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

Based on review of facility policy, clinical records, observation, and interviews with staff and family, it was determined that the facility failed to provide preventative interventions, and treatments which resulted in the development of avoidable pressure ulcers for two of two residents (Resident R5 and Resident R13), resulting in an infection for one of two residents (Resident R5). This failure resulted in an immediate jeopardy. Findings Include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, muscle wasting and atrophy (occurs when muscle fibers shrink due to disuse, aging, malnutrition, genetic factors, or nerve-related conditions), and Parkinson's Disease (a disorder of the nervous system that affects movement and gets worse over time). Review of Resident R5's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/20/26, indicated the diagnoses were current. Review of Section M: Skin Conditions indicated the resident was not at risk for developing pressure ulcers. It was also documented on this MDS that the resident had one unstageable (occurs when prolonged pressure, often over bony prominences such as the heels, sacrum, hips, or tailbone, causes localized tissue damage and necrosis, but the true depth of the wound is obscured by dead tissue or other coverings) pressure ulcer. Review of Resident R5's care plan initiated 8/18/25, indicated the resident remained a high risk for pressure injuries due to decreased mobility, incontinence, decrease in nutrition, and decline in overall medical condition. The care plan was revised on 12/9/25, by Registered Assessment Coordinator (RNAC), Employee E12 with interventions that included confer with physician about wound progress or lack of each week during weekly wound rounds, reduce friction and shear when moving using lift sheets, float heels off the bed, Heel medix (refers to a line of heel protectors designed to relieve pressure on vulnerable heels and prevent pressure ulcers) to both feet at all times. Review of progress note dated 12/7/25, indicated that Resident R5 was readmitted from the hospital. A deep tissue injury (DTI- a type of pressure-induced tissue damage that begins beneath the skin, often over bony prominences, and can develop into serious wounds) was observed to the resident's left heel. A further review of clinical record failed to include a skin assessment of left heel DTI upon admission which includes at a minimum, the following: -Documentation that includes the date observed and location and staging -Size, depth and the presence, location and extent of any undermining or tunneling -Exudate, if present: type (such as purulent/serous), color, odor and approximate amount -Pain, if present: nature and frequency (e.g., whether episodic or continuous) -Wound bed including a description of color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and description of wound edges and surrounding tissue. Review of Resident R5's Braden Scale Assessment (a standardized assessment tool used in healthcare to evaluate a patient's risk of developing pressure injuries/ulcer) dated 12/7/25, identified the resident to be at high risk for the development of pressure injuries. Review of Resident R5's wound assessment dated [DATE], created by Wound Care Nurse, Employee E7 revealed the resident had a left heel DTI that measured 2.5 cm x 3.5 cm. Review of Resident R5's physician order dated 12/8/25, indicated to apply cavilon (a thin, durable, waterproof coating that shields the skin from irritants such as urine, feces, wound drainage, and adhesives) daily to left heel deep tissue injury. Review of Resident R5's wound care assessment dated [DATE], completed by Certified Registered Nurse Practitioner (CRNP), Employee E8 revealed the resident was seen for a left heel deep tissue injury acquired while out to the hospital. Treatment recommendations indicated to apply Cavilon every three days and leave open to air. Review of Resident R5's physician order dated 12/10/25, indicated to apply Cavilon daily to left heel. Review of Resident R5's physician orders failed to include an order to apply Cavilon every three days and leave open to air as ordered by CRNP, Employee E8 on 12/10/25. Review of Resident R5's December Medication Administration Record (MAR) revealed the resident's left heel pressure ulcer was cleansed with betadine daily. The facility failed to apply Cavilon every three days and leave open to air as CRNP, Employee E8 ordered on 12/10/25. During an interview on 7/16/26, at 10:06 a.m. the DON stated Wound Care Nurse, Employee E7 rounds with CRNP, Employee E8 each week and is responsible for entering wound care orders into the resident's clinical record. The DON confirmed Resident R5 did not receive treatment as ordered by CRNP, Employee E8 on 12/10/25, to apply Cavilon to left heel every three days. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 indicated recommendations to apply skin prep (or similar protective barrier film) to bilateral heels per facility protocol as prophylactic measure. Plan of care and education discussed with facility staff. Review of Resident R5's clinical record revealed weekly wound care assessments dated 1/14/26, and 1/21/26, included, but not limited to, all of the above information from previous note dated 1/7/26. During an interview on 7/16/26, at 10:06 a.m. the DON confirmed Wound Care Nurse, Employee E7 failed to enter an order to apply skin prep (or similar protective barrier film) to Resident R5's bilateral heels as ordered by CRNP, Employee E8 on 1/7/26, 1/14/26, and 1/21/26. The DON confirmed the facility failed to implement the wound care orders as recommended by wound care CRNP, Employee E8. During an interview on 7/16/26, at 2:12 p.m. Wound Care Nurse, Employee E7 confirmed each week wound rounds are conducted with CRNP, Employee E8. Wound Care Nurse, Employee E7 indicated she keeps track of wound orders provided by CRNP, Employee E8 and inputs the orders and care planning in the resident's clinical record. Recommendations provided are entered as order. Wound care nurse, Employee E7 stated skin prep requires an order, and it must be signed off as completed in the clinical record. Wound Care Nurse, Employee E7 confirmed an order to apply skin prep (or similar protective barrier film) to Resident R5's bilateral heels was not entered prior to the development of the resident's right heel wound. Review of Resident R5's wound assessment dated [DATE], indicated the resident developed a right heel stage three pressure ulcer that was not present on admission/reentry. The pressure ulcer measured 1.2 centimeters (cm) x 1.4 cm with light bloody exudate. During an interview on 7/16/26, at 10:06 a.m. the DON confirmed Wound Care Nurse, Employee E7 failed to enter an order to apply skin prep (or similar protective barrier film) to Resident R5's bilateral heels as ordered by CRNP, Employee E8 on 1/7/26, 1/14/26, and 1/21/26. The DON confirmed the facility failed to have a preventative measure such as skin prep (or similar protective barrier film) applied to Resident R5's bilateral heels as ordered by CRNP, Employee E8 prior to the development of the resident's right heel wound. During an interview on 7/16/26, at 1:37 p.m. the DON confirmed Resident R5 failed to have a physician order to treat the right heel stage III pressure ulcer on 1/26/26, and 1/27/26. Review of Resident R5's physician orders dated 1/28/26, indicated to cleanse right heel with betadine (a topical solution that treats minor cuts, scrapes, burns, and abrasions), cover with a border gauze three times a day as needed. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 revealed the resident had a right heel unstageable pressure injury. The measurements were 4.7 cm x 3.2 cm. The wound increased in size from 1/26/26. Small amount of sero-sanguineous drainage (a type of wound exudate that is a mixture of serous (a type of fluid that comes out of a wound with tissue damage) fluid and small amounts of blood was noted. Treatment recommendations included to cleanse right heel with normal saline (a sterile solution used primarily for wound irrigation and cleansing), apply xeroform (a sterile, non-adherent petrolatum gauze dressing containing microbial agents, used to protect wounds and promote moist healing while reducing infection risk) cover with dry clean dressing daily, and change as needed. Plan of care and education discussed with facility staff. Review of Resident R5's physician order dated 1/29/26, indicated to cleanse right heel with betadine, cover with a border gauze daily. The facility failed to enter the order to treat the unstageable pressure injury which was assessed on 1/28/26, by CRNP, Employee E8. During an interview on 7/16/26, at 2:12 p.m. Wound Care Nurse, Employee E7 confirmed she failed to enter an order to cleanse Resident R5's right heel with normal saline, apply xeroform, cover with dry clean dressing daily, and change as needed as CRNP, Employee E8 ordered on 1/28/26. Review of Resident R5's January and February Medication Administration Record (MAR) revealed the resident's right heel unstageable pressure ulcer was cleansed with betadine and covered with a border gauze once a day from 1/29/26, to 2/4/26. There was no evidence Resident R5's right heel was cleansed with normal saline, xeroform was applied and it was covered with dry clean dressing daily, and changed as needed. The facility failed to implement wound care treatment as CRNP, Employee E8 ordered on 1/28/26. During an interview on 7/16/26, at 1:37 p.m. the DON confirmed the facility failed to provide wound care treatment as ordered by CRNP, Employee E8 ordered on 1/28/26. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 revealed resident's right heel had copious amounts of green drainage. The wound measured 5.7 cm x 5.4 cm. The wound is deteriorating. The peri wound skin presents with signs and symptoms of infection. A wound culture (a laboratory test that identifies bacteria or other organisms in a wound to confirm infection and determine the best antibiotic treatment), and an x-ray was ordered. Review of Resident R5's progress note dated 2/4/26, entered by Physician Assistant, Employee E32 revealed the resident was seen for worsening right heel wound. Resident has an unstageable right heel ulceration and was seen on wound care rounds this morning. It was noted to have worsening of the wound with odor and drainage. Review of Resident R5's physician orders dated 2/4/26, revealed an order to implement enhanced barrier precautions (EBP- an infection control strategy using gowns and gloves during high-contact care to prevent the spread of multidrug-resistant organisms (MDROs) for wound management, a total of eight days since the wound developed to an unstageable pressure ulcer. The facility failed to timely implement EBP for a resident with a wound. Review of Resident R5's x-ray results dated 2/4/26, revealed the right heel was negative for osteomyelitis. Review of Resident R5's physician order dated 2/4/26, indicated to administer 800-160mg sulfamethoxazole-trimethoprim (combination antibiotic used to fight infections), one tablet, twice a day, due to right heel wound with concern for infection. Review of Resident R5's wound culture results dated 2/7/26, revealed there was heavy growth of pseudomonas aeruginosa (a bacteria that causes an infection). During an interview on 7/13/26, at 2:20 p.m. Resident R5's spouse had a concern with the development of Resident R5's right heel wound. Resident R5's spouse indicated they visit everyday and feel there were no preventative measures in place from preventing the wound from developing. Resident R5's spouse stated the offloading boots were implemented after the resident's heel wounds developed. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 revealed the resident's stage three right heel pressure injury measure 3.9 cm x 2 cm x 0.2 cm with light serosanguineous The wound is deteriorating. During an interview on 7/16/26, at 1:37 p.m. the Director of Nursing (DON) confirmed the facility failed to provide preventative measures such as skin prep or another protective barrier prior to the development of Resident R5's right heel pressure injury. The facility failed to implement wound care recommendations as ordered by CRNP, Employee E8 on 1/28/26, and Resident R5 failed to receive wound care treatment as ordered by CRNP, Employee E8. The DON confirmed Resident R5's right heel pressure injury became infected. Review of Resident R13's clinical record indicated that she was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/4/25, indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Section M0150 indicated that resident is at risk for developing pressure ulcers. Section M0120 indicated that resident did not have any unhealed pressure ulcers. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], that resident was being evaluated for skin tears on her left leg that she acquired on 12/4/25, and that one of the recommendations was to continue skin prep (or similar protective barrier film) to both heels per facility protocol as preventative measure. Review of Resident R13's Braden Scale assessment dated [DATE], identified the resident to be at high risk for the development of pressure injuries. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], that stated resident has BLE (bilateral lower extremities- legs) contractures (a permanent tightening of muscles, tendons, or ligaments that causes joints to become stiff and restricts normal movements) and tends to pull left leg up underneath herself. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], as resident was still being evaluated for a skin tear on her left leg. Recommendations included: Facility Pressure Ulcer Prevention Protocol- apply pillow under left knee to alleviate pressure to calf; continue skin prep to both heels. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], that indicated that a Deep Tissue Pressure Injury (DTI) was acquired on 12/31/26, on the left lateral ankle (the outside of the ankle). Recommendations included: apply skin prep to the area every other day; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure to calf. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], indicated that resident still presented with the DTI on the left lateral ankle; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure to calf. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], indicated that resident still presented with the DTI on the left lateral ankle, and that this wound is deteriorating. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation (walking) for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure to calf. Review of Resident R13's medical record revealed that a physician's order dated 1/14/26, to have Medi helix boots (a soft boot designed to prevent pressure ulcers) on at all times. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], indicated that resident still presented with the DTI on the left lateral ankle, and that resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record revealed weekly wound care assessments dated 1/28/26, 2/4/26, 2/11/26, and 2/18/26, that included, but not limited to, all of the above information from previous note dated 1/21/26. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], that stated left lateral ankle wound is now a Stage Three Pressure Ulcer (pressure injury that have burrowed past the second layer of the skin and reached fat layers beneath). New treatment orders included but not limited to apply Medihoney (a medical grade honey product used to treat wounds), cover with foam dressing change every Monday, Wednesday, and Friday. Previous notes that resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle; utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and also to apply pillow under left knee to alleviate pressure, remain in this note. Review of Resident R13's clinical record revealed wound care assessments dated 3/4/26, 3/11/26, 3/18/26, and 3/25/26, included previous data that resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included; utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's Braden Scale assessment dated [DATE], identified the resident to be at high risk for the development of pressure injuries. Review of Resident R13's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: place a pillow under left knee, and apply skin prep to heels, as had been stated in 12/22/25, wound care assessment, and virtually weekly since. Review of Resident R13's clinical record revealed wound care assessments dated 3/31/26, and 4/8/26, included previous data that resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record revealed a wound care assessment dated [DATE], that the Stage Three Pressure ulcer on left lateral ankle is now resolved, and included the following information: Resident has chronic BLE contractures and tends to pull left leg up underneath herself which subsequently places pressure on lateral left ankle, and recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record during the above timeline from 12/10/25, through 4/29/26, failed to include documentation that the order was implemented to place a pillow under left knee, and to apply skin prep to heels. Review of Resident R13's clinical record revealed wound care assessments dated 4/29/26, indicated that left lateral ankle wound reopened, and is a Stage Three Pressure Ulcer. Documentation continued to state that resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record revealed wound care assessments dated 5/6/26, and 5/13/26, which included; resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record from 4/29/26, through 5/20/26, failed to include documentation that the order was implemented to place a pillow under left knee, and to apply skin prep to heels. Review of Resident R13's clinical record revealed wound care assessments dated 5/20/26, that stated left lateral ankle pressure ulcer is now a stage four (pressure injury with full thickness skin loss with extensive destruction; tissue necrosis: or damage to muscle, bone or supporting structure), and continued to include the same documentation; resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record revealed wound care assessments dated 5/27/26, and 6/3/26, continued to include the same documentation; resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, and apply pillow under left knee to alleviate pressure. Review of Resident R13's Braden Scale assessment dated [DATE], identified the resident to be at high risk for the development of pressure injuries. Review of Resident R13's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: place a pillow under left knee, and apply skin prep to heels, as had been stated in 12/22/25, wound care assessment, and virtually weekly since. Review of Resident R13's clinical record revealed wound care assessments dated 6/17/26, stated that the left lateral ankle wound is a Stage Four Pressure Ulcer, and Muscle and bone are exposed. Documentation continued to include the following; resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention; continue skin prep to both heels, an apply pillow under left knee to alleviate pressure. Review of Resident R13's clinical record revealed wound care assessments dated 6/24/26, 7/1/26, 7/6/26, and 7/15/26, that continued to address the stage four pressure ulcer on the left lateral ankle, and documentation continued to include the following; resident has BLE contractures and tends to pull left leg up underneath herself putting pressure on lateral left ankle. Recommendations included: utilize soft heel boots to be on at all times aside from ambulation for pressure ulcer prevention: continue skin prep to both heels, an apply pillow under left knee to alleviate pressure. During an observation on 7/14/26, at 2:13 p.m. Resident R13 was observed lying in bed with no Medi Helix boots applied. During an observation on 7/15/26, at 1:06 p.m. Resident R13 was observed lying in bed with no Medi helix boots applied. During an additional observation, and interview on 7/15/26, at 1:52 p.m. Resident R13, did not have boots applied as ordered, and LPN Employee E4, confirmed that the resident did not have her boots on as ordered, and proceeded to look for the boots amongst ResidentR13's possessions. At this time LPN Employee E4 confirmed that the resident did not have any Medi helix Boots in her room. During an interview on 7/16/26, at 9:01 a.m. Nurse Aide (NA) Employee E16 stated that when resident can't change positions on their own, the staff should be helping them change position every two hours to prevent pressure ulcers from occurring. NA Employee E16 stated that if any preventative skin care intervention is required, it needs to be entered as an order so that it will show in the computer system and that staff can be reminded to complete the task and document that it was completed. This would include turning and positioning, pillow placement, and applying boots. During an interview on 7/16/26, at 9:13 