensure that all parts and hardware are secure, that components are in good working order and not worn, torn, frayed, or loose, and that there are no obstructions or impediments to normal, safe operation. If any part or mechanism appears to be unsafe or damaged, do not use the product. Review of clinical record for Resident R87 revealed that the resident was admitted to the facility on [DATE] with diagnoses including below knee amputation of right lower extremity, hypertension and charcot's (a rare and disabling disorder. It is a result of nerve damage to the feet) joint to left ankle and foot. Review of MDS (Minimum Data Set-Assessment of Resident care Needs) for Resident R87 dated November 10, 2023, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that the cognitive status of the resident was intact. Interview with Resident R87 on January 17, 2024, at 10:46 a.m., stated the shower chair collapsed and he fell to the floor when he was taking shower couple months ago. He stated he started taking shower and all the sudden the shower chair broke and fell to the floor. He stated went to the hospital and got a fracture to the leg and back pain. He stated at the moment he had a pain level of 8 out of 10 and the worst pain he experienced was 10. He stated he started taking Oxycontin (pain medication) after the fall. Resident stated he took pictures of the broken shower chair and showed the pictures. He stated staff did not assist him with shower or checked the shower chair prior to the incident. Review of the pictures provided by Resident R87 revealed that the shower chair was broken. The right side legs of the shower chair were broken to the side. One side was intact, and the other side was broken. It was observed that the floor was wet, and resident was wet after the fall. There were rubber tippers on the intact side of the chair. The broken side of the shower chair leg was not visible. Review of a statement completed by Employee E20, Licensed Nurse on November 26, 2023, revealed that the nurse was at the nurse's station around 11:20 a.m. with other staff members when a loud noise was heard from the bathroom. Upon approaching the common shower room Resident R87 could be heard yelling for help. Nurse found resident on the floor. Resident stated his shower chair broke in half. Resident was complaining his back was hurting. Review of a statement completed by Employee E26, Registered Nurse on November 27, 2023 revealed that the resident reported to the staff that he was sitting in the shower chair in the shower room when it broke. Review of facility investigation dated November 26, 2023 revealed that the resident was found in the shower chair floor. He stated his shower chair broke in half. Also nurse observed that the shower chair broke in half. Resident complained that his back hurting a lot and appeared as if he could not move. Resident stated the shower chair broke and he thought they fixed it. Staff stated other residents recently showered and no other issues noted with the shower chair. Resident was transferred to the emergency room for evaluation. Review of X-ray report for Resident R87 dated November 26, 2023, revealed that resident sustained avulsion fracture of medial malleolus (the small prominent bone on the inner side of the ankle at the end of the tibia). Review of nurse practitioner progress note dated November 27, 2023, revealed that the resident sustained a possible acute avulsion fracture of the medial malleolus status post shower chair collapse. Review of nurse practitioner progress note dated December 6, 2023, revealed that the resident sustained an acute left medial malleolus avulsion fracture. Review of an orthopedics consult for Resident R87 dated December 18, 2024, revealed that the resident sustained a severe sprain of left ankle. Lateral sided swelling and pain consistent with severe sprain. Review of progress note for Resident R87 dated December 13, 2023, revealed that resident had complaints of pain to swelling and pain to his left leg. Resident sustained an acute avulsion fracture related to recent fall. New order for Oxycontin (This medication is used to help relieve severe ongoing pain, belongs to a class of drugs known as opioid analgesics) 10 mg every 12 hours for pain was ordered by the practitioner. Continued review of facility investigation revealed no evidence that the facility conducted a thorough investigation of the reason or cause of shower chair collapse. There was no documented evidence that a maintenance inspection of the broken shower chair. During a follow up interview with Resident R87 on January 22, 2024, at 1:07 p.m., with Nursing Home Administrator stated he was sitting in the shower and started taking shower when all of the sudden the shower chair collapsed, and he fell to the floor. Interview with Maintenance Director, Employee E27 on January 22, 2024, at 1:05 p.m. stated he completed a routine check of started checking emergency exit doors, mag locks, shower chairs, floors room temperature, oxygen supply approximately a month after he started working at the facility which was in October 2023. Prior to his employment there was no routine check. Employee E27 stated he did not think he started the routine check at the time Resident R87's fall from broken shower chair. Employee E27 stated he did not document his daily observation/checks anywhere, so he did not know if there was the process on November 26, 2023. Employee E26 also stated the incident happened over a weekend and staff should have checked for shower chair prior to resident using it to ensure it was safe to use. Employee E27 stated he did not see the broken shower chair because it was thrown away before he could inspect it, however from the picture it looked like it just collapsed in half possibly due to the age of the chair or due to a broken or missing rubber tippers. Review of clinical record and facility document revealed no documented evidence that the facility staff checked the shower chair for proper functioning and safe condition. Interview with Nursing Home Administrator on January 22, 2024, at 1:05 p.m. stated there was no manufactures recommendations or user guide available for the brand of the shower chair. Administrator also stated it was unable to determine the brand of the broken shower chair. Administrator confirmed that the facility did not have any evidence that a preventative maintenance, visual inspection of the shower chair before and after Resident R87's injury was completed. This failure resulted in actual harm to Resident R87, who fell from the a shower chair which broke while the resident was taking a shower and sustained an avulsion fracture of medial malleolus and a sprain of the left ankle. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure residents are free from physical and sexual abuse which resulted in actual harm to Resident R43. This failure resulted in an immediate jeopardy situation for Resident R43 who was sexually abused and Resident R30 who was hit and verbally abused by Resident R74 for three of 22 residents reviewed. (Resident R29, Resident R43 and Resident R30) Findings include: The facility policy, Abuse Prevention Program with a revision date of October 2022, stated that the Administrator is responsible for designating an Abuse Coordinator, and the Administrator, Director of Nursing (DON), and/or designated individual are responsible for the investigation and reporting of suspected, or alleged abuse, neglect, and exploitation and misappropriation. Continued review of the facility policy revealed that the facility's orientation program and ongoing training programs will include but may not be limited to: freedom from abuse, neglect and exploitation requirements; dementia management and resident abuse preventions; the utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff; how to provide protection for residents; and components of a complete and through investigation. The facility leadership will identify situations in which abuse, neglect, mistreatment, exploitation, and misappropriation may be more likely to occur such as with residents who have needs/behaviors which might lead to conflict or abuse/neglect. Further the policy stated: Sexual Abuse includes but is not limited to, humiliation, harassment, coercion, or sexual assault. Sexual abuse is non-consensual sexual contact of