Every finding on record at John J Kane Regional Center-Mc

Based on review of facility policy, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents (Resident R1).Findings include: Review of the facility policy, Elopement: Missing Resident dated, 6/30/25, indicated It is the policy of the facility to provide each resident with adequate monitoring and interventions to maintain safety. If a resident is discovered to be missing, the center will immediately take all possible measures to assure the resident's safe return. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 3/11/26, included diagnoses of encephalopathy (broad term for any brain disease, damage, or dysfunction that alters mental state, causing confusion, memory loss, and personality changes) and coronary artery disease (damage or disease in the heart's major blood vessels). Review of the facility diagnosis list included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), dysphagia, muscle weakness, unsteadiness on feet, history of falling, adult failure to thrive. Review of hospital documentation provided to the facility upon admission on [DATE], indicated, She presents emergency department after being found by her daughter covered in feces, urine, and vomit. Per EMS (emergency medical services) that house was in a poor state of hygiene when they picked patient up ED (emergency department) reported concerns that Adult Protective Services may need to be called to help provide resources. The patient's daughter lives near and checks on her daily, when I saw the patient the daughter stated that she felt like her last normal day was 48hrs ago, the last two days she said she saw her sitting on the same couch in her house but did not realize she was developing pressure sore, then yesterday realized that she had soiled herself and called EMS. The daughter is also not the best historian overall and it's difficult to get an accurate assessment. Per EMS report to ED, they were concerned about the condition of the patient's home, found her covered in urine, feces, and vomit, wearing multiple shirts and with her house key safety pinned to her shirt. Daughter lives next door and visit's patient regularly to help with care and she is the one that found her. Review of an Elopement Evaluation assessment completed on 5/19/25, indicated Resident R1 was not at risk for elopement due to not being able to ambulate or use a wheelchair independently. Review of Elopement Evaluation assessments completed on 7/2/25, and 9/18/25, indicated Resident R1 was not at risk for elopement due to not having exit-seeking behaviors. Further review of the clinical record failed to reveal additional elopement assessments after 9/18/25. Review of Resident R1's plan of care initiated 5/19/25, did not include goals and interventions related to elopement. Review of Resident R1's plan of care for Discharge Planning initiated 5/19/25, indicated the risk for long-term care, unable to care for self, limited assistance in the community. Possible protective care services. The care plan included the goal of, Resident will be discharged appropriately/ or will remain long term care. Review of a physician's order dated 5/19/25, reordered 3/22/26, indicated, Resident level of supervision: May move about unit and facility without supervision but may not leave facility without supervision. Review of a physician's order dated 4/2/26, indicated, Overnight LOA (leave of absence) 4/2 to 4/3 with meds. Review of a physician note dated 3/6/26, at 5:32 a.m. indicated that on 3/5/26, Resident R1 stated she is ready to go home. The plan listed in the physician notes was, For PT (physical therapy), OT (occupational therapy) and social worker to determine safety at home and follow-up with PCP (primary care physician). We will discharge when above is in place. Review of a progress note dated 3/20/26, at 1:02 p.m. indicated resident was heard to state, If I get to go home with my dtr (daughter), I'm not coming back. Review of a progress note dated 3/31/26, at 2:23 p.m. indicated LOA from 4/2-4/3, MD notified and agreeable, med list sent to pharmacy. Review of a late entry progress note dated 4/1/26, at 1:30 p.m. (created 4/7/26), indicated, Resident, nursing, SS (Social Services), and therapy attended meeting to discuss resident request of possible discharge in the future. Resident was admitted in 2025 as an APS (Adult Protective Services) case due to not being able to care for herself at home. Resident has been working in therapy with hopes to discharge, but does not have a safe place to go at this time. In therapy, resident still needed some assistance and cueing with ADLs (activities of daily living). Before meeting began, resident got her wheelchair stuck and needed help. SS explained to resident that if she would be home alone, she would have to be able to do these things by herself. Resident had a planned LOA Thursday with an overnight stay until Friday and return around 5pm. When resident was asked where she was going, she could not give SS a detailed answer. She stated a church event. [Physical Theryapy Employee E1] asked resident multiple times how she would be getting to the event, and resident kept repeating my daughter will pick me up. However, her daughter does not drive. Resident stated she would like to get an apartment that is handicap accessible and have her daughter be a paid caregiver. None of these things are in place at this time. This meeting was to touch base with resident on her wishes of some day discharging if possible. Review of a progress note dated 4/4/26, at 12:12 a.m. indicated, This resident was supposed to be back from her LOA at by 6pm No answer and message left for daughter (name and contact phone number) regarding the LOA of this resident. Review of a progress note dated 4/4/26, at 1:11 a.m. indicated, On the LOA paper this resident signed herself out leaving [phone number]; in calling this number the automated voice comes on saying the call cannot be completed as dialed and to please check the number or ask the operator. Review of a progress note dated 4/4/26, at 1:16 a.m. indicated, Attempted to call the daughter again [phone number] this time straight to voicemail. Review of a progress note dated 4/4/26, at 2:42 a.m. indicated, Attempted to call [daughter] regarding the LOA and where abouts of her mother. Again, the LOA was for 4/2/26 until 4/3/26 at 6PM message left for the daughter [phone number] to call us back. Review of a progress note dated 4/6/26, at 11:05 a.m. indicated, Call placed to [daughter / phone number] and message left to call facility. Call placed to [pastor] of resident's church at [phone number] and number restricted. Call placed to [resident's church friend] at [phone number] and straight to busy signal. Review of a progress note dated 4/7/26, at 9:54 a.m. indicated that the facility attempted to contact the resident's primary care physician in the community but was unable to do so. A message was received that indicated the office was closed since 2/1/26. Review of a progress note dated 4/9/26, at 11:11 a.m. indicated, Spoke with APS agent with update. This nurse received information from the business office. The progress note included an email address, physical address, and phone number for Resident R1's daughter. Review of a progress note dated 4/28/26, at 12:25 p.m. indicated that APS was contacted, who confirmed that they were able to make contact with Resident R1's daughter, who stated that the resident was fine. Resident R1's daughter was unwilling to provide further information or the location of Resident R1. During an interview on 4/28/26, at approximately 12:35 p.m. the Director of Nursing and the Assistant Director of Nursing confirmed that the facility failed to take actions other than phone calls when Resident R1 did not return to the facility as scheduled on 4/3/26, that they were unaware of the location of Resident R1, and had not known of her location or safety since she departed on 4/2/26. Review of information submitted by the facility dated 4/6/26, indicated that on 4/4/26 [incorrect date, incident occurred on 4/3/26], at approximately 6 PM alert x 3 (mentally alert to person, place, and time) [Resident R1] (BIMS 15, indicating cognitively intact) did not return from an overnight leave of absence. Resident is alert, verbal and able to make needs known. Resident went on an approved LOA from 4/3/26 to 4/4/26 [correct dates are 4/2/26 to 4/3/26] with her daughter to daughter's home. Resident was picked up by her daughter, who is her emergency contact and a friend via private car. When resident did not return to facility at 6 PM on 4/4/26 [correct date 4/3/26] multiple attempts were made to call all listed contacts. Daughter called and message left with no response. Resident's second and third contacts called and unavailable. MD (Doctor of Medicine) notified, and facility continued to make multiple attempts to contact resident. When MD updated of residents non return to facility resident considered AMA (against medical advice). Adult protective services notified and informed that resident left on a therapeutic LOA with one day of meds, all belongings and wheelchair to daughter's home. Resident able to ambulate with assistance and was in process of completing care giver training with daughter for possible discharge. APS to investigate further. Facility called 911 for a wellness check. [Local] Police Department returned call stating no answer at residence but utilities appear to be on. The NHA and the DON were made aware that an Immediate Jeopardy situation existed and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. The Immediate Jeopardy began on 4/2/26. On 4/28/26, at 6:05 p.m. an acceptable Corrective Action Plan was reviewed which included the following interventions: Actions Related to Resident R1:4/3/26: Resident failed to return from approved LOA at 6:00 p.m. Calls made to daughter at 11:45 PM, 11:49 PM (no answer).4/4/26: Documentation of phone calls from 12:12 a.m. through 2:42 a.m. (2.5 hours) to attempt to locate resident through daughter and phone number listed on LOA form.4/6/26: Adult Protective Services at 11:20AM. Notification to local police at 5:20 PM (three days after Resident did not return). Calls made by staff at 11:04 AM, 12:35 PM, 12:44PM to daughter number. Calls made to Pastor (second contact person) at 11:08AM, 11:09AM, 12:34PM, 12:45PM and 12:50PM. Calls made to Friend (third contact) at 11:10AM, 12:34 PM.4/7/26: Attempt made to contact residents PCP in community. Number called and office closed as of 2/1/26. Ombudsman notified. Attempted to call pastor.4/9/26: Spoke with APS agent with update of daughter's contact information received from the business office. Identification of other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken. Immediately the facility will reevaluate all residents to ensure any wandering behaviors are identified; update care plans as needed and ensure adequate.Elopement risk assessment will be completed on every resident currently in facility completed by 4/28/26. Thereafter Elopement Risk Assessment will be done on admission, annually, and quarterly MDS review, and with any change in condition.Resident care plans will be updated to include elopement risk, residents identified as an elopement risk will have a Wander guard placed and security notified immediately completed by 4/28/26.Accountability check sheets used to account for residents' location at the beginning and end of each shift will be completed daily to ensure monitoring of residents by 4/28/26.Residents exhibiting wandering/elopement behavior will be identified on 24hr report for follow up and safety by 4/28/26.Residents that exhibit wandering/elopement behavior will be placed on q1h (every hour) safety checks x 72 hours by 4/28/26.Resident contact information will be verified before each Therapeutic Leave of Absence to ensure viable phone number and address. Measures to be put into place or what system changes will you make to ensure that the deficient practice does not occur? Facility will in-service all scheduled nursing staff, including agency, beginning immediately on Elopement-Missing Resident and Therapeutic Leave of Absence policy on 4/28/26, with completion on 4/29/26, at 1:00 p.m. Staff will be identified via facility roster/signature log to ensure full attendance.Comprehensive care planning, addressing elopement risk and level of supervision.Comprehensive whole house elopement observations have been completed.Therapeutic Leave of Absence policy created 4/28/26.Elopement policy reviewed immediately at QA/QAPI (Quality Assurance and Process Improvement) on 4/28/26. How will the corrective action be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance programs will be established? ADON/designee will perform monitoring of Leave of Absence log to ensure the safe and timely return of residents for completion three per week for four weeks, beginning on 4/28/26; weekly for four weeks; biweekly for four weeks; then monthly for four months. Review of resident