a.m. Rehabilitation Director Employee E17 stated that Resident R13 does have contractures, and that sometimes using a brace on a contracture may worsen the skin conditions, and that a Pillow is probably the most effective, to utilize for wound prevention, and healing. Review of Resident R13's clinical record conducted on 7/16/26, failed to reveal the following: no documentation that turning and repositioning resident had occurred until 1/14/26. Review of physician's orders and care plan failed to include evidence that a pillow was ordered, or had been placed under her left knee; and also failed to include evidence that skin prep was ordered to be applied to both heels. During an interview on 7/16/26, at 3:14 p.m. the DON confirmed that the facility failed to implement pressure injury prevention strategies for Resident R13 that were repeatedly recommended by Wound Care CRNP Employee E8, such as placing the pillow under the left knee, and applying skin prep to the heels, as these strategies were not entered into the computer system as an order. Failure to enter these interventions as an order prevented staff from knowing that these strategies should be implemented. The DON confirmed that there was no evidence that pillow placement, and application of skin prep had been completed since December of 2025, and that turning and positioning of Resident R13 was completed prior to 1/14/26. During an interview on 7/16/26, at 3:15 p.m. Wound Care CRNP Employee E8 confirmed that a pillow under Resident R13's left knee Definitely would have helped prevent the pressure ulcer on her left lateral ankle. During an interview on 7/16/26, at 9:32 a.m. Nurse Aide, Employee E9 stated for pressure ulcer prevention, pressure relieving boots, pillows are used for offloading. Residents should also be turned and repositioned every two hours. During an attempted phone interview on 7/16/26, at 12:11 p.m. Wound CRNP, Employee E8 was unavailable for an interview. During an interview on 7/16/26, at 2:05 p.m. Chief Clinical Official Wound Care Consultant, Employee E13 stated resident care and treatment recommendations are transcribed into an order. The wound care consultants notes are entered into the electronic record under progress notes. The facility nurse coordinates to ensure orders are entered into the clinical record. The nurse practitioners are not responsible for entering their own orders. Clinical Official Wound Care Consultant, Employee E13 confirmed Wound CRNP, Employee E8 is the provider that rounds at the facility and is not responsible for entering orders into the resident's clinical record. Facility staff are to enter the physician orders and Wound CRNP, Employee E8 signs the orders off. During a phone interview on 7/16/26, at 2:10 p.m. Wound Care Nurse, Employee E7 stated she conducts weekly rounds with the wound care nurse practitioner every Wednesday at the facility. It was indicated Wound Care Nurse, Employee E7 provides Wound CRNP, Employee E8 a list of residents each week for needs to be evaluated. During wound rounds, Wound Care Nurse, Employee E7 keeps track of orders for treatments and inputs orders and care plans. The recommendations for treatment are transcribed into an order. Wound Care Nurse, Employee E7 stated skin prep does require an order and it must be signed off in the electronic record. For interventions such as offloading boots, and turning and repositioning, it is entered so that it populates under nurse aide tasks to sign off as completed, that way I am ensuring nurse aides are documenting as well as nurses to ultimately ensure it is getting done. Wound Care Nurse stated interventions for contractures include utilizing devices such as wedges, braces, or a pillow for different repositioning, which should be entered as an order. During a phone interview on 7/16/26, at 3:14 p.m. Wound CRNP, Employee E8 stated the facility is provided with preventative and treatment orders such as offloading measures and wound treatments. Wound CRNP, Employee E8 confirmed the facility is responsible for entering the orders. Wound CRNP, Employee E8 confirmed Resident R13 skin is prone to breakdown and should have had a pillow in between lower leg and ankle. The Nursing Home Administrator (NHA) and DON were notified of the Immediate Jeopardy (IJ) situation on 7/16/26, at 4:26 p.m. An Immediate Action Plan was requested and the IJ template was provided to the NHA. The Immediate Action Plan was accepted on 7/16/26, at 7:36 p.m. The plan included: Whole house audit will be conducted on all residents by the Director or Nursing/designee to ensure Care plans match the current resident condition by July 17, 2026. All residents will have a Braden completed by the primary nurse assigned by July 17, 2026. The DON or designee will audit the pressure injury orders from last wound report dated July 15, 2026 to ensure reconciliation with resident orders completed by July 17, 2026. All residents will be provided with a head-to-toe skin assessment to ensure that there are no new pressure injuries, This will be done by the primary assigned nurses on the units. This will be completed on July 17, 2026. Education to the designated wound nurse will be provided by the Staff Development Coordinator/designee on the expectations of her coordination and implementation with the Wound and Vascular teams recommendations and orders by July 17, 2026. Education will be provided to CNA, LPN, Therapy, RN, Dietary staff on pressure injuries using the directed in-service power point from CHR Consulting Services by the Staff Development Educator or designee which includes preventative measures, interventions, and care planning and what to do when they identify missing preventative measure, interventions, and care plans . This power point reference F 686, Pressure Ulcer Prevention and Treatment. This will be completed by July 17, 2026 or prior to next shift. Our Wound Care: Treatment (Policy N-W-60) and Wound Care – Pressure Ulcer/Injury Prevention (Policy N-W-45) will be reviewed by [NAME] Executive Director and Chief Nursing Officer by July 17, 2026 and revised as needed. Weekly audits will be conducted by the DON or designee to ensure that pressure injuries are not worsening. If they are worsening, new interventions will be implemented by nursing to decrease the risk of worsening. Audits will be conducted weekly by the DON or designee on 5 random residents with pres

Based on clinical record review, review of resident fund reports, and staff and resident interviews, it was determined that the facility failed to provide quarterly resident trust fund (resident funds account with current accounts open and holding resident monies) statements for three of three residents (Residents R12, R23, and R48), and failed to accurately account for resident personal funds for one of three residents (Resident R48).Findings include: Review of the facility trust fund account dated 7/16/26, indicated the following residents had active resident fund accounts: Residents R12, R23, and R48. Further review of facility business records and resident records did not include evidence that the residents were provided with quarterly statements. During a phone interview on 7/16/26, at 11:30 a.m. Revenue Accounting Manager Employee E10 stated that quarter one statements were not sent out to residents or resident representatives and confirmed that the facility failed to have documented evidence for the previous quarters as well. During an interview on 7/16/26, at 11:41 a.m. Assistant Business Office Manager (ABOM) Employee E2 confirmed that the facility could not provide evidence of sending quarterly statements to residents or resident representatives, and the facility failed to provide quarterly resident fund statements for Residents R12, R23, and R48, as required. Review of the clinical record indicated Resident R48 was admitted to the facility on [DATE]. During a review of Resident R48's resident fund statement on 7/15/26, indicated the facility received one payment on 4/17/26. On 5/13/26, Resident R48's resident fund only had one month's worth of allotted amount of money in the resident fund account. During an interview on 7/16/26, at 11:50 a.m. the ABOM Employee E2 stated It appears that the facility only got one lump payment that included the residents stay from September 2025, through April 2026. When the facility got that payment, the computer recognized it as one month payment and only took out one month resident fund allowance and placed it in Resident R48's account. The facility should have transferred eight months of monthly allowance into the account. We moved the correct amount to the account today. During an interview on 7/16/26, at 12:01 a.m. the ABOM Employee E2 confirmed that the facility failed to have an accurate resident personal fund statement for Resident R48. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of clinical records, and staff interviews, it was determined that the facility failed to develop and implement care plans that included instructions to provide person centered care for four of eight residents (Resident R1, R59, R61, and R123).Based on a review of facility policy, clinical records, and staff and resident interviews, it was determined that the facility failed to develop and implement care plans that included instructions to provide person centered care for four of eight residents (Resident R1, R59, R61, and R123). Findings include: Review of facility's policy Assessment-Comprehensive Person-Centered Care Planning dated 5/28/26, 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. Practitioner orders, Medication and Treatment Administration records, progress notes which include treatment plans are part of the whole resident comprehensive person-centered care plan. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and adult failure to thrive. Review of Resident R1's hospital Discharge summary dated [DATE], revealed the resident the resident had bladder mass and the plan included to monitor for hematuria (blood in urine), consider urology appointment, in case of worsening hematuria, surgical pathology from 5/15/26 pending, continue 0.4 mg Flomax (medication primarily used to treat benign prostatic hyperplasia (BPH), a condition in which the prostate gland enlarges and obstructs urine flow) daily. The resident had an acute pulmonary embolism (a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body (deep vein thrombosis) and the plan included to continue Eliquis (blood thinning medication to reduce the risk of clot formation) twice a day, administer 20 mg Lasix (a loop diuretic (water pill) that helps the body eliminate excess water and salt by increasing urine output) for five days and to continue if resident remains hypervolemic (a condition where there is too much fluid in the body), monitor input and outputs, and to continue dysphagia diet. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/31/26, failed to include above diagnoses. Section I: Active Diagnoses failed to include diagnoses of pulmonary embolism, and bladder mass. Review of Resident R1's care plan on 7/15/26, failed to include a care plan with goals and interventions for the resident's pulmonary embolism and bladder mass. Interview on 7/15/26, at 12:19 p.m. Registered Assessment Coordinator (RNAC), Employee E7 stated I didn't know he had a pulmonary embolism. RNAC, Employee E7 confirmed the resident's care plan failed to include interventions related to the resident's pulmonary embolism and bladder mass. Review of the clinical record indicated Resident R59 was admitted to the facility on [DATE], with diagnoses of lymphedema (condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues), morbid obesity, and muscle wasting and atrophy. Review of Resident R59's MDS dated [DATE], indicated the diagnoses were current. Review of Resident R59's care plan dated 3/24/20, indicated to apply lymphedema pumps to both legs for edema, no more than 60 minutes per leg. The care plan was updated 12/22/25, with interventions to apply lymphedema wraps to right leg as ordered and as tolerated. Review of Resident R59's physician order dated 6/22/26, indicated to apply lymphedema pump to left leg as tolerated, no more than 60 minutes at a time at bedtime. Nursing to call resident's brother if resident refuses. Review of Resident R59's June Treatment Administration Record revealed the following: -6/25/26, 8:47 p.m. the lymphedema pump was not applied to left leg as tolerate, no more than 60 minutes at a time because the resident stated it doesn't work. -6/26/26, 9:36 p.m. the lymphedema pump was not applied to left leg as tolerate, no more than 60 minutes at a time because the Resident states that pumps not working again and has an error msg to call 1-800 number. -6/27/26, at 7:27 p.m. the resident refused -6/28/26, at 7:31 p.m. the resident refused Review of Resident R59's care plan revised 7/7/26, indicated the resident has the right to refuse care and services, interventions included to educate the resident on the importance of use of lymphedema pumps. Review of Resident R59's July Treatment Administration Record revealed the following: -7/10/26, at 9:41 p.m. the resident refused. States that it is broken and keeps having an error message to call 1-800 number. -7/11/26, at 8:59 p.m. the resident refused. States she wanted a number to call to get them serviced and waiting for someone to sit with her for call. -7/12/26, at 8:22 p.m. the resident refused. -7/13/26, at 7:32 p.m. the resident states pump not working properly. -7/14/26, at 8:54 p.m. the resident refused. Resident refused, stated she has to call the 1-800 number tomorrow because they aren't inflating properly. During an interview and observation on 7/13/26, at 11:28 a.m. Resident R59 stated they haven't been able to use their lymphedema pumps for a while. It was indicated they both initially inflate, but they don't stay filled and inflated. It was indicated they have been dealing with this issue for over a year and believes staff do not believe her. Resident R59's lymphedema pumps were observed sitting in a box next to their nightstand in the corner. Review of Resident R59's clinical record failed to include evidence the resident was educated on the importance of use of lymphedema pumps when refused or that nursing called the resident's brother if resident refuses. The facility failed to implement the care plan interventions related to the resident's lymphedema pumps. During an interview on 7/15/26, at 9:59 a.m. the DON confirmed the facility was made aware of the allegation of the broken pumps and on 6/22/26, they lymphedema pumps were in working order. During an interview on 7/15/26, at 9:02 a.m. Registered Nurse (RN), Employee E9, stated she put the lymphedema pumps on Resident R59 a few weeks ago, and the machine came on, and once she left the room and returned there was an error message. It was indicated the resident was not nappy, and it's been an ongoing issue. During an interview and observation on 7/15/26, at 9:04 a.m. Resident R59's lymphedema pumps were observed sitting in a box next to their nightstand in the corner. Resident R59 stated they were not used last evening. Review of the clinical record failed to include evidence the resident's brother was notified if the resident refuses and failed to provide evidence the resident was educated on importance of lymphedema pumps when refused. During an interview on 7/15/26, at 10:26 a.m. the Director of Nursing confirmed the facility failed to implement the resident's care plan and apply lymphedema pumps as ordered. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of lymphedema, morbid obesity, and muscle wasting and atrophy. Review of Resident R61's care plan dated 6/28/26, revealed a care plan with a category of behavioral symptoms. It was indicated the resident had high blood pressure and heart failure and uses oxygen continuously. Interventions included to monitor for tolerance to activities/self-care (fatigue, shortness of breath, pallor (unusually pale skin) or cyanosis (a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood), vertigo (feeling of spinning), weakness, etc.). Ensure oxygen is placed, check oxygen saturation ( measures the fraction of hemoglobin molecules in the blood that are carrying oxygen at a given time) as needed for shortness of breath. Review of Resident R61's MDS dated [DATE], indicated the diagnoses were current. During an observation on 7/13/26, Resident R61 was observed utilizing oxygen with humidification. Review of Resident R61's physician order dated 6/26/26, indicated to administer 2 Liters (L) of oxygen at all times. Review of Resident R61's care plan on 7/15/26, failed to include interventions related to the resident's humidification and oxygen tubing. Review of the clinical record indicated Resident R123 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure with hypoxia, lymphedema, and anxiety. Review of Resident R123's MDS dated [DATE], indicated the diagnoses were current. Review of Resident R123's care plan dated 7/20/22, indicated the resident has the potential for respiratory distress due to requiring oxygen, sleep apnea. Review of Resident R123's physician order dated 7/28/24, indicated to administer 3 (L) of oxygen from 8:00 a.m. to 8:00 p.m. titrate to keep blood oxygen saturation above 92%. Review of Resident R123's physician order dated 2/4/26, indicated to ensure oxygen humidifier bottle is filled appropriately. During an observation on 7/13/26, at 9:36 a.m. Resident R123 was observed receiving oxygen via nasal cannula with humidification. Review of Resident R123's care plan on 7/14/26, failed to include interventions related to the resident's humidification and oxygen tubing. During an interview on 7/15/26, at 9:14 a.m. the Director of Nursing stated if a resident uses oxygen, it is expected they are care planned for oxygen. During an interview on 7/15/26, at 9:15 a.m. Registered Assessment Coordinator (RNAC), Employee E7 confirmed Resident R61's and Resident R123's care plan failed to include care interventions related to Resident R123's humidification and how often to change the oxygen tubing. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on facility policy, clinical record review, resident and staff interview, it was determined that the facility failed to procure complete physician's orders for residents with an ostomy (an opening into the abdomen that removes waste) for one of three residents (Resident R7), and residents utilizing a bedside commode for two of two residents (Residents R7 and R126).Findings include: Review of the facility policy Transcription-Reconciliation of Practitioner Orders last reviewed5/28/26, indicated to ensure that all new, changed, and discontinued orders are entered into facility approved forms. Review of Resident R7's clinical record indicated an admission date of 11/9/19. Review of Resident R7's Minimum Data Set Assessment (MDS-A periodic assessment of resident care needs) dated 4/21/26, indicated the diagnosis of hypertension (high blood pressure), depression and right hip fracture. Review of Resident R7's physician orders dated 5/1/26, indicated provide colostomy care every shift. Ensure site is clean, dry, and intact. The orders failed to include specific information that included product type, size of product or frequency in which to change the products. During an observation completed on 7/13/26, at 12:12 p.m. resident was sitting on the edge of her bed getting ready to eat her lunch. A bedside commode was viewed at the foot of her bed. During an observation completed on 7/14/26, at 2:18 p.m. Nurse Aid Employee E5 was observed emptying the bedside commode. Review of Resident R7's current physician orders failed to reveal Resident R7 was to utilize a bedside commode. During an interview completed on 7/14/26, at 2:28 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R7 did not have specific orders for a colostomy that included product type, size of product or frequency in which to change the products and that Resident R7 failed to have physician orders for a bedside commode. Review of Resident R126's clinical record indicated an admission date of 11/30/22. Review of Resident R126's MDS dated [DATE], indicated the diagnosis of heart failure (the heart doesn't pump the way it should), diabetes (high sugar in the blood) and hyperlipidemia (high fat in the blood). During an observation completed on 7/13/26 at 9:52 a.m. Resident R126 was in her bed. A bedside commode was noted to the left side of the bed. During an observation completed on 7/15/26, at 9:11 a.m. the bedside commode was noted to the left side of Resident R126's bed. Review of Resident R126's current physician orders failed to reveal Resident R126 was to utilize a bedside commode. During an interview completed on 7/15/26, at 9:16 a.m. Registered Nurse Employee E6 confirmed that Resident R126 did not have physician orders for the bedside commode and that the facility failed to procure complete physician's orders for Resident R126's bedside commode. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services.

Based on observations, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing, and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three nursing units (Three East), and two of five residents (Group Resident (GR)1, and GR2)Findings include: During an observation of the lunch meal on 7/13/26, at 12:07 p.m. no residents were eating in the Third-Floor East Dining Room. During an interview on 7/13/26, at 12:07 p.m. Nurse Aide (NA) Employee E20 confirmed that no resident would be dining in the Dining Room on this day, and stated: When we have six aides, we use the Dining Room, today we only have five, and stated that they need extra aides to get the residents up, and ready to transport them down to the Dining Room. During an observation, and interview on 7/14/26, at 12:15 p.m. no residents were observed eating in the Third Floor East Dining Room, and NA Employee E20 confirmed the above observation, and stated that they only had five aides again today. During a group interview on 7/15/26, at 10:24 a.m. two of five residents (GR1, and GR2) stated that they could not eat in the Dining Room when there wasn't enough staff. During an interview on 7/18/26, at 1:44 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three nursing units. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 211.12(d)(1)(4) Nursing services.

Based on review of personnel records and staff interview, it was determined that the facility failed to complete annual performance evaluation at least once every 12 months for three of five nurse aide (NA) personnel records (NA Employee E23, E25, and E26).Findings include: Review of NA Employee E23's personnel record indicated a hire date of 6/7/21. Review of NA Employee E23's personnel records revealed a performance evaluation was conducted on 5/29/25, and no other performance evaluation has been completed since 5/29/25. Review of NA Employee E25's personnel record indicated a hire date of 6/27/16. Review of NA Employee E25's personnel records revealed a performance evaluation was conducted on 6/6/25, and no other performance evaluation has been completed since 6/6/25. Review of NA Employee E26's personnel record indicated a hire date of 1/16/24. Review of NA Employee E26's personnel records revealed a performance evaluation was conducted on 2/6/25, and no other performance evaluation has been completed since 2/6/25. During an interview on 7/18/26, at 10:11 a.m. the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluation at least every 12 months for NA Employee E23, E25 and E26. 28 Pa Code: 201.14 (b) Responsibility of licensee28 Pa Code: 201.18 (b)(1)(3) Management

Based on facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a medication pass, failed to follow Enhanced Barrier Precautions (EBP- infection control measures recommended by the Center for Disease Control (CDC) to reduce the transmission of multidrug-resistant organisms (MDROs) for one of three residents (Resident R7), failed to prevent cross contamination during a dressing change (Resident R13), and failed to conduct an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread for twelve of twelve months (April 2025 to April 2026). Findings include: Review of Center for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, stated washing your hands with soap and water include the following: -Wet hands with water. -Apply the manufacturer recommended amount of product to your hands. -Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. -Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet. -Avoid using hot water to prevent drying of the skin Review of the facility policy Infection Prevention and Control Program and Plan last reviewed 5/28/26, indicated it is the policy of the facility to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Staff utilize Enhanced Barrier Precautions as indicated, staff perform hand hygiene as indicated and use personal protective equipment (PPE). Review of the facility policy Medication Administration General Guidelines last reviewed 5/28/26, indicated to provide direction in the safe and effective administration of medications, including preparation and technique to store and handle medications in accordance with manufacture recommendations and/or stated and federal requirements. Review of the facility's water management plan last reviewed 5/28/26, revealed it is the facility's policy to reduce Legionella Growth and Spread indicated it is recommended that a facility-wide chlorination procedure be completed at least twice a year, but no less than annually. The Environmental Service Department will ensure that all water sources that are not used on a regular basis be placed on a weekly flushing system. Those flushes will be conducted to help reduce the build-up of dirt, debris, and/or bacteria. Any taps found to show blackish debri or general dirt will be flushed until they run clear. All resident shower rooms will be placed on a weekly fluish to ensure the constant flow of water and prevent legionella growth. During a medication pass observation completed on 7/14/26, at 9:15 a.m. Registered Nurse (RN) Employee E11 was preparing the medications for Resident R37. RN Employee E11 applied gloves to both hands. RN employee E11 then punched out the medication from the dispensing pack directly into her right hand and used her left hand to pluck the medication out of her right hand and place the medication into the medication cup. This process continued with all the medications scheduled for Resident R37's morning medications. RN Employee E11 confirmed touching the medications prior to placing into the medication cup and stated, but I was wearing gloves and confirmed that the facility failed to prevent cross contamination during a medication pass. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7s Minimum Data Set (MDS - a period assessment of care needs) dated 5/21/26, indicated diagnoses of anemia (low iron in the blood), urinary tract infection, and right hip fracture. Review of Resident R7's physician orders dated 6/3/26, indicated multi drug resistant organism (MDRO) related to Extended-Spectrum Beta-Lactamase (ESBL) Escherichia coli (E-coli- bacteria normally found in the gut that enters the urinary tract). Special instruction MDRO is colored purple. Confirm isolation bin is on resident's door, confirm bin is stocked with PPE, if not notify housekeeping. During an observation and interview completed on 7/14/26, at 2:18 p.m. Nurse Aid (NA) Employee E5, was emptying Resident R7's bedside commode. NA employee E7 was not utilizing the required PPE. Upon asking NA Employee E7 concerning the purple sticker on the door replied, I don't know why they have the purple sticker, the pink one is for her ostomy bag. Upon asking concerning utilizing the appropriate PPE replied, I would wear a gown if doing her ostomy care and pointed to the pink dot on the door. I don't know of anything in her urine and confirmed the facility failed to follow EBP to reduce the transmission MDROs for one of three residents (Resident R7). Review of Resident R13's clinical record indicated that she was admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R13's MDS dated [DATE], indicated diagnoses of high blood pressure, difficulty swallowing, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R13's physician order dated 5/29/26, revealed an order for enhanced barrier precautions (infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in healthcare settings, that involve the use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with MDROs, as well as those at increased risk of MDRO acquisition, such as residents with wounds or indwelling medical devices.) due to wound. Review of Resident R13's physician order dated 6/24/26, revealed an order to cleanse left lateral ankle pressure injury with Dankins (antiseptic used to cleanse wounds and prevent infection) solution 0.125%, apply small amount of mupirocin (an antibacterial drug) ointment and santyl (a prescription collagenase ointment used to remove dead tissue from chronic skin ulcers and severe burns, promoting wound healing) to wound bed, cover with foam dressing daily. During an observation of Resident R13's wound dressing change on 7/16/26, at 11:13 a.m. completed by Licensed Practical Nurse (LPN), Employee E4 the following was observed: -LPN, Employee E4 failed to wash hands prior to donning gown and gloves -LPN, Employee E4 entered the hallway with doffed gown and gloves -LPN, Employee E4 failed to wash hands prior to opening supplies -LPN, Employee E4 placed wound dressing supplies on unclean surface while preparing wound care supplies -LPN, Employee E4 placed contaminated wound care supplies on clean surface and failed to prevent cross-contamination -LPN, Employee E4 failed to wash hands for a total of 15 seconds -LPN, Employee E4 failed to turned off the faucet with hand creating the potential for cross contamination -LPN, Employee E4 entered into hallway prior to doffing gown -LPN, Employee E4 failed to clean bed side table that was utilized after dressing change was complete During an interview on 7/16/26, at 11:54 p.m. LPN, Employee E4 confirmed the above observations and that the facility failed to perform appropriate hand hygiene, discard personal protective equipment, and prevent the potential for cross contamination. During an interview on 7/16/26, at 12:00 p.m. the Director of Nursing confirmed the facility failed to prevent the potential for cross contamination and perform hand hygiene during a wound dressing change for Resident R13. During an interview on 7/17/26, at 12:12 p.m. Plumber, Employee E31 stated the fixtures on the 2nd floor on the closed units must be flushed weekly at minimum. Review of facility provided documents failed to include evidence the closed unit located on the 2nd floor had weekly flushing completed from 4/1/25, to 4/31/26. During an interview on 7/17/26, at 2:42 p.m. Epidemiologist, Employee E30 confirmed the facility failed to implement their water management plan to prevent the growth of legionella by failing to conduct weekly flushes for the closed unit located on 2 [NAME] from April 2025, to April 2026. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code: 211.10 (d) Resident care policies. 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

Based on a review of clinical records and resident and staff interviews, it was determined that the facility failed to provide pain management consistent with professional standards of practice for one of two residents (Resident R103). Findings include: Review of the facility policy Standards of Practice for Rx Partners INC. Consultant Pharmacists last reviewed 5/28/26, indicated that the consultant pharmacist reviews the drug regimen of each resident and medical chart at least monthly, reports and documents any irregularities to the residents nursing staff and/or attending physician. Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE]. Review of Resident R103's Minimum Data Set (MDS - a period assessment of care needs) dated 6/22/26, indicated diagnoses of anxiety, depression and Amyotrophic lateral sclerosis (ALS-progressive disease that affects nerve cells controlling voluntary muscles, leading to muscle weakness, atrophy, and eventually loss of movement, speech, and breathing). Review of Resident R103's physician orders dated 1/1/26, indicated ibuprofen (Motrin) tablet 800 milligram (mg) tablets one tablet by mouth every 8 hours as needed for left elbow pain. Review of Resident R103's physician orders dated 1/2/26, indicated acetaminophen (Tylenol) tablet 500 mg, 2 tabs by mouth three times a day for pain. Review of Resident R103's physician orders dated 4/17/26, indicated gabapentin (Neurontin) 100 mg capsule 1 capsule by mouth two times a day for nerve pain. Review of Resident R103's physician orders dated 6/13/26, indicated fentanyl (Duragesic) patch 75 micrograms (mcg) /hour (hr) 1 patch every three days for pain left elbow fracture. Review of Resident R103's physician orders failed to indicate any documented non-pharmacological interventions for the use of pain medication. During an interview completed on 7/16/26, at 2:00 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R103's clinical record failed to indicate any documented non-pharmacological interventions for the use of pain medication and that the facility failed to provide pain management consistent with professional standards of practice for one of two residents (Resident R103). 28 Pa. Code 211. 10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information for one of three nursing stations (Third floor East) and failed to maintain the confidentiality of residents' medical information for one of five medication carts (Third floor medication cart ten). Findings include: During an observation completed on 7/15/26, at 1:12 p.m. the Third-floor East Nursing Station had therapy schedules and nurse aid worksheets containing resident personal and confidential information sitting on the counter available to anyone passing the area to view. During an interview completed on 7/15/26, at 1:19 p.m. Registered Nurse Employee E6 confirmed that the therapy schedules and nurse aid worksheets containing resident personal and confidential information were sitting on the counter available to anyone passing the area and that the facility failed to maintain the confidentiality of residents' medical information for one of three nursing stations (Third-floor East). During an observation on 7/15/26, at 1:17 p.m. in the Third-Floor East hallway, medication cart number ten was left unattended with the computer screen open, which revealed identifiable, personal, and confidential resident information that any passerby could see. During an interview on 7/15/26, at 1:19 p.m. Registered Nurse Employee E6 confirmed the above observation, and that the facility failed to maintain confidentiality of a resident's medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(c.3) Resident Rights. 28 Pa. code: 211.5(b) Medical records. 28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on review of clinical records and staff interview, it was determined that the facility failed to inform a resident or resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of five residents (Resident R103).Findings include: Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE]. Review of Resident R103's Minimum Data Set (MDS - a period assessment of care needs) dated 6/22/26, indicated diagnoses of anxiety, depression and Amyotrophic lateral sclerosis (ALS-progressive disease that affects nerve cells controlling voluntary muscles, leading to muscle weakness, atrophy, and eventually loss of movement, speech, and breathing). Review of Resident R103's physician orders dated 1/1/26, indicated Duloxetine (Celexa) capsule (used to treat depression), delayed release 30 milligrams(mg) 1 capsule by mouth twice a day for major depressive disorder. Review of Resident R103's physician orders dated 6/8/26, indicated Lorazepam (Ativan) 0.5 mg 1 tablet three times a day for anxiety. Review of Resident R103's clinical record failed to include a signed consent form for Duloxetine or Lorazepam that included the risk and benefits of the prescribed medication. During an interview completed on 7/16/26, at 2:00 p.m. the Assistant Director of Nursing Employee E1 did provide a consent for the duloxetine and lorazepam, however, the form failed to contain a signature from the resident or the residents responsible party and confirmed that the that the facility failed to inform a resident's or resident representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of five residents (Resident R103). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a): Resident rights.

Based on review of clinical records and staff interview, it was determined that the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Residents R12) reviewed.Findings included: Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE]. Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/20/26, indicated diagnoses of high blood pressure, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R12's clinical record revealed weights to be as follows:1/14/26: 117.1 pounds2/1/26: 117.4 pounds3/1/26: 109.1 pounds3/4/26: 110.0 pounds (a significant weight loss of 6.3% in one month)April 2026: no weight recorded5/11/26: 111.8 pounds Review of Resident R12's clinical record revealed a Nutrition progress note dated 3/20/26, that confirms that resident had a significant weight loss in March 2026. During an interview on 7/17/26, at 9:35 a.m. RD Employee E5 confirmed that Resident R12, had significant weight loss in March 2026 and that the facility failed to obtain her weight in April 2026. As a result the facility failed to properly monitor weight and nutrition status by failing to obtain weights for one of three residents (Residents R12) reviewed. 28 Pa Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy, and staff interviews, it was determined that the facility failed to ensure that residents' medication regime was free from unnecessary psychotropic (a mind-altering medication) medication for two of three residents (Resident R5 and R103). Findings include: Review of the facility policy Standards of Practice for Rx Partners INC. Consultant Pharmacists last reviewed 5/28/26, indicated that the consultant pharmacist reviews the drug regimen of each resident and medical chart at least monthly, reports and documents any irregularities to the residents nursing staff and/or attending physician. Review of the facility policy Unnecessary Medication Monitoring last reviewed 5/28/26, indicated unnecessary medications are defined as any medication when used in excessive dose, or for excessive duration or without adequate monitoring, or without adequate indications for use. Psychotropic Dugs are any drug that affects brain activities associated with mental process and behavior. Theses drugs include but not limited to: Antipsychotics, Antidepressant, Antianxiety and Hypnotics. Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], with diagnoses of muscle weakness, anxiety, and depression. Review of Resident R5's care plan dated 1/28/25, revealed the resident was on antidepressant/antianxiety medication. Interventions included to observe for side effects of antidepressant/antianxiety such as headaches, drowsiness, insomnia, nervousness, constipation, dry mouth, or complaints of ringing in ears, lethargy. Review of Resident R5's physician order dated 7/10/25, indicated to administer half a tablet of 0.5 mg lorazepam, once a day as needed for anxiety. There was no stop date. The order was discontinued on 7/28/25, at total of 18 days later. The facility failed to limit as need psychotropic drugs to 14 days. Review of Resident R5's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/25/25, indicated the diagnoses were current. Section N0145. High-Risk Drug Classes: Use and Indication revealed the resident was taking an antianxiety medication. Review of Resident R5's physician order dated 7/28/25, indicated to administer half a tablet of 0.5 mg lorazepam, once a day as needed for 180 days for ongoing/chronic anxiety. The order was discontinued on 12/6/25. Review of Resident R5's psychiatric note dated 8/12/25, revealed the resident was on as needed lorazepam that was added by the medical doctor since 7/28/25. Review of Resident R5's psychiatric note dated 10/21/25, revealed the resident was on as needed lorazepam that was added by the medical doctor since 7/28/25. Review of the clinical record from 7/10/25, to 12/6/25, failed to include the attending physician's or prescribing practitioner's rationale for the as needed lorazepam order to be extended beyond 14 days. During an interview on 6/4/26, at 11:29 a.m. the Assistant Director of Nursing, Employee E1 confirmed Resident R5 was ordered as needed lorazepam from 7/10/25, to 7/28/25, and 7/28/25, to 12/6/25, and the clinical record failed to provide a rationale as to why the medication was ordered past 14 days and confirmed that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medications for Resident R5. Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE]. Review of Resident R103's MDS dated [DATE], indicated diagnoses of anxiety, depression and Amyotrophic lateral sclerosis (ALS-progressive disease that affects nerve cells controlling voluntary muscles, leading to muscle weakness, atrophy, and eventually loss of movement, speech, and breathing). Review of Resident R103's physician orders dated 1/1/26, indicated Wellbutrin XL extended release 150 milligram tablet by mouth daily for major depressive disorder. Review of Resident R103's physician orders dated 1/1/26, indicated duloxetine (also known as Celexa) capsule delayed release 30 milligrams (mg) 1 capsule by mouth twice a day for major depressive disorder. Review of Resident R103's physician orders dated 6/8/26, indicated lorazepam (also known as Ativan) 0.5 mg 1 tablet three times a day for anxiety. Review of Resident R103's clinical record failed to indicate any documented non-pharmacological interventions or effectiveness of pharmacological interventions; the clinical record also failed to indicate evidence that the facility had implemented side effect or behavior monitoring for psychotropic medication use. During an interview completed on 7/16/26, at 2:00 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R103's clinical record failed to indicate any documented non-pharmacological interventions or effectiveness of pharmacological interventions; the clinical record also failed to indicate evidence that the facility had implement side effect or behavior monitoring for psychotropic medication use. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code 211.10(a) Resident care policies

Based on reviews of facility policy, facility documents, clinical records and staff interviews it was determined that the facility failed to implement written policies and procedures to ensure a complete, thorough and timely investigation was completed for one of two residents (Resident R72).Findings include: Review of the facility policy Abuse-Resident and Reasonable Suspicion of a crime dated 5/28/26, indicated it is the policy of this facility to treat every resident with consideration, respect and full recognition of his/her dignity and individuality. This policy is part of the center's overall prevention of abuse, neglect, exploitation and misappropriation of resident property. Neglect is 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. Every complaint or allegation of resident abuse shall be promptly reported to the Administer and an investigation initiated. The house Registered Nurse Supervisor/Designee initiates investigation promptly. Assures that the Nursing Home Administrator (NHA) and Director of Nursing (DON) are notified promptly. Interviews and obtain written statements from complaining party and witnesses. Completes Incident Report and notifies practitioner. Updates resident's person-centered care plan promptly. Consults with the interdisciplinary team (IDT) for person centered care plan updates to address the residents medical, nursing, physical, or psychosocial needs or preferences. Review of Resident R72's clinical record indicated an admission date of 9/23/25. Review of Resident R72's Minimum Data Set (MDS-a period assessment of care needs) dated 6/3/26, indicated the diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood) and anxiety. Review of physician orders dated 11/25/25, revealed Resident R72 transfers with assistance of two. Review of nursing progress notes dated 1/5/26, revealed Nurse Aid (NA) notified nurse and supervisor that resident had been lowered to the floor by herself. There were no injuries from this event. All vital signs are within normal limit per baseline. Safety maintained, will monitor. Call light, fluids, and personals are all within reach. Review of nursing progress note dated 1/7/26, revealed Resident R72 status post fall vital signs stable. No complaints of pain or distress noted at this time. Resting in chair. Assisted with all needs by nursing staff. Call bell within reach. Plan of care continues. Review of facility progress notes revealed during a care conference held 1/13/26, Resident R72's representative was given a grievance form based on a care concern. Representative stated he would fill it out and bring it back to the facility during his next visit. Review of physician progress note dated 1/14/26, physician monthly note revealed seeing the patient today for routine assessment. She states she is feeling well today. Using hearing aids for hearing loss. Good appetite. Sleeping well. She does report a minor fall last week but states she was not injured. She was being assisted to transfer into bed and stated she could not stand any longer and was lowered to the floor, this occurred 1/5/26. Review of nursing progress notes failed to reveal any further documentation concerning Resident R72 being lowered to the floor by NA on 1/5/26. During an interview completed on 7/16/26, at 10:15 a.m. upon asking the Director of Nursing concerning the event that took place on 1/5/26, stated I was not employed here when it happened. From what I reviewed it seemed that Resident R72 was transferred with assist of one, it was from a grievance received later. I'm not really sure. During a telephonic interview completed on 7/16/26, at 10:45 a.m. upon asking Licensed Practical Nurse Employee E14 concerning the event that took place on 1/5/26, stated I notified the supervisor as soon as it happened. She would have been the one to notify. Resident R72 was lowered to the floor by a NA, no injuries as far as I can remember. During an interview completed on 7/17/26, at 11:10 a.m. upon asking Registered Nurse Assessment Coordinator (RNAC) Employee E12 (former Director of Nursing) concerning Resident R72's event replied I was not in the facility when it happened, I just know from the grievance I received on 1/23/26, that's when I started the investigation. I don't know if it was reported to other administration staff. I just know what I did from 1/23/26, and reviewed the investigation statements, and confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation in a timely manner for one of two residents (Resident R72). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(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 record review, and staff interview, it was determined that the facility failed to ensure the resident's representative was provided with written a notice of transfer for one of four residents (Resident R1), and notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of four resident hospital transfers (R103). Findings include: Review of facility policy Bed Holds and Return dated 5/18/26, indicated all residents or representatives are provided with written information regarding the facility bed hold policies upon admission, upon hospital transfer, and upon therapeutic leave of absence. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and adult failure to thrive. Review of the clinical record indicated Resident R1 was transferred to the hospital on 5/23/26. Review of Resident R1's clinical record revealed the resident was not responsible for self. Review of Resident R1's clinical record failed to include documented evidence that the resident's representative was provided with written a notice of transfer. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/31/26, indicated diagnoses were current. During an interview on 7/15/26, at 1:46 p.m. the Director of Nursing confirmed that the facility failed to maintain documentation that resident's representative were provided a written notice of transfer for Resident R1. Review of the clinical record indicated Resident R103 was admitted to the facility on [DATE]. Review of Resident R103's MDS dated [DATE], indicated diagnoses of anxiety, depression and Amyotrophic lateral sclerosis (ALS-progressive disease that affects nerve cells controlling voluntary muscles, leading to muscle weakness, atrophy, and eventually loss of movement, speech, and breathing). Review of Resident R103's clinical records revealed that on 12/30/25, resident was transferred to the hospital for a change in condition. Review of Resident R103's clinical record revealed that on 12/28/26, resident was transferred to hospital for a change in condition. Review of Resident R103's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE], or 12/28/26. During an interview completed on 7/15/26, at 1:45 p.m. the Director of Nursing confirmed that the clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE], or 12/28/26. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) accurately reflected the resident's status for one of six residents (Residents R1).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and adult failure to thrive. Review of the clinical record indicated Resident R1 was transferred to the hospital on 5/23/26, and readmitted to the facility 5/27/26. Review of Resident R1's hospital discharge summary revealed the resident the resident had a pulmonary embolism, and bladder mass with a history of prostate cancer. Review of Resident R1's MDS dated [DATE], failed to include above diagnoses. Section I: Active Diagnoses failed to include diagnoses of pulmonary embolism, and bladder mass. Interview on 7/15/26, at 12:19 p.m. Registered Assessment Coordinator (RNAC), Employee E7 stated I didn't know he had a pulmonary embolism. RNAC, Employee E7 confirmed the Residents MDS assessment failed to include diagnoses of pulmonary embolism, bladder mass, and history of prostate cancer. Interview on 7/15/26, at 12:24 p.m. the Director of Nursing (DON) confirmed the facility failed to ensure MDS accurately reflected the resident's status for one of six residents (Residents R1). 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received a copy of the baseline care plan and understood the baseline care plan for two of four residents (Resident R1 and R72). Findings include: The facility Assessment Comprehensive Person-Centered care planning policy last reviewed 5/28/26, indicated to assure documentation, development, and implementation of a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. The Interdisciplinary Team (IDT) develops and implements a baseline care plan for each resident, within 48 hours of admission, that includes instructions needed to provide effective and person-centered care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses of high blood pressure, anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and adult failure to thrive. Review of Resident R1's progress note dated 5/22/26, revealed a care conference was held this date. Resident R1 was invited, but did not attend. The resident's representative participated via phone. Care plan was reviewed. Resident R1's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R1 and/or their representative. During an interview on 7/16/26, at 10:55 a.m. the Case Work Supervisor, Employee E18 confirmed there was no evidence that a written summary of the baseline care plan and order summary were provided to Residents R1 or their representative. Review of Resident R72's clinical record indicated an admission date of 9/23/25. Review of Resident R72's Minimum Data Set Assessment (MDS-A periodic assessment of resident care needs) dated 6/3/26, indicated the diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood) and anxiety. Review of Residents R72's clinical record failed to reveal evidence that a baseline care plan was received by the resident or resident representative. During an interview completed on 7/17/26, at 8:41 a.m. the Assistant Director of Nursing Employee E1 confirmed that that a baseline care plan was not received by Resident R72 or Resident R72's representative and that the facility failed to ensure that the resident or resident representative received a copy of the baseline care plan and understood the baseline care plan. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner for one of 12 sampled residents. (Resident R5)Findings include: Review of the clinical record revealed that Resident R5 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses of muscle weakness, muscle wasting and atrophy, and Parkinson's Disease (a disorder of the nervous system that affects movement and gets worse over time). Review of Resident R5's care plan initiated 8/18/25, indicated the resident remained a high risk for pressure injuries due to decreased mobility, incontinence, decrease in nutrition, and decline in overall medical condition. The care plan was revised on 12/9/25, by Registered Assessment Coordinator (RNAC), Employee E12 with interventions that included confer with physician about wound progress or lack of each week during weekly wound rounds. Review of progress note dated 12/7/25, indicated the resident arrived at facility. A deep tissue injury (DTI- a type of pressure-induced tissue damage that begins beneath the skin, often over bony prominences, and can develop into serious wounds if not recognized early) was observed to the resident's left heel. No measurements were obtained. Review of Resident R5's physician progress note dated 12/8/25, failed to include evidence the physician assessed or evaluated the resident's left heel deep tissue injury or skin. The physician failed to provide physician oversight and supervise Resident R5's wound care and treatment. Review of Resident R5's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/20/26, indicated the diagnoses were current. Review of Section M: Skin Conditions indicated the resident was not at risk for developing pressure ulcers. It was revealed the resident had one unstageable deep tissue injury that was present upon admission/reentry. Review of Resident R5's physician orders from 1/7/26, to 1/26/26, failed to include an order to apply skin prep (or similar protective barrier film) to bilateral heels. Review of Resident R5's wound assessment dated [DATE], indicated the resident developed a right heel stage three pressure ulcer that was not present on admission/reentry. The pressure ulcer measure 1.2 centimeters (cm) x 1.4 cm with light bloody exudate. Review of Resident R5's clinical record failed to include an order for the resident's right heel stage three pressure ulcer for 1/26/26, and 1/27/26. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 revealed the resident had a right heel unstageable pressure injury (occurs when prolonged pressure, often over bony prominences such as the heels, sacrum, hips, or tailbone, causes localized tissue damage and necrosis, but the true depth of the wound is obscured by dead tissue or other coverings). The measurements were 4.7 cm x 3.2 cm. Small amount of sero-sanguineous drainage (a type of wound exudate that is a mixture of serous (a type of fluid that comes out of a wound with tissue damage) fluid and small amounts of blood was noted. Treatment orders included to cleanse right heel with normal saline (a sterile solution used primarily for wound irrigation and cleansing), apply xeroform (a sterile, non-adherent petrolatum gauze dressing containing microbial agents, used to protect wounds and promote moist healing while reducing infection risk) cover with dry clean dressing daily, and change as needed. It was documented the plan of care and education was discussed with facility staff. The wound increased in size. Review of Resident R5's physician orders from 1/28/26, to 2/4/26, failed to include an order to cleanse right heel with normal saline, apply xeroform, cover with dry clean dressing daily, and change as needed. The facility failed to follow wound care orders and treatment. Review of Resident R5's physician progress note dated 2/3/26, failed to include evidence the physician evaluated or assessed the resident's right heel wound or skin. The physician failed to provide physician oversight and supervise Resident R5's wound care and treatment. Review of Resident R5's wound care assessment dated [DATE], completed by CRNP, Employee E8 revealed the resident's right heel had copious amounts of green drainage. The wound measure 5.7 cm x 5.4 cm. The wound was deteriorating. The peri wound skin presents with signs and symptoms of infection. A wound culture, and an x-ray was ordered. Review of Resident R5's progress note dated 2/4/26, revealed the resident was observed on wound rounds. Serous drainage noted to right heel wound. New orders for wound culture, right foot x-ray, right foot venous doppler. Testing ordered through express mobile, heel wound culture obtained. Resident placed in enhanced barrier precautions (EBP).Review of Resident R5's wound culture results dated 2/7/26, revealed there were heavy growth of pseudomonas aeruginosa (a bacteria that can cause infections). Review of Resident R5's clinical record from 12/8/25, to 2/7/26, failed to include evidence the physician supervised care in a timely manner for Resident R5's wound care and treatment. During an interview on 7/17/26, at 11:56 a.m. the Assistant Director of Nursing (ADON) Employee E1, confirmed the facility failed to ensure that a physician supervised care in a timely manner for one of 12 sampled resident (Resident R5). 28 Pa. code 211.2(d)(3) Medical director.

Based on clinical record review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews (MRR) were completed by the facility for two of six residents (Resident R48 and R72). Findings include: Review of the facility policy Resident Medication Regimen Review last reviewed 5/28/26, indicated pharmacists will review all charts in accordance with the standard established by the American Society of Consult Pharmacist in accordance with state and federal recommendations. The goal of this review is to promote positive outcomes and minimize adverse consequences associated with medication; the review includes preventing, identifying, reporting and resolving medication related problems, medication errors. or other irregularities and collaborating with other members of the Interdisciplinary Team (IDT). Review of admission record indicated Resident R48 was admitted to the facility on [DATE]. Review of Resident R48's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/4/26, indicated the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain), and depression. Review of Resident R48's MRR dated 6/10/26, indicated the following recommendation from the pharmacist to the physician: Can we safely add Jardiance (medication used to treat high blood sugars) 10 milligrams daily to optimize residents' diabetes? Recommendation: Review of Resident R48's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 6/10/26. On 6/27/25, a Physician Assistant (PA) addressed the MRR, stating, Jardiance added. Review of Resident R48's MRR dated 1/15/26, indicated the following recommendation from the pharmacist to the physician: Based on resident's blood sugars, please consider a dose increase in Metformin (a medication used to treat high blood sugar) for better control. Recommendation: Review of Resident R48's clinical record failed to include a response from the resident's attending physician regarding the recommendation made on 1/15/26. On 1/21/26, a PA addressed the MRR, stating, Check labs on 1/27/26 then will evaluate Metformin. During an interview on 7/17/26, at 9:26 a.m. the Assistant Director of Nursing Employee E1 confirmed the above findings and that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for Resident R48. Review of Resident R72's clinical record indicated an admission date of 9/23/25. Review of Resident R72's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure), diabetes, and anxiety. Review of Resident R72's MMR dated 5/12/26, indicated the following: Second request: At the psychiatric (psych) IDT meeting held on 4/15/26, staff mentioned that Resident R72 is anxious despite treatment with Buspar. Resident R72 is due for a psych follow up evaluation. Please refer to psych (last seen 10/21/25) to evaluate if Resident R72 may benefit from additional psych medications to help treat her anxiety/possible depression. Review of Resident R72's clinical record failed to include documentation that Resident R72 completed a psych evaluation. Review of Resident R72's MRR dated 6/4/26, indicated the following: Third request: At the psych IDT meeting held on 4/15/26, staff mentioned that Resident R72 is anxious despite treatment with Buspar. Resident R72 is due for a psych follow up evaluation. Please refer to psych (last seen 10/21/25) to evaluate if Resident R72 may benefit from additional psych medications to help treat her anxiety/possible depression. Review of Resident R72's clinical record failed to include documentation that Resident R72 completed a psych evaluation. During an interview completed on 7/17/26, at 2:20 p.m. the Assistant Director of Nursing Employee E1 confirmed that the MMRs were not followed up with the Psych recommendations for Resident R72 and that facility failed to ensure Medication Reviews were completed by the facility for Resident R72. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.9 (k) Pharmacy services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for two of three residents (Residents R7 and R72).Findings include: The facility Assessment Comprehensive Person-Centered care planning last reviewed 5/28/26, indicated to assure documentation, development, and implementation of a comprehensive person-centered care plan for all residents to attain or maintain the highest practicable physical, mental and psychosocial wellbeing. The Interdisciplinary Team (IDT) develops, reviews, revises, and implements a comprehensive person-centered care plan for each resident, consistent with resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. Review of Resident R7's clinical record indicated an admission date of 11/9/19. Review of Resident R7's Minimum Data Set Assessment (MDS-A periodic assessment of resident care needs) dated 4/21/26, indicated the diagnosis of hypertension (high blood pressure), depression and right hip fracture. During an observation completed on 7/13/26, at 12:12 p.m. Resident was sitting on the edge of her bed getting ready to eat her lunch. A bedside commode was viewed at the foot of her bed. During an observation completed on 7/14/26, at 2:18 p.m. Nurse Aid Employee E5 was observed emptying the bedside commode. Review of Resident R7's current care plan failed to have intervention for the bedside commode. During an interview completed on 7/14/26, at 2:28 p.m. the Assistant Director of Nursing Employee E1 confirmed that Resident R7's current care plan failed to have interventions for a bedside commode and that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for Resident R7. Review of Resident R72's clinical record indicated an admission date of 9/23/25. Review of Resident R72's MDS dated [DATE], indicated the diagnosis of hypertension, diabetes, and anxiety. Review of Resident R72's care plan with approach start date 10/24/25, indicated ADL assistance needed. Transfer training sit to stand, supine to sit moderate/maximum (MOD/MAX) assist. The care plan failed to indicate the number of staff required for transfers. Review of Resident R72's physician orders dated 11/25/25, revealed ADL-transfers: assist of 2. During an interview completed on 7/17/26, at 11:10 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E12 confirmed that Resident R72's transfer status was not updated in the care plan with the order change on 11/25/25, and that facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for Resident R72. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of clinical records and staff interviews it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Residents R61 and Resident R123).Findings Include: Review of the Oxygen Guideline policy last reviewed 5/28/26, indicated it is the facility policy to administer oxygen when prescribed to provide comfort and improve quality of life. Sets ups (cannulas, face masks, respiratory delivery, humidification bottles) should be changed at least every seven days and are labeled with date of change initiated by staff. Humidification bottles should be filled with distilled water and should be checked every shift and filled if needed. Review of the clinical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses of lymphedema, morbid obesity, and muscle wasting and atrophy. Review of Resident R61's physician order dated 6/26/26, indicated to administer 2 Liters (L) of oxygen at all times. Review of Resident R61's care plan dated 6/28/26, revealed a care plan with a category of behavioral symptoms. It was indicated the resident had high blood pressure and heart failure and uses oxygen continuously. Interventions included to monitor for tolerance to activities/self-care (fatigue, shortness of breath, pallor (unusually pale skin) or cyanosis (a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood), vertigo (feeling of spinning), weakness, etc.). Ensure oxygen is placed, check oxygen saturation ( measures the fraction of hemoglobin molecules in the blood that are carrying oxygen at a given time) as needed for shortness of breath. Review of Resident R61's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/2/26, indicated the diagnoses were current. During an observation on 7/13/26, Resident R61 was observed utilizing oxygen. The humidification canister was empty and there was no date observed on the resident's nasal cannula tubing. During an interview on 7/13/26, at 10:30 a.m. Licensed Practical Nurse (LPN), Employee E19 confirmed the resident's humidification canister was empty and the nasal cannula tubing was undated. Review of the clinical record indicated Resident R123 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure with hypoxia, lymphedema, and anxiety. Review of Resident R123's MDS dated [DATE], indicated the diagnoses were current. Review of Resident R123's care plan dated 7/20/22, indicated the resident has the potential for respiratory distress due to requiring oxygen and sleep apnea. Review of Resident R123's physician order dated 7/28/24, indicated to administer 3 Liters (L) of oxygen from 8:00 a.m. to 8:00 p.m. titrate to keep blood oxygen saturation above 92%. Review of Resident R123's physician order dated 2/4/26, indicated to ensure oxygen humidifier bottle is filled appropriately. During an observation on 7/13/26, at 9:36 a.m. Resident R123 was observed receiving oxygen via nasal cannula and the humidification bottle was empty. During an interview on 7/13/26, at 9:44 a.m. Nurse Aide (NA) Employee E9, confirmed Resident R123's humidification was empty. During an interview on 7/15/26, at approximately 3:00 p.m. information was disseminated to the Director of Nursing the facility failed to provide appropriate respiratory care for two of four residents (Residents R61 and Resident R123). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility documents, facility policy, clinical records, resident interviews, and staff interviews, it was determined that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide adequate supervision and assistance for one of two residents (Resident R2), which resulted in actual harm of a hematoma (localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2. Findings include: Review of facility policy Accident Prevention dated 1/2/25, indicated it is the policy of the facility to prevent resident accidents and injuries to the extent possible by maintaining an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. Review of facility policy Abuse, Resident and Reasonable Suspicion of a Crime dated 1/2/25, indicated that facility will treat every resident with consideration, respect, and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property program. Definition of neglect is defined by 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 facility job description for Nursing Assistant (NA), indicated that staff will provide each of his or her assigned residents with routine daily individualized nursing care and services in a safe and effective manner using therapeutic interactions in accordance with the resident ' s assessment and care plan to assure that the highest degree of quality resident care is maintained at all times. Duties and responsibilities include delivers care in accordance with the daily review of the resident ' s care plan, provides personal hygiene to residents such as bathing, toileting incontinent residents, and grooming. NA will utilize safe techniques in care of residents. Review of Resident R1's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 4/7/25, indicated diagnoses of high blood pressure, arthritis, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Resident R1's MDS assessment section C0200 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. Resident R1's BIMS score was a 1 indicating Resident R1 was severe impairment. Review of Section GG Functional Abilities GG0120 was coded wheelchair for device. During a review of Resident R1's physician orders dated 6/12/25, at 11:04 a.m. indicated that resident to wear post op shoe to right foot when out of bed daily for eight weeks for right 5th toe fracture. Review of a written witness statement dated 6/11/25, from NA Employee E6 stated: While taking Resident R1 down the hall for her shower, she put both of her feet down and I think that's where the open wound came from on her foot. During her shower saw right lateral (side) foot with open area. During an interview conducted by Assistant Director of Nursing Employee E7 on 6/12/25, with NA Employee E6, NA stated I wheeled resident to shower room. I wasn ' t paying attention to her feet, but at some point Resident R1 lowered her foot all the way down to the floor and her shoe came off. I took her to the shower and afterwards we took the resident back to her room. During an interview conducted by Assistant Director of Nursing Employee E7 on 6/12/25, with NA Employee E9, NA stated I was helping NA Employee E6 with a shower. Halfway down the hallway she dropped her feet and then turned her around in the wheelchair and then pulled her backwards because it was safer pushing her backwards. She seemed out of it all day. Review of documentation provided by the facility dated 6/12/25, stated the following: On 6/11/25, at 8:00 a.m. Resident R1 was taken to the shower room by two NA's. As per NA Employee E6, resident was wearing a gown and her black shoes, was in wheelchair that had no footrests. While wheeling the resident to the shower room, resident dropped her foot all the way down, her shoe came off. NA could not remember if she put shoe back on. NA continued to wheel resident with her foot all the way down. Once in the shower room, resident placed in shower chair and the Registered Nurse (RN) came in to do shower skin assessment. The nurse noticed a bruise on the right dorsal (refers to the back of foot). Description of follow-up action: Investigation was initiated immediately. NA's removed from the assignment. Resident was assessed, a bruise observed on the right foot which presented with scattered petechiae (tiny, flat, reddish or purple spots on the skin caused by minor bleeding from capillaries (small blood vessels). Physician was notified and ordered a X-ray of the foot. During a review of Resident R1's clinical record on 7/7/25, at 12:04 p.m. indicated results of X-ray to right foot were an acute fracture of the 5th proximal phalanx neck (left side of little toe). During a review of facility provided documentation labeled Resident Incident/Event Investigation Form dated 6/11/25, at 10:00 a.m. indicated Registered Nurse Employee E8 completed the form. Describe Injury: Right foot reddened/open areas 1.0 cm by 4.0 cm by 0.1 c.m. Resident dropped foot down when being taken to shower room. During an observation on 7/7/25, at 1:02 p.m. Resident R3 was observed being pushed in her wheelchair without leg rests by Beautician Employee E2. During an observation on 7/7/25, at 1:03 p.m. R5 was observed being pushed in her wheelchair without leg rests by an unidentified employee. During an observation on 7/7/25, at 1:05 p.m. Resident R4 was observed being pushed in her wheelchair without leg rests by NA Employee E4. During an interview on 7/7/25, at 1:15 p.m. Director of Nursing stated that leg rest orders are not ordered by the physician for anyone typically and staff know if residents do have leg rests because they are sitting on the wheelchair. DON stated the facility failed to inform nursing staff of who needs leg rests, and they would know only if leg rests were on the chair. During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 stated that leg rests are in their room or on their chair. If they don ' t have any, I will ask them to hold their legs up. During an interview on 7/7/25, at 1:48 p.m. NA Employee E10 was asked, How do you know if someone needs leg rests? NA Employee E10 stated I ' m not gonna lie, I can't give you an answer. If I was to push someone, I would look for leg rests. During an interview on 7/7/25, at 2:58 p.m DON stated that Resident R1 was being pushed to the shower room without leg rests, resident dropped her feet to the floor and sustained a fractured toe on 6/11/25. During an interview on 7/7/25, at 3:04 p.m DON stated that NA Employee E6 was an agency employee and was put on the facilities Do Not Return list. Review of Resident R2's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 5/21/25, indicated diagnoses of depression, high blood pressure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Resident R2's MDS assessment section C0200 BIMS score was a 15 indicating Resident R2 was cognitively intact. Review of Resident R2's MDS Section GG- Functional Abilities were as follows: - Toileting was coded a 1- dependent, helper does all the effort - Shower/Bathe Self was coded a 2- Substantial Maximum Assistance, helper does more than half the effort - Roll left and right was coded a 1- dependent, helper does all the effort Review of Resident R2's care plan dated 5/22/25, indicated Activity of Daily Living Functional Bed Mobility Assistance. Long term goal indicated resident will accept assistance of two for bed mobility, and tasks while on air mattress. Approach indicated is to provide assist of two at all times for bed mobility related tasks. Air mattress will increase and decrease pressure with rolling, and movement and may increase risk for injury. Review of a written witness statement dated 6/14/25, from NA Employee E1 stated, Resident rolled out of bed. When asked, Did you know or were you aware that Resident R2 was a two assist for bed mobility? NA Employee E1stated, No. When asked, Did you have the assignment sheet? NA Employee E1 stated, Yes, but I do not know if that was on there. I saw a metal box and I asked the resident to lean towards me, more on your back and I stood in the doorway to talk to the nurse to ask what it was and to get a new patch on the wire. At that time, I heard a loud bang and then my worst fear came true, my resident fell out of bed. Review of documentation provided by the facility dated 6/14/25, stated the following: Factual Description. On 6/14/25, at approximately 1:00 p.m. NA Employee E1 was providing care to Resident R2. During care, the NA placed the resident in a lateral position (side lying) near the edge of the bed. While the resident remained in this position NA Employee E1 noted a spinal cord stimulator (an implanted device in the body that had wires exposed within a wound) and stepped out of the room to consult with the nurse regarding whether a new patch was required. While unattended, the resident rolled out of bed. Description of follow-up action: Immediate assistance was provided, physical assessment performed, bleeding from above the left eyebrow was noted, both knees presented with bruising. Supervisor determined Resident R2 was able to be moved, was transferred back to bed via a Hoyer lift (a mechanical lift) with three caregivers present. A full post fall evaluation was conducted. At the time of the incident, the resident had a care plan and assignment sheet indicating that two caregivers were required for bed mobility and personal care, but the NA stated that she was unaware that a second caregiver was required, although the assignment sheet clearly reflects this instruction. MD, family, and Adult Protective Serviced notified. The NA was removed from the schedule. Education will be provided to all aides regarding the requirement for two-person assistance with bed mobility. In addition, staff will be instructed to review their assignments thoroughly prior to the start of each shift to ensure awareness of residents' specific care needs and safety precautions. During an interview on 7/7/25, at 2:44 p.m. the facility was unable to provide the education provided to all aides regarding two-person assistance with bed mobility and to review their assignment every shift per facilities plans of correction as described in their follow up action to incident. During a review of Resident R2's physician orders dated 8/14/24, indicated resident's Bed Mobility: Assist of two due to air mattress. Review of documentation provided by the facility labeled Event Report dated 6/14/25, indicated that Resident R2's fall that occurred on 6/14/25, in her room. Fall was unwitnessed as NA Employee E1 went to the door to ask the nurse a question and heard resident yell for help. Resident R2 reported pain to her right knee. Resident was observed on the floor next to her bed and stated, I was too close to the edge of the bed and rolled off. Resident was bleeding from around her left eye, forehead and bilateral knees. During a review of Resident R2 progress note dated 6/14/25, indicated that resident has a hematoma to left side of forehead measuring approximately 5.0 cm by 4.5 cm, resident has a small laceration above left eye, 1.0 cm long with moderate bleeding that has stopped. Steri-strips (a thin adhesive strip used to close small wounds, lacerations, and surgical incisions). Resident sustained hematoma under her left eye approximately 3.0 cm by 2.0 cm. Right knee hematoma that measures approximately 4.0 cm by 3.0 cm. Spoke to physician who ordered hold Xarelto (blood thinner) for two days, monitor neurological status, Xray ordered to bilateral knees due to pain. Daughter was notified. Review of a written witness statement dated 6/14/25, from Registered Nurse (RN) Employee E3 stated: I was standing in the hallway at the medicine cart when NA Employee E1 came out of the room to as a question. Resident R2 yelled from the room. Employee E1 and I entered room to find resident on the floor. Resident R2 stated she was too close to the edge of her bed, and she rolled off to the floor. Resident was bleeding form her left eye area, forehead and bilateral knees with hematomas. Resident placed back into bed. Physician was notified. During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 indicated that Resident R2 required assist of two. The amount of assistance a resident needs is on our assignment sheets. I would not leave anyone unattended during care. During an interview on 7/7/25, at 1:13 p.m. NA Employee E5 stated that if a resident is on an air mattress, it takes two people, or if I check assistance level in the computer or assignment sheets and it says two, I get someone to help me. I wouldn't ever leave someone unattended if I was giving care. During an observation on 7/7/25, at 1:30 p.m. Resident R2 had light bruising noted to her left side of her face that included forehead, around left eye, and left cheek. During an interview on 7/7/25, at 1:33 p.m. Resident R2 was lying in bed with the television on. Resident stated, An aide left me at the edge of the bed, and I fell out of bed. Two NA's help me now since my fall. During an interview on 7/7/25, at 3:15 p.m. Director of Nursing (DON) stated that Resident R2 did fall out of bed on 6/14/25, was left unattended and received injuries. DON stated that NA Employee E1 was an agency aide and was put on a Do Not Return list related to the incident findings. During an interview on 7/7/25, at 3:45 p.m. the DON confirmed that the facility failed to provide appropriate equipment to prevent an accident for one of two residents (Resident R1), which resulted in actual harm of bruising and a fracture of residents right foot for Resident R1, and failed to provide appropriate goods and services to prevent falls for one of two residents (Resident R2), which resulted in actual harm of a hematoma on residents left side of forehead, a laceration above the left eye, and a hematoma to right knee with pain for Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R2), which resulted in actual harm of a hematoma (a localized collection of blood outside the blood vessels, typically caused by blood vessel damage from trauma or injury) on residents left side of forehead, a laceration (cut) above the left eye, and a hematoma to right knee with pain for Resident R2. Findings include: Review of facility policy Abuse, Resident and Reasonable Suspicion of a Crime, dated 1/2/25, indicated that facility will treat every resident with consideration, respect, and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property program. Definition of neglect is defined by 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 facility job description for Nursing Assistant (NA), indicated that staff will provide each of his or her assigned residents with routine daily individualized nursing care and services in a safe and effective manner using therapeutic interactions in accordance with the resident's assessment and care plan to assure that the highest degree of quality resident care is maintained at all times. Duties and responsibilities include delivers care in accordance with the daily review of the resident ' s care plan, provides personal hygiene to residents such as bathing, toileting incontinent residents, and grooming. NA will utilize safe techniques in care of residents. Review of Resident R2's admission record indicated resident was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) dated 5/21/25, indicated diagnoses of depression, high blood pressure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Resident R2's MDS assessment section C0200 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, Resident R2's BIMS score was a 15 indicating Resident R2 was cognitively intact. Review of Resident R2's MDS Section GG- Functional Abilities were as follows: - Toileting was coded a 1- dependent, helper does all the effort - Shower/Bathe Self was coded a 2- Substantial Maximum Assistance, helper does more than half the effort - Roll left and right was coded a 1- dependent, helper does all the effort Review of Resident R2's care plan dated 5/22/25, indicated Activity of Daily Living Functional Bed Mobility Assistance. Long term goal indicated resident will accept assistance of two for bed mobility, and tasks while on air mattress. Approach indicated is to provide assist of two at all times for bed mobility related tasks. Air mattress will increase and decrease pressure with rolling, and movement and may increase risk for injury. Review of a written witness statement dated 6/14/25, from NA Employee E1 stated, Resident rolled out of bed. When asked, Did you know or were you aware that Resident R2 was a two assist for bed mobility? NA Employee E1 stated, No. When asked, Did you have the assignment sheet? NA Employee E1 stated, Yes, but I do not know if that was on there. I saw a metal box and I asked the resident to lean towards me, more on your back and I stood in the doorway to talk to the nurse to ask what it was and to get a new patch on the wire. At that time, I heard a loud bang and then my worst fear came true, my resident fell out of bed. Review of documentation provided by the facility dated 6/14/25, stated the following: Factual Description. On 6/14/25, at approximately 1:00 p.m. NA Employee E1 was providing care to Resident R2. During care, the NA placed the resident in a lateral position (side lying) near the edge of the bed. While the resident remained in this position NA Employee E1 noted a spinal cord stimulator (an implanted device in the body that had wires exposed within a wound) and stepped out of the room to consult with the nurse regarding whether a new patch was required. While unattended, the resident rolled out of bed. Description of follow-up action: Immediate assistance was provided, physical assessment performed, bleeding from above the left eyebrow was noted, both knees presented with bruising. Supervisor determined Resident R2 was able to be moved, was transferred back to bed via a Hoyer lift (a mechanical lift) with three caregivers present. A full post fall evaluation was conducted. At the time of the incident, the resident had a care plan and assignment sheet indicating that two caregivers were required for bed mobility and personal care, but the NA stated that she was unaware that a second caregiver was required, although the assignment sheet clearly reflects this instruction. MD, family, and Adult Protective Serviced notified. The NA was removed from the schedule. Education will be provided to all aides regarding the requirement for two-person assistance with bed mobility. In addition, staff will be instructed to review their assignments thoroughly prior to the start of each shift to ensure awareness of residents' specific care needs and safety precautions. During an interview on 7/7/25, at 2:44 p.m. the facility was unable to provide the education provided to all aides regarding two-person assistance with bed mobility and to review their assignment every shift per facilities plans of correction as described in their follow up action to incident. During a review of Resident R2's physician orders dated 8/14/24, indicated resident's Bed Mobility: Assist of two due to air mattress. Review of documentation provided by the facility labeled Event Report dated 6/14/25, indicated that Resident R2's fall that occurred on 6/14/25, in her room. Fall was unwitnessed as NA Employee E1 went to the door to ask the nurse a question and heard resident yell for help. Resident R2 reported pain to her right knee. Resident was observed on the floor next to her bed and stated, I was too close to the edge of the bed and rolled off. Resident was bleeding from around her left eye, forehead and bilateral knees. During a review of Resident R2 progress note dated 6/14/25, indicated that resident has a hematoma to left side of forehead measuring approximately 5.0 cm by 4.5 cm, resident has a small laceration above left eye, 1.0 cm long with moderate bleeding that has stopped. Steri-strips (a thin adhesive strip used to close small wounds, lacerations, and surgical incisions). Resident sustained hematoma under her left eye approximately 3.0 cm by 2.0 cm. Right knee hematoma that measures approximately 4.0 cm by 3.0 cm. Spoke to physician who ordered hold Xarelto (blood thinner) for two days, monitor neurological status, Xray ordered to bilateral knees due to pain. Daughter was notified. Review of a written witness statement dated 6/14/25, from Registered Nurse (RN) Employee E3 stated: I was standing in the hallway at the medicine cart when NA Employee E1 came out of the room to ask a question. Resident R2 yelled from the room. Employee E1 and I entered room to find resident on the floor. Resident R2 stated she was too close to the edge of her bed, and she rolled off to the floor. Resident was bleeding from her left eye area, forehead and bilateral knees with hematomas. Resident placed back into bed. Physician was notified. During an interview on 7/7/25, at 1:00 p.m. NA Employee E4 indicated that Resident R2 required assist of two. The amount of assistance a resident needs is on our assignment sheets. I would not leave anyone unattended during care. During an interview on 7/7/25, at 1:13 p.m. NA Employee E5 stated that if a resident is on an air mattress, it takes two people, or if I check assistance level in the computer or assignment sheets and it says two, I get someone to help me. I wouldn ' t ever leave someone unattended if I was giving care. During an observation on 7/7/25, at 1:30 p.m. Resident R2 had light bruising noted to her left side of her face that included forehead, around left eye, and left cheek. During an interview on 7/7/25, at 1:33 p.m. Resident R2 was lying in bed with the television on. Resident stated, An aide left me at the edge of the bed, and I fell out of bed. Two NA's help me now since my fall. During an interview on 7/7/25, at 3:15 p.m. Director of Nursing (DON) stated that Resident R2 did fall out of bed on 6/14/25, was left unattended and received injuries. DON stated that NA Employee E1 was an agency aide and was put on a Do Not Return list related to the incident findings. During an interview on 7/7/25, at 3:45 p.m. the DON confirmed that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R2), which resulted in actual harm of a hematoma on residents left side of forehead, a laceration above the left eye, and a hematoma to right knee with pain for Resident R2. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(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, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). Findings include: Review of the policy Accident Prevention dated 1/2/25, indicated the facility policy is to prevent resident accidents and injuries to the extent possible by maintaining, as much as possible, an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. Review of the policy Wanderguard and Elopement dated 1/2/25, indicated the facility implements safety measures for residents who wander and/or are at risk for elopement to attempt to prevent elopement. Nursing evaluates resident upon admission and when the resident exhibits an exit seeking behavior in the Electronic Health Record (EHR) - Elopement Observation. Implements person-centered interventions to attempt to prevent elopement. Review of the admission record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/15/25, indicated the diagnoses of metabolic encephalopathy (a brain disorder caused by metabolic disturbances in the body, leading to impaired brain function), repeated falls, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Section C0500 indicated a Brief Interview for Mental Status (BIMS - a screening test that aides in detecting cognitive impairment) score of 12 - moderately impaired cognition. Review of Resident R6's Elopement Observation dated 10/24/24, indicated no elopement risk factors identified or verbalized. Review of Resident R6's Elopement Observation dated 10/30/24, indicated new admission who has made statements questioning the need to be here checked yes. Does the resident exhibit any additional elopement risk criteria? - Other -wanting to go outside was checked as yes. Elopement care plan initiated. Review of Resident R6's care plan dated 10/30/24, indicated behavioral symptoms - apply wanderguard (a bracelet that alerts staff if a resident has gone through an alarmed doorway to the outside of the facility) to resident. Check placement of wanderguard every shift. If not on resident, then replace as soon as possible. Check function every night. Review of Resident R6's care plan intervention dated 10/31/24, indicated resident needs supervision to go outside to the courtyard. Review of Resident R6's progress notes indicated 31 occasions of incidents of confusion, resisting care, agitation, self-propelling up and down hallways, being found on the basement level of the facility, seven falling episodes and ultimate elopement from 3West Unit on 3/14/25, as follows: -10/24/24, at 3:00 p.m. indicated resident is alert and oriented at baseline but brother states resident is having some short-term memory issues related to recent urinary tract infections. Resident had fallen at his personal care home and hurt his wrist. Resident enjoys being outside and sitting in the sun. Resident's brother states resident has been doing this for years. -10/25/24, at 2:02 p.m. care conference indicated resident requires this level of care as lesser levels of care were unsuccessful. -10/25/24, at 10:18 p.m. indicated resident transfers with assist of one and self-propels in wheelchair independently. -10/26/24, at 2:43 p.m. Indicated resident is alert, verbal, confused at times. Self-propels in wheelchair around room and unit. -10/27/24, 6:39 a.m. indicated resident gets in and out of bed unassisted and sits in wheelchair. Somewhat confused. -10/27/24, 2:24 p.m. indicated resident alert, verbal, confused at times. -10/28/24, 2:20 p.m. indicated resident presented as alert and oriented times three, with periods of forgetfulness. Resident has short term memory loss and is very social. -10/30/24, at 3:14 p.m. indicated resident verbalized wanting to go outside. Courtyard assessment completed and found resident to be unsafe to do so without supervision. Resident's cognition fluctuates. His confusion increases at different times of the day as well as when resident has a medical issue occurring. Resident's brother reported resident would stay outside for hours on end in extreme heat and not drink or use the restroom which had resulted in multiple infections and episodes of dehydration prior to placement. Resident does lack safety awareness. Residents gets irritated at times when resident is reminded of safety issues including going outside and verbalizing to staff, resident would go regardless of supervised request. A wander guard has also been ordered. -11/6/24, 12:34 p.m. indicated resident was refusing grip socks. Resident's brother indicated resident is impulsive and implored resident that it's easier to call for help to the chair than help off of the floor. Resident is non-compliant. -11/7/24, at 5:29 a.m. resident found in wheelchair dressing himself. Resident indicated he is able to do for himself without help and refused for staff's assistance. After resident dressed, he self-propelled up and down the corridor. Resident is non-compliant. -11/7/24, at 12:47 p.m. indicated resident was seen by therapy, then within the hour was found to be walking around in the room, pants at his ankles and brief around his knees. Resident was very agitated. This has become regular practice that resident exhibits impulsiveness and sudden mood changes. -11/7/24, physician note indicated staff called earlier today because it seems like resident is having a little bit of an adjustment, where resident becomes quickly agitated with staff. Also seemed a little more confused than normal. The staff found resident urinating throughout his room, instead of in the bathroom where resident normally goes. -11/8/24, at 7:48 a.m. indicated resident alert to name only. Confused to time and place. Resident stated sometimes he does feel anxious, agitated, and depressed at times. Resident is often not asking staff for help when he needs help with transfers. Resident does have a history of encephalopathy. Staff noting that resident has periods of increased confusion as well as emotional lability. -11/20/24, physician note indicated staff noting that resident has periods of increased confusion as well as emotional lability. Resident said he likes to do outdoor activities and would previously kayak. IMPRESSION AND PLAN: 1. Normal pressure hydrocephalus (a rare condition that occurs when too much cerebrospinal fluid builds up in the brain) has caused chronic gait abnormality and imbalance. Mostly scoots around in the wheelchair. Also has led to some increased confusion and memory issues. Monitor closely. -12/15/24, at 2:25 a.m. indicated resident found on the floor. Registered Nurse (RN) in to initiate investigation. -12/17/24, at 12:11 p.m. indicated resident continues to transfer independently. -12/26/24, at 1:33 p.m. indicated resident continues to be non-compliant. -12/27/24, physician's note indicated resident incorrectly told me that when he fell , he went to the emergency room and had X-rays, but it was confirmed with the staff that this was simply not true. Resident does have baseline confusion. IMPRESSION AND PLAN: Fall. Again, this was 11 days ago. Resident did not complain of left arm pain initially to the staff. Staff does report that there are times they have discovered that resident has fallen and does not tell people. -1/26/25, at 10:59 a.m. resident with increasing agitation. Staff found stool on the floor and on resident and offered to help clean resident, but resident refused. -1/26/25, at 1:17 p.m. indicated while Nurse Aide (NA) was delivering lunch tray into residents' room, resident was seen in bathroom on the floor, in a sitting position underneath the sink. Resident explained he placed himself on the floor to do plumbing. Water was slowly coming out of the pipes underneath the sink. -2/8/25, 12:33 p.m. indicated resident was found sitting on floor in front of toilet in his bathroom. -2/9/25, at 6:03 a.m. indicated resident observed sitting on the edge of low bed at approximately 4:45 a.m. Assisted into wheelchair per resident request. Resident easily agitated with staff intervention. Remains moderate fall risk with impaired safety awareness. -2/17/25, at 4:15 a.m. physician note indicated a note in the communication book said resident has had some confusion. The resident does admit that he had some confusion last week and starting maybe ten days ago. Resident had a urinary tract infection. -2/19/25, at 6:31 a.m. indicated resident with increased confusion this, and prior shift. Hard time accepting help. Attempting to exercise in the bathroom and refusing to let staff help transfer to wheelchair. -2/19/25, at 11:50 a.m. indicated NA reported resident refused care this morning. Refused to go to orthopedic appointment and refused again to be cleaned up by NA. -2/20/25, physician's note indicated staff reported resident is having increased pain and noted to be more confused. -3/10/25, at 8:12 p.m. indicated resident was moving around the facility at approximately 7:00-7:15 pm. Resident was seen on the first floor (basement) by NA Employee E15, who notified the supervisor. But then resident's nurse Licensed Practical Nurse (LPN) Employee E16 came by, re-oriented resident and took resident back to his unit. Resident was placed safely in resident's room. Wanderguard is on the left wrist. Resident will be monitored every hour until midnight. When supervisor asked resident why he was on the first floor, resident said he wanted to see the sunset. -3/11/25, at 10:20 p.m. indicated resident self-propels throughout facility. Every one-hour checks maintained. -3/12/25, at 4:37 p.m. indicated staff notified that resident can't leave unit without supervision. -3/14/25, at 7:53 p.m. indicated spoke with resident's brother regarding resident wanting to go outside and safety concerns. Resident has wanderguard and needs to be supervised when outside in the courtyard. Resident on every two-hour safety checks due to recent increase in leaving the unit and trying to go outside. Resident's brother explained that resident loves to be outside and will spend most of his time out there if he can. Resident's brother said that he would try to come visit as often as possible to take him outside. -3/14/25, at 9:57 p.m. indicated around 3:45 p.m. NA reported that Resident R6 had eloped to the second floor and that she brought him up in his wheelchair. Review of the clinical record failed to include an Elopement Observation on 3/10/25, when Resident R6 was found in the basement unsupervised. Review of Resident R6's care plan failed to include an update or revision after resident was found in the basement unsupervised on 3/10/25. Review of a submitted facility document dated 3/14/25, at 3:30 p.m. indicated Resident R6's whose orders for level of supervision indicated may not leave third floor without supervision, was found on the second floor of the facility. Resident was seen on closed caption television getting on the elevator alone at 3:29 p.m. Resident attempted to go into the courtyard and was unsuccessful because the wanderguard alarmed. Resident is not permitted in the courtyard unsupervised. At 12:30 p.m. resident heads towards security (who turned the wanderguard alarm off). At 3:33 p.m. resident was observed in the second-floor activity room where activities were doing an activity. Interview on 4/7/25, at 9:50 a.m. Unit Clerk Employee E17 indicated some residents have wanderguards, night shift checks placement and function. When asked if there was a book with high-risk residents who wander on the unit, she replied no. Security has one on the second floor at the facility's entrance. Interview on 4/7/25, at 9:55 a.m. LPN Employee E18 indicated the wanderguard alarm goes off to the outside doors. The wanderguard doesn't stop residents from getting on and using the elevator. Interview on 4/7/25, at 10:00 a.m. Registered Nurse (RN) Employee E6 indicated in the evenings and overnight they have the elevators set so you cannot go to the basement. Staff cannot go from second floor or third floor to the basement on the evening or night shifts. Staff use the stairs. When asked who is in charge of the wander management program, RN Employee E6 indicated she believed it was Security or Administration, and that there was a list of wanderguards but no photographs. There's also a graph in the back of the DEA (narcotic book) book, which she went into the locked medication room to retrieve and brought back to the nursing desk area. Interview on 4/7/25, at 10:15 a.m. NA Employee E19 indicated we try to keep an eye on the ones that wander around. Interview on 4/7/25, at 12:53 p.m. LPN Employee E16 indicated on 3/10/25, she recalled coming back from dinner, and saw Resident R6 on the basement level of the facility where the employee cafeteria is located. LPN Employee E16 indicated she saw Resident R6 with NA Employee E15 who indicated Resident R6's trying to leave. LPN Employee E16 said to Resident R6 You know you're not supposed to be down here. Resident R6 responded with a laugh. Interview on 4/8/25, at 11:00 a.m. with NA Employee E19 indicated she recalled working 3/14/25, when Resident R6 got off the 3rd floor, stated NA Employee E20 was pushing Resident R6 back to the unit as she was coming out of the shower room with the shower bed and another resident. Interview on 4/8/25, at 11:08 a.m. LPN Employee E21 indicated Resident R6 likes to go down to the snack shop in the basement. Interview on 4/8/25, at 12:30 p.m. Unit Clerk Employee E17 pulled a binder out from the nursing desk on 3 [NAME] that had a wander list dated 10/31/24, and was unsure how often it should be updated. When asked how agency staff would know who was at risk for elopement, she indicated the staff would tell them who to watch. Interview on 4/8/25, at 2:30 p.m. NA Employee E22 indicated Resident R6's allowed to second floor but not outside by himself. Resident R6 goes to the vending machine in the basement, and he'll come back up. Interview on 4/8/25, at 10:30 a.m. Security Guard (SG) Employee E23 at the front lobby entrance, indicated security has a book of photographs. When asked if it was available for review SG Employee E23 indicated sure, I'll go get it. It's locked in the security office down the hall. Review of the admission record indicated Resident R111 was admitted to the facility on [DATE]. Review of Resident R111's MDS dated [DATE], indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), muscle weakness, and need for assistance with personal care. Section C0500 indicated a BIMS score of six - severely impaired cognition. Review of Resident R111's Elopement Observation dated 9/25/24, indicated no elopement risk factors identified or verbalized. Elopement care plan not needed at this time. Review of Resident R111's care plan dated 9/26/24 (the next day), indicated to monitor safety status on an ongoing basis and intervene immediately if found in an unsafe environment, position, or etc. Apply wanderguard to resident. Review of Resident R111's progress notes indicated the following: -11/24/24, at 3:38 p.m. resident is disoriented today. Resident called her daughter to notify her that she was in downtown Pittsburgh. Resident indicated I've been calling my family to tell them I am in downtown Pittsburgh, and they keep telling me to take a nap. -11/25/24, 9:30 a.m. physician's note indicated resident's daughter was concerned that she visited yesterday at the facility and her mother seemed to be more confused than her baseline. Concerned because resident refuses care at times and thinks she may not be clean and have a urinary tract infection. Informed daughter that Dementia does slowly progress. -11/26/24, at 9:24 p.m. indicated resident observed by staff and other residents as being aggressive and yelling at roommate. Resident did state she was upset with roommate and was yelling at her but would not hurt her. When questioned resident indicated I'm sick of everyone coming into my room to bully me. -12/3/24, at 5:17 a.m. practitioner's note indicated resident has dementia and was seen last week by physician for increased confusion. Behavior is thought likely due to advancing dementia. Resident has had some more behaviors in the last few days as well. -12/15/24, at 1:27 p.m. indicated Medical Records Employee E24 found Resident R111 in the 2 [NAME] breakroom (this unit was closed at the time and without supervision of staff. Employee E24 happened upon Resident R111 only by the need for employee to use the restroom). Resident was easily redirected. Informed the staff on 2 East (Resident R111's unit that is not a locked unit) and suggested resident be checked on regularly. Will inform Administrative staff. -12/17/25, at 11:23 a.m. indicated nursing reports that resident Sundown's (a neurological phenomenon that causes increased confusion and restlessness in people with dementia typically starting in the late afternoon). Staff report that she can be nasty and difficult to redirect in the evenings. Review of the clinical record failed to include an Elopement Observation on 12/15/24, when Resident R111 was found in the closed 2 [NAME] unit's break room. Review of Resident R111's care plan failed to include an update or revision after documented increased confusion on 11/24/24, 11/25/25, 11/26/24, 12/3/24, and 12/17/25 showing concerns about mental status changes, sundowners and advancing Dementia prior to resident being found unsupervised on the closed 2 [NAME] unit's break room on 12/15/24. The care plan failed to be updated or revised after Resident R111 was found on the closed 2 [NAME] unit. The care plan did not reflect a resident centered approach until revisions on 4/9/25, nearly four months post event. Review of a submitted facility document dated 12/15/24, at 1:01 p.m. indicated Resident R111 was found in the staff breakroom on the closed and unsupervised 2 [NAME] unit. Resident wandered there from her unit of 2 East without staff's knowledge. Wander guard was in place; however, would not have alarmed unless Resident R111 wound have gotten to an exit door leading to the outside of the facility. Review of Medical Records Employee E24's witness statement dated 12/17/24, at 10:35 a.m. indicated, I witnessed a resident sitting in the 2 [NAME] bathroom area. I asked her if she was okay. She responded yes. After I used the bathroom, I asked again if she needed anything. I informed the nurse there was a resident sitting in the 2 [NAME] bathroom area. Review of facility provided timeline indicated the following on 12/15/24: (information on timeline was received post event from CCTV.) -12:56 p.m. Resident R111 walks past agency staff member on 2 East nursing station. -12:57 p.m. Resident R111 walks past security guard and dietary worker at the entrance of 2 East and proceeded to the 2 East dining hall. -12:58 p.m. Resident R111 exits dining hall and heads towards 2 West. -1:00 p.m. Resident R111 goes past orange cones on 2 [NAME] in front of nurses station toward the low hall and goes behind the nurses station entering the employee lounge. Interview on 4/9/25, at 9:44 a.m. the Director of Nursing confirmed that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement for Residents R6 and R111. The Director of Nursing and the Nursing Home Administrator were made aware that an Immediate Jeopardy situation existed for residents on 4/9/25, at 11:05 a.m. and an immediate action plan was requested. On 4/9/25, at 11:05 a.m. the Immediate Jeopardy template was provided to the facility administration. On 4/9/25, at 3:44 p.m. an acceptable Corrective Action Plan was received which included the following interventions: DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk on 4/9/25. DON/Designee will re-evaluate all residents for exit seeking behaviors by 4/9/25. Nursing staff/Designee will provide every one-hour safety checks on all residents for 24 hours. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety. DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. by 4/10/25. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk. DON/Designee will audit appropriate supervision levels for four weeks. DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions. DON/Designee will audit all incidents for four weeks. DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping on 4/10/25. DON/Designee will audit all interventions for four weeks. DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk. Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents by 4/10/25, and will be updated upon resident's admission and/or discharge. Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers on 4/10/25. Wander books to be updated upon resident admission/discharge and with room changes. Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents by 4/10/25. Facility will review incidents at QI/QAPI quarterly. Immediate Jeopardy was lifted on 4/10/25, at 1:28 p.m. and the abatement plan was verified as follows: Both residents have been re-assessed, updated care plans, and physician orders for wandering with patient centered interventions added. 116 of 116 total residents were re-assessed, updated care plans, and physician orders for wandering with patient centered interventions as appropriate. 24 hours of every one-hour safety checks completed on all residents. Photo wander books located and verified 3 west, 3 east, 2 east, Security desk. 26 [NAME] staff are off and will receive education prior to the next shift worked. Total staff of facility is 108 the remaining 15 staff will be educated prior to the next shift worked. 55 agency staff have been trained and 93 regular staff have received education. 44 in person interviews verified education received 4/10/25, at 12:26 p.m. Addendum For [NAME] Ross Facility added to the policy and procedure for Wanderguard and Elopement for the [NAME] Community Living Centers. Next QAPI meeting will be held April 29, 2025. Exit interview on 4/11/25, at 2:30 p.m. information was disseminated to the Director of Nursing and Nursing Home Administrator that the facility failed to make certain each resident received adequate supervision and person-centered care plan interventions that resulted in an elopement for two residents. This failure created an immediate jeopardy situation for two of 21 residents who were identified as at risk for elopement (Residents R6, and R111). 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for one of three residents (Resident R52) who had two choking episodes, which resulted in actual harm during the second choking episode that required the Heimlich maneuver (abdominal thrusts that elevate the diaphragm and increase airway pressure, forcing air from the lungs; used to expel a foreign body from the airway). Findings include: Review of facility policy Accident Prevention dated 1/3/24, indicated the interdisciplinary team (IDT) is to assess, observe, and identify environmental and resident risks/hazards. The IDT implements or revise person centered interventions to decrease the potential for accidents by evaluating previous accidents and incidents. The IDT monitors and evaluates effectiveness of interventions and modifies as needed. The IDT provides or revises training and competency as needed, identifies what triggered or contributed to the accident, identifies underlying causes and any risk factors that may have contributed to the accident, and implements interventions promptly to attempt to prevent this from happening again. Review of facility policy Assessment - Comprehensive Person-Centered Care Planning dated 1/3/24, indicated the IDT develops, reviews, revises, and implements a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record indicated Resident R52 was admitted to the facility on [DATE]. Review of Resident R52's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/29/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), unspecified intellectual disabilities, and dysphagia (difficulty swallowing). Review of Resident R52's care plan dated 3/27/23, indicated Resident R52 places non-food items in her mouth due to having [NAME] (an eating disorder characterized by a tendency to eat substances that provide no nutritive value such as soil, chalk, hair, paper, etc.). Goals included Resident R52 will not choke or aspirate on non-food items. Interventions included resident is eating tissues and paper towels, request made for housekeeping to remove and will lock the bathroom door. Review of Resident R52's care plan dated 4/1/23, indicated Resident R52 take food from other residents trays, putting herself at risk for choking. Goals included Resident R52 will have fewer episodes of taking food from others trays as evidenced by behavior occurring less than three times monthly. Interventions included staff to closely monitor Resident R52 during meals and that she does not take food from others trays every meal. Report to physician any choking incidents. If food is found in resident's mouth, attempt to remove it immediately. Review of a physician order dated 2/29/24, indicated Resident R52 was ordered a puree diet, fortified foods, liquids by cup only, no straw, puree sandwich on bread, banana, pancakes, coffee cake, donut, muffin, cheerios, soft cookies, cakes, and brownies ok. Review of information received by State dated 5/20/24, indicated, Social Worker alerted nurses at the nurses station that Resident R52 was on the floor bleeding from laceration (a deep cut or tear in skin) to forehead, upon assessment she began vomiting clear brown fluid with strong smell of tobacco and 3-5 pouches of chewing tobacco and paper towel. Resident has a history of Pica. Administrator, Direct of Nursing, and Social Work Supervisor met with Resident R112 the following day and explained we could no longer accommodate his chewing habit as he clearly put another resident at risk for injury. All tobacco products were removed from him, his family was contacted and in agreement with the termination of his chewing habit. Review of a nursing progress note dated 5/20/24, completed by Registered Nurse (RN) Employee E8 stated, Alerted by staff that resident was in a fetal position in the hallway near the nurses station at 10:30 a.m. Resident had fallen out of the wheelchair, upon assessment resident was noted to be bleeding from a laceration on her forehead and cyanotic (bluish skin due to lack of oxygen) in the face. The charge nurse repositioned the resident and she began to vomit, at first it was just clear vomit with brown specks in it. She then proceeded to vomit chewing tobacco pouches which were whole in size and smelled of the tobacco. There was 5 pouches in total. She also vomited a paper towel and some clear/brown vomit. Immediately after vomiting her color returned and resident was placed in her chair, the laceration was irrigated (cleansed). Review of a progress note dated 5/22/24, completed by Physician Assistant (PA) Employee E10 stated, The patient was initially evaluated lying on her right side of the floor. She has a small laceration to her right forehead with a hematoma (a solid swelling of clotted blood within the tissues) forming. On inspection of the right forehead laceration, it is approximately 1 centimeter (cm), irregular. She does have about two cm of surrounding swelling and bruising forming around the laceration. It appears that the patient ingested another resident's tobacco chew pouches. She was seemed to potentially choking and fell out of her wheelchair head first and hit her forehead on the floor. She vomited up three pouches that she had ingested. Staff is potentially going to contact poison control. Pica: the patient is known to do this quite frequently. She often takes a food or other items from other residents' rooms, trays, and wheelchairs and ingests them. Review of a facility event submitted to the State dated 6/18/24, indicated, Resident R52 was being assisted to her room by staff when the staff noticed her choking (her face was noted to be blue/purple). Nursing staff alerted other staff she needed assistance and nurse administered Heimlich maneuver until resident started coughing. LPN swiped residents' mouth and found several long red onions and some other unidentified food substances. Review of a progress note dated 6/18/24, completed by LPN Employee E5 stated, Called into resident's room by NA Employee E9, she came to the door and yelled she's choking. Upon entering the room, resident's face was blue/purple in color and no air was moving. I proceeded to do the Heimlich maneuver until I heard the resident start to cough. LPN Employee E12 swiped her mouth and removed several long onions and some other unidentified food substances. Review of a witness statement dated 6/18/24, completed by NA Employee E9 stated, I seen Resident R52 in the hallway in her wheelchair rolling pass the lunch cart. I took her back to her room to feed her and noticed once in the room she was choking. I called out for the nurses at the nursing station. LPN Employee E5 performed Heimlich and LPN Employee E12 swept her mouth to remove food. Review of a witness statement dated 6/18/24, completed by NA Employee E13 stated, On June 18, around 12:00 p.m. or 12:35 p.m. I was in the dining room. I seen a nurse running back towards another resident, I went to help the nurse with. Resident R52 was grabbing a tray off the table. A nurse and I got the tray from Resident R52, the lid was on the plate. I took Resident R52 back over to 3 East to LPN Employee E12. She was trying to get something. When I looked at her I didn't see anything in her mouth or her choking and she did not have nothing in her hands. Review of Resident R52's care plan dated 6/18/24, indicated the resident is at risk for swallowing problems related to attempting to eat others food or non-food items. Interventions included provide one to one supervision while awake and if resident is found with any food/nonfood items in her mouth besides her food, remove immediately and report to the supervisor. During an interview on 6/26/24, at 1:41 p.m. the Director of Nursing (DON) confirmed that the facility did not contact poison control after Resident R52 ingested tobacco chew pouches on 5/20/24. During an interview on 6/27/24, at 9:38 a.m. Nurse Aide (NA) Employee E4 stated, If I knew a resident had Pica, I would watch them really well and look for signs of choking. If I saw a resident eating a non-food item, I would take it away from them and notify the nurse. During an interview on 6/27/24, at 9:40 a.m. Licensed Practical Nurse (LPN) Employee E5 stated, If I knew a resident had Pica, I would make sure that items are not kept within their reach for them to grab. I would perform frequent mouth checks. If I saw a resident eating a non-food item I would remove it from their mouth and report it to my supervisor. During an interview on 6/27/24, at 9:43 a.m. LPN Employee E6 stated, If I knew a resident had Pica, I would keep non-food items out of their reach. I would expect to perform hourly rounding and I would expect the facility to educate the staff about the disorder. I would attempt to educate the resident frequently. If I saw a resident eating a non-food item, I would remove it from them, notify my supervisor, and re-educate the resident. During an interview on 6/27/24, at 9:10 a.m. Registered Dietitian Employee E7 confirmed that Resident R52 is the only resident in the facility with a [NAME] diagnosis. During an interview on 6/28/24, at 8:49 a.m. the DON confirmed that the facility did not update Resident R52's plan of care after the incident on 5/20/24. The DON stated, I made rounds on the unit and took puzzles away from the common area. Resident R52 is always under someone's feet. She hadn't gone after anything for months, then she suddenly did with the tobacco. I thought we fixed things by removing Resident R112, he had a little office set up in the dining room. I thought the incident occurred because Resident R112 was putting her at risk. No updates were made to Resident R52's plan of care after the incident on 5/20/24. During an interview on 6/28/24, at 12:06 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to provide adequate supervision for a resident with [NAME] and previous choking episodes, which resulted in actual harm during the second choking episode that required the Heimlich maneuver for one of three residents (Resident R52). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(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.

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and utilize equipment for the transfer needs that resulted in actual harm (large left chest hematoma - collection of blood in the chest cavity) for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Accident Prevention dated 1/4/23, indicated the facility will prevent accidents and injuries by assuring residents receive adequate supervision and assistive devices to prevent accidents. Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-resident assessment and care screening) dated 1/3/23, indicated diagnoses of stroke and hemiplegia (paralysis on one side) affecting the left non-dominant side. Review of Section G - Functional Status, indicated that Resident R1 required total dependence of two staff members for transfers. Review of Resident R1's plan of care for Fall Risk related to weakness initiated 1/11/23, indicated Resident R1 required Assist of two with a Hoyer Lift (mechanical lift used to lift residents who require a total assist with transferring -resident is total dependent) for all transfers. Review of a progress note written by Registered Nurse (RN) Employee E3 dated 1/20/23, at 1:15 p.m., indicated Resident R1 called this nurse into the room and said her left shoulder and left breast area was hurting and stated earlier when transferring off the toilet she slumped down and the straps pushed up under her arms. A 2 cm (centimeter) x 2 cm abrasion was noted to the left breast. Left shoulder was tender to touch and resident stated it was painful. There was a grossly (large) swollen area to the left chest/shoulder area. Hard when touched. The physician was notified and Resident R1 was transferred to the hospital for evaluation. Review of progress note written by Physician Assistant (PA) Employee E4 dated 1/20/23, at 1:35 p.m. indicated Resident R1 had pain to left shoulder after using a sit to stand mechanical lift (lift that requires the resident use of legs and arms to assist - resident participates in transfer) to use the bathroom. Resident reported she started to fall and the strap that was behind her back, underneath both of her arms, pulled on her arms and torso (middle of body) causing an abrasion to her left breast. Resident now complaining of pain in left upper extremity and left chest/ribcage area. Left thorax (rib cage area) appears displaced and swollen. Resident transported to hospital for evaluation. A review of an incident report dated 1/20/2023, indicated Resident R1 complained of left shoulder and left breast pain. The resident stated that earlier when she was transferring using the sit to stand mechanical lift, she slumped down and the straps pushed up under her arms. A review of a hospital X-ray report dated 1/21/2023, indicated a large left chest wall hematoma measuring 11.0 x 12.9 x 1.5 cm (centimeters). A review of NA (Nursing Aide) Employee E1 Witness Statement dated 1/20/2023, indicated that the Nurse Aide moved Resident R1 from the wheelchair to the toilet using the sit to stand lift (mechanical lift that requires resident to assist in transfer) with assistance of NA Employee E2 without incident. A review of NA Employee E2 Witness Statement dated 1/23/2023, indicated that NA Employee E1 asked her to lie and say she helped her with Resident R1's transfer on 1/20/23. A review of RN Employee E3 Witness Statement dated 1/20/23, indicated Resident R1 stated she was transferred with assist of one using a sit to stand mechanical lift and she got tired and slumped down and the straps pulled up under her arms and her left shoulder was hurting. During an interview with the Nursing Home Administrator (NHA) on 2/22/23, at 1:00 p.m. revealed NA Employee E1 was not cooperative with the investigation and refused any further questioning on 1/23/23. NA Employee E1 was not available for interview as she was terminated on 1/30/23, and did not return a telephone voice message attempt on 2/22/23. A review of NA Employee E1's employee transcript dated 8/24/22, indicated she had received education on proper body mechanics, transfers, mechanical lift and stand aides, and abuse/neglect annually and last updated 8/1/22. During an interview on 2/22/23 at 8:30 a.m., NA Employee E2 revealed she did not assist NA Employee E1 with Resident R1's transfer on 1/20/23, and NA Employee E1 asked her to lie. During an interview on 2/22/23 at 8:55 a.m., RN Employee E3 revealed on 1/20/23, Resident R1 stated she was transferred with assist of one using the sit to stand mechanical lift and was unable to stand and hurt her left chest and shoulder. RN Employee E3 further revealed that she questioned NA Employee E1 on 1/20/23, to corroborate, and NA Employee E1 denied any incident during transfer of Resident R1. During interviews on 2/22/23, at 1:00 p.m. through 1:30 p.m. NA Employees E2, E5, E6, E7, and E8, revealed that all mechanical lift transfers require an assist of two persons. All resident's transfer status is found on the care plan and daily assignment sheets. During an interview on 2/22/23, at 2:00 p.m. the DON confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 as they did not use a mechanical lift as ordered and provide appropriate two person assist to transfer Resident R1. During an interview on 2/22/23, at 2:30 p.m. the NHA confirmed that the facility failed to provide adequate supervision and utilize equipment for the transfer needs that resulted in actual harm (large left chest hematoma - collection of blood in the chest cavity) for Resident R1. 28 Pa. Code 201.14(a)(c)(d)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the necessary services, which resulted in actual physical harm (large left chest hematoma - collection of blood) for one of three residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse-Resident and Reasonable Suspicion of a Crime dated 1/4/23, indicated the facility will provide a safe environment where residents are protected from all forms of abuse to include neglect. Residents must not be subjected to abuse/neglect by anyone including facility staff. Through elements of screening, training, prevention, identification, investigation, protection, and reporting, the facility will act to prevent abuse. A review of the facility policy Lifting and Moving Residents, Mechanical Lift Transfers dated 1/4/23, indicated mechanical lifts will be used for residents who cannot be transferred comfortably and/or safely by normal transfer techniques. There must always be at least two staff members present when using a mechanical lift for transfers. During an interview with the Director of Nursing (DON) on 2/21/22, at 12:00 p.m. revealed the facility has Hoyer lift (passive mechanical lift-support provided by caregiver alone) and Sit to Stand lift (active mechanical lift-resident requires participation using arms and legs to stand) in use at the facility. A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included heart failure, diabetes, and end stage kidney disease. A review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 1/3/2023, indicated that the diagnoses remained current. Resident R1 is alert and oriented and able to make needs known. A review of Resident R1's care plan dated 1/11/2023, indicated that Resident R1 was at risk of falls due to weakness. Facility staff would provide Resident R1 with appropriate assistive devices for safe transfers. The care plan stated that the resident required assist of two with Hoyer lift for all transfers. A review of Resident R1's physician orders summary dated 1/6/2023, indicated that Resident R1 was to be transferred with a Hoyer lift. A review of an incident report dated 1/20/2023, indicated Resident R1 complained of left shoulder and left breast pain. The resident stated that earlier when she was transferring using the sit to stand, she slumped down and the sit to stand straps pushed up under her arms. A review of Registered Nurse (RN) Employee E3's progress note dated 1/20/23, indicated Resident R1 complained of pain on left shoulder and left chest. A 2 cm x 2 cm abrasion was noted to the left lateral (outer) breast. There was a large swollen area on the left chest/shoulder area that was hard to touch. Resident R1 was sent to the hospital for evaluation. A review of a hospital X-ray report dated 1/21/2023, indicated a large left chest wall hematoma measuring 11.0 x 12.9 x 1.5 cm (centimeters). A review of NA (Nursing Aide) Employee E1 Witness Statement dated 1/20/2023, indicated that the Nurse Aide moved Resident R1 from the wheelchair to the toilet using the sit to stand lift with assistance of NA Employee E2 without incident. A review of NA Employee E2 Witness Statement dated 1/23/2023, indicated that NA Employee E1 asked her to lie and say she helped her with Resident R1's transfer on 1/20/23. During an interview with the Nursing Home Administrator (NHA) on 2/22/23, at 1:00 p.m. revealed NA Employee E1 was not cooperative with the investigation and refused any further questioning on 1/23/23. During an interview on 2/22/23 at 8:30 a.m., NA Employee E2 revealed she did not assist NA Employee E1 with Resident R1's transfer on 1/20/23, and NA Employee E1 asked her to lie. A review of NA Employee E1's employee transcript dated 8/24/22, indicated she had received education on proper body mechanics, transfers, mechanical lift and stand aides, and abuse/neglect annually and last updated 8/1/22. NA Employee E1 was not available for interview as she was terminated on 1/30/23 and did not return a telephone voice message attempt on 2/22/23. During interviews on 2/22/23, at 1:00 p.m. through 1:30 p.m. NA Employees E2, E5, E6, E7, and E8, revealed that all mechanical lift transfers require an assist of two persons and transfer status for all residents is found on the care plan and daily assignment sheets. A review of RN Employee E3 Witness Statement dated 1/20/23, indicated Resident R1 stated she was transferred with assist of one using the sit to stand lift and she got tired and slumped down and the straps pulled up under her arms and her left shoulder was hurting. During an interview on 2/22/23, at 8:55 a.m., RN Employee E3 revealed on 1/20/23, Resident R1 stated she was transferred with assist of one using the sit to stand lift and was unable to stand and hurt her left chest and shoulder. RN Employee E3 further revealed that she questioned NA Employee E1 on 1/20/23, to corroborate, and NA Employee E1 denied any incident during transfer of Resident R1. During an interview on 2/22/23, at 2:00 p.m. the DON confirmed the facility's investigation of the incident found that it involved a substantiated neglect of service against NA Employee E1 as they did not use a mechanical lift as ordered to transfer Resident R1. During an interview on 2/22/23, at 2:30 p.m. the NHA confirmed that the facility failed to ensure that Resident R1 was free from neglect by not providing the necessary services, which resulted in Resident R1 suffering physical harm from a large left chest hematoma injury. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)(j) Resident rights. 28 Pa Code 211.12(d)(1)(5) Nursing services. 28 Pa Code 211.12(d)(3) Nursing services.