any type with a resident. Mental/Emotional Abuse The facility may apply the reasonable person concept to determine whether the resident has suffered psycho-social harm under the following circumstances: - When a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to, the resident's death, cognitive impairments, physical impairments, or insufficient documentation by the facility; or - When a resident's reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person in the resident's position would have to the alleged incident. Review of the March 2023, physician orders for Resident R74 indicated that the resident was admitted into the facility on [DATE], with diagnoses of hypertension (high blood pressure); epilepsy (seizures); diabetes (a disorder in which the body has high sugar levels for prolonged periods of time); bipolar (a mental health condition that causes extreme mood swings) and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Review of the resident's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated September 8, 2022, indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident utilized a walker and a wheelchair for ambulation. Review of the Resident R74's nursing notes from May 2022 through August 21, 2022, indicated physical and verbal aggressiveness with other residents and included, but were not limited to the following incidents from the above-referenced time period: On May 13, 2022, Resident R74 punched Resident 30 in the stomach. On May 25, 2022, Resident R74 was standing outside Resident R30's room, yelling for that resident to come out, and threatening harm upon that resident if that resident did decide to come out. On June 7, 2022, Resident R74 was described as aggressive and swinging at residents during the 7:00 a.m. through the 3:00 p.m. nursing shift. On June 8, 2022, Resident R74 reported hearing voices that he said instructed him to bang a guitar that he happened to be in possession of at the time. On August 7, 2022, Resident R74 was touching a female Resident R29 on her buttocks. Review of Resident R30's March 2023 physician orders revealed the diagnoses of depression (major loss of interest in pleasurable activities), cerebral infarction (a stroke), Alzheimer's disease (progressive degenerative disease of the brain) and schizophrenia (mental disease characterized by loss of reality contact). Review of Resident R30's quarterly MDS dated [DATE] revealed that the resident was assessed with a BIMS (Brief Interview of mental Status) of 14, which indicated that the resident was cognitively intact. Review of facility documentation revealed a witness statement by nurse aide, Employee E40 related to an incident involving Resident R30 and Resident R74 that took place on May 13, 2022 at 7:30 p.m. during the 3:00 p.m.-11:00 p.m. nursing shift. The statement indicated that Resident R30 was sitting in the hallway on the nursing unit and was hit in the stomach by Resident R74. While hitting Resident R30, Resident R74 was observed screaming at Resident R30, and telling him to Get out of here. An assessment of Resident R30 by nursing staff was completed and redness was observed on the left side of the resident's abdomen. Further review of the incident indicated that Resident R74 came outside of his room again and made an attempt to attack Resident R30 a second time, but staff were able to intervene. Review of a nursing note dated May 25, 2022, at 10:34 p.m. described an incident that occurred during the above date and time where Resident R74 was heard yelling for Resident R30 to come out of his room, and threatened to beat Resident R30 up if he did come out. The nursing note stated that Resident R74 stated come out mother f****r, come out, I'm going to kick your a**. When nursing staff asked Resident R74 why he was acting towards Resident R30 in the above manner, nursing staff documented that Resident R74 provided no response when asked. During an interview with the Director of Nursing on March 24, 2023, at 11:45 a.m. it was confirmed that Resident R74 had no care plan interventions developed to address Resident R74's behaviors following the May 13, 2022 and May 25, 2022, incidents to protect residents in the facility from further resident abuse from Resident R74. Review of Resident R29's annual MDS dated [DATE], revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 15, which indicated that the resident was cognitively intact. Review of nursing notes dated August 7, 2022, at 1:02 p.m. indicated that Resident R29 had an interaction with another resident. Review of an incident regarding the above indicated that Resident R29 notified staff on the above reference date and time revealed that Resident R74 smacked her on her buttocks. The incident also stated that Resident R29 contacted the police on her own. Continued review of the incident reported that when police were contacted regarding the incident and arrived at the facility, Resident R74 stated to the police that Resident R74 was trying to smack some a** in reference to his interaction with Resident R29. Review of the March 2023, physician orders for Resident R43 indicated that the resident was admitted into the facility on [DATE] with diagnosis that included psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality); anxiety, dysphagia (difficulty swallowing), arthritis, and Huntington's disease (a rare, inherited disease that causes the gradual breakdown of nerve cells in the brain, and can result in movement, thinking, and psychiatric disorders). Review of Resident R43's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated April 9, 2022, revealed that the resident was assessed with a BIMS (Brief Interview of Mental Status) of 12 which indicated that the resident had moderate cognitive impairment. Review of Resident R43's annual MDS dated [DATE], revealed that the resident required extensive assistance of two staff for transfer and extensive assistance of one staff for ambulation and dressing. Review of Resident R43's plan of care last revised August 1, 2019, revealed that the resident was care planned for impaired cognition and impaired decision-making related to Huntington's disease. A plan of care was last revised on June 12, 2018, for being at risk for falls related to Huntington's disease and on October 15, 2021, the resident's care plan for activities of daily living independently was revised due to impaired cognition, impaired balance, in addition to the progression of Huntington's disease. Review of Resident R43's nursing note dated August 21, 2022, at 1:15 p.m. revealed that an event took place in the dining room on August 21, 2022, which indicated that Resident R29 notified Employee E6 (Licensed nursing) that Resident R74 was in the dining room pulling up Resident R43's shirt and touching her breast. Continued review of the nursing note indicated that by the time Licensed nurse, Employee E6 got to the dining room, Resident R74 was lying in his bed. Resident R43 was assessed by Licensed nurse, Employee E6 with no noted skin issues. Continued review of the nursing note indicated that while providing care to another resident, Licensed nurse, Employee E6 heard Employee E20, Nursing assistant, tell Resident R74 to move away from Resident R43 after Nurse aide, Employee E20 witnessed Resident R74 to be back in the dining room with Resident R43 touching on her breast during a 2nd incident on August 21, 2022. Review of the facility's investigation revealed a written statement from Resident R29 who reported I saw [Resident 74] put his hands under [Resident R43] and was feeling around. Then he reached for her dress on her shoulder and pull it down and off of her. Review of a written statement from nursing assistant, Employee E21, revealed that around 1:00 p.m Employee E21 noticed [Resident 74] sitting next to [Resident 43] in the common area with his hand down [Resident 43's] shirt. I quickly rushed to check on them and that's when I saw [Resident R74] touching [Resident R43's] left breast. I separate them and then informed the nurse on duty. [Resident R74] was put under observation (q15) (every 15 minutes checks) in his room and Resident R43 was taken to her room away from [Resident R74]. Review of the written statement from Licensed nurse, Employee E6 revealed that she was called into the common area and notified that Resident R74 was in the dining room pulling up Resident R43's shirt and touching her breast area. By the time this nurse arrived Resident R74 was already out laying in his bed. Resident R43 assessed and noted no skin issues. No discomfort noted. Resident R43 sitting calm with no noted distress. This nurse went back to her nurses cart to initiate this report when a cna (nurse aide) heard telling [Resident R74] to move away from her. Turned to see the [Resident R74] back in dining room next to [Resident R43] again touching her breast. [Resident R74] taken to his room and [Resident R43] removed from dining room and taken to room. Assessed again with no noted issues. [Resident R43] states she's ok. Resident R74 educated that he is not allowed to touch other resident and placed on 1:1 sup. (supervision). A second statement obtained from Licensed nurse, Employee E6 revealed that the time frame from 1st encounter between Resident R74 and Resident R43 was about 5 mins. apart. Review of the facility investigation submitted to the Department of Health on August 29, 2022, revealed that Resident R74 was moved to another floor in the facility and remained on 1:1 supervision. The facility identified Resident R43 as the victim of sexual abuse and Resident R74 as the perpetrator. The facility substantiated that Resident R43 was sexual abused. The above resident abuse incident was discussed with the Nursing Home Administrator, Director of Nursing, and Licensed nurse, Employee E6 on March 13, 2023, at 12:00 p.m. Review of the investigation provided no documentation as to whether or not facility staff was present in the dining room providing supervision to Resident R43, a vulnerable resident, who was in the dining room with Resident R74, with history of aggressive behaviors, and inappropriate touching toward other residents. The facility could not provide any information or documentation in the investigation that facility staff was present in the dining room during the incident supervising residents in the dining room. The facility failed to ensure that Resident R43 was free from sexual abuse which resulted in actual harm to Resident R43, who was sexually abuse by Resident R74. Based on the above findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, the Regional Nurse, Employee E43 and the Director of Nursing on March 27, 2023, at 2:16 p.m. for failure to ensure that residents were free from physical and sexual abuse from Resident R74, and that other residents were protected from further abuse. The Immediate Jeopardy template was provided to the Nursing Home Administrator on March 27, 2023, at 2:16 p.m. and an immediate action plan was requested. On March 27, 2023, at 8:55 p.m. the facility provided the following corrective action plan. 1. A facility wide education including all departments regarding the facility's policy on prevention of abuse, including a written competency. 2. Performing body checks on all residents to ensure residents had not experienced abuse or had any physical signs of abuse. 3. Updating the facility's abuse policy to include care plan updates. 4. An audit of the resident's electronic medical record twice a week for 30 days in order to monitor resident behaviors who may lead to abuse. 5. Continuing to review resident rights during resident council meetings and encouraging residents to report abuse. 6. Reviewing the plan of correction during Quality Assurance Meetings. The implementation of the action plan was verified on March 28, 2023. Interviews conducted with facility staff on March 28, 2028, reported they had all been in-serviced on the facility resident abuse prohibition policy, recognizing the signs of resident abuse, to whom to immediately report an allegation of resident abuse and actions to be taken related to incidents of resident abuse. The Immediate Jeopardy was lifted on March 28, 2023, at 6:37p.m. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies, clinical record review, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that one of six residents (Resident R1) remained free from physical and psychosocial abuse resulting in Resident R1 being pushed against the wall by a facility employee. Findings include: Review of facility policy, Abuse Prevention Program dated March 2022, revealed that physical abuse includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc. Continued review revealed that Residents must not be subject to abuse by anyone, including, but not limited to, facility staff. Interview on June 29, 2022, at 9:45 a.m. with Resident R1 revealed that he had a physical altercation with a nurse aide, Employee E9, a few weeks ago. Resident R1 stated that he wanted to go out for a smoke break and went to the lobby to retrieve his cigarettes. Resident R1 stated that Employee E9 chased him to the lobby and grabbed at his hands trying to take the cigarette box from him. Resident R1 admitted that he smacked the box out of Employee E9' s hands. In response, Resident R1 stated that Employee E9 grabbed his chest, pushed him in his wheelchair back against the wall. Employee E9 continued to hold his hand on the resident' s chest to hold him against the wall until another employee came to intervene. Resident R1 stated that other staff and residents witnessed the incident. Further during interview Resident R1 communicated that he felt guilty because several staff at the facility lost their jobs. In addition he felt that other residents treated him differently after the incident. Review of Resident R1's Admission MDS (Minimum Data Set - a periodic mandatory assessment) dated April 8, 2022, revealed that the resident was admitted to the facility April 3, 2022, with diagnoses including osteomyelitis of the vertebra (infection of the spinal bones), intraspinal abscess (infection inside the spine), spinal stenosis (narrowing of the spine) and low back pain. Continued review revealed a BIMS (Brief Interview for Mental Status) scored of 15, indicating that the resident was cognitively intact. Further review revealed that the resident required a wheelchair for mobility. Interview on June 29, 2022, at 10:15 a.m. with Resident R2 revealed that he observed a nurse aide abuse another resident. Resident R2 stated that nurse aide, Employee E9 tried to take the cigarette box off of Resident R1 and that Employee E9 put his hands on Resident R1 during the tussle. Resident R2 stated that he witnessed nurse aide, Employee E9 push Resident R1 back and against the wall. Review of Resident R2' s Quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating that the resident was cognitively intact. Interview on June 29, 2022, at 2:15 p.m. Resident R3 stated that she witnessed nurse aide, Employee E9 grab Resident R1's shirt then push him back and against the wall. Review of Resident R3's Annual MDS, dated [DATE], revealed a BIMS score of 15, indicating that the resident was cognitively intact. Review of facility documentation submitted to the Department of Health on June 9, 2022, revealed that Resident R1 alleged that a nurse aide spoke to him in an inappropriate manner, pushed him and handled him inappropriately when he attempted to help himself to the smoking box. The alleged incident was reported to have occurred on June 7, 2022, at 8:30 p.m. Review of a written statement from the Social Worker dated June 8, 2022 related to an interview conducted with Resident R1 revealed that Resident R1 stated he pushed me against the wall and shoved me in the chest pinning me against the wall. He tried to take something form my hands, but I wouldn't let him. The written statement further revealed that the Social Worker asked Resident R1 if the perpetrator (Employee E9) hurt the resident and Resident R1 replied yes, I am sore from defending myself. The facility substantiated the allegation of physical abuse. Review of facility documentation revealed a summary of camera footage reviewed by the Nursing Home Administrator (NHA). The NHA indicated that, The footage revealed that [Resident R1] in an attempt to retrieve the smoking box, approached the accused employee and struck the smoking box out of the employee's hands causing the box to open and disperse the contents in the hallway. The accused employee then was seen pushing the resident [Resident R1] against the wall as they grabbed each other's arms. An employee [Employee E14] intervened and separated them. [Employee E9] was escorted out of the resident care area and off the floor. Continued review of the camera footage summary revealed that Residents R2 and R3 were present and visible on the camera footage. Further, Employees E10, E12 and E13 were present and visible on the camera footage. Interview on June 29, 2022, at 3:30 p.m. the NHA confirmed that camera footage of the incident showed Employee E9 pushing Resident R1 and that Employee E14 intervened and physically removed Employee E9 from Resident R1. The NHA confirmed that Employees E10, E12 and E13 were observed to be present on the camera footage during the incident and stated that they would have witnessed the event. The facility failed to ensure that Resident R1 remained free from physical and psychosocial abuse resulting in harm for Resident R1. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on observation, clinical record review, staff and resident interviews and review of facility documentation, it was determined that the facility failed to provide a safe environment and to supervise/monitor one of 27 residents reviewed which resulted in actual harm to one resident (Resident R90). Findings include: The Minimum Data Set assessment (MDS - an assessment of resident care needs) dated September 2, 2016, revealed that Resident R90 had [DIAGNOSES REDACTED]. The assessment also indicated that the functional status of Resident R90 required one person physical assist with transfers. The assessment indicated that Resident R90 had no functional limitation in the range of motion of the upper and lower extremities. The assessment also revealed that Resident R90 was occasionally incontinent (loss of control) of bladder. There was no care plan that indicated that the resident needed a one person physical assist as per the MDS. Interview with Registered Nurse Unit Manager, Employee E7, revealed the transfer status for Resident R90 was that the resident had the ability to ambulate to the bathroom pushing the wheelchair and transfer to the toilet from the wheelchair independently. An interview with Resident R90 at 9:30 a.m., on October 3, 2016, confirmed the information obtained from Employee E7. Resident R90 reported that within the past several months, the resident's family member had requested on several occasions that the wheelchair be repaired because the brakes were not locking correctly. A review of the logs kept by the Maintenance Director, Employee E6, for April 2016 revealed that there were no requests made by the facility staff for repairs to Resident R90's wheelchair until April 18, 2016. Nursing progress notes on April 18, 2016, indicated that Resident R90 fell in the bathroom. The nursing progress note indicated that Resident R90 reported that she was transferring herself from the wheelchair to the toilet, when the wheelchair rolled backwards. An X-ray report dated April 18, 2016, indicated that Resident R90 sustained a nasal fracture. The nursing progress note indicated that Resident R90 was known to lock her wheelchair and stand to adjust her clothing. Review of the information dated April 18, 2016, submitted by the facility, indicated that Resident R90's wheelchair brakes were repaired after the resident's fall. The facility failed to develop a care plan to prevent accidents, provide supervision and provide properly functioning resident care equipment for Resident R90. Resident R90 fell on [DATE], and sustained an injury (nasal fracture) requiring physician intervention. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 06/24/16 28 Pa. Code 201.18(a) Management Previously cited 07/15/16 28 Pa. Code 201.18(b)(1) Management Previously cited 07/15/16, 06/24/16, 03/18/16, 11/19/15 28 Pa. Code 209.3(a) Smoking 28 Pa. Code 211.10(c) Resident care policies Previously cited 07/15/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/15/16, 06/24/16, 05/12/16, 03/18/16, 11/19/15, 10/29/14 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 07/15/16, 06/24/16, 03/18/16, 11/19/15, 10/29/14

Based on review of clinical records, review of facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to effectively prevent pressure ulcer development for one of 27 residents reviewed resulting in actual harm to one resident (Resident R45). Findings include: Review of the facility policy, Wound Prevention and Treatment Overview, undated, revealed that skin assessments are to be completed on all residents weekly. Additionally, the policy indicated that the Braden Scale Assessment (a tool used to determine risk factors for pressure ulcer (an area of skin that breaks down when pressure is applied or something keeps rubbing against it)) would be completed when a significant change in a residents condition occurs. The policy further indicated that a preventive plan of care should be developed and implemented for all residents identified as at risk for the development of pressure ulcers. The plan of care should contain preventive and treatment interventions that have been individualized to meet the resident's specific needs. Additionally, the care plan should be reviewed and revised as needed. Clinical record review for Resident R45, revealed a physician's order dated September 1, 2016. The physician's order indicated [DIAGNOSES REDACTED]. to perform everyday activities), and muscle weakness (a decrease in the strength in one or more muscles). A review of Resident R45's clinical record revealed that Resident R45, did not have any identified skin issues indicated on the weekly skin assessments, completed by a licensed nurse, for the last quarterly assement review, between April 1, 2016 thru June 14, 2016. A review of Resident R45's clinical record revealed a plan of care revised on April 18, 2016, titled, Skin Integrity Risk, that indicated that the resident had the potential for impairment of skin integrity because of chronic vascular changes and incontinence with interventions to prevent skin break down. Further review of Resident R45's Care Plan, titled, Skin Integrity Risk, updated April 18, 2016, indicated that nursing was to take precautionary measures such as review potential factors which could cause skin breakdown and eliminate/resolve where possible. Further review of Resident R45's clinical record revealed a Braden Scale assessment dated [DATE], which indicated that Resident R45 was a high risk for pressure ulcer development. Review of Resident R45's clinical record revealed documentation titled, Skin Grid for Pressure Ulcers, dated June 15, 2016, which revealed that on this date, Resident R45 was identified to have a pressure ulcer (break down of skin) on the left ischium (buttocks), measuring 2.0 c.m. x 2.0 c.m. x 0.1 cm (depth), with scant serosanguinous drainage (blood and clear discharge of liquid) noted a Stage III (full thickness skin loss) pressure ulcer. Further review of Resident R45's Care Plan revealed that on June 21, 2016, six days after the pressure ulcer was identified, a plan of care was developed and titled, Actual Wound, indicating that the resident had an actual pressure ulcer on the left ischium, and to care for the area identified. Continued review of Resdient R45's clinical record revealed a quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated August 10, 2016, which indicated that Resident R45 was always incontent (loss of control) of bowel and frequently incontent of urine. Review of the, Weekly Skin Check Assessment for Resident R45, completed on the following dates: June 18, 24, 2016, July 1, 8, 15, 22, 29, 2016, August 5, 12, 19, 26, 2016, and September 2, 9, 16, 23, 2016, did not reveal any indication that Resident R45 had and/or was being monitored for an identified Stage III pressure ulcer that had been identified on June 15, 2016. An interview with Employee E11, a Licensed Nurse, on September 29, 2016, at 10:20 a.m. revealed that precautionary measures were not appropriately in place to prevent Resident R45, from having skin breakdown. During an interview with Employee E11, on September 29, 2016, at 10:20 a.m. confirmed there was a delay by nursing in developing a Care Plan related to Resident R45, having a newly identified area of skin breakdown. An interview with Employee E2, the Director of Nursing, on September 29, 2016, at 2:45 p.m. confirmed that Resident R45 developed a pressure ulcer and it was not identified by the facility staff until June 15, 2016, at which time, it was identified as a Stage III presure ulcer. An interview with Employee E11, a Licensed Nurse, on October 3, 2016, at 9:25 a.m. confirmed that the, Weekly Skin Check Assessment for Resident R45, completed after June 15, 2016, were not an accurate and complete reflection of Resident R45, skin condition related to the Stage III pressure area identified on the left ischium area on June 15, 2016. During an observation completed on September 29, 2016, at 1:50 p.m. of Resident R45's left ischium area, revealed that, at the time of the observation, Employee E11, confirmed the presence of the pressure ulcer. During the same interview Employee E2, indicated that the facility did not implement measures necessary to prevent Resident R45 from developing a Stage III presure ulcer. The facility failed to ensure that the skin assessment process developed in their established policy, Wound Prevention and Treatment Overview, (undated) was implemented by the staff and failed to ensure that a resident identified with actual alteration in skin integrity was routinely monitored and assessed in a consistent manner. The facility also failed to ensure that statistical information obtained during weekly wound rounds was complete and accurate, resulting in actual harm to one resident. 28 Pa. Code 201.4(a) Responsibility of licensee Previously cited 07/15/16, 06/24/16, 03/18/16 28 Pa. Code 201.18(b)(1) Management Previously cited 07/15/16, 06/24/16, 03/18/16, 11/19/15 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 07/15/16, 06/24/16, 05/12/16, 03/18/16, 11/19/15, 10/29/14 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited 07/15/16, 06/24/16, 05/12/16, 11/19/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 07/15/16, 06/24/16, 03/18/16, 11/19/15, 10/29/14

Based on clinical record reviews, review of facility documentation and interviews with residents and facility staff, it was determined that the facility's decisions and actions to discharge residents to a facility located over 400 miles away resulted in emotional distress, anxiety and actual harm for four of 5 residents reviewed (Residents R1, R2, R4 and R5). Findings include: Review of the facility policy titled, Resident/Family Care and Services (Discharge Planning), dated June, 2013, indicated residents being discharged from the facility will be provided with adequate preparation to ensure a safe and orderly transfer from the facility, and the home or setting to which the resident is discharged will have accepted the resident. Further review of the facility policy indicates that the facility is to ensure that the resident is in agreement with the facility selected. A review of the facility policy titled, Supervised Smoking Policy, updated April, 2014, revealed the objective of the policy is not to discourage or restrict one's smoking privileges, but to promote safety for all persons within the facility. A review of the clinical record for Resident R1 who had an initial admitted [DATE], revealed physician's orders dated July 1, 2016, which indicated [DIAGNOSES REDACTED]. Continued clinical record review revealed a quarterly Minimum Data Set assessment (MDS- periodic assessment of needs) dated June 7, 2016, which indicated that Resident R1 was assessed as a 15 on the BIMS (Brief Interview for Mental Status - a screening tool used to assess cognition) indicating that Resident R1 was cognitively intact. An interview with Resident R1 on July 14, 2016, at 7:50 a.m. revealed that a, 30 Day Discharge Notice, (a facility notice provided to the resident regarding a pending discharge from the facility) dated June 7, 2016, was given to Resident R1 by the Nursing Home Administrator (NHA). Review of the, 30 Day Discharge Notice, indicated that Resident R1 would be discharged from the facility and the discharge notice indicated that the resident would be transferred to a facility located in Erie, PA, which was 400 miles from the current facility, family and friends. Further review of the, 30 Day Discharge Notice, revealed that the section of the document allotted for the NHA's signature was left blank. During the interview, Resident R1 revealed being anxious about going to a facility that was so far away from his/her family and friends and further indicated not being offered the opportunity to visit the facility prior to the pending discharge date . Resident R1 indicated being a smoker since a young age and with current medical conditions, smoking allows Resident R1 to have one simple pleasure, which the facility continues to focus on. During the interview with Resident R1, a friend who was visiting the resident explained that he/she was a friend of over two years from the local church that Resident R1 had attended over the last 2 years. Resident R1's friend indicated that the discharge notice has caused Resident R1 an increased amount of added anxiety and stress. The friend also indicated that Resident R1's father passed away this week (July 11, 2016), adding to Resident R1's anxiety. An interview with the NHA on July 14, 2016, at 12:15 p.m. indicated that she should have signed the, 30 Day Discharge Notice, to make it an official notice. The NHA also confirmed that she did not educate Resident R1 on his/her rights regarding the discharge and/or educate him/her regarding the procedure to appeal the discharge notice. Continued review of the, 30 Day Discharge Notice, indicated that the documented reason for the discharge was that Resident R1 had failed to adhere to the facility's, Supervised Smoking Policy, which had been updated in April 2014. A review of the, Smoking Policy, updated, April, 2014, revealed that, Appropriate orientation shall be provided to residents/patients, as deemed appropriate. During the same interview the NHA confirmed that the facility never made any effort to educate Resident R1 on the facility's, Supervised Smoking Policy. An interview with the NHA, the Director of Nursing and the Social Service Director on July 14, 2016, at 11:30 a.m. confirmed that the facility did not ensure that Resident R1 received the care and services necessary to assist him/her to reach and maintain the highest level of mental and psychosocial functioning related to the, 30 Day Discharge Notice. On July 14, 2016, at 12:15 p.m. the NHA also confirmed that no documentation was available for review to show or confirm that Resident R1 was educated and/or informed about the facility's, Smoking Policy. An interview with Employee E3, the Social Services Director, on July 14, 2016, at 12:45 p.m. confirmed that Resident R1 was not provided or educated about the facilities that would allow Resident R1 to remain in the vicinity to allow Resident R1 to be close to family and friends and his church. The facility failed to ensure that Resident R1 was provided or received the care and services necessary to assist him/her to reach and maintain the highest level of mental and psychosocial functioning related to the, 30 Day Discharge Notice. Review of the physician's orders for Resident R1 revealed an order dated June 21, 2016, which included an order for [REDACTED]. An interview with the NHA on July 14, 2016, at 2:00 p.m. confirmed that the facility did not have the Nicotine patch available for administration for Resident R1 as ordered by the physician. A review of the clinical record for Resident R2 who had an initial admitted [DATE], revealed physician's orders dated July 1, 2016, which indicated [DIAGNOSES REDACTED]. Continued clinical record review revealed a quarterly MDS assessment dated [DATE], which indicated that Resident R2 was assessed as a 15 on the BIMS section of the MDS, indicating that Resident R2 was cognitively intact. An interview with Resdient R2 on July 14, 2016, at 9:50 a.m. revealed that a, 30 Day Discharge Notice, dated June 6, 2016, was given to Resident R2 by the NHA. Review of the, 30 Day Discharge Notice, indicated that Resident R2 would be discharged from the facility and the discharge notice indicated the resident would be transferred to a facility located in Erie, PA, which was 400 miles from the current facilty, family and friends. Further review of the, 30 Day Discharge Notice, revealed that the section of the document allotted for the NHA's signature was left blank During the interview, Resident R2 became tearful talking about being transferred to Erie, PA. The resident indicated not having any family or friends in the Erie area and/or not knowing anything about the area or where Erie, PA was located. Resident R2 indicated that he/she was not offered the opportunity to visit the facility nor was he/she given any information about the facility. Resident R2 further indicated that he/she is [AGE] years old, living in a nursing home and that he/she can not walk. During the interview, Resident R2 further indicated that he/she started smoking as a teenager and that the facility was aware that he/she smoked when he/she was first admitted to the facility on [DATE]. A review of Resident R2's clinical record revealed a recent smoking assessment dated [DATE], which indicated that Resident R2 was an independent smoker and had not had any issues related to smoking since being admitted to the facility. Continued review of the, 30 Day Discharge Notice, indicated that the documented reason for the discharge was that Resident R2 had failed to adhere to the facility's, Supervised Smoking Policy. An interview with the NHA on July 14, 2016, at 12:15 p.m. confirmed that she did not sign the, 30 Day Discharge Notice, that was given to Resident R2 on June 6, 2016, and also did not educate Resident R2 on his/her rights regarding the discharge and/or educate him/her regarding the procedure to appeal the discharge notice. The NHA also confirmed that no documentation was available for review to show or confirm that Resident R2 was educated and/or informed about the procedure to appeal the discharge notice. During the same interview, the NHA confirmed that the facility failed to educate Resident R2 about the facility's Supervised Smoking Policy. An interview with the NHA revealed that the facility did not re-educate Residents R1, R2, R4 and R5, about the updated smoking policy that went into effect, April, 2014. The NHA, could only offer to the surveyor the initial Smoking Safety Education and Acknowledgement for each of the 4 Resident's R1, (July 21, 2014), R2, (October 16, 2014), R4 (November 13, 2015), and R5 (December 14, 2015). Which did not indicate education on the updated, smoking policy, effective, April, 2014 The NHA also confirmed that no documentation was available for review to show or confirm that Resident R2 was educated and/or informed about the facility's, Supervised Smoking Policy upon receipt of the, 30 Day Discharge Notice. An interview with the NHA on July 14, 2016, at 2:25 p.m. revealed she was waiting for a check from the corporate office that would pay for the transportation to move Resident R2 to Erie, PA and upon receipt of the check, Resident R2 would be transferred to the facility in Erie, PA. The facility failed to ensure that Resident R2 was provided or received the care and services necessary to assist him/her to reach and maintain the highest level of mental and psychosocial functioning related to the, 30 Day Discharge Notice. A review of the clinical record for Resident R4, who had an initial admitted [DATE], revealed physician's orders dated July 1, 2016, which indicated [DIAGNOSES REDACTED]., or sometimes convulsions, loss of consciousness). Continued clinical record review revealed a quarterly MDS assessment dated [DATE], which indicated that Resident R4 was assessed as a 15 on the BIMS section of the MDS, indicating that the resident was cognitively intact. An interview with Resident R4 on July 14, 2016, at 12:35 p.m. revealed that a, 30 Day Discharge Notice, dated June 6, 2016, and then crossed out and dated June 7, 2016, was given to Resident R4, by the NHA. Review of the, 30 Day Discharge Notice, indicated that Resident R4 would be discharged from the facility and the discharge notice indicated the resident would be transferred to a facility located in Erie, PA, which was 400 miles from the current facility, family and friends. Further review of the, 30 Day Discharge Notice, revealed that the section of the document allotted for the NHA's signature was left blank. A review of Resident R4's clinical record and care plan did not reveal any indication that Resident R4 had not complied with the facility smoking policy and procedure. The clinical record also failed to reveal any evidence that the facility has offered the resident any assistance to quit smoking. Review of Resident R4's smoking assessment dated [DATE], indicated that Resident R4 is an independent smoker and has not had any issues related to smoking since being admitted to the facility on [DATE]. During an interview on July 14, 2016, at 10:05 a.m. Resident R4 revealed that the facility was aware that he/she was a smoker when he/she was admitted to the facility. Resident R4 further indicated that the facility has taken issues with several residents who are smokers and that the facility does not want them any longer as residents in the facility. An interview with Employee E9, a Licensed Nurse, on July 14, 2016, at 10:45 a.m. confirmed that Resident R4 was not offered the Nicotine patch, to quit smoking. Continued review of the, 30 Day Discharge Notice, indicated that the documented reason for the discharge was that Resident R4 had failed to adhere to the facility's, Supervised Smoking Policy, which had been updated in April 2014. On July 14, 2016, at 1:30 p.m. the NHA also confirmed that no documentation was available for review to show or confirm that Resident R4 was educated and/or informed about the facility's, Smoking Policy, upon receipt of, 30 Day Discharge Notice. During the same interview, the NHA confirmed that the facility failed to educate Resident R4 on the facility's, Supervised Smoking Policy. The facility failed to ensure that Resident R4 was provided or received the care and services necessary to assist him/her to reach and maintain the highest level of mental and psychosocial functioning related to the, 30 Day Discharge Notice. A review of the clinical record for Resident R5 who had an initial admitted [DATE], revealed physician's orders dated July 1, 2016, which indicated [DIAGNOSES REDACTED]. Continued clinical record review revealed a quarterly MDS assessment dated [DATE], which indicated that Resident R5, was assessed as a 15 on the BIMS section of the MDS, indicating the resident was cognitively intact. During an interview with Resdient R5 on July 14, 2016, at 12:35 p.m. it was revealed that a, 30 Day Discharge Notice, dated June 10, 2016, was given to Resident R5 by the NHA. Review of the, 30 Day Discharge Notice, indicated that Resident R5 would be discharged from the facility and the proposed facility for the discharge would be located in Erie, PA, which was 400 miles from current facility, family and friends. Further review of the, 30 Day Discharge Notice, revealed that the section of the document allotted for the NHA's signature was left blank During the interview with Resident R5 it was revealed that he/she was being discharged from the facility because his/her health insurance was not paying the facility. An interview with the NHA on July 14, 2016, at 12:35 p.m. revealed the facility failed to contact Resident R5's insurance carrier about nonpayment before the, 30 Day Discharge Notice, was given to Resident R5. An interview with the NHA on July 14, 2016, at 2:25 p.m., revealed she was waiting for a check from the corporate office that would pay for the transportation to move Resident R5 to Erie, PA and upon receipt of the check Resident R5 would be transferred to the facility in Erie, PA. The facility failed to ensure that Resident R5 was provided or received care and services to assist him/her to reach and maintain the highest level of mental and psychosocial functioning related to the 30 day discharge notice. During an interview with Employee E3 on July 14, 2016, at 1:25 p.m. it was confirmed that the facility did not look into any facilities in the greater Philadelphia area that might be willing to accept Residents R1, R2, R4 and R5. Employee E3 further indicated that a facility in Erie, PA, was willing to accept Residents R1, R2, R4 and R5 immediately. During an interview with the NHA and Employee 3 on July 14, 2016, at 1:00 p.m. they confirmed that the Ombudsman (an advocate for individuals in Long Term Nursing Care Facilities) was not notified of the, 30 Day Discharge, notices for Residents R1, R2, R4 and R5 as required. During an interview with the NHA on July 14, 2016, at 2:20 p.m. it was confirmed that the facility failed to plan for a discharge consistent with the residents psychosocial need to remain close to family members and friends for four of five residents, causing mental anguish and anxiety resulting in actual harm to the residents. An interview with the Nursing Home Administrator on July 14, 2016, at 2:15 p.m. confirmed that the facility did not provide, Appropriate orientation of the smoking policy to Residents R1, R2, R4 and R5 prior to the time the, 30 Day Discharge Notice, was given to the residents. 28 Pa Code 201.18(b)(1)(e)(1) Management Previously cited 6/24/16, 3/18/16, 11/19/15 28 Pa Code 201.18(b)(3) Management Previously cited 6/24/16, 5/12/16 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.10(d) Resident care policies Previously cited 6/24/16, 5/12/16, 3/18/16, 11/19/15, 10/29/14 28 Pa Code 211.12(d)(1)(3) Nursing services Previously cited 6/24/16, 5/12/16, 11/19/15 28 Pa Code 211.12(d)(5) Nursing services Previously cited 6/24/16, 3/18/16, 11/19/15, 10/29/14

Based on clinical record reviews, a review of facility documentation, hospital documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision and monitoring for three residents (Residents CL1, CL2 and R1) who had demonstrated evidence of unsafe behaviors and resulted in actual harm to one resident (Resident CL1). Findings include: Review of Resident CL1's closed clinical record revealed that the resident was admitted to the facility on [DATE]. The [DATE], physician's orders [REDACTED].) and abnormal gait and mobility (ambulation). A psychiatric consultation dated [DATE], stated that the resident had [DIAGNOSES REDACTED]. Review of Resident CL1's quarterly Minimum Data Set assessment (MDS-a periodic assessment of needs) dated [DATE], revealed that the resident had impaired vision, sometimes understood others, had exhibited physical (hitting, kicking, pushing, scratching, grabbing) and verbal (threatening, screaming, cursing) behavioral symptoms towards others on one to three days during the assessment period and required limited assistance of one staff member for eating. A nutrition assessment dated [DATE], stated that the resident required supervision for eating and drinking. Review of the Speech Therapist evaluation for [DATE], through [DATE], noted that the resident had poor safety awareness during meals, that frequent direction was required in several situations, that the resident was pocketing foods (holding food inside the cheek) and that instructions were provided to caregivers (staff) to control the amount of food taken at a time and to make sure the mouth was clear prior to taking more food. The Speech Therapist stated in an interview on [DATE], at 2:45 p.m. that therapy was discontinued on [DATE], due to a hospital admission to a behavioral health unit. Resident CL1 returned to the facility on [DATE]. On [DATE], the Speech Therapist noted that the resident was having difficulty swallowing during a meal and that the resident would be further assessed. A speech therapy daily note dated [DATE], stated that Resident CL1 was very impulsive with taking large amounts of food at a time and this was discussed with the staff. Review of the Speech Therapist's documentation for [DATE], stated that instructions were provided to decrease the speed of eating. The instructions indicated that the resident continued to have deficits in safety awareness and that the staff reported that Resident CL1 continued to require assist with safety and noted precautions for impulsivity and decreased safety awareness. Review of the Speech Therapist's evaluation dated [DATE], stated that treatment included teaching and training for the staff and the resident regarding safety awareness and safe techniques while eating. The evaluation noted the transition of care from therapy to the caregivers, that nursing continued to have to observe the resident due to decreased safety awareness and decreased communication skills and that caregivers were educated on the importance of instructing the resident to use safe swallow techniques at all times. Nursing documentation for [DATE], at 8:59 p.m. reported that Resident CL1 had been observed at the nurses' station putting a sandwich into his mouth at 8:30 p.m., turned away from the nurses' station, and after a few short steps, the resident fell to the floor. The resident's facial color started to turn bright red. A call was placed to 911 for choking and respiratory distress and that abdominal thrusts and mouth sweeps were partially effective. The documentation also stated that the resident went from respiratory distress to cardiac arrest (heart stopped) as 911 personnel entered the building, CPR (cardiopulmonary resuscitation - A life-saving emergency procedure that involves breathing for the victim and applying external chest compression) was started and the resident was transferred to the emergency room . Facility documentation dated [DATE], regarding the event stated, the resident was observed by the staff collapsing in the hallway to the floor, apparently choking on a turkey and cheese sandwich that staff had given him just prior at the nurses station, staff observed him placing entire sandwich into his mouth. Employee E4, a Speech Therapist, stated in an interview on [DATE], at approximately 2:45 p.m., that she had provided speech therapy for Resident CL1. She stated that her notes included that the resident may eat independently but that he was always supervised for all his meals. She stated that she had seen the resident eating quite fast and that the resident had aggressive behaviors. She would have preferred him to be seated at a table to eat and that he wasn't able to always follow directions. Review of the hospital records for Resident CL1 noted that Resident CL1 arrived in the Emergency Department at 9:00 p.m., that the resident had a hypoxic (lack of oxygen) arrest secondary to choking on a sandwich leading to a cardiac arrest and was admitted to the intensive care unit with a poor prognosis. Nursing documentation dated [DATE], 11:15 a.m. stated that Resident CL1's family had called the facility to advise them that the resident had died that morning. The facility failed to provide adequate monitoring and supervision to one resident with impulsiveness and poor safety awareness while eating, to prevent choking, which caused actual harm to Resident CL1. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE]. The physician's progress notes for [DATE], included [DIAGNOSES REDACTED]. The [DATE], physician's orders [REDACTED]. Additionally, the orders stated to administer Lasix (a water pill, which can cause dizziness) 20 milligrams by mouth daily for edema (swelling), Trazodone (an antidepressant) 75 milligrams by mouth at bedtime, Lyrica (a medication to treat nerve pain) 300 milligrams by mouth every 12 hours, Baclofen (a muscle relaxant) 10 milligrams by mouth daily and Valium (a muscle relaxant) 2 milligrams by mouth every 8 hours for muscle spasms. Review of a nursing note dated [DATE], at 12:36 p.m. reported that the resident was heard yelling for help from his bathroom and he was found on the floor on his buttocks. Review of the Director of Nursing's (DON) documentation dated [DATE], at 12:12 p.m. noted that the staff notified the DON that morning that the resident had eloped in his electric wheelchair on Monday, [DATE] (two days previously), and at approximately 3:45 p.m., the resident was seen approaching the facility entrance from Old Arch Road (a road with no pedestrian sidewalk). A psychiatric consultation dated [DATE], stated that the resident would be, continued on same medication for now due to alcohol seeking behavior, that the resident was caught with alcohol on person, that the resident denies leaving the grounds, that someone brought it in to him. On [DATE], a late entry nursing note for [DATE], reported that when the staff responded to the resident after a fall in his bathroom (four days previously) they discovered two empty alcohol bottles (a two ounce bottle of rum and a two ounce bottle tequila) on the resident's wheelchair, that a third empty bottle (a two ounce bottle vodka) was found on the bed and that the resident had a strong odor of alcohol. The resident initially denied consuming the alcohol, but later indicated that he had received the three bottles on Sunday, [DATE], from a visitor who had it in their car but the resident would not disclose the name of the visitor. Written transcript of the resident's statement regarding the event on [DATE], reported that the resident stated, someone came and visited me on Sunday, they gave me three small bottles (approximately two ounces each), I drank all three on Monday morning. There was no evidence available to review at the time of the survey that interventions had been developed to address the resident's continuing alcohol seeking behavior and to ensure Resident R1's safety after the elopement. Facility documentation on [DATE], reported that Resident R1 was discovered missing from the facility when the charge nurse was unable to locate him to administer his medications. Residents who were sitting outside the building on the patio, advised the nursing supervisor that Resident R1 had been seen exiting the parking lot in his wheelchair. He was located approximately thirty minutes later, traveling down the road from the facility in his electric wheelchair with four bottles of alcohol in a plastic bag on his lap. In an interview on [DATE], at 3:45 p.m. the Nursing Home Administrator stated that she did not know about Resident R1's elopement in April. The facility failed to provide adequate monitoring and supervision to a resident with a history of alcohol seeking, wandering behaviors and a prior elopement. A review of Resident CL2's closed clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. to provide nutrition), a Foley catheter (tube inserted into urethra for output of urine), chronic kidney disease and obesity. A review of the resident care plan for risk of falls initiated [DATE], revealed that the resident was an assist of two persons when providing care to the resident. A review of the quarterly MDS assessment dated [DATE], revealed that the resident was rarely understood or could rarely understand. The resident required two person assistance with transfers, dressing, bathing and care. The resident needed extensive assistance with all activities of daily living. A review of the nurses' notes dated [DATE], at 6:24 p.m. revealed that on [DATE], at 4:05 p.m. the resident's caregiver was providing care to the resident while the resident was in bed and rolled the resident on her side. The caregiver then reached behind her for a towel and the resident fell off the bed and onto the floor. The resident hit her head on the metal tube feeding pole. The resident received a laceration (a deep cut to the skin) to her forehead which was bleeding. The resident was sent to the hospital and received seven staples (used to repair a laceration) and three sutures (used to repair a laceration) for the laceration. The facility failed to provide adequate supervision for a resident who required care by two staff members to prevent a fall. As a result, the resident sustained [REDACTED]. 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(3) Nursing services Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE], [DATE]

Based on reviews of clinical records and facility documentation and interviews with residents and facility staff, it was determined that the facility failed to ensure adequate assessments and monitoring for one of two residents with history of falls, resulting in injury and harm to Resident R17, and failed to follow physician's orders [REDACTED]. (Residents R17, R34, and R87.) Findings: Clinical record review of Resident R17 revealed [DIAGNOSES REDACTED]. A review of the resident assessment, dated July 22, 2013, indicated that the resident was alert, oriented and required extensive assistance with activities of daily living. A review of Event Reporting System for July 10, 2013, indicated that the resident sustained [REDACTED]. The facility reported that the ambulance driver failed to report the event to the facility upon return from the consultant visit. A review of the physician's progress note, dated July 15, 2013, revealed that the resident told the physician that his legs were more swollen than normal. Nursing documentation, dated July 16, 2013, at 8:00 a.m., stated that the resident's two legs were swollen, discolored and painful to touch. On July 22, 2013, the orthopedic physician determined that the resident had sustained bilateral fractures of the tibia and fibula after reviewing the CT scan results. In an interview with Resident R17, on November 19, 2013, at 1:50 p.m., in the presence of Employee E5, a licensed nurse, he indicated that he reported a fall in the ambulance, on July 10, 2013, to nursing but that it was not acknowledged. A review of facility documentation dated July 26, 2013, confirmed the resident's statement. Interview with Employee E2, Director of Nursing, on November 19, 2013, at 11:50 a.m., confirmed that there was a delay in evaluation and treatment as a result of the inaccurate assessments. The facility failed to adequately assess and monitor this resident with severe bilateral extremity contractures, perform daily skin checks, and identify changes in pain, color and [MEDICAL CONDITION] for six days, resulting in a delay in treatment for [REDACTED]. Clinical record review for Resident R34 revealed [DIAGNOSES REDACTED]. A further review of the physician's orders [REDACTED]. A review of the clinical record revealed there was no evidence that these laboratory studies were completed. Interview with the Administrator, on November 20, 2013, at 3:45 p.m., confirmed these findings. Clinical record review for Resident R87 revealed a [DIAGNOSES REDACTED]. There was no evidence in the clinical record that this laboratory study was completed. This was confirmed by Employee E6 on November 18, 2013 at 1:30 p.m. 28 PA Code: 211. 12 (d)(1)(3)(5) Nursing services 28 PA Code: 201.18 (b)(1) Management

Based on a review of a clinical record, facility documentation, and staff interviews, it was determined that the facility failed to assess, monitor and develop effective behavioral interventions for a resident with depression and suicidal thoughts, resulting in actual harm to Resident R1. Findings include: Review of the admission History and Physical assessment dated [DATE], for Resident R1 revealed a [DIAGNOSES REDACTED]. It indicated that Resident R1 received medications ([MEDICATION NAME]) for depression. A review of nursing admission documentation dated November 25, 2010, revealed Resident R1 was admitted to this facility from a behavioral health unit for depression and suicidal attempt. The Social Service assessment dated [DATE], revealed a [DIAGNOSES REDACTED]. It was indicated on the assessment that resident was having a difficult time with adjusting to new placement. On November 29, 2010, the Social Worker made a referral for a psychologist to complete an evaluation and begin treatment for [REDACTED]. The current plan of care was not developed to address this residents behavioral needs with appropriate interventions for depression or suicidal ideation. Review of a Nursing Note dated December 5, 2010, at 6:00 p.m., revealed that nursing staff observed Resident R1, to be seclusive to the room, verbalized feeling sad to staff, tearful at times, withdrawn and required much encouragement to get out of room. Another Nursing Note dated December 11, 2010, at 9:00 p.m., revealed that nursing staff observed Resident R1, with a towel wrapped around the left wrist. Nursing assessment of Resident R1 at the same time revealed that the resident had moderate amount of bleeding at the area of the wrist from cutting herself with a razor. A razor coated with blood was found by nursing staff on Resident R1's bedside table. The resident was transferred to the hospital emergency room for treatment and admitted into the hospital's behavioral health unit for attempting suicide. Interview with Administrator on December 21, 2010, at 1:10 p.m., revealed that nursing staff was not proactive with a resident who has been diagnosed of [MEDICAL CONDITION], previous suicidal attempt and had not been seen by a psychologist after social service assessment on November 29, 2010. The facility failed to adequately supervise and monitor this resident who had a history of [REDACTED]. 28 PA Code: 201.14(a) Responsibility of licensee. Previously cited 11/3/09. 28 PA Code: 201.18(b)(1) Management. Previously cited 11/3/09. 28 PA Code 201.18(b)(3) Management. Previously cited 11/3/09. 28 PA Code 211.10(d) Resident care policies.