clinical records on 4/29/26, confirmed that all residents were reevaluated for elopement risk on 4/28/26. Review of facility-provided sign-in sheets, dated 4/28/26, and 4/29/26, confirmed reeducation was provided to licensed nurses on the updated Elopement / Missing Resident policy and the Therapeutic Leave of Absence policy. During interviews conducted on 4/29/26, confirmed 15 of 15 nurses (facility-employed and agency staff) received reeducation on the updated Elopement / Missing Resident policy and the Therapeutic Leave of Absence policy. After confirming the plan was implemented as outlined the Immediate Jeopardy was lifted. During an interview on 4/29/26, at approximately 12:00 p.m. the Chief Nursing Officer confirmed that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of job descriptions, facility documents, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents (Resident R1).Findings include: Review of the facility-provided Nursing Home Administrator (NHA) job description indicated the NHA directs the day-to-day functions of the facility and manages all aspects of the Center's operations to ensure the safety and comfort of the residents is maintained, and the monitoring of service providers. Work is performed in accordance with federal, state, and local standards, guidelines, and regulations that govern long-term facilities to assure that high quality care is provided to all residents. Review of the facility-provided Director of Nursing (DON) job description indicated the DON's responsibilities are to plan, organize, develop, and direct the overall operation of the Nursing Department in accordance with Professional Nursing Law, and current federal, state, and local standards, guidelines, and regulations that govern the facility. Based on findings identified in this report, the facility failed to take appropriate action when a resident failed to return to the facility after a leave of absence. The previously employed NHA and the previously employed DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 4/30/26, at approximately 12:30 p.m. the current NHA and current DON confirmed that facility administration failed to effectively manage the facility to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of forty residents 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of five residents (Resident R1)A review of the facility policy Notification of Changes in Resident Condition and Treatment Changes dated 6/30/25, indicated to notify physician of changes, accidents, and injuries; and assessment findings and secures treatment and diagnostic direction and orders from physician. Also indicated to, document findings and notifications in the nurses' notes.A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficits and congestive heart failure (chronic condition where the heart muscle is too weak or stiff to pump enough blood and oxygen to body).A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 12/31/25, indicated the diagnoses remained current.A review of a change in condition report dated 12/31/25, indicated Resident R1 was observed to have change in condition, specific to altered mental status.A review of Resident R1's nurse progress notes did not include documentation of physician notification, or any follow up assessments or treatment plans. Interview with RN (registered nurse) Employee E1 on 2/4/26 at 11:50 a.m., indicated that physician was made aware of change in condition via text message from personal phone, however this RN did not document this conversation in the medical record. During an interview on 2/4/26, at 1:15 p.m. the Director of Nursing confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R1.28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the medical provider of abnormal vital signs for one of four residents (Resident R31).Findings include: Review of the American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, dated 2017, indicated the following levels: Normal-systolic: less than 120 mm Hg (millimeters of mercury)-diastolic: less than 80 mm Hg Elevated-systolic: 120-129 mm Hg-diastolic: less than 80 mm Hg High blood pressure (hypertension)-systolic: 130 mm Hg or higher-diastolic: 80 mm Hg or higher Review of the clinical record indicated Resident R31 was admitted to the facility on [DATE]. Review of Resident R31's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/3/25, included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated that Resident R31 had severe cognitive impairment. Review of a physician's order dated 1/16/25, indicated that Resident R31 received 40 milligrams of Valsartan (medication used to treat high blood pressure) once daily. The order directed staff to hold the medication if the resident's systolic blood pressure was below 110 mmHg. Review of the plan of care initiated 7/5/22, indicated that Resident R31 was at risk for complications related to high blood pressure. The goal listed in the care plan was, Resident's blood pressure will range within parameters set by MD. Included in the interventions was, Observe for signs and symptoms of elevated blood pressure (systolic BP >140, diastolic BP >90, dizziness, flush face, headache, nosebleed, nausea/vomiting). Further review of Resident R31's clinical records failed to reveal any physician documented parameters for Resident R31's blood pressure values, or actions to take if Resident R31's blood pressure was elevated. Review of Resident R31's blood pressure record for 9/1/25, through 11/6/25, indicated the following blood pressure values without corresponding documentation of notification of a provider. 9/2/25 172/789/6/25 161/949/8/25 193/829/15/25 163/819/20/25 168/829/22/25 177/91, 173/909/25/25 168/849/26/25 162/869/30/25 171/7810/6/25 187/84, 174/8410/8/25 170/8910/10/25 171/83, 182/91, 179/9510/11/25 187/8610/12/25 175/8710/14/25 178/8410/21/25 184/8410/22/25 173/7910/23/25 171/8911/3/25 160/9311/6/25 172/63 During an interview on 11/5/25, at approximately 11:00 a.m. the Director of Nursing confirmed that the facility does not maintain a specific policy regarding notification of out-of-range blood pressure values. Provided at this time were the values that the electronic medical record flags in the system as being out-of-range: systolic greater than 160 mmHg and diastolic greater than 90 mmHg. During an interview on 11/6/25, at 9:55 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, Licensed Practical Nurse (LPN) Employee E1 stated, knowledge and sometimes there's parameters. During an interview on 11/6/25, at 10:04 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, LPN Employee E2 stated she would look at the resident's diagnosis, look at previous blood pressure values, and recheck. During an interview on 11/6/25, at 10:06 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, registered nurse (RN) Employee E3 stated she would look at the resident's parameters in their order. When asked the process if the resident did not have parameters, RN Employee E3 stated she would notify if the blood pressure flagged as high. During an interview on 11/6/25, at 10:11 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, LPN Employee E4 stated she would look would see what the resident's normal blood pressure was and would notify the supervisor or the medical provider. During an interview on 11/6/25, at 10:17 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, RN Employee E5 stated, Common sense. During an interview on 11/6/25, at 10:21 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, RN Employee E6 stated, Anything over 160 (160 mmHg systolic blood pressure). During an interview on 11/6/25, at 10:26 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, LPN Employee E7 stated that the electronic medical record automatically flags when a blood pressure is high, and she would look at the resident's parameters and if they have received their blood pressure medication. When asked about a resident who may not have parameters, LPN Employee E7 stated that she would notify a supervisor if the blood pressure was high. During an interview on 11/6/25, at 10:26 a.m. when asked how she knew that an elevated blood pressure required notification to the provider, LPN Employee E8 stated she would document the elevated blood pressure and provide them their blood pressure medications and recheck. When asked about a resident who is not on blood pressure medications, LPN Employee E8 stated she would call the doctor. During an interview on 11/6/25, at 11:10 a.m. the Assistant Director of Nursing confirmed that Resident R31's elevated blood pressures were not communicated to the supervisor or provider. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the medical provider of abnormal vital signs for one of four residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect for one of four residents (Resident R39). Findings include: Review of the facility policy Abuse - Resident and Reasonable Suspicion of a Crime dated 6/30/25, defined neglect as the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/3/25 included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section G: Functional Abilities indicated Resident R39 required substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair) and indicated Resident R39 had range of motion impairment to her lower body. Review of the plan of care initiated 6/29/22, last reviewed 10/14/25, indicated Resident R39 is at risk for falls related to a right leg amputation. Review of a physician's order dated 5/24/25, active on 8/3/25, indicated Resident R39 was to be transferred with two people utilizing a Hoyer (mechanical) lift. Review of a physician's note dated 8/3/25, at 10:47 a.m. indicated Resident R39 was lowered to the ground by staff while assisting her to transfer from bed to chair. Review of a Resident Incident/Event Investigation Form dated 8/3/25, indicated Nurse Aide Employee E13 Was attempting to transfer resident without hoyer. Review of an employee statement written by NA Employee E13 dated 8/3/25, indicated, Was transferring resident to wheelchair could not make it to chair. I slid resident to floor in a sitting position. Review of facility provided documentation dated 8/6/25, indicated, It was determined that the staff member did not follow the plan of care / orders while transferring a resident. [NA Employee E2] failed to identify the transfer order prior to care. Resident requires mechanical lift with 2 staff for transfers. [NA Employee E2] transferred resident by self and had to lower resident to the floor. [NA Employee E2] is placed on the do not return list for failure to follow physician orders for transfers prior to care. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from neglect for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to implement policies and procedures to report allegations of abuse for one of four residents (Resident R39). Findings include: Review of the facility policy Abuse - Resident and Reasonable Suspicion of a Crime dated 6/30/25, indicated that alleged violations, whether or not confirmed, must be reported to the State Department of Health. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/3/25 included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section G: Functional Abilities indicated Resident R39 required substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair) and indicated Resident R39 had range of motion impairment to her lower body. Review of the plan of care initiated 6/29/22, last reviewed 10/14/25, indicated Resident R39 is at risk for falls related to a right leg amputation. Review of a physician's order dated 5/24/25, active on 8/3/25, indicated Resident R39 was to be transferred with two people utilizing a Hoyer (mechanical) lift. Review of a physician's note dated 8/3/25, at 10:47 a.m. indicated Resident R39 was lowered to the ground by staff while assisting her to transfer from bed to chair. Review of a Resident Incident/Event Investigation Form dated 8/3/25, indicated Nurse Aide Employee E13 Was attempting to transfer resident without hoyer. Review of an employee statement written by NA Employee E13 dated 8/3/25, indicated, Was transferring resident to wheelchair could not make it to chair. I slid resident to floor in a sitting position. Review of facility provided documentation dated 8/6/25, indicated, It was determined that the staff member did not follow the plan of care / orders while transferring a resident. [NA Employee E2] failed to identify the transfer order prior to care. Resident requires mechanical lift with 2 staff for transfers. [NA Employee E2] transferred resident by self and had to lower resident to the floor. [NA Employee E2] is placed on the do not return list for failure to follow physician orders for transfers prior to care. Review of documentation submitted by the facility to the State Survey Agency failed to include a report of neglect for Resident R39. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to implement policies and procedures to report allegations of abuse for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of clinical record was determined that the facility failed to develop a person-centered care plan related to discharge for one of eight residents (Resident R10).Findings include: Review of the facility policy, Assessment - Comprehensive Person-Centered Care Planning dated 6/30/25, previously reviewed 1/6/25, indicated the facility will document, develop, and implement a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Review of the clinical records indicated Resident R10 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 10/22/25, included diagnoses diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), parkinson's disease (progressive neurological disorder that affects movement, balance, and coordination), seizure disorder or epilepsy(brain electrical activity that causes temporary changes in behavior, consciousness, or movement), schizophrenia (chronic mental illness characterized by a combination of positive, negative, and cognitive symptoms that significantly impair daily functioning). Review of Resident R10's facility diagnosis list included history of repeated falls, dysphagia, anxiety disorder, bipolar disorder current episode mixed, chronic obstructive pulmonary disease and essental hypertension. Review of the clinical record revealed that Resident R10's comprehensive care plan initiated on 10/27/25, failed to include plans of care with goals and interventions for diabetes. Review of the diagnoses list revealed the diagnosis of diabetes was added on 7/7/23 when resident was transferred from another facility to this facility for long-term care. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to develop a person-centered care plan for one of eight residents. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of decreased Capillary Blood Glucose (CBG) levels for two of five residents reviewed (Resident R26 and R12).Findings include:The Centers for Disease Control define diabetes as Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body ' s cells for use as energy. If you have diabetes, your body either doesn' t make enough insulin or can ' t use the insulin it makes as well as it should. When there isn' t enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dL). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias, and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable level of CBG ' s. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it is untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage, and non-healing wounds.Review of the facility policy Emergency Care Guidelines: Hypoglycemia Protocols reviewed 6/30/25 and 1/6/25, indicated staff are to provide timely initiation of emergency treatment for an acute hypoglycemic episode utilizing specific protocols approved by the medical director. Blood Glucose Monitoring: 1. Hold all diabetic medication and insulin until reviewed with physician. 2. Treatment-a. If unable to take po or via GT, administer 4 ounces of soda or juice followed by 4 ounces of milk. B. If unable to take po or via GT, an RN may administer glucagon IM. 3. Recheck BGM in 15 minutes, treat according to protocol, and notify physician. 4. May repeat such administrations of this medication up to 2 times within 30-minute time-period in the event of an acute hypoglycemic episode. 5. Document all actions.Review of the facility policy Notification of Changes in Resident Condition and Treatment Changes reviewed 6/30/25 and 1/6/25, ensures and protects a resident ' s right to fully be informed of his or her health condition and treatment. As noted in the Treatment Changes section: Nurse- 1. Notifies resident and responsible party where applicable of changes in physician order where a significant change or treatment plan has occurred involving a new condition or significant exacerbation of a pre-existing condition. Communication changes verbally with resident. 2. Documents notification in nurse ' s notes.Review of the clinical record revealed Resident R26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes, vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), hypertensive heart disease with heart failure (longstanding pressure and volume overload in the heart which causes the heart not to work correctly leading to failure), chronic obstructive pulmonary disease (a group of lung diseases that causes airflow obstruction and breathing difficulties).Review of the Minimum Data Set (MDS- a mandated assessment of a resident ' s abilities and care needs) dated 8/22/25, indicated diagnoses remain current.Review of Resident R26 ' s physician orders revealed the following orders:-On 5/8/25, Novolog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks about 1 hour, keeps working for 2-4 hours) administer before meals (8 am, 12 pm, 4 pm).-On 5/8/25, Ozempic (lowers blood sugar, slowing your digestion and reducing appetite) give one time a day on Saturday.-On 7/2/25, at 8:12 a.m. the CBG was noted as 53, no recheck documented.-On 7/26/25, at 8:09 a.m. the CBG was noted as 56, no recheck documented.-On 9/27/25, at 8:21 a.m. the CBG was noted as 52, no recheck documented.Review of Resident R26 ' s eMAR (computerized charting) and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.Review of the clinical record revealed Resident R12 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included diabetes, vascular dementia, hypertensive heart disease with heart failure, and schizoaffective disorder-bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disease).Review of the Minimum Data Set (MDS- a mandated assessment of a resident ' s abilities and care needs) dated 10/24/25, indicated diagnoses remain current.Review of Resident R12 ' s physician orders revealed the following orders:-On 6/2/25, Admelog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks about 1 hour, keeps working for 2-4 hours) administer before meals (8 am, 12 pm, 4 pm).-On 5/8/25, Basaglar (a long-acting insulin that works slowly and consistently over 24 hours) administer one time a day at bedtime.-On 9/20/25, at 12:01 p.m. the CBG was noted as 66, no recheck documented.-On 10/4/25, at 7:33 a.m. the CBG was noted as 60, no recheck documented.Review of Resident R12 ' s eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates.During an interview on 11/6/25, at 8:20 a.m. Licensed Practical Nurse (LPN) Employee E9 stated if blood sugar is below 70, they would assess for symptoms, if less than 60 they would give half a glass of orange juice with two packets of sugar, notify the nursing supervisor, call the doctor to await further instructions and repeat another blood sugar in 15 minutes, whether the blood sugar was below 70 or 60 would hold insulin until further instructions.During an interview on 11/6/25, at 8:30 a.m. LPN Employee E2 stated they would follow orders, if less than 60 would give half a glass of orange juice followed by half a glass of milk, notify the physician and repeat the blood sugar every 15 minutes until stable.During an interview on 11/6/25, at 8:50 a.m. Registered Nurse (RN) Employee E6 stated if blood sugar was below 60 would hold the insulin and then provide a half a glass of orange juice with a snack and then provide a half a glass of milk, repeat the sugar in 15 minutes, notify the nursing supervisor and the physician.During an interview on 11/6/25, at 8:53 a.m. LPN Employee E4 stated if blood sugar was below 60 would notify the physician and treat per protocol by giving half a glass of juice followed by half a glass of milk, recheck blood glucose at 15 minutes, if symptomatic and unable to swallow would give glucagon which is kept in the med room.During an interview on 11/6/25, at 9:03 a.m. LPN Employee E8 stated if blood sugar is below 60 will hold insulin, if the patient is symptomatic or not will administer half a glass of juice with a sugar packet followed by half a glass of milk, repeat glucose in 15 minutes and give a snack at this time if the blood sugar is not increasing, repeat blood sugar 15-30 minutes after snack. Notify physician and nursing supervisor of all actions.During an interview on 11/6/25, at 9:10 a.m. LPN Employee E10 stated if blood sugar was below 60 would hold insulin, give a half a glass of orange juice with two sugar packets and then a half a glass of milk along with a snack (graham crackers), repeat blood sugar in 15 minutes and notify the nursing supervisor and physician of resident ' s status and actions that were taken.During an interview on 11/5/25, at 10:45 a.m. the Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition and failed to document an assessment or interventions used related to abnormal blood glucose levels for Residents R26 and R12.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.29 (d) Resident Rights.28 Pa. Code 211.10 (c )(d) Resident Care Policies.28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during transfers for one of four residents (Resident R39). Findings include: Review of the facility policy Accident Prevention dated 6/30/25, indicated it is the facility's policy to prevent resident accidents and injuries. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/3/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section G: Functional Abilities indicated Resident R39 required substantial/maximal assistance to transfer to and from a bed to a chair (or wheelchair) and indicated Resident R39 had range of motion impairment to her lower body. Review of the plan of care initiated 6/29/22, last reviewed 10/14/25, indicated Resident R39 is at risk for falls related to a right leg amputation. Review of a physician ' s order dated 5/24/25, active on 8/3/25, indicated Resident R39 was to be transferred with two people utilizing a Hoyer (mechanical) lift. Review of a physician ' s note dated 8/3/25, at 10:47 a.m. indicated Resident R39 was lowered to the ground by staff while assisting her to transfer from bed to chair. Review of a Resident Incident/Event Investigation Form dated 8/3/25, indicated Nurse Aide Employee E13 Was attempting to transfer resident without hoyer. Review of an employee statement written by NA Employee E13 dated 8/3/25, indicated, Was transferring resident to wheelchair could not make it to chair. I slid resident to floor in a sitting position. Review of facility provided documentation dated 8/6/25, indicated, It was determinedthat the staff member did not follow the plan of care / orders while transferring a resident.[NA Employee E2] failed to identify the transfer order prior to care. Resident requires mechanical lift with 2 staff for transfers. [NA Employee E2] transferred resident by self and had to lower resident to the floor. [NA Employee E2] is placed on the do not return list for failure to follow physician orders for transfers prior to care. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision during transfers for one of four residents. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of eight residents (Resident R37, R39, and R7).Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: -Section J: Health Conditions, Question J1300: If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. Review of the admission record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's MDS dated [DATE] included diagnoses of osteoarthritis (degeneration of the joint causing pain and stiffness) and a hip fracture. Review of Section J, Health Conditions, Question J1300 indicated Resident R37 did not use tobacco. Review of the plan of care last reviewed 7/25/25, indicated Resident R37 wished to continue to smoke. Review of the facility provided list of residents who smoke included Resident R37. Review of the admission record indicated Resident R39 was admitted to the facility on [DATE]. Review of Resident R39's MDS dated [DATE] included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of Section J, Health Conditions, Question J1300 indicated Resident R39 did not use tobacco. Review of the plan of care last reviewed 10/14/25, indicated Resident R39 wished to continue to smoke. Review of the facility provided list of residents who smoke included Resident R39. Review of the admission record indicated Resident R7 was admitted to the facility on [DATE]. Review of resident R7's MDS dated [DATE] included diagnoses of dementia and high blood pressure. Review of Section P Restraints and Alarms P0100 Physical restraints indicated Resident R7 had a trunk restrain applied less than once daily. Review of a physician order dated 9/24/25, indicated the resident transfers independently. Observation on 11/5/25, revealed Resident R7 does not use a physical restraint. During an interview on 11/5/25, at 10:40 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E14 confirmed Resident R7 did not have a physical restraint in place and the MDS assessment was inaccurate for Resident R7. During an interview on 11/6/25, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of twelve residents. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Accident Prevention, dated 1/6/25, indicated it is the facility's policy to prevent resident accidents and injuries. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/15/25 included diagnoses of chronic obstructive pulmonary disease (COPD - a group of progressive lung disorders characterized by increasing breathlessness) and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Section GG: Functional Abilities indicated that Resident R1 required partial/moderate assistance for chair/bed-to-chair transfers. Review of a physician order dated 9/13/24 indicated Resident R1 required an assist of one staff member and the use of a rolling walker. Review of Resident R1's plan of care for ADLs (activities of daily living) Functional Status / Rehabilitation Potential, dated 2/5/25, indicated that the resident will have all necessary assistance with ADLs. Review of an on-call physician note dated 5/3/25 at 10:15 a.m. indicated, Patient sustained a deep laceration to right lower leg from [his/her] wheelchair. Patient with profuse bleed and subsequently transferred to Emergency department for evaluation. Review of a progress note dated 5/3/25 at 10:22 a.m. indicated, Called to pt (patient) room by nurse on unit. During stand to pivot transfer leg caught on wheelchair causing laceration to right lower extremity. Approx 7 centimeters (cm) x 1 cm. Moderate bleeding noted. Pressure dressing applied to control bleeding. [On-call provider] contacted and pt sent to hospital for eval. Review of hospital documentation, dated 5/3/25, indicated, [Resident R1] presents to the emergency room from [facility] sent for laceration right lower extremity. Apparently patient sustained a laceration to [his/her] right lower extremity on the leg of [his/her] wheelchair. An addendum dated 5/3/25 at 5:45 p.m. indicated that while waiting for transportation to return to the facility, Resident R1 appeared to bleed through the dressing. Sutures, surgifoam (dressing or powder used to control bleeding), and dressing applied to the wound. Review of a progress note dated 5/3/25 at 5:47 p.m. indicated Resident R1 returned from the hospital with 11 staples and 2 sutures per report from ER nurse, states that resident has had excessive bleeding at hospital and the 2 sutures were added as the resident was being d/c (discharged ) from the hospital due to the excessive bleeding, nurse advised pressure dressing was put on and 2 rounds of quick clot (gauze or granules that promote blood clotting). Review of a progress note dated 5/3/25 at 8:42 p.m. indicated Resident R1's pressure dressing from the hospital had bled through, and the wound was redressed with a pressure dressing and applied ABD (highly absorbent dressing that provides padding and protection for large wounds), Kerlix (absorbent rolled bandage), ace (elastic bandage). Review of a progress note dated 5/4/25 at 4:22 a.m. indicated Resident R1's wound continued to ooze. Review of a progress note dated 5/4/25 at 7:40 a.m. indicated, Notified by nurse on unit that blood saturating through the pressure dressing to the right lower extremity. Dressing removed with nurses on unit present to eval (evaluate). Dressing was from knee to ankle, moderate to gross amount of blood noted on dressing. Upon removal clot noted to area approx. 4 cm round with a 1 cm wide tail approx. 6-7 cm. Staples intact. 2-3 sutures noted at top of area where blood continued to ooze steadily. Pressure applied with folded 4x4 (four-inch square gauze) but blood continued to penetrate through. Review of a provider note dated 5/4/25, at 7:43 a.m. indicated, to send Resident R1 to the emergency department for further evaluation. Review of a progress note dated 5/4/25, at 1:18 p.m. indicated the hospital called and stated two additional staples were inserted and quick clot administered. Review of hospital documentation dated 5/4/25, indicated, [Resident R1] was brought into the emergency room due to bleeding at the laceration site which was repaired yesterday. Patient apparently sustained a contusion and laceration of the right leg when she hit her wheelchair yesterday and the laceration was repaired with staple and stitches. Dressing was applied but apparently kept bleeding this morning hence was sent to the emergency room for evaluation. Documentation further stated that two additional staples were used to control the bleeding site and quick clot dressing was applied. Review of facility submitted information on 5/6/25, indicated on 5/3/25, At approximately 10:00 AM alert x 1 resident [Resident R1] sustained a laceration to the right lower extremity during transfer from bed to wheelchair. During transfer with CNA (Nurse Aide) resident became weak and buckled at the knees. CNA braced resident to prevent fall and placed [him/her] in the w/c (wheelchair). When resident was safely in w/c CNA noticed blood from his/her] right leg. CNA applied pressure to the area and called out for help. LPN (licensed practical nurse) responded immediately and assessed wound. Supervisors notified and assessed resident. Area cleansed with normal saline and pressure dressing applied. Call placed to [medical providers] ordered resident sent to hospital for evaluation. Emergency contact notified. Review of an update to the facility submitted information dated 5/14/25, indicated, It is believed that the w/c leg rest hinge bracket caused the laceration. No sharp edges noted. OT (occupational therapy) padded both sides of w/c. Resident transfer was assist x 1 with wheeled walker at time of incident. Transfer changed to assist x 2 with rolling walker per OT. Review of an employee statement written by NA, Employee E1, dated 5/3/25 indicated, I was transferring [Resident R1] from the bed to the w/c. When [he/she] stood up and began to pivot into w/c [he/she] stated [he/she] was going to fall, I assisted in the pivot to w/c. When [he/she] was in the w/c safely I noticed blood on the floor. I applied pressure with my hands and called out to the HK (housekeeper) to grab the nurse. They came in dressed area and I assisted with vitals. We got [him/her] back into bed and comfortable. Review of the facility's plan of correction included: -Wound will be monitored for signs/symptoms of infection. -Nursing care plan updated to include any new orders. -Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs. -PT/OT (physical therapy / occupational therapy) consult ordered for transfers. -Wheelchair removed from service to be inspected for sharp edges. -All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments. -All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries. Review of education provided by the physical therapy department specific to Resident R1's transfer needs was provided to staff on 5/12/25. Review of facility provided education information and on-going quality assurance measures revealed facility staff received education on accident prevention, falls, and reviewing ADL information in the computerized charting system, as well as ongoing monitors to prevent future accidents and improve systems. This education was completed on 5/23/25. During an interview on 5/28/25 at approximately 3:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of four residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy Wanderguard and Elopement Prevention dated 1/6/24, most recently reviewed 11/6/24, indicated it is the policy of the facility to implement safety measures for residents who wander and/or are at risk for elopement to attempt to prevent elopement. Review of the clinical record revealed Resident R1 was originally admitted to the facility on [DATE], at 6:14 p.m. with diagnoses of high blood pressure and alcohol abuse disorder. Review of facility submitted information dated 12/7/24, indicated. On 12/7/24, at approximately 5:30 AM during resident accountability checks it was determined that resident [Resident R1] was not in his room. Supervisors and security notified, and facility check was done. CCTV (closed-circuit television) camera reviewed, resident observed leaving 3A unit at 10:00 p.m. on 12/6/24 ambulating independently, fully dressed in pants, hat, winter coat, and surgical mask. Resident viewed on CCTV entering the main lobby. Resident asked security how to exit the building. Resident stated, How do I get out of here? Security guard did ask will you be returning [Resident R1] stated I ' m finished for the day and leaving. Security had no idea [Resident R1] was a newly admitted resident to the facility and was under the impression he was a visitor. [Resident R1] exited the facility at 10:04 p.m. Resident ' s sister notified. Sister stated he might be at a friend ' s house located near the facility. Sister provided staff with a name, address, [Resident R1 ' s] cell phone number. Police notified and given all information provided by sister. [Local] police reported resident was not found at address provided and no answer to resident ' s cell phone. Sister was updated. UPDATE: Several attempts were made to contact [Resident R1]. A message was left on his personal cell phone requesting a call back. At 9:26 p.m. on 12/8/24, [Resident R1] returned a call to the center stating he would like to enter a program and requested a call back. Call was returned and message left for [Resident R1] to call the DON (Director of Nursing) on per person cell phone or to the facility. On 12/9/24 at 11:00 a.m., Police reported that [Resident R1 ' s] cell phone was pinged at his home. At 11:15 a.m. Police arrived at his home and spoke with [Resident R1]. Police reported that he was alert and orient X3 (alert to person, place, and time), clean, neat, and the home was in good order. [Resident R1] stated to the officers that he was at [facility] for a few hours, but they did not have the program he wanted so he left the facility. [Resident R1] called a jitney (vehicle carrying passengers for a low fare) for transportation. At 11:25 a.m. police called and stated that the paramedics visited and evaluated [Resident R1]. Assessment was that he is alert and oriented and refused to go to the hospital for evaluation and did not want to return to the facility. Review of a Safety Check Record dated 12/7/24, indicated for a newly admitted resident, with no name indicated, that the resident was coded as B (Safe in Bed) at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m., 6:00 a.m., and 7:00 a.m. Each of these entries was initialed with the initials of Registered Nurse (RN) Employee E2, and each of the entries was had circular marks written over the initials, partly obscuring them. The initials remained legible. Review of an employee statement written by Nurse Aide (NA) Employee E1 on 12/7/24, at 5:30 a.m. indicated, I came on shift around 10:45. Aides on unit + nurse gave me report saying the resident was new admit and that he was continent and selfcare and that he stayed in his room. I notices his door was shut so I did not go into his room to physically check on him. I signed off accountability on their word. I also charted before completing care because it is a very busy unit and I don ' t always have the time at the end of shift to complete it. So I charted what report I was given and was going to complete the rest after my morning rounds. The nurse made it down to the room before I got there to do his vitals and noticed he was not in his room. We then proceeded to check the entire unit for resident ' s whereabouts. When we could not locate him, we made supervisors aware. Review of facility provided human resource documents indicated NA Employee E1 failed to do accountability and safety checks every two hours on a newly admitted resident and further documented ADL (activities of daily living) care in the electronic medical record. Review of an employee statement written by RN Employee E2 on 12/7/24, indicated, When I took the cart at 11pm I saw the CNA (nurse aide) walking down the hall. I assumed he was in the room I was given the accountability sheet and placed it in the census book. It was taken down to the supervisor office. I was stopped in another patient ' s room who had thrown up. After cleaning him up I did not continue finishing my round At approximately 5-5:30 a.m. I went to the patient ' s room to take his vitals that when realized he was not in his room. When I asked the CNA if she had seen him she did not know if she checked him. Review of facility provided human resource documents indicated RN Employee E2 failed inform the doctor of an admission and did not conduct safety checks. Review of an employee statement written by Security Employee E3 on 12/7/24, indicated, On 12/9/24, at approximately 10:02 p.m. resident [Resident R1] approached the security desk and inquired about how to leave. I asked [Resident R1] was he coming back in and he stated that he was leaving. [Resident R1] was dressed in regular clothes as I mistakenly assume that he was a visitor because there were visitors coming in and out of the building after hours because hospice care was also in the building for a family for a potential demise and I assume that he was a visitor and I unlocked the door for him. On 12/7/24, the facility initiated a plan of correction that included: -County police and county managers notified by the facility administrator. -Medical Director and QAPI (Quality Assurance and Performance Improvement) Director notified. -All facility residents reassessed for elopement risk. -Assigned nurse ' s agency was notified, and nurse requested not to return to the facility. -Assigned nurse aide ' s agency was notified, and aide requested not to return to the facility. -Facility staff nurse aide suspended pending investigation. -All staff reeducated on new admission safety checks, accountability checks, elopement policy, and Wanderguard (electronic monitoring bracelet) system and protocol. -ADON (Assistant Director of Nursing)/designee will monitor and audit compliance of safety checks and Wanderguard system and follow-up with appropriate disciplinary action for non-compliance. -All incidents and accidents are forwarded to quality assurance committee for review and follow-up. Review of reeducation literature and sign-in sheets revealed all facility staff received reeducation on new admission safety checks, shift accountability, and the elopement policy. During six interviews on 12/23/24, ten staff members confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 12/23/24, at approximately 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of four residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed accurately for two of 18 residents (Resident R41 and R45) and failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents (R13, R35, R41, R169, R174, and R190). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2023 indicated: -Section C, C0100, Brief Interview for Mental Status: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. -Section D, D0100, Resident Mood Interview: Resident interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's MDS dated [DATE], Section I: Active Diagnoses, Question 16100, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and hemiplegia (paralysis on one side of the body). Review of the facility provided list of residents who receive hospice services included Resident R41. Review of Resident R41's MDS dated [DATE], Section O: Special Treatments, Procedures, and Programs, Question O100K, indicated that Resident R39 did not receive hospice services while a resident at the facility. During an interview on 11/8/24, at 11:18 a.m. the Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the facility failed to make certain that MDS assessments were completed accurately for two of 18 residents. -Resident R13 had an MDS completion date of 8/14/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R13 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R13 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R13 is rarely understood, and the Resident Mood Interview was not completed. -Resident R35 had an MDS completion date of 10/16/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R35 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. Review of Section D: Mood, Question D0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. -Resident R41 had an MDS completion date of 7/31/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R41 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. Review of Section D: Mood, Question D0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. -Resident R53 had an MDS completion date of 8/7/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R53 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that the BIMS assessment should be completed; No further questions on the assessment were completed. -Resident R169 had an MDS completion date of 10/11/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R169 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R169 is rarely understood, and the BIMS assessment was not completed. -Resident R174 had an MDS completion date of 8/26/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R174 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R76 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R174 is rarely understood, and the Resident Mood Interview was not completed. -Resident R190 had an MDS completion date of 8/17/24. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R105 is understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R190 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R190 is rarely understood, and the Resident Mood Interview was not completed. During an interview on 11/8/24, at 11:40 a.m. the Social Services Director Employee E2 confirmed that the facility failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents. During an interview on 11/8/24, at approximately 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to make certain that comprehensive MDS assessments were completed accurately for two of 18 and failed to make certain that BIMS and/or PHQ-9 assessments were completed accurately for six of 12 residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on a review of facility admission documents and staff interview, it was determined that the facility failed to ensure resident rights to make informed decisions and choices about important aspects of residents' health, safety and welfare by making certain residents understand the Notice of Medicare Non-Coverage (NOMNC - a form that providers must deliver to a patient covered under a Medicare when services are terminating. The NOMNC informs beneficiaries of their right to request a review of the discharge) form and failed to ensure the agreement is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents (Resident R203). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R203's admission records indicated the resident was admitted to the facility on [DATE]. Review of Resident R203's demographic information available in the electronic medical record indicated that Resident R203's spouse was designated as the emergency contact. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 8/14/24, included diagnoses of Parkinson's disease (progressive movement disorder of the nervous system) and insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or both). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R203's score to be 15, intact cognition. Review of the NOMNC dated 9/06/24, as a last covered day and it was never signed or received by Resident R203 or his contact. During an interview on 11/06/24, at 11:10 a.m. the Director of Nursing Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed Resident R203 did not receive the arbitration agreement, and confirmed the facility failed to ensure the NOMNC is explained to the resident and his or her representative in a form and manner that he or she understands for one of three residents. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a)(j) Resident Rights.

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents reviewed (Residents R40). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective October 2023, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of the clinical record indicated that Resident R40 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 9/25/24, included diagnoses of Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). Review of a physician order dated 10/7/24, indicated Resident R40 was admitted to hospice care (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care). Review of Resident R40's MDS assessments revealed a MDS significant change was not completed to include hospice services. During an interview on 11/8/24, at 11:18 a.m. Registered Nurse Assessment Coordinator Employee E1 confirmed that a Significant Change MDS was not completed for Resident R40. During an interview on 11/8/24, at approximately 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to complete a Significant Change Minimum Data Set (MDS- assessments completed indicating a change in condition of a resident requiring change in care) assessment for one of four residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eight of 10 months (December 2023 and January, February, March, April, May, June, July, and August 2024). Findings include: Review of the facility policy Discharge and Transfer dated 1/6/24, indicated a monthly list will be sent to the Ombudsman of residents who were facility-initiated transfer or discharged . Review of Title 42 Code of Federal Regulations S483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. During an interview on 11/7/24, at 2:30 p.m., the Director of Nursing confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division since 12/31/23. 28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Abuse - Resident and Reasonable Suspicion of a Crime dated 1/16/24, defined neglect as the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/11/24, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions) and osteoarthritis (degeneration of the joint causing pain and stiffness). Review of Section G: indicated that Resident R1 required substantial/maximal assistance to roll left and right. Review of a physician order dated 10/18/23, indicated Resident R1 required an assist of three staff members for bed mobility. Review of Resident R1's plan of care for Morbid obesity - impaired mobility intervention dated 12/5/23, indicated to provide Assist of 3 for turning and repositioning. Review of Resident R1's plan of care for Risk for falls intervention dated 7/31/24, indicated to Provide individualized toileting interventions based on needs/patterns. Review of a progress note dated 9/3/24, at 10:32 a.m. indicated, CNA (nurse aide) reports that while rolling patient to put her own the bedpan. Resident assisted with rolling by grabbing onto the headboard. Resident then stated she was starting to fall. CNA reports that resident fell face down hitting her legs first causing a laceration to her left lower leg and decrease in ROM (range of motion) to left knee as resident states it hurts to move. Was able to leave resident on the floor until EMS (emergency services) arrived. Pressure dressing applied to left lower leg, bleeding did stop prior to dressing being applied. During this time resident stated pain to right knee and she thinks her left knee is broke. MD (doctor of medicine) and son notified. Review of facility submitted information dated 9/4/24, indicated, On 9/3/2024 at approximately 10:05 AM alert x 3 resident [Resident R1] fell from the bed. During AM care resident assisted CNA (nurse aide) to roll by grabbing the headboard and rolling to the left side of bed. The CNA then reached for the bedpan and resident pulled to far causing body weight (338 pounds) to carry the resident over the side of the bed. CNA attempted to prevent resident from rolling too far but lower body exited the bed. Upper body was lowered to the floor by CNA. Resident assessed by RN (registered nurse). Laceration noted to left knee. Area cleansed with normal saline, and dressing applied. Resident complaint of right knee pain. MD notified and ordered out to hospital for evaluation. Review of emergency room documentation dated 9/3/24, at 3:30 p.m. indicated Resident R1 was treated for a 7 cm (centimeter) laceration that required 13 sutures and a comminuted fracture of the distal femur (a fracture of the lower end of the thigh bone, that resulted in the bone breaking into multiple pieces). Resident R1 was transferred to a higher-level hospital for additional evaluation. Review of an employee statement written by NA Employee E1 dated 9/3/24, indicated, Before proceeding to do care on [Resident R1] I asked the nurses how she is with transfer and bed mobility. The nurses at the nursing station said [Resident R1] would be fine with care and to get her up if she wants to. So then I proceeded to do my care. When I went in [Resident R1] room the plan was to wash her up and change her. Before washing she wanted to get on bed pan so I proceeded to put her on the bed pan. [Resident R1] grabs the left side of the headboard with her right hand to pull herself over. She did well with pulling herself over so I didn't have to struggle. She was turned on her left side positioned well before slowly starting to fall over the bed. When she fell she fell to her knees first then we were able to lay her down on her side slowly. Review of a facility document dated 9/9/24, stated, During an investigation of a resident incident on 9/3/24, it was determined that the staff member did not follow the plan of care / orders while caring for a resident. [NA Employee E1] failed to identify the bed mobility order prior to care. Resident requires 3 staff for bed mobility. [NA Employee E1] rolled the resident by herself, and resident fell out of the bed resulting in two fractures. [NA Employee E1] is placed on the do not return list for failure to follow physician orders and verify bed mobility prior to care. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 9/10/24, included the information, CNA failed to ensure resident orders or plan of care for bed mobility prior to performing care. Allegation of neglect substantiated. During an interview on 9/19/24, at approximately 2:00 p.m. the Director of Nursing confirmed the facility failed to protect residents from neglect that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, General Guidelines dated 1/16/24, indicated All care and services must be delivered as prescribed by the practitioner, and according to thre resident's person-centered plan of care. Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the clinical record indicated Resident R1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/11/24, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions) and osteoarthritis (degeneration of the joint causing pain and stiffness). Review of Section G: indicated that Resident R1 required substantial/maximal assistance to roll left and right. Review of a physician order dated 10/18/23, indicated Resident R1 required an assist of three staff members for bed mobility. Review of Resident R1's plan of care for Morbid obesity - impaired mobility intervention dated 12/5/23, indicated to provide Assist of 3 for turning and repositioning. Review of Resident R1's plan of care for Risk for falls intervention dated 7/31/24, indicated to Provide individualized toileting interventions based on needs/patterns. Review of a progress note dated 9/3/24, at 10:32 a.m. indicated, CNA (nurse aide) reports that while rolling patient to put her own the bedpan. Resident assisted with rolling by grabbing onto the headboard. Resident then stated she was starting to fall. CNA reports that resident fell face down hitting her legs first causing a laceration to her left lower leg and decrease in ROM (range of motion) to left knee as resident states it hurts to move. Was able to leave resident on the floor until EMS (emergency services) arrived. Pressure dressing applied to left lower leg, bleeding did stop prior to dressing being applied. During this time resident stated pain to right knee and she thinks her left knee is broke. MD (doctor of medicine) and son notified. Review of facility submitted information dated 9/4/24, indicated, On 9/3/2024 at approximately 10:05 AM alert x 3 resident [Resident R1] fell from the bed. During AM care resident assisted CNA (nurse aide) to roll by grabbing the headboard and rolling to the left side of bed. The CNA then reached for the bedpan and resident pulled to far causing body weight (338 pounds) to carry the resident over the side of the bed. CNA attempted to prevent resident from rolling too far but lower body exited the bed. Upper body was lowered to the floor by CNA. Resident assessed by RN (registered nurse). Laceration noted to left knee. Area cleansed with normal saline, and dressing applied. Resident complaint of right knee pain. MD notified and ordered out to hospital for evaluation. Review of emergency room documentation dated 9/3/24, at 3:30 p.m. indicated Resident R1 was treated for a 7 cm (centimeter) laceration that required 13 sutures and a comminuted fracture of the distal femur (a fracture of the lower end of the thigh bone, that resulted in the bone breaking into multiple pieces). Resident R1 was transferred to a higher-level hospital for additional evaluation. Review of an employee statement written by NA Employee E1 dated 9/3/24, indicated, Before proceeding to do care on [Resident R1] I asked the nurses how she is with transfer and bed mobility. The nurses at the nursing station said [Resident R1] would be fine with care and to get her up if she wants to. So then I proceeded to do my care. When I went in [Resident R1] room the plan was to wash her up and change her. Before washing she wanted to get on bed pan so I proceeded to put her on the bed pan. [Resident R1] grabs the left side of the headboard with her right hand to pull herself over. She did well with pulling herself over so I didn't have to struggle. She was turned on her left side positioned well before slowly starting to fall over the bed. When she fell she fell to her knees first then we were able to lay her down on her side slowly. Review of a facility document dated 9/9/24, stated, During an investigation of a resident incident on 9/3/24, it was determined that the staff member did not follow the plan of care / orders while caring for a resident. [NA Employee E1] failed to identify the bed mobility order prior to care. Resident requires 3 staff for bed mobility. [NA Employee E1] rolled the resident by herself, and resident fell out of the bed resulting in two fractures. [NA Employee E1] is placed on the do not return list for failure to follow physician orders and verify bed mobility prior to care. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 9/10/24, included the information, CNA failed to ensure resident orders or plan of care for bed mobility prior to performing care. Allegation of neglect substantiated. During an interview on 9/19/24, at approximately 2:00 p.m. the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a leg fracture and a skin tear that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents (Residents R2). Findings include: Review of the facility policy, General Pharmacy Standards dated 1/16/24, indicated the contracted pharmacy will include Accurately dispensing prescriptions based on authorized prescriber orders. Review of Residents R2's admission record indicated she was admitted to the facility on [DATE]. Review of Residents R2's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 8/7/24, indicated that she had diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and aftercare following surgery. Review of Residents R2's care plan for pain dated 8/4/24, indicated to medicate as ordered. Review of a psychiatric evaluation dated 8/8/24, indicated a new order for gabapentin (medication used to treat seizures, nerve pain, and an off-label use for depression) 100 mg (milligrams) twice per day. Review of a progress note dated 8/9/24, at 8:15 a.m. indicated a new order for gabapentin 100 mg twice daily for anxiety. Review of Residents R2's medication administration record (MAR) for September 2024, indicated: -8/09/24, morning, gabapentin 100 mg provided. -8/09/24, afternoon, gabapentin 800 mg provided. -8/10/24, morning, gabapentin 800 mg provided. -8/10/24, afternoon, gabapentin 800 mg provided. -8/11/24, morning, gabapentin 800 mg provided. -8/11/24, afternoon, gabapentin 800 mg provided. -8/12/24, morning, gabapentin 800 mg provided. -8/12/24, afternoon, gabapentin 800 mg refused. -8/13/24, morning, gabapentin 800 mg provided. -8/13/24, afternoon, gabapentin 800 mg refused by family. -8/14/24, morning, gabapentin 800 mg provided. During an interview on 9/19/24, at approximately 2:00 p.m. Director of Nursing confirmed that there was a pharmacy error, and the gabapentin 100 mg, twice daily order was inadvertently changed to a gabapentin 800 mg, twice daily, and further confirmed that Resident R2 received the incorrect dose from 8/9/24, through 8/14/24. During an interview on 8/7/24, at 11:42 a.m. the Director of Nursing (DON) confirmed that the facility failed to implement pharmaceutical services to ensure accurate provision of medications for one of four residents. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.9 (a)(1)(k)(l)(1)(2)(3)(4) Pharmacy services 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on review of facility policy, clinical records, facility documents and staff interview, it was determined that the facility failed to make certain a resident was free from a physical restraint for one of five residents reviewed (Resident R1). This was identified as past non-compliance. Findings include: A review of the facility policy, Restraint, Physical last reviewd, 2/07/23, defined a restraint as anything that restricted freedom from movement, and limited one's sense of control and independence. Review of the clinical record indicated that Resident R1 was admitted to the facility 10/6/23. The Minimum Data Set (MDS - periodic assessment of care needs) dated 3/7/24, included diagnoses of unspecified dementia, muscle wasting, diabetes and adult failure to thrive. The Brief Interview of Mental Status (BIMS - a screening too to determine cognition) recorded a score of 5, indicating the resident is cognitively impaired. Review of facility provided documents dated 3/13/24, indicated Resident R1 was found by the 7-3 shift with the sheet tied behind the lower back and corners of the lower gown tied behind the resident's thighs. Review of facility provided documents dated 3/13/24, revealed that Nurse Aide (NA) Employee E1, was identied as the individual that tied the sheet behind the resident and the gown behind the thighs. Review of a written statement from NA Employee E1 dated 3/13/24, indicated, Resident was very active all night, could not rest, kept tying her gown herself, I changed her and had a gown on her the right way, I cleaned BM (feces) off her hands and face. Review of a written state from NA Employee E2 dated 3/13/24 (worked the on-coming 7 a.m. shift) indicated, When I went in to see Resident R1, I tried to pull down her sheet to pull her up in bed but it wouldn't come out so I turned her over to see why and found the sheet was tied under her, I reported this, when we went in to pull up in bed, we seen her gown was was tied around her legs as well. Review of NA Employee E1's employee file indicated that on 4/4/23 she had a previous verbal warning for abuse and neglect and was re-educated at that time. Further review indicated that NA Employee E1 was suspended on 3/13/24 and employment was terminated on 3/20/24. Review of Resident R1's clinical record indicated a physician note dated 3/16/24, that the facility made him aware of the incident on the date it occurred. On 3/18/24, the facility initiated education on physical restraints. This education included: 1) defining restraints 2) identifying physical risks and psychosocial impacts of restraint use 3) determining if the use of position change alarms are restraints 4) denitrifying key elements of non-compliance During interviews on 3/26/24 from 11:00-11:30, seven direct care staff indicated they had received education on physical restraints. The facility has demonstrated compliance with the regulation since 3/20/24. During an interview on 3/26/24 at 1:00 p.m., the Nursing Home Administrator, and a review of of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance to make certain ensuring residents are free from physical restraints. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility documents, resident interview, and staff interview, it was determined that the facility failed to provide adequate supervision resulting in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge). This failure created an immediate jeopardy situation for one out of 195 residents (Resident R1). Findings include: The facility Wanderer management program policy last reviewed on 1/9/23, indicated that the facility will provide safety measures for all residents who are deemed to be in need of additional safety measures including wander management. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. The resident should have interventions in their comprehensive care plan to address elopement, residents should be assessed for safety, and physician orders written directing what level of access within the facility for which a resident is determined to be safe without direct supervision. Nurse aide staff will account for all monitored residents at the beginning of each shift, every two hours during the shift, and at the end of the shift. Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (a condition impacting blood circulation through the heart related to poor pressure), chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), cerebral infarction (a blockage to the brain resulting loss of blood and oxygen), chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination), and Strabismus (a vision disorder in which the eye does not properly align). A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of Resident R1's MDS assessment dated [DATE], Section C0500-BIMS screening indicated a score of 13 revealing that Resident R1 was alert and oriented to person, place and situation. Review of Resident R1's physician orders dated 7/6/23, resident may move about units without supervision; supervision for off campus. Review of Resident R1's admissions documentation indicated that his home address was 1.2 miles from the nursing facility. Review of Resident R1's clinical nurse notes dated 8/7/23, indicated he exited the building via the front door, wander guard applied to right wrist and Resident R1 was educated. Thorough review of Resident R1's clinical record indicated no additional information related to this elopement. Review of Resident R1's care plan dated 8/8/23, indicated that he will not elope from the unit or building. Provide routine monitoring, wander guard at all times, checks every shift and as needed. Review of Resident R1's elopement evaluation on 8/30/23, indicated that Resident R1 attempted to go outside to leave without alerting staff on 8/7/23. The Elopement evaluation indicated Resident R1 displayed behaviors indicating an attempt to leave, he made statements questioning the need to be at the nursing home. Review of Resident R1's clinical nurse note dated 10/1/23, indicated Nurse aide (NA) doing wander guard checks found that Resident R1 was not in his room and could not be found on the nurse unit. These documents were not part of the clinical record. Review of Resident R1's safety event/elopement incident note dated 10/2/23, indicted that on 9/30/23 at 2:38 a.m. it was discovered that Resident R1 was not in his room. Security notified and facility check was done. Security camera reviewed and observed Resident R1 leave the 4B nurse unit fully dressed, exited through the ambulance door and walked through the parking lot. Family was called. Police were notified and provided address as Resident R1 expressed desire to return home. Facility staff continued search for Resident R1. Police contacted facility and reported that Resident R1 was located at his home address. Resident R1 returned at 4:28 a.m. and was assessed with no injuries found. The wander guard was found with the resident, did not indicate if the wanderguard was on the original placement area of Resident R1's body. The National Weather Service records indicated that the overnight temperature on 9/30/23 into 10/1/23 was 56 degrees Farenheit. Review of facility submitted documents dated 10/2/23, indicated that Resident R1 was discovered not present in his room at 2:38 a.m. on 10/1/23. Nursing staff and security will be re-educated on wander guard system and safety checks. Review of Facility meeting minutes dated 10/3/23, indicated that the facility implemented accountability checks on 10/3/23 as a part of corrective actions. However, the corrective actions did not include whole house re-training for all nursing staff and retraining for security staff. Review of facility investigation documents dated 10/3/23, indicated that Nurse Aide (NA) Employee E8 documented that she provided care to Resident R1 on 10/1/23, at 12:05 a.m., however, Resident R 1 exited the facility at 8:52 p.m., on 9/30/23, three hours and 13 minutes prior. Security Guard Employee E7 provided a statement that he silenced the alarm on 9/30/23, and did not see a resident walk out of the ambulance exit. Review of all facility documentation revealed that there was no additional information available in the clinical record or in the facility investigation surrounding the elopement of Resident R1. During a review of security footage with Maintenance Supervisor Employee E1 and Security Chief Officer Employee E2 on 10/10/23, at 10:20 a.m. the following was observed: Footage starts at 9/30/23, at 8:23 p.m. Resident R1 observed fully clothed, with a jacket and a hat, getting on elevator at 8:23 p.m. At 8:24 p.m. Resident R1 exits the elevator to the first floor. Resident R1 went outside to the smoking area at 8:25 p.m. Resident R1 was observed without a walker or cane. Resident R1 spoke to staff in smoking area. At 8:40 p.m. Resident R1 gets up and wandered the smoking area. At 8:45 p.m. Resident R1 re-entered the facility. At 8:46 p.m. Resident R1 walks to ambulance exit and goes through the ambulance exit area. At 8:47 p.m. Resident R1 was observed via security footage in the parking lot leaving the area. At 8:52 p.m. Resident R1 left the facility campus. During an interview on 10/10/23, at 10:20 a.m. Maintenance Supervisor Employee E1 stated: the alarm would go off to the ambulance door exit only if Resident R1 was wearing a wander guard. The alarm on 9/30/23 did go off. Security Guard Employee E7 was the security guard that evening and did not respond to the alarm. Security Guard Employee E7 reset the alarm at 8:46 p.m. and he did not recheck the cameras. The alarm can be reset at the security station. During an interview on 10/10/23, at 10:39 a.m. Security Chief Officer Employee E2 stated: we had two security officers working on 9/30/23. Security Guard Employee E7 and Security Guard Employee E9. Security Guard Employee E9 was walking the floor at the time of the incident and Security Guard Employee E7 was at the security desk. During an interview on 10/10/23, at 11:32 a.m. Resident R1 stated that he cannot see as well as he used to out of his left eye. He has a place that is local. That is where he lived before, I got sick. Been here for 5 months and he is ready to get out of the nursing home. During an interview on 10/10/23, at 11:53 a.m. the Director of Nursing (DON) stated: Resident R1 returned on 10/1/23 at 4:33 a.m. We do not have statements from all the staff working the evening of 9/30/23. We completed accountability sheets. The sheets are done by nursing staff. Nursing staff coming on the shift and leaving the shift, do a head count of the residents and sign the sheets. This is a part of our corrective action. During a phone interview on 10/10/23, at 1:54 p.m. Nurse Aide (NA) Employee E4 stated: been working at the facility a couple of months. Resident R1 was not my resident that evening. I just know that a staff member said that Resident R1 was not there. That staff person went to the supervisor. I don' t recall name of the staff person; I think she was agency staff as well. No re-education was done with me. During a phone interview on 10/10/23, at 2:08 p.m. with Agency Registered Nurse (RN) Employee E5 stated: I came to the work, around 11:30 p.m. The supervisor gave me the keys for my assignment. As I went through my chart, someone was checking on people. We realized Resident R1 was missing. The aides said they did not see him. I called and told the supervisor he was not here. I went and started looking for him. I think the RN supervisor went to look for him. The aides also were looking for him. I cannot recall the time, the RN Supervisor said he was located, and his family brought him back. The RN Supervisor stated he thought he eloped. The family never called to say he was gone. The RN supervisor was (Proper name) something. Or another name. It was an aide that figured out he was missing. The resident is fully alert and oriented. He did not come with any medicine or paperwork. I was told he cut his wander guard off. I was just going down and the aide came and told me he was missing. The resident was fully dressed, like he was going to church, like a visitor. During a interview on 10/10/23, at 2:57 p.m. Registered Nurse (RN) Supervisor Employee E6 stated the following: I did not provide a statement to the Director of Nursing. On 9/30/23, in the middle of the night, a nurse aide that does the wander guard checks said Resident R1 was not here. Camera checks found Resident R1 left the facility around 8:45 p.m. I contacted the Director of Nursing and attempted to call Resident R1's family and was unsuccessful in doing so. We called the police, and they were able to locate Resident R1. I did assess Resident R1 upon his return. No issues found. I'm not familiar with this guy. The Nurse aide that found he was missing was Nurse Aide (NA) Employee E11. We task one individual to the tasks to check the wander guards. Nurse Aide (NA) Employee E 11 was tasked with other things that evening. And I was not provided re-education about elopement. On 10/10/23, at 3:01 p.m. Nurse Aide (NA) Employee E11 was called for her statement and did not answer. During a phone interview on 10/10/23, at 3:21 p.m. Security Guard Employee E7 stated the following: I was working with another senior guard. I was new. This individual that eloped saw the guard and figured there was no one at the front desk and walked out. When Resident R1 hit the door, I was under the assumption that if the door alarm was going off, it would lock. I did not recognize Resident R1 as a patient. Normal patients are in wheelchairs. I did not know this guy. Resident R1 looked quite normal, like a worker. Like someone going out the wrong door. When the chief told me someone eloped, then we looked at the tape. I was told I should have looked at the tape sooner. Since I was new, I did not. I just assumed someone walked by the door and thought someone would go to where they were assigned. I thought it was a false alarm and I shut off the alarm. It was a complete failure. There was a 6-hour difference between the time Resident R1 walked out and the time he left. We had a lot going on that night on 9/30/23. I thought the doors locked when the alarm goes off, and they do not. I should have done more. Security Guard Employee E7's personnel record indicated he started working at the facility on 9/12/23 and he was trained on emergency preparedness procedures and the routine tasks involved in his job description. On 10/10/23, at 4:13 p.m. Nurse Aide (NA) Employee E8 was called for her statement and did not answer. Nurse Aide (NA) Employee E8 personnel record indicated that her first start date at the facility was 6/25/23. Her record indicated that she received orientation on abuse and elopement procedures on 7/27/23. On 10/10/23, Immediate Jeopardy (IJ) was called and a template was provided to the facility at 2:24 p.m., and a corrective action plan was requested. On 10/10/23, at 7:20 p.m. an immediate action plan was received and accepted which included the following interventions: 1. Resident R1 was evaluated for injuries and none were found, Resident R1 was re-evaluated for safety, Resident R1 doctor was notified, 1-hour checks were put in place, his careplan was updated to include self-removal of wander guard, and a photo was placed at the front desk. 2. All residents were immediately re-evaluated using the elopement risk assessment to ensure wandering behaviors were identified, care plans updated, and ensure monitoring of wandering residents via Q1-hour safety checks completed 10/11/23 at 11:00 a.m. 3. Whole house audit of elopement risk assessments was completed by 10/11/23 at 11:00 a.m. 4. Updated care plans for residents with elopement risk, residents identified as elopement risk have a wander guard, security notified by 10/11/23. 5. Accountability checks forms completed at shift change every shift to ensure monitoring of all residents by 10/11/23, end of the 7 a.m. to 3 p.m. shift. 6. Residents identified as exhibiting wandering/elopement behavior will be identified on the 24-hour report by 10/11/23 at 11:00 a.m. 7. Residents identified as elopement risk will have wander guard placed and have Q1-hour checks for wandering residents for 72 hours by 10/11/23 at 11:00 a.m. 8. Nursing Staff Inservice beginning immediately on 10/10/23 and continuing at the start of each shift about elopement policy, accountability sheets, and Wander guard system. The training will be completed by 10/11/23, at 3:00 p.m. Nursing staff was identified via facility signature log to ensure full attendance. 9. Security staff was in-serviced the beginning of the shift about the elopement policy, exit-seeking behaviors, and the Wander guard system. All security staff completed the in-service by 10/11/23 at 3:00 p.m. Security staff was identified via facility signature log to ensure full attendance. 10. Quality Manager notified of the elopement and plan of correction on 10/10/23. Elopement policy reviewed and revised on 10/10/23. Review of updated Elopement policy on 10/11/23 during QAPI meeting. 11. The ADON/designee will monitor daily the accountability sheets daily for 4-weeks starting 10/10/23; weekly for 4-weeks, bi-weekly for 4-weeks, then monthly for 4-weeks. On 10/11/23, at 7:42 a m. the facility provided an updated Elopement policy. On 10/11/23, at 9:00 a.m. facility QAPI meeting took place and included the review of the new Elopement policy. During observations on 10/11/23 starting at 10:00 a.m. each nursing units (Nursing units 2A, 2B, 3B, 4A, and 4B) were found with a binder containing accountability sheets used to verify resident whereabouts. On 10/11/23, at 11:32 a m. the facility provided a report used for auditing elopement assessments. The Report indicated all residents were re-assessed for elopement risk. During observations on 10/11/23, at 11:44 a.m. Security binder with wandering risk residents was observed. Review of 12 resident clinical records on 10/11/23 indicated that the facility staff completed elopement assessments, updated care plans, and put accountability sheets in place. During interviews on 10/11/23, from 12:58 p.m. through 1:39 p.m. 16 employees confirmed they had received education on the new facility elopement policy and procedures, exit-seeking behaviors and interventions, and use of the Accountability sheets. On 10/11/23, at 1:47 p.m. the Director of Nursing provided audit documentation verifying appropriate use of Accountability sheets. Verification of the facility's Corrective Action Plan revealed all elements of plan were substantially completed and the Immediate Jeopardy was lifted on 10/11/23, at 2:32 p.m. During an interview on 10/11/23, at 3:02 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision resulting in an elopement for Resident R1. This failure created an immediate jeopardy situation for one of 195 residents. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services.

Based on observation, review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain comprehensive infection surveillance records to prevent the potential spread of infection for 11 of 11 months (December 2015 through October 2016), failed to exercise proper infection control technique during a dressing change for two of two residents observed (Resident R13 and R8), failed to prevent the potential for cross-contamination during glucometer testing (a machine used to test blood sugar measurement) for one of three residents observed (Resident R34), and failed to implement the infection control plan to investigate, prevent and control the spread of infection resulting in harm to one of eight residents reviewed (Resident R26). Findings include: The facility policy entitled, Infection Control Plan: Surveillance and Reporting dated 9/21/16, indicated that the Infection Control Coordinator will examine all aspects of the spread of infection and will collect surveillance data including multi-drug resistant (MDRO - organisms resistant to antibiotics) cultures, healthcare associated and community associated infections and will determine if an infection is present using the McGreer (symptom based definition of an infection) criteria. The Infection Control Coordinator will tabulate and consolidate data for analysis, evaluation and interpretation to control and prevent transmission of infections. During an interview on 10/27/16, at 10:20 a.m. the Infection Preventionist (IP), Employee E13, confirmed that the facility failed to maintain comprehensive infection control surveillance data including a line listing of all pertinent infections. The IP Employee E13 confirmed that documentation did not include monthly data for the period of December 2015 through October 2016. During an interview on 10/28/16, at 1:55 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain monthly comprehensive infection control data for all infections for the purpose of infection prevention and control for the period of December 2015 through October 2016. The facility policy entitled, Laboratory Testing: Blood Glucose Testing/Capillary dated 9/21/16, indicated that the licensed nurse will follow procedures including infection control measures for common use equipment and will clean the surface of the glucometer prior to and after use with the facility approved germicidal wipes allowing for wet contact time of usually two minutes or as specified in the package directions. During an observation of the medication pass on 10/25/16, at 4:05 p.m. Licensed Practical Nurse (LPN), Employee E16, performed capillary blood sugar testing on Resident R34 then put the glucometer, which was a universal glucometer to be used on multiple residents, back into the storage pouch without cleaning the unit with a germicidal wipe. During an interview on 10/25/16, at 4:25 p.m. LPN Employee E16, confirmed that she failed to clean the glucometer with the germicidal bleach solution before and after use as required. The facility, Guidelines for Dressing Changes policy dated 1/27/16, instructed the nurse to use aseptic technique during preparation of supplies and to place a plastic bag for discarding items in close proximity to the dressing location but not on the bedside table. A physician's order dated 10/19/16, instructed the nurse to cleanse the wound on Resident R8's sacrum (a triangular bone at the base of the spine) with normal saline, apply [MEDICATION NAME] (a wound ointment) to the wound base, cover with Calcium Alginate (an absorptive dressing made with Calcium and fibers) and a sterile dry dressing daily. During an observation of a dressing change on 10/26/16, at 10:50 a.m. Registered Nurse (RN), Employee E10, placed the plastic bag for discarding items on top of the bedside table beside the clean supplies and gathered the tube of [MEDICATION NAME], a package of 4x4 gauze and the package of Calcium Alginate dressing, in gloved hands and then squirted [MEDICATION NAME] into Resident R8's sacral wound, took the 4x4 gauze out of the package and placed it on the wound and then took the Calcium Alginate dressing out of its package and applied it to the wound. During interviews on 10/26/16, at 11:05 a.m. and at 11:15 a.m. RN Employee E10 and Resident Care Coordinator, Employee E11, it was confirmed that the outer packaging of the dressing supplies were contaminated and that the facility failed to exercise proper infection control technique during the dressing change for Resident R8. Review of the Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 6/13/16, indicated that Resident R13 had two Stage III (full thickness loss of skin, in which fat is visible in the ulcer and granulation (healing pink) tissue) pressure ulcers on the right ischium (posterior hip bone) and sacro-coccygeal (tailbone) area and was on contact isolation precautions due to a Methicillin Resistant Staphylococcus Aureus (MRSA - an antibiotic resistant organism) wound infection. Review of the Wound Care Physician's progress note dated 10/18/16, indicated that Resident R13 had purulent drainage (pus) from the sacro-coccygeal wound and that the right ischial wound had pink granulation tissue at the base, and that both wounds were Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed). During an observation of a dressing change on 10/26/16, at 1:35 p.m. Licensed Practical Nurse, Employee E17, was noted to remove the dressing on the sacro-coccygeal wound while the right ischial wound dressing had already been removed, thus exposing both wounds at the same time for the dressing change. During an interview on 10/26/16, at 2:00 p.m. LPN Employee E17 confirmed that the wounds were both exposed while the sacro-coccygeal wound dressing was completed allowing for possible cross-contamination. During an interview on 10/26/16, at 3:00 p.m. the Director of Nursing confirmed that the potential for cross contamination of Resident R13's wounds was increased by performing the dressing change while both open wounds were exposed. Review of the facility policy entitled, Legionella, Prevention and Control of Legionella Infection dated 9/21/16, indicated that the facility conducts annual monitoring of the potable water supply as a proactive measure to prevent Legionella Disease (a severe, possibly fatal disease, causing pneumonia, transmitted by water containing Legionella bacterium). It also states that the Administrator and Medical Director will be involved with results requiring remediation. The Legionella, Prevention and Control of Legionella Infection policy dated 9/21/16, also indicated that the Resident Care Coordinator (RCC - a Unit Nurse Manager) completes a report on every resident that displays signs and symptoms and is diagnosed or treated for [REDACTED]. During an interview on 10/27/16, at 10:20 a.m. Employee E13 confirmed that Resident R26's respiratory illness was not reported by the nursing unit staff, was not documented on the 10/25/16 list of active infections and was not documented on the infection control precautions list. Employee E13 indicated that the documentation did not include a comprehensive list of all infections in the facility, the list did not identify residents experiencing respiratory symptoms and that no listing of infections was maintained in the facility's monthly surveillance to allow the identification of trends or clusters of similar infections. The Centers for Disease Control Guidelines for Prevention of Legionella dated 5/13/16, indicated that the key to this is maintenance of the water system in which Legionella may grow and if it is found the facility should be prepared to eliminate the bacteria. Review of the annual facility water testing completed by an outside laboratory specializing in Legionella testing on 7/11/16, indicated that the Legionella bacterium was detected in the following locations: Unit 4A showers and room [ROOM NUMBER], Unit 4B: room [ROOM NUMBER], Unit 3A: room [ROOM NUMBER], Unit 2B: rooms [ROOM NUMBERS]. The water testing results were submitted to the facility on [DATE]. A facility email dated 7/25/16, from the Infection Preventionist (IP) Employee E13, to the facility's Environmental Services Department, instructed that the faucets and shower heads be cleaned and to let Employee 13 know when cleaning was completed so that re-testing could be done. During an interview on 10/26/16, at 11:30 a.m. Employee E13 confirmed that the water was never retested after the cleaning. Resident R26 was re-admitted to the facility on [DATE] and the 9/21/16, physician's orders sheet had [DIAGNOSES REDACTED]. Review of information submitted by the facility dated 10/24/16, indicated that Resident R26 had developed respiratory congestion on 10/18/16, and was transferred to the hospital on [DATE], due to respiratory distress. The resident was subsequently diagnosed with [REDACTED]. Review of the infection control surveillance reports and a list of infections in the facility on 10/25/16, did not include documentation of Resident R26's respiratory illness. During an interview on 10/26/16, at 2:00 p.m. the Nursing Home Administrator (NHA) confirmed that she was not notified of the 7/11/16 positive Legionella water testing results and there was no further follow-up testing done with the water since the July 2016 positive results. Review of information submitted by the facility dated 10/27/16, indicated that on this date, there was a Legionella [DIAGNOSES REDACTED]. During an interview on 10/27/16, at 1:30 p.m. the facility Medical Director, Employee E14, confirmed that he was not notified of the 7/11/16, positive Legionella water testing results. The positive water test results from 7/11/16, were not communicated to the NHA or the Medical Director. Additionally, a resident who was transferred to the hospital with respiratory congestion approximately 3 months following the positive water test, was diagnosed with [REDACTED]. The facility neglected to conduct re-testing of the water supply following cleaning of the faucets and shower heads in response to a positive annual test for Legionella. 42 CFR 483.65 Infection Control, Prevent Spread, Linens. Previously cited 9/12/14. 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/27/16, 10/27/14. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/27/14. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/12/14. 28 Pa. Code 201.29(a) Resident rights. Previously cited 10/27/14. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/28/16, 11/20/15, 10/27/14. 28 Pa. Code 211.5(f) Clinical records. Previously cited 9/12/14. 28 Pa. Code 211.5(g) Clinical records. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 4/27/16, 11/20/15, 9/12/14. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 4/27/16, 1/28/16, 11/20/15, 10/27/14, 9/12/14.

Based on review of clinical records, investigation documents, policies and staff interviews, it was determined that the facility failed to adequately investigate an accident/injury to prevent neglect that resulted in actual harm for one of 25 residents reviewed (Resident R1). Findings include: The facility policy, "Abuse - Resident," dated 2014, identified neglect as inattentiveness, carelessness, or omission, to provide, consistent, safe, adequate and appropriate services and to provide goods and services necessary to avoid physical harm. The facility policy, "Incident Report - Resident," dated 2014, indicates that incident reports are to identify the location, time, date and condition of any equipment involved and to include possible causative factors and safety recommendations, to prevent a recurrence. Resident R1 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 9/25/14, included [DIAGNOSES REDACTED]. (a pattern of deteriorating intellectual function). A review of Resident R1's clinical record indicated that a laceration was sustained to the right lower leg on 10/11/14, requiring 14 staples to that area. A review of Resident R1's clinical record indicated another laceration was sustained to the right lower leg on 10/14/14, requiring seven staples to that area. A review of a facility Resident Incident Report dated 10/11/14, revealed that the facility did not know how the laceration occurred. The report indicated that only circumstances surrounding the chair were investigated with no other causative factors. A thorough investigation following the 10/11/14, incident was not conducted as required. A review of a facility Resident Incident Report dated 10/14/14, revealed that the facility did not know how the laceration occurred. No investigation was conducted following the 10/14/14, incident as required. During an interview on 10/22/14, at 12:00 p.m., the Director of Nursing confirmed that the actual reason for Resident R1's injuries was not determined. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa Code: 201.18(a)(b)(1)(3) Management. 28 Pa. Code:211.12(c)(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical record, investigation documents, and staff interviews, it was determined that the facility failed to complete a thorough investigation into the cause of lacerations and failed to report neglect for one of 25 residents reviewed (Resident R1). Findings include: The facility policy, "Incident Report (Resident)," dated 2014, indicated that all unusual incidents involving residents are to be documented, reported, and investigated. The report is to contain the location, time, date and condition of any equipment involved, including any possible causative factors and safety recommendations to prevent a recurrence. The facility policy, "Abuse - Resident," dated 2014, indicated that neglect means a failure to provide the goods and services necessary to avoid physical harm and that the State Survey Agency will be notified as soon as possible, but no later than 24 hours. Resident R1 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment (MDS - periodic assessment of care needs) dated 9/25/14, included [DIAGNOSES REDACTED]. (a pattern of deteriorating intellectual function). A review of a facility Resident Incident Report dated 10/11/14, indicated that Resident R1 had a large deep laceration that was approximately five inches in length, to the right lower leg and that the Nursing Assistant (NA), Employee E1, did not know how it happened. A physician's orders [REDACTED]. A review of a facility Resident Incident Report dated 10/14/14, indicated that Resident R1 had a laceration above the right ankle, that measured 0.3 centimeters (cm - unit of measure) by 4.5 cm and the depth was unobtainable due to bleeding. A physician's orders [REDACTED]. A review of the physician's progress note dated 10/15/14, indicated that the wheelchair was examined and no rough edges were found that could account for the lacerations as Resident R1, "cannot be suffering lacerations almost on an every other day basis." During an interview on 10/22/14, at 10:30 a.m., the Director of Nursing and the Nursing Home Administrator confirmed that the investigation only concentrated on Resident R1's wheelchair and circumstances surrounding the wheelchair. When it could not be determined that the wheelchair caused the lacerations, no other determination was made. 28 Pa. Code: 201.14(c)(e) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights.