Every finding on record at Kadima Rehabilitation & Nursing at Cheswick

Based on review of facility policy, clinical records, staff interview, and observations, it was determined that the facility failed to provide appropriate respiratory care for three of four residents (R1, R2, and R3).Findings include: Review of facility policy Oxygen Administration dated 4/28/26, indicated oxygen therapy will be provided when a resident needs oxygen at a concentration greater than room air. The purpose is to administer oxygen to the residents when insufficient oxygen is being carried by the blood to the tissues. Review of Resident R1's admission record indicated resident was admitted to facility on 5/23/22. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 5/6/26, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/12/26, at 12:33 p.m. Resident R1 was lying in bed with the oxygen tubing on the concentrator. The nasal cannula (a thin tubing that delivers oxygen from the oxygen concentrator to the nose) was dated 7/30/26. Review of physician order dated 11/18/25, indicated change oxygen tubing every Wednesday night on night shift and date tubing for maintenance. Review of Resident R2's admission record indicated resident was admitted to facility on 5/7/20. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/12/26, at 12:41 p.m. Resident R2 was lying in bed with the oxygen, watching tv. The nasal cannula failed to have a date on it, the humidification bottle failed to have a date on it, and was empty. Review of physician order dated 5/19/26, indicated change oxygen tubing every Wednesday night on night shift and date tubing for maintenance. Review of Resident R3's admission record indicated resident was admitted to facility on 6/1/26. Review of Resident R3's MDS dated [DATE], indicated diagnoses of arthritis, atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Section O Special Treatments, Procedure and Programs O0110, C1 Oxygen Therapy is marked as while a resident. During an observation on 8/12/26, at 12:48 p.m. Resident R3 was sitting on the edge of the bed eating lunch with the oxygen on. The nasal cannula failed to have a date on it. Review of physician order dated 6/1/26, indicated change oxygen tubing every Wednesday night on night shift and date tubing for maintenance. During an interview on 8/12/26, at 12:53 p.m. Licensed Practical Nurse (LPN) Employee E1 stated that oxygen tubing and set up should be changed every week by night shift and dated. LPN Employee E1 confirmed that Resident R1's oxygen tubing failed to be changed per physician order, Resident R2's oxygen tubing and humidification was not dated and empty, and Resident R3's oxygen tubing was not dated. During an interview on 8/12/26, at 3:33 p.m. Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for three of four residents (R1, R2, and R3). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Third Floor).Findings include: Review of the facility's Resident Environment policy dated 4/28/26, indicated the facility will provide an environment that is safe, clean, comfortable, and homelike. During a tour of the Third Floor on 8/12/26, at 12:11 p.m. on the Third Floor, the following were observed: Resident R1's room had cobwebs hanging from the ceiling in the corner of the room.Resident R1 had plaster chipping around the plug at head of bed.Resident R4's privacy curtain had stains and unknown debris on it.Resident R5's room had a hole in the wall behind the bed.Resident R6's privacy curtain had stains and unknown debris on it.Resident R7's privacy curtain had stains and unknown debris on it. During an interview on 8/12/26, at 12:50 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the above findings and confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment for one of three floors (Third floor). 28 Pa. Code 201.18(b)(3)(e)(2) Management. 28 Pa code 211.12(d)(1) Nursing services.

Based on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for two of three residents (Resident R1, and R2).Findings include: Revies of the facility's Flow of Care policy dated 4/28/26, indicated care will be provided to residents as needed 24-hours a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the residents. Residents are to have two bath/showers a week unless the resident states otherwise. Review of Resident R1's admission record indicated resident was admitted to facility on 5/23/22. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 5/6/26, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Section GG0130-Self-care (resident's need for assistance with bathing, dressing, using the toilet) was coded 3, indicating that resident is partial-moderate need of assistance. Helper does less than half of the effort. Review of Resident R1's July 2026 shower documentation indicated there was no shower provided on 7/22/26. Review of Resident R1's August 2026 shower documentation indicated there was no shower provided on 8/8/26. Review of Resident R2's admission record indicated resident was admitted to facility on 5/7/20. Review of Resident R2's MDS dated [DATE], indicated diagnoses of high blood pressure, heart failure, and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Section GG0130-Self-care (resident's need for assistance with bathing, dressing, using the toilet) was coded 2, indicating that resident is substantial maximal need of assistance. Helper does more than half of the effort. Review of Resident R2's July 2026 shower documentation indicated there were no showers provided on 7/13/26, 7/16/26, and 7/30/26. During an interview on 8/12/26, at 2:45 p.m. Director of Nursing confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance for two out of three residents (Resident R1, and R2). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(6) Management. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services. 28 Pa. Code: 201.20 Staff development.

Based on review of facility policies, Resident Assessment Instrument (RAI) User's Manual, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization resulting in psychosocial harm for one of three residents (Resident R1).Findings include: Review of facility policy Trauma Informed Care dated 4/28/26, indicated the facility will provide individualized and personalized care to the residents. Understanding and adapting care to those with known trauma is an important part of the care provided. This care will be personalized to each resident based on the situation and past experiences of each resident. This policy takes into consideration that events in one's past play an important role in current functioning. Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. An individualized care plan will be initiated as appropriate to address trauma related issues. Review of facility policy Documentation dated 4/28/26, indicated the purpose is to communicate resident's status and provide accurate accounting of care and monitoring provided.Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2025, indicated that a Brief Interview for Mental Status ( BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/1/26, indicated diagnoses of high blood pressure, chronic pain, and personal history of traumatic brain injury (a disruption in the normal function of the brain). Question C0500 BIMS Summary Score indicated the resident scored a 15, cognitively intact. Review of a nursing progress note dated 5/3/26, stated, Resident was in the hallway when an active shooter fired a gun. He was whisked away to safety. He had a skin assessment done. No bruises, no shots fired at him. Called a family member to inform of his safety. Policeman called to report what happened. Review of a nursing progress note dated 5/3/26, stated, Clarification - Resident R1 stated that he heard a loud noise which he believed sounded like a gunshot. He reported getting out of bed into his wheelchair to investigate. Resident stated that he observed an unfamiliar female individual near the elevator. He reported that the individual walked back from the elevator, and, at that time, he observed what appeared to be a pistol secured at her waist. He stated that the individual then returned to the elevator and left the area. Resident was never around when the occurred. POA (Power of Attorney), MD (physician) was notified just due to the fact he got out of bed to investigate and observed after the fact. Review of a Social Services progress note dated 5/6/26, stated, Resident reports ongoing distress related to the incident on the 3rd floor. States he now flinches when approached, experiences intrusive images of the person with a weapon, and is unable to sleep. Reports symptoms have worsened over time despite psychiatry visits and medication/sleep aid adjustments. Resident appears anxious, hypervigilant, and on edge. Affect congruent with reported distress. Thought process coherent but preoccupied with the event. Resident shows signs of acute stress reaction/possible PTSD (Post Traumatic Stress Disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions) with persistent hypervigilance, intrusive thoughts, and sleep disturbance. Symptoms continue to impact daily functioning. Continue supportive counseling, teach grounding/relaxation techniques, monitor sleep and coping, coordinate with psychiatry regarding ongoing symptoms, consider trauma-focused therapy referral, follow-up regularly. Review of a Follow Up note dated 5/19/26, completed by Certified Registered Nurse Practitioner (CRNP) Employee E6 stated, Patient notes he has been shook up lately since recent incident at facility earlier this month. Patient notes he has followed with psych and medication adjusted; noted below. Emotional support provided and discussed what has been going on with him. Patient states he cannot understand why this has him so bothered lately and I provided patient with the fact he is currently more vulnerable than when he was out in the community. Patient now missing a right foot and has been wheelchair bound waiting for his prosthesis to arrive. Patient notes he's never thought of it like that and states that makes sense to him. Depression/anxiety: worse due to recent incident at facility earlier this month. Psych following for medication management. Increase duloxetine (Cymbalta - a medication used to treat depression) to 90 mg (milligrams) daily. Monitor mood and behaviors. Conditional labile (easily or frequently changed). Review of a 1-Month progress note dated 5/27/26, completed by CRNP Employee E6 stated, Patient acutely seen for depression/anxiety/insomnia. Patient states he continues to have trouble sleeping due to loud noises affecting him since the recent incident at the facility. Depression/anxiety: worse due to recent incident at facility earlier this month. Psych following for medication management. Continue recently increased duloxetine 90 mg daily. Increase melatonin (a medication given to improve sleep patterns) to 10 mg qHS (every night). Monitor mood and behaviors. Condition labile. Review of a resident concern dated 5/28/26, completed by Resident R1, stated, On May 3rd someone brought a gun and shot it outside of my room. I saw the person walking towards me messing with the gun in their waistband and now I can't sleep at night, loud noises scare me and I'm scared to leave my room. Review of a Follow Up progress note dated 6/2/26, completed by CRNP Employee E6 stated, Patient notes ongoing anxiety/PTSD regarding incident at facility causing patient to feel anxious, depressed and having trouble sleeping at night due to thinking about the incident. Patient states any loud noise causes increased anxiety and fear. Psych following patient as well as with recent increase in medications noted below. Depression/anxiety: worse due to recent incident at facility earlier this month - ongoing insomnia. Psych following for medication management. Continue duloxetine 90 mg daily. Add trazodone (a medication used to treat depression) 50 mg qHS with plan to reduce melatonin 10 mg qHS. Not much improvement noted with recent increase in melatonin. Monitor moods and behaviors. Condition labile. Review of a Palliative Care Note dated 6/10/26, completed by CRNP Employee E9 stated, Insomnia: labile. Patient attributes to PTSD and recent trigger of fearful memories - Psych as indicated. Monitor for increase of daytime fatigue/irritability. Provide calm, noise-reduced environment. Continue melatonin 10 mg QHS, trazodone 50 mg QHS - both recently added by Medical, full benefit not yet known. Implement non-pharmacologic strategies such as sleep hygiene education and relaxation techniques, addressing reversible causes like pain or anxiety. Review of Resident R1's care plan dated 5/4/26, indicated resident is at risk for alteration in mood related to: hearing recent firearm discharged in facility on 5/3. Interventions include nursing to monitor resident, will notify MD if has any mood alteration and psych consult. Resident R1's care plan failed to include identified triggers and how to avoid them. During an interview on 6/10/26, at 10:12 a.m. Resident R1 stated, This place sucks. After that incident they gave me melatonin to sleep, it wasn't working. Last week I saw the doctor and CRNP Employee E6. I told the doctor I was still having trouble sleeping, he says, oh we'll change the melatonin dose, and left. I asked CRNP Employee E6, does he know about the incident? She said, Oh yeah but he doesn't know about you being involved. A couple of days later, I saw CRNP Employee E6 in the hallway, she said she talked to the doctor and told him about my involvement in the incident. She said they were going to put me on another medication to help sleep, Trazodone. I talked to psychiatry, I'm on Cymbalta for my leg issue and depression, they changed that dose. Every loud noise scares the shit out of me. I was sitting in the hallway waiting for the elevator the other day, someone dropped a tray lid on the floor and it sounded like the gun shot, I about shit my pants. I kind of got shitty with the aide who dropped it, I later apologized. This place is trying to sweep the incident and myself under the fucking rug. This place wants you to fail. They just throw fucking pills at you. I've had no counseling sessions offered to me. All they've done is added and increased medications. It's a damn shame. The van driver was supposed to take me to the park down the street and let me get out of here for a while. It went from planned to it would have to be an activity and more people would have to go to we don't know if the van can accommodate everyone. All I wanted was to get out of this building for a moment. Staff have not implemented any interventions to avoid loud noises. They act like it never happened. The nurses and aides working today know me and I don't have an issue with them, it's more at nighttime. It's like Def Jam Comedy Hour (a stand-up comedy television series) out there, slamming doors, that's why I can't sleep at night. I used to go out of my room, now I don't as much. Even therapy staff noticed, the one therapist said, you haven't been the same since then. I don't want to leave this room. This is my home and I do not feel safe and comfortable. The only silver lining is that I'm going to be gone soon. During an interview on 6/11/26, at 10:47 a.m. Licensed Practical Nurse (LPN) Employee E1 stated, Resident R1's triggers have not been communicated to me. I only know because the resident told me. It should probably be in his care plan. During an interview on 6/11/26, at 10:48 a.m. LPN Employee E2 stated, The facility hasn't communicated his triggers to me, I know because he's told me. It should be in the care plan. During an interview on 6/11/26, at 11:05 a.m. Nurse Aide (NA) Employee E3 stated, The resident has been telling me sometimes loud noises are triggers for him. Usually that information gets passed on in report, but I don't recall getting education about him specifically. I would hope to see triggers in the care plan. He'll sometimes come out of his room. He was a little jumpy when I walked in his room this morning. During an interview on 6/11/26, at 11:34 a.m. Physical Therapy Assistant Employee E4 stated, He did mention he doesn't feel comfortable coming out of his room. He was definitely rattled when it happened. I don't recall being informed by anyone other than the resident himself that loud noises are a trigger for him. Review of Resident R1's clinical record revealed an imported Psychiatry progress note dated 5/17/26. The progress note stated, Collateral information obtained from interdisciplinary team and EHR (electronic health record) review, including progress notes and medication review. Nursing staff report no concerns regarding mood or behaviors and indicate resident remains psychiatrically stable at this time. No new psychiatric concerns identified in recent progress notes. Assessment and plan: Resident stable with mood and behaviors. At baseline. No acute psychiatric concerns. No medication changes. Recommendations: continue Cymbalta 90 mg daily for diagnosis of adjustment with depressed mood/sexual behaviors. Continue melatonin 5 mg qhs for sleep. Monitor and document any changes in mood such as increased signs and symptoms of depression or anxiety, mood lability, or generalized psychiatric decline. Encourage social interactions/participation in group activities in facility to prevent feelings of isolation. Review of Resident R1's clinical record failed to include any additional documentation from Psychiatry or Psychology services. During an interview on 6/11/26, at 12:00 p.m. Social Worker Employee E5 stated, He was referred to both Psychology and Psychiatry. I would expect to see counseling and the incident discussed by Psychiatry in the 5/17 note. I'm surprised there isn't a note from Psychology. During an interview on 6/11/26, at 12:43 p.m. CRNP Employee E6 stated, The physician was not previously made aware of the resident's involvement with the shooting, he just thought the resident was having trouble sleeping because people are loud at night, he said, get some earplugs. I've only seen the Psychiatry note from 5/17 in Resident R1's chart. I'm surprised the event is not referenced in that note. I'm also not sure why it's documented that the resident is receiving duloxetine (Cymbalta) for sexual inappropriateness. We have someone from Psychology who does talk therapy, I'm not sure why there isn't a note from Psychology. I do think Resident R1 meets the appropriate criteria for a PTSD diagnosis, he had this traumatic event happen and now he has experiences that he references back to that event. During an interview on 6/11/26, at 12:52 p.m. Social Worker Employee E5 provided physical copies of two progress notes dated 5/5/26 from Psychology services and 5/6/26 from Psychiatry services. Review of the provided Psychology note dated 5/5/26, stated, Resident referred to psychology per facility request after an incident in the facility over the weekend in which a firearm was discharged . Resident reportedly heard the gunshot and witnessed the person leaving. Resident reports feeling fine. Resident states that he is unaffected. Resident shared that he has been shot at previously, so this was nothing. Processed and discussed safety precautions such as closing the door and barricading in the unlikely event that this should happen again. Resident again declined future psychology services. Resident was encouraged to let staff know should he need services in the future. Assessment and plan: Resident politely declined psychological services at this time. Resident informed he could request services in the future. Discharge from psychology. Review of the provided Psychiatry note dated 5/6/26, stated, Resident seen in his room, sitting up in bed. He was pleasant, cooperative, and able to answer questions appropriately, with bright affect. He reports witnessing aspects of a recent active shooter incident at the facility, including seeing the individual at the elevator and hearing a pop consistent with a gunshot. He stated he is fine overall but notes increased sensitivity to loud noises since the event. Medication adjustment was discussed, including increasing Cymbalta; resident was agreeable and stated, I really think that may help me not feel as anxious. Education was provided regarding expected time to benefit, and he verbalized understanding. He reports good sleep and appetite but asked if he could have melatonin to help sleep better. He appears calm and in no acute distress. Assessment and Plan: Resident stable with mood and behaviors. Active shooter incident is making him more anxious. At baseline. No acute psychiatric concerns. Recommendations: increase Cymbalta to 90 mg daily for diagnosis of adjustment with depressed mood/sexual behaviors. Start melatonin 5 mg q hs for sleep. Monitor and document any changes in mood such as increased signs and symptoms of depression or anxiety, mood lability, or generalized psychiatric decline. Encourage social interactions/participation in group activities in facility to prevent feelings of isolation. During an interview on 6/11/26, at 1:32 p.m. CRNP Employee E6 stated, I have never seen the Psychology note from 5/5 or the Psychiatry note from 5/6 because they were not uploaded into the resident's chart, that's how I see them. I thought the resident was still receiving talk therapy from Psychology. I would have written a consult for Psychology. During an interview on 6/11/26, at 1:44 p.m. Social Worker Employee E5 stated, The Psychology note from 5/5 and the Psychiatry note from 5/6 were sent to us through an email and were supposed to have been uploaded into the clinical record. They used to be automatically uploaded but lately we've had to manually upload them. They should have been given to Medical Records to upload into the clinical record. We dropped the ball. During an interview on 6/11/26, at 2:01 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for Resident R1. During an interview on 6/11/26, at 3:02 p.m. the Nursing Home Administrator and DON confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization resulting in psychosocial harm for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(2)(3) Management.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate documentation for one of three residents (Resident R1).Findings include: Review of facility policy Documentation dated 4/28/26, indicated the purpose is to communicate resident's status and provide accurate accounting of care and monitoring provided. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/1/26, indicated diagnoses of high blood pressure, chronic pain, and personal history of traumatic brain injury (a disruption in the normal function of the brain). Review of a nursing progress note dated 5/3/26, stated, Resident was in the hallway when an active shooter fired a gun. He was whisked away to safety. He had a skin assessment done. No bruises, no shots fired at him. Called a family member to inform of his safety. Policeman called to report what happened. Review of a nursing progress note dated 5/3/26, stated, Clarification - Resident R1 stated that he heard a loud noise which he believed sounded like a gunshot. He reported getting out of bed into his wheelchair to investigate. Resident stated that he observed an unfamiliar female individual near the elevator. He reported that the individual walked back from the elevator, and, at that time, he observed what appeared to be a pistol secured at her waist. He stated that the individual then returned to the elevator and left the area. Resident was never around when the occurred. POA (Power of Attorney), MD (physician) was notified just due to the fact he got out of bed to investigate and observed after the fact. Review of a Social Services progress note dated 5/6/26, stated, Resident reports ongoing distress related to the incident on the 3rd floor. States he now flinches when approached, experiences intrusive images of the person with a weapon, and is unable to sleep. Reports symptoms have worsened over time despite psychiatry visits and medication/sleep aid adjustments. Resident appears anxious, hypervigilant, and on edge. Affect congruent with reported distress. Thought process coherent but preoccupied with the event. Resident shows signs of acute stress reaction/possible PTSD (Post Traumatic Stress Disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions) with persistent hypervigilance, intrusive thoughts, and sleep disturbance. Symptoms continue to impact daily functioning. Continue supportive counseling, teach grounding/relaxation techniques, monitor sleep and coping, coordinate with psychiatry regarding ongoing symptoms, consider trauma-focused therapy referral, follow-up regularly. Review of a Follow Up note dated 5/19/26, completed by Certified Registered Nurse Practitioner (CRNP) Employee E6 stated, Patient notes he has been shook up lately since recent incident at facility earlier this month. Patient notes he has followed with psych and medication adjusted; noted below. Emotional support provided and discussed what has been going on with him. Patient states he cannot understand why this has him so bothered lately and I provided patient with the fact he is currently more vulnerable than when he was out in the community. Patient now missing a right foot and has been wheelchair bound waiting for his prosthesis to arrive. Patient notes he's never thought of it like that and states that makes sense to him. Depression/anxiety: worse due to recent incident at facility earlier this month. Psych following for medication management. Increase duloxetine (Cymbalta - a medication used to treat depression) to 90 mg (milligrams) daily. Monitor mood and behaviors. Conditional labile (easy or frequently changed). Review of a 1-Month progress note dated 5/27/26, completed by CRNP Employee E6 stated, Patient acutely seen for depression/anxiety/insomnia. Patient states he continues to have trouble sleeping due to loud noises affecting him since the recent incident at the facility. Depression/anxiety: worse due to recent incident at facility earlier this month. Psych following for medication management. Continue recently increased duloxetine 90 mg daily. Increase melatonin (a medication given to improve sleep patterns) to 10 mg qHS (every night). Monitor mood and behaviors. Condition labile. Review of a Follow Up progress note dated 6/2/26, completed by CRNP Employee E6 stated, Patient notes ongoing anxiety/PTSD regarding incident at facility causing patient to feel anxious, depressed and having trouble sleeping at night due to thinking about the incident. Patient states any loud noise causes increased anxiety and fear. Psych following patient as well as with recent increase in medications noted below. Depression/anxiety: worse due to recent incident at facility earlier this month - ongoing insomnia. Psych following for medication management. Continue duloxetine 90 mg daily. Add trazadone (a medication used to treat depression) 50 mg qHS with plan to reduce melatonin 10 mg qHS. Not much improvement noted with recent increase in melatonin. Monitor moods and behaviors. Condition labile. Review of Resident R1's clinical record revealed an imported Psychiatry progress note dated 5/17/26. The progress note stated, Collateral information obtained from interdisciplinary team and EHR (electronic health record) review, including progress notes and medication review. Nursing staff report no concerns regarding mood or behaviors and indicate resident remains psychiatrically stable at this time. No new psychiatric concerns identified in recent progress notes. Assessment and plan: Resident stable with mood and behaviors. At baseline. No acute psychiatric concerns. No medication changes. Recommendations: continue Cymbalta 90 mg daily for diagnosis of adjustment with depressed mood/sexual behaviors. Continue melatonin 5 mg q hs for sleep. Monitor and document any changes in mood such as increased signs and symptoms of depression or anxiety, mood lability, or generalized psychiatric decline. Encourage social interactions/participation in group activities in facility to prevent feelings of isolation. Review of Resident R1's clinical record failed to include any additional documentation from Psychiatry or Psychology services. During an interview on 6/11/26, at 12:00 p.m. Social Worker Employee E5 stated, He was referred to both Psychology and Psychiatry. I would expect to see counseling and the incident discussed by Psychiatry in the 5/17 note. I'm surprised there isn't a note from Psychology. During an interview on 6/11/26, at 12:43 p.m. CRNP Employee E6 stated, I've only seen the Psychiatry note from 5/17 in Resident R1's chart. I'm surprised the event is not referenced in that note. I'm also not sure why it's documented that the resident is receiving duloxetine for sexual inappropriateness. We have someone from Psychology who does talk therapy, I'm not sure why there isn't a note from Psychology. I do think Resident R1 meets the appropriate criteria for a PTSD diagnosis, he had this traumatic event happen and now he has experiences that he references back to that event. During an interview on 6/11/26, at 12:52 p.m. Social Worker Employee E5 provided physical copies of two progress notes dated 5/5/26 from Psychology services and 5/6/26 from Psychiatry services. Review of the provided Psychology note dated 5/5/26, stated, Resident referred to psychology per facility request after an incident in the facility over the weekend in which a firearm was discharged . Resident reportedly heard the gunshot and witnessed the person leaving. Resident reports feeling fine. Resident states that he is unaffected. Resident shared that he has been shot at previously, so this was nothing. Processed and discussed safety precautions such as closing the door and barricading in the unlikely event that this should happen again. Resident again declined future psychology services. Resident was encouraged to let staff know should he need services in the future. Assessment and plan: Resident politely declined psychological services at this time. Resident informed he could request services in the future. Discharge from psychology. Review of the provided Psychiatry note dated 5/6/26, stated, Resident seen in his room, sitting up in bed. He was pleasant, cooperative, and able to answer questions appropriately, with bright affect. He reports witnessing aspects of a recent active shooter incident at the facility, including seeing the individual at the elevator and hearing a pop consistent with a gunshot. He stated he is fine overall but notes increased sensitivity to loud noises since the event. Medication adjustment was discussed, including increasing Cymbalta; resident was agreeable and stated, I really think that may help me not feel as anxious. Education was provided regarding expected time to benefit, and he verbalized understanding. He reports good sleep and appetite but asked if he could have melatonin to help sleep better. He appears calm and in no acute distress. Assessment and Plan: Resident stable with mood and behaviors. Active shooter incident is making him more anxious. At baseline. No acute psychiatric concerns. Recommendations: increase Cymbalta to 90 mg daily for diagnosis of adjustment with depressed mood/sexual behaviors. Start melatonin 5 mg qhs for sleep. Monitor and document any changes in mood such as increased signs and symptoms of depression or anxiety, mood lability, or generalized psychiatric decline. Encourage social interactions/participation in group activities in facility to prevent feelings of isolation. During an interview on 6/11/26, at 1:32 p.m. CRNP Employee E6 stated, I have never seen the Psychology note from 5/5 or the Psychiatry note from 5/6 because they were not uploaded into the resident's chart, that's how I see them. I thought the resident was still receiving talk therapy from Psychology. I would have written a consult for Psychology. During an interview on 6/11/26, at 1:44 p.m. Social Worker Employee E5 stated, The Psychology note from 5/5 and the Psychiatry note from 5/6 were sent to us through an email and were supposed to have been uploaded into the clinical record. They used to be automatically uploaded but lately we've had to manually upload them. They should have been given to Medical Records to upload into the clinical record. We dropped the ball. During this interview, Social Worker Employee E5 confirmed that the facility failed to maintain complete and accurate documentation for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy and documents, clinical record review, and resident and staff interviews, it was determined that the facility failed to create an environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit. This failure created an immediate jeopardy situation for all residents.Findings include: Review of facility policy Accidents and Incidents dated 4/28/26, indicated all accidents and incidents occurring on our premises must be investigated and reported to the administrator. The charge nurse should conduct initial assessment and provide any emergency interventions. If necessary, call 911 (emergency services) for evaluation and possible transfer to Hospital/Medical Center. Review of facility policy Security dated 4/28/26, indicated the facility will provide security services as needed. In the absence of specific security staff, the Maintenance Department will be responsible for facility security. The following items are not permitted on facility property: all types of firearms or personal knives, dangerous chemicals, explosives, including blasting caps, any object that could be used for the purpose of injury or intimidation. Good judgment is also important for safety and health in the workplace. The following guidelines can help reduce the likelihood of problems: call your supervisor immediately regarding any unusual behavior or incident. Ask any unauthorized visitor to leave. An unauthorized visitor is anyone who does not have permission to visit the work are or who is not working in the facility at the time. All visitors must check in at the front desk. The facility doors will be locked at night after visiting hours. Call 911 if there is a serious concern for your safety or the safety of co-workers or residents. If you become aware of either a prowler or break-in, call 911. Review of the facility Emergency Preparedness Program and Plan - Workplace Violence/Active Shooter dated 4/28/26, indicated in order to preserve life and address the reality of an active shooter event, these guidelines have been established to guide our response to this event to maximize survivability. Most importantly, quickly determine the most reasonable way to protect your own life. Run if there is an accessible escape path, attempt to evacuate the premises. Call 911 when you are safe. Hide if evacuation is not possible, find a place where the active shooter is less likely to easily find you. Dial 911, if possible, to alert police to the active shooter's location. Fight, take action against the active shooter - as a last resort, and only when your life is in imminent danger. Recovery: account for all residents, staff and visitors. Review of a facility submitted document dated 5/3/26, stated, After midnight, an individual who is no longer employed by the facility brought food to her sister. A firearm was exposed in the presence of staff on the third floor and discharged . Staff immediately secured the facility until police arrived. All residents on the third floor were immediately accounted for and assessed, with no injuries identified. Law enforcement was notified and responded. Review of an undated witness statement, completed by Licensed Practical Nurse (LPN) Employee E3 stated, On 5/2/26 at 2315 (11:15 p.m.) I pulled in, 2 CNA (Certified Nurse Aide) at pillar talking and said hello to me. IDK (I didn't know) anything happened. At 0400 (4:00 a.m.) Registered Nurse (RN) Employee E5 Came on 2, pulled Nurse Aide (NA) Employee E12 to side told her and said don't tell anyone. She then told me and NA Employee E6. Me and NA Employee E6 took a break, NA Employee E6 seen and asked RN Supervisor Employee E2 why no police called. RN Supervisor Employe E2 stated she is going to do this quietly and call Assistant Director of Nursing (ADON) and Director of Nursing (DON). RN Supervisor Employee E2 told NA Employee E6 to be supervisor and take her badge if she could do better. But she, RN Supervisor Employee E2, will be doing this quietly. Review of a witness statement dated 5/3/26, completed by RN Employee E5 stated, I was the nurse on the first floor cart. The supervisor [RN Supervisor Employee E2] informed a staff member and myself that she had a bullet slug in her hand. And told us she was told an ex-employee pulled a hand gun out in the 3rd floor dining room and accidentally discharged a gun that went into the dining room wall. RN Supervisor Employee E2 went upstairs and dug the slug from the wall. The ex-employee had left the building by this time. Review of a witness statement dated 5/3/26, completed by NA Employee E6 stated, I witnessed nothing, we heard what happened at 4:00 (a.m.) and we were upset we should of been told and police should of been called when it happened this is a serious matter. Review of a witness statement dated 5/3/26, completed by LPN Employee E7 stated, During night shift around midnight RN Supervisor Employee E2 was talking about something happened on 3rd floor. She pulled me aside and showed me a piece of metal. I said whats that. She proceeded to tell me about the aide's sister on the 3rd floor having a gun and it went off. The person had left. I asked if she dialed 911 and she said no. She said she was going to call someone. I did see hole in wall when going upstairs to use microwave. Review of a typed statement indicated, On May 3, 2026, at approximately 0920 (9:20 a.m.) the DON and Nursing Home Administrator (NHA) conducted a recorded conversation with Resident R3. Resident R3 stated that he heard a loud noise which he believed sounded like a gunshot. He reported getting out of bed into his wheelchair to investigate. Resident R3 stated that he observed an unfamiliar female individual near the elevator. He reported that the individual walked back from the elevator and, at that time, he observed what appeared to be a pistol secured at her waist. He stated that the individual then returned to the elevator and left the area. Review of a typed statement indicated, On May 3, 2026, at approximately 0927 (9:27 a.m.) the DON and NHA conducted a recorded conversation with Resident R2. Resident R2 stated that he was seated in the dining room, seated in his usual location, using his phone and watching television. He reported that his back was against the wall and that he was facing the parking lot. Resident R2 stated that he heard a loud explosion and observed smoke. He reported that he was unsure of what had occurred until staff entered the area. Resident R2 indicated that the time of the incident was approximately 12:30 a.m., which he stated he verified by the time displayed on his phone and dining room clock. Resident R2 verbalized that he does not feel scared and continues to feel safe at the facility. Review of a typed statement indicated, On May 3, 2026 at 1335 (1:35 p.m.) the DON and Registered Nurse Supervisor spoke with NA Employee E1 via phone. During this discussion, NA Employee E1 stated that she wished to exercise her right to remain silent and declined to provide a statement, indicating that doing so may incriminate her. The DON informed NA Employee E1 that she was being placed on suspension pending investigation. NA Employee E1 then activated a recording device on her phone. The DON advised that permission to record the conversation was not granted, and the conversation ended at that time. Review of a witness statement dated 5/4/26, completed by NA Employee E8 stated, I was in the med office getting my charger when I heard a loud noise. When I came out it was smoky and smelled weird. I started looking around to make sure nobody was injured after a resident said it was a gun shot and he seen someone leaving with a gun. I don't know that girls name or know her. She had on purple with braids. I'm also unsure on how she got in the building. Review of a witness statement dated 5/4/26, completed by NA Employee E9 stated, I was on 1st floor not sure what has occurred. Just know officers arrived around 6:30 a.m. - 7:00 a.m. clocked out and went home on 5/3/26. During an interview on 5/7/26, at 9:23 a.m. the NHA stated, People have always had to have a code to come in. Visitors and vendors didn't know the code, but employees knew the code. Agency employees usually don't know the code, but facility employees do. On Sunday, I came in, the DON came in and Maintenance came in. We disabled the previous entrance code and made a brand new one. Only myself and the Maintenance Director know what the code is. Everyone must be buzzed in now. Everyone can leave the building with a different code. The front entrance door does open when pushed in emergencies, that's the way it's designed. We have ordered visitor passes for visitors to wear while they are in the building. They already have to sign in, so the passes will have their name and date, something to identify them. NA Employee E1 is the sister. She [visitor/former employee] worked for us as an aide, she was hired in December, stopped coming to work in March. We didn't terminate her, we kept her on our roster. She may have told Human Resources she wanted to go per diem (as needed). She was not scheduled for any shifts. If you don't pick up any shifts for a month when you're per diem, you are automatically terminated. On 4/16/26 she was officially out of our system as an employee. LPN Employee E3 had no reason not to think she would be here. She had brought lunch up for her sister [NA Employee E1], she wasn't on the deployment sheet. She showed LPN Employee E3 her pistol in her purse. LPN Employee E3 said you can't have this in here, she said it's not loaded, then a gunshot went off. Then she immediately took off. NA Employee E1 was apologetic. When police arrived, no one would state who the shooter was. RN Supervisor Employee E2 is the one who notified me at 6:15 a.m. I had to direct her to call 911. The detective stated he was notified at 6:30 a.m. When I got here, first responders were already here. Two officers, a lieutenant, and the detective were here. During an interview on 5/7/26, at 12:59 p.m. LPN Employee E10 stated, If I was here and something like that happened, I would notify someone right away, check on everyone and make sure they're safe, definitely call 911. I'd let the supervisor know, then the administrator. We get annual education, including emergency preparedness. During an interview on 5/7/26, at 1:03 p.m. Resident R3 stated, I was lying in bed, I heard this noise, I knew it was a gun shot. I was like, What the hell? I jumped up in my wheelchair. I got to my doorway and I saw a lady standing at the elevator. I never saw her before. She started walking towards me and I saw her fiddling with her gun in her waistband. She walked past me and went towards the nurse's station and said to someone, I'm gonna take the steps just as she said that the elevator opened. At first, it didn't really bother me, the first day or so, but now every time I hear a loud noise, I get freaked out and I'm real jumpy. I got freaked out when you knocked on the door. I talked to the Social Worker yesterday and I told her about what was going on. A psychiatrist came yesterday and I talked to them. I'm on Cymbalta (a medication used to treat depression), I get phantom limb pain (the real sensation of pain in a limb or body part that has been amputated or is missing), so she upped that dose and added something for sleeping. I'm having trouble sleeping since the incident, that's new for me. All of these symptoms are new, I never felt jumpy or anxious before. It's weird because I've been around guns my whole life and been through a lot. You think you're in a safe environment and you wouldn't expect something like that, so I'm not sure if that's what's going on in my head. I pride myself in being a badass, this is different for me. During an interview on 5/7/26, at 1:20 p.m. Resident R4 stated, I heard the shot, I thought I was dreaming, it woke me up out of a silent sleep. I heard people running around so I figured something had happened. She wasn't supposed to be in the building, let alone with a gun. During an interview on 5/7/26, at 1:22 p.m. Resident R5 stated, I heard the shot. It was down at the desk, you could see a 38 mm (millimeter) in the wall. I know because I used to shoot when I was a kid. It hit the tray cart in the dining room, the metal door was dented. There were cops all over the place in the morning when I got up. Must have been about 15 officers down in that dining room. If I had been down there, I would have knocked the gun out of her hand, put her on the ground, and held her down till the cops got here. I'd put my elbow in the back of her head. I would have protected the residents here. I'll take you down there right now and show you the bullet holes. During an observation on 5/7/26, at 1:24 p.m. on the Third Floor Nursing Unit, the bullet entrance hole was observed to be patched and painted. The bullet exit hole in the Third Floor Dining Room was also observed to be patched and painted. During an interview on 5/7/26, at 1:26 p.m. Resident R2 stated, I heard a big boom, didn't realize it was a gunshot at first. I don't remember hearing anyone yelling or coming in the dining room. You're not supposed to have guns here, it's on the front door. I was in the dining room by myself. I think someone checked on me. In the morning I talked to the police. I still feel safe in the building. They need to beef up security. This happened around 12:30 a.m., the police didn't come until I woke up in the morning. The facility has not explained what changes have been made to prevent it from happening again, but they should. During an interview on 5/7/26, at 1:47 p.m. LPN Employee E11 stated, If something like this happened while I was here, I would notify someone right away, especially 911. We do get education on emergency preparedness, usually annually. During a telephonic interview on 5/7/26, at 3:57 p.m. RN Supervisor Employee E2 stated, I was downstairs getting oxygen tanks in the basement, I work on the 1st floor. I didn't know what had gone on. A lady who used to work there, hired and fired multiple times, she was very angry, came in and said, Do you feel safe? I said, Yeah I'm fine. She said, Do you love me? here to find out, she shot her gun at a resident. I didn't know about this until later, I found out at 2:00 a.m. because a resident told me about it, the one who was in the dining room. Another resident described the gun as about the size of your hand, he saw the gun. He said that kind is a repeating one. That was kind of scary. I found the slug on the floor and gave it to the police. The hole in the wall was about the size of your pinkie, a 50 cent piece at the exit. I was very distraught, that was too close to the patients. That girl was disgruntled. I called the DON around 4:00 a.m. People were screaming at me. The girl said she pushed on the door and said, I can come in at any time. I did notify the police when I stopped throwing up, around 4:00 a.m. I feel safer with a buzzer at the door. That girl said, I can come in any of the doors, I know all the codes, I can lean on the glass. She let herself in. Only two people were nearby. LPN Employee E3 saw the gun. The girl said, I brought my sister lunch and she did have a plate of food. It took me so long to notify the police of the incident because I was getting the facts from other patients, that one gentleman who told me the gun was the size of his hand. I was also trying to gather evidence. I found the shell casing and put that in my pocket. I wanted to hand it to the police. I showed them where the shot had gone through. During a telephonic interview on 5/7/26, at 4:13 p.m. LPN Employee E3 stated, There was a CNA that I didn't know was DNR'd (do not rehire) from the facility until she said it. I asked why, she gave some reason, I don't remember. She said, Wanna see my gun? and pulled it right out, don't know where she pulled it out of. Next thing I know she's showing it. I just stood there and didn't say much. When she went to put the clip in she said, Don't worry, it's not loaded. As I said, That's how people get killed that's when the gun went off. It happened so fast. I'm still in shock about the whole thing. I can't get past it. Other nurses are saying, I would have called the cops good for you, why didn't you? I don't care if it was four hours late. After the gun went off the girl said, I'm getting the fuck out of here hurried up and left. One of the residents saw the gun, that was Resident R3. He said he came out of his room and said, Did you do the gunshot? I wasn't saying a word to anybody. She got on the elevator and I sure as hell wasn't getting on with her. I waited and went down to the first floor and told RN Supervisor Employee E2. I told her what happened and she understood. She went to the phone, I thought she was gonna call somebody, I don't know who she called or texted. Obviously she didn't talk to the NHA or anybody. The cops never came so I was kind of wondering myself why they didn't come. She [RN Supervisor Employee E2] was well aware of it and I really thought she was calling the police after I told her. That scared the crap out of me, there was a resident sitting at the table not very far away from where the bullet came out, I'm not sure if it's still on the wall. I didn't know she was DNR'd, I worked with her a million times, she's a good aide. That's ridiculous. I know people who carry guns all the time, but not into a facility. All I heard was, Well I would have called the cops I believe in going through the chain of command, that's exactly what I did, I don't think I should be in trouble at all. I was told she lawyered up. For what? Every step she took was wrong. Getting in the building, pulling out a gun, and then discharging it. She was acting normal, not aggressive or angry. I trust my supervisor, I believe in chain of command. I think it happened around 11:30 p.m. I guess. It was a blur. I told RN Supervisor Employee E2 about 15 minutes after it happened. I'm not sure how that girl got in the building. On 5/7/26, at 5:47 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) was called due to the failure to create an environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit. The NHA was provided an Immediate Jeopardy template, and a corrective action plan was requested. On 5/7/26, at 8:06 p.m. an acceptable Corrective Action Plan was received which included the following interventions: The facility will create an environment free of avoidable accidents. The facility cannot retroactively correct the concern identified for the incident that occurred on 5/3/26. The DON and or designee will assess all residents for injuries, psychosocial needs and mental harm related to incident and if necessary provide needed treatment, update resident care orders and care plans. This will be completed by 5/8/26. The NHA and or designee will notify families and physicians of incidents, and this will be completed by 5/8/26. The NHA and Regional team will review and update the facility policy on weapons in the facility by 5/7/26. At this time, the facility investigation is unable to determine the root cause of how the visitor/former staff member entered the facility due to an open investigation with the police and we are unable to speak with this person. The NHA or designee will continue to investigate if any staff let visitor/former employee into the facility and will take action as appropriate. The facility has locked the front entrance of the facility and all visitors and staff will have to be let in by a staff member and complete screening at the front entrance prior to work or visiting. This will be implemented by 5/8/26. The NHA and or designee will educate all staff on the facility for weapons, visitation, visitor screening and active shooter policy prior to their next scheduled shift, education to be completed on 5/8/26. The NHA or designee will develop a visitor and staff screening process to prevent weapons from entering the facility. The process will include a staff member letting visitors/staff enter the facility and sign in at front desk. The sign in sheet will include asking the staff/visitor if they have any weapons, if yes, they will not be permitted to visit or work, and asked to leave the facility immediately. This will be implemented by 5/8/26. This incident as all other incidents will be reviewed at the monthly Quality Assurance and Performance Improvement Committee for review and recommendations as necessary. On 5/8/26, at 2:00 p.m. it was confirmed 112 residents were present at the facility during the incident. 112/112 residents had a skin assessment performed with no injuries noted. 113/113 residents were assessed on 5/7/26 for psychosocial needs and mental harm. One resident was identified as having mental harm related to the incident. Two additional residents were identified as potential witnesses to the incident. 3/3 resident physician orders were verified to include behavior monitoring related to discharge of firearm. 3/3 care plans were verified to include interventions related to risk for alteration in mood related to hearing/witnessing unintentional gun discharge on 5/3. Review of facility documents on 5/8/26, indicated the facility had notified all resident families of the incident on 5/3/26. The Medical Director was notified of the incident on 5/8/26. The facility's policy Security/Visitor Screening was revised on 5/7/26. The revision included the facility doors will be locked at all times, a staff member will let in visitors and staff and they will be asked to sign in at the front desk and complete screening. If the visitor or staff member possesses an item that is prohibited, they will be asked to leave the facility immediately. On 5/8/26, at 8:27 a.m. it was verified that in order to gain entrance into the facility, a doorbell must be rung at the main entrance. A staff member must enter a code before the main entrance door opens. Upon entering the facility, all visitors and staff are required to sign in at the main entrance and are screened for weapons at that time. Review of facility documents on 5/8/26, revealed the facility had 109 employees and 16 agency employees. 67 employees signed they received formal education on the policies Weapons, Visitation/Visitor Screening and Active Shooter education. 51 employees were noted as they received education via phone as they had not been working in the building. During employee interviews on 5/8/36, from 11:11 a.m. through 2:18 p.m. 24 employees confirmed they had received education on the facility's weapons, visitation/visitor screening policies and active shooter education, as stated above. The Immediate Jeopardy was lifted on 5/8/26, at 4:00 p.m. when the action plan implementation was verified. During an interview on 5/8/26, at 5:00 p.m. the NHA and DON confirmed that the facility failed to create an environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, resulting in immediate jeopardy for all residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to four of five direct care facility staff reviewed (Employees E11, E13, E14, and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for Employees E11, E13, E14, and E16 for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide QAPI training to four of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Behavioral Health training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Behavioral Health training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of in-service education training each year for three out of three Nurse Aide (NA) Employees (Employee E13, E14, and E15)Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Nurse Aide (NA) Employees E13, E14, and E15. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for Employees E13, E14, and E15 for the year 2025, and confirmed that the facility failed to provide the required 12 hours of annual in-service education for three out of three Nurse Aide Employees. 28 Pa. Code 201.19(7) Personnel policies and procedures28 Pa. Code 201.20(a)(d) Staff development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Compliance and Ethics training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Compliance and Ethics training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Infection Control training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Infection Control training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Abuse, Neglect, and Exploitation training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Abuse, Neglect, and Exploitation training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Communication training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Communication training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide Resident Rights training to five of five direct care facility staff reviewed (Employees E11, E13, E14, E15 and E16).Findings include: During an interview on 5/8/26, at 3:33 p.m. the Nursing Home Administrator (NHA) stated that education is conducted by calendar year running January through December, and State Agency requested Employee Education records for Licensed Practical Nurse (LPN) Employee E11, Nurse Aide (NA) Employee E13, NA Employee E14, NA Employee E15, and Registered Nurse (RN) Employee E6. During an interview on 5/8/26, at 4:17 p.m. the NHA stated that the facility was unable to find any education records for the above employees for the year 2025. During an interview on 5/8/26, at 4:55 p.m. Human Resources Director Employee E17 confirmed that the facility failed to provide Resident Rights training to five of five direct care facility staff. 28 Pa. Code: 201.14(a) Responsibility of Licensee28 Pa. Code: 201.20(a) Staff Development

Based on facility policy, observation and staff interview, it was determined that the facility failed to provide a safe, clean, and comfortable environment for one of three nursing unit shower rooms. (Second floor)Findings include:Review of facility policy Environmental Services, Clean, Safe and Orderly Environment dated 4/28/26, indicated the exterior and interior of the facility will be maintained in clean, safe and orderly manner. Housekeeping, Laundry and Maintenance services will provided properly with precautions taken to prevent infection and cross contamination. Observations on 5/7/26, at 1:30 p.m. revealed the second-floor shower room had 5 ceiling tiles that were brown and one ceiling tile that was brown and caving in. During an interview on 5/7/26, at 3:50 p.m. Nursing Home Administrator confirmed the second floor shower room ceiling tile and that she was not aware of its condition and unsafe environment. 28 Pa. Code 201.14(a)Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(2.1) Management

Based on review of facility policy and documents, and interviews with staff, it was determined that the facility staff failed to implement policies and procedures to notify the administrator and local law enforcement in a timely manner after a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on one of three nursing units (Third Floor Nursing Unit).Findings include: Review of facility policy Abuse Protection dated 4/28/26, indicated our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc.; training is provided as time of hire, annually and as needed. The reporting and filing of accurate documents relative to incidents of abuse; reporting to State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. Review of facility policy Accidents and Incidents dated 4/28/26, indicated all accidents and incidents occurring on our premises must be investigated and reported to the administrator. The charge nurse should conduct initial assessment and provide any emergency interventions. If necessary, call 911 (emergency services) for evaluation and possible transfer to Hospital/Medical Center. Review of facility policy Security dated 4/28/26, indicated the facility will provide security services as needed. In the absence of specific security staff, the Maintenance Department will be responsible for facility security. The following items are not permitted on facility property: all types of firearms or personal knives, dangerous chemicals, explosives, including blasting caps, any object that could be used for the purpose of injury or intimidation. Good judgment is also important for safety and health in the workplace. The following guidelines can help reduce the likelihood of problems: call your supervisor immediately regarding any unusual behavior or incident. Ask any unauthorized visitor to leave. An unauthorized visitor is anyone who does not have permission to visit the work are or who is not working in the facility at the time. All visitors must check in at the front desk. The facility doors will be locked at night after visiting hours. Call 911 if there is a serious concern for your safety or the safety of co-workers or residents. If you become aware of either a prowler or break-in, call 911. Review of the facility Emergency Preparedness Program and Plan - Workplace Violence/Active Shooter dated 4/28/26, indicated in order to preserve life and address the reality of an active shooter event, these guidelines have been established to guide our response to this event to maximize survivability. Most importantly, quickly determine the most reasonable way to protect your own life. Run if there is an accessible escape path, attempt to evacuate the premises. Call 911 when you are safe. Hide if evacuation is not possible, find a place where the active shooter is less likely to easily find you. Dial 911, if possible, to alert police to the active shooter's location. Fight, take action against the active shooter - as a last resort, and only when your life is in imminent danger. Recovery: account for all residents, staff and visitors. Review of a facility submitted document dated 5/3/26, stated, After midnight, an individual who is no longer employed by the facility brought food to her sister. A firearm was exposed in the presence of staff on the third floor and discharged . Staff immediately secured the facility until police arrived. All residents on the third floor were immediately accounted for and assessed, with no injuries identified. Law enforcement was notified and responded. Review of an undated witness statement, completed by Licensed Practical Nurse (LPN) Employee E3 stated, On 5/2/26 at 2315 (11:15 p.m.) I pulled in, 2 CNA (Certified Nurse Aide) at pillar talking and said hello to me. IDK (I didn't know) anything happened. At 0400 (4:00 a.m.) Registered Nurse (RN) Employee E5 Came on 2, pulled Nurse Aide (NA) Employee E12 to side told her and said don't tell anyone. She then told me and NA Employee E6. Me and NA Employee E6 took a break, NA Employee E6 seen and asked RN Supervisor Employee E2 why no police called. RN Supervisor Employe E2 stated she is going to do this quietly and call Assistant Director of Nursing (ADON) and Director of Nursing (DON). RN Supervisor Employee E2 told NA Employee E6 to be supervisor and take her badge if she could do better. But she, RN Supervisor Employee E2, will be doing this quietly. Review of a witness statement dated 5/3/26, completed by RN Employee E5 stated, I was the nurse on the first floor cart. The supervisor [RN Supervisor Employee E2] informed a staff member and myself that she had a bullet slug in her hand. And told us she was told an ex-employee pulled a hand gun out in the 3rd floor dining room and accidentally discharged a gun that went into the dining room wall. RN Supervisor Employee E2 went upstairs and dug the slug from the wall. The ex-employee had left the building by this time. Review of a witness statement dated 5/3/26, completed by NA Employee E6 stated, I witnessed nothing, we heard what happened at 4:00 (a.m.) and we were upset we should of been told and police should of been called when it happened this is a serious matter. Review of a witness statement dated 5/3/26, completed by LPN Employee E7 stated, During night shift around midnight RN Supervisor Employee E2 was talking about something happened on 3rd floor. She pulled me aside and showed me a piece of metal. I said whats that. She proceeded to tell me about the aide's sister on the 3rd floor having a gun and it went off. The person had left. I asked if she dialed 911 and she said no. She said she was going to call someone. I did see hole in wall when going upstairs to use microwave. Review of a typed statement indicated, On May 3, 2026, at approximately 0920 (9:20 a.m.) the DON and Nursing Home Administrator (NHA) conducted a recorded conversation with Resident R3. Resident R3 stated that he heard a loud noise which he believed sounded like a gunshot. He reported getting out of bed into his wheelchair to investigate. Resident R3 stated that he observed an unfamiliar female individual near the elevator. He reported that the individual walked back from the elevator and, at that time, he observed what appeared to be a pistol secured at her waist. He stated that the individual then returned to the elevator and left the area. Review of a typed statement indicated, On May 3, 2026, at approximately 0927 (9:27 a.m.) the DON and NHA conducted a recorded conversation with Resident R2. Resident R2 stated that he was seated in the dining room, seated in his usual location, using his phone and watching television. He reported that his back was against the wall and that he was facing the parking lot. Resident R2 stated that he heard a loud explosion and observed smoke. He reported that he was unsure of what had occurred until staff entered the area. Resident R2 indicated that the time of the incident was approximately 12:30 a.m., which he stated he verified by the time displayed on his phone and dining room clock. Resident R2 verbalized that he does not feel scared and continues to feel safe at the facility. Review of a typed statement indicated, On May 3, 2026 at 1335 (1:35 p.m.) the DON and Registered Nurse Supervisor spoke with NA Employee E1 via phone. During this discussion, NA Employee E1 stated that she wished to exercise her right to remain silent and declined to provide a statement, indicating that doing so may incriminate her. The DON informed NA Employee E1 that she was being placed on suspension pending investigation. NA Employee E1 then activated a recording device on her phone. The DON advised that permission to record the conversation was not granted, and the conversation ended at that time. Review of a witness statement dated 5/4/26, completed by NA Employee E8 stated, I was in the med office getting my charger when I heard a loud noise. When I came out it was smoky and smelled weird. I started looking around to make sure nobody was injured after a resident said it was a gun shot and he seen someone leaving with a gun. I don't know that girls name or know her. She had on purple with braids. I'm also unsure on how she got in the building. Review of a witness statement dated 5/4/26, completed by NA Employee E9 stated, I was on 1st floor not sure what has occurred. Just know officers arrived around 6:30 a.m. - 7:00 a.m. clocked out and went home on 5/3/26. During an interview on 5/7/26, at 9:23 a.m. the NHA stated, People have always had to have a code to come in. Visitors and vendors didn't know the code, but employees knew the code. Agency employees usually don't know the code, but facility employees do. On Sunday, I came in, the DON came in and Maintenance came in. We disabled the previous entrance code and made a brand new one. Only myself and the Maintenance Director know what the code is. Everyone must be buzzed in now. Everyone can leave the building with a different code. The front entrance door does open when pushed in emergencies, that's the way it's designed. We have ordered visitor passes for visitors to wear while they are in the building. They already have to sign in, so the passes will have their name and date, something to identify them. NA Employee E1 is the sister. She [visitor/former employee] worked for us as an aide, she was hired in December, stopped coming to work in March. We didn't terminate her, we kept her on our roster. She may have told Human Resources she wanted to go per diem (as needed). She was not scheduled for any shifts. If you don't pick up any shifts for a month when you're per diem, you are automatically terminated. On 4/16/26 she was officially out of our system as an employee. LPN Employee E3 had no reason not to think she would be here. She had brought lunch up for her sister [NA Employee E1], she wasn't on the deployment sheet. She showed LPN Employee E3 her pistol in her purse. LPN Employee E3 said you can't have this in here, she said it's not loaded, then a gunshot went off. Then she immediately took off. NA Employee E1 was apologetic. When police arrived, no one would state who the shooter was. RN Supervisor Employee E2 is the one who notified me at 6:15 a.m. I had to direct her to call 911. The detective stated he was notified at 6:30 a.m. When I got here, first responders were already here. Two officers, a lieutenant, and the detective were here. During an interview on 5/7/26, at 12:59 p.m. LPN Employee E10 stated, If I was here and something like that happened, I would notify someone right away, check on everyone and make sure they're safe, definitely call 911. I'd let the supervisor know, then the administrator. We get annual education, including emergency preparedness. During an interview on 5/7/26, at 1:03 p.m. Resident R3 stated, I was lying in bed, I heard this noise, I knew it was a gun shot. I was like, What the hell? I jumped up in my wheelchair. I got to my doorway and I saw a lady standing at the elevator. I never saw her before. She started walking towards me and I saw her fiddling with her gun in her waistband. She walked past me and went towards the nurses station and said to someone, I'm gonna take the steps just as she said that the elevator opened. At first it didn't really bother me, the first day or so, but now every time I hear a loud noise, I get freaked out and I'm real jumpy. I got freaked out when you knocked on the door. I talked to the Social Worker yesterday and I told her about what was going on. A psychiatrist came yesterday and I talked to them. I'm on Cymbalta, I get phantom limb pain, so she upped that dose and added something for sleeping. I'm having trouble sleeping since the incident, that's new for me. All of these symptoms are new, I never felt jumpy or anxious before. It's weird because I've been around guns my whole life and been through a lot. You think you're in a safe environment and you wouldn't expect something like that, so I'm not sure if that's what's going on in my head. I pride myself in being a badass, this is different for me. During an interview on 5/7/26, at 1:20 p.m. Resident R4 stated, I heard the shot, I thought I was dreaming, it woke me up out of a silent sleep. I heard people running around so I figured something had happened. She wasn't supposed to be in the building, let alone with a gun. During an interview on 5/7/26, at 1:22 p.m. Resident R5 stated, I heard the shot. It was down at the desk, you could see a 38 mm (millimeter) in the wall. I know because I used to shoot when I was a kid. It hit the tray cart in the dining room, the metal door was dented. There were cops all over the place in the morning when I got up. Must have been about 15 officers down in that dining room. If I had been down there, I would have knocked the gun out of her hand, put her on the ground, and held her down till the cops got here. I'd put my elbow in the back of her head. I would have protected the residents here. I'll take you down there right now and show you the bullet holes. During an observation on 5/7/26, at 1:24 p.m. on the Third Floor Nursing Unit, the bullet entrance hole was observed to be patched and painted. The bullet exit hole in the Third Floor Dining Room was also observed to be patched and painted. During an interview on 5/7/26, at 1:26 p.m. Resident R2 stated, I heard a big boom, didn't realize it was a gunshot at first. I don't remember hearing anyone yelling or coming in the dining room. You're not supposed to have guns here, it's on the front door. I was in the dining room by myself. I think someone checked on me. In the morning I talked to the police. I still feel safe in the building. They need to beef up security. This happened around 12:30 a.m., the police didn't come until I woke up in the morning. The facility has not explained what changes have been made to prevent it from happening again, but they should. During an interview on 5/7/26, at 1:47 p.m. LPN Employee E11 stated, If something like this happened while I was here, I would notify someone right away, especially 911. We do get education on emergency preparedness, usually annually. During a telephonic interview on 5/7/26, at 3:57 p.m. RN Supervisor Employee E2 stated, I was downstairs getting oxygen tanks in the basement, I work on the 1st floor. I didn't know what had gone on. A lady who used to work there, hired and fired multiple times, she was very angry, came in and said, Do you feel safe? I said, Yeah I'm fine. She said, Do you love me? here to find out, she shot her gun at a resident. I didn't know about this until later, I found out at 2:00 a.m. because a resident told me about it, the one who was in the dining room. Another resident described the gun as about the size of your hand, he saw the gun. He said that kind is a repeating one. That was kind of scary. I found the slug on the floor and gave it to the police. The hole in the wall was about the size of your pinkie, a 50 cent piece at the exit. I was very distraught, that was too close to the patients. That girl was disgruntled. I called the DON around 4:00 a.m. People were screaming at me. The girl said she pushed on the door and said, I can come in at any time. I did notify the police when I stopped throwing up, around 4:00 a.m. I feel safer with a buzzer at the door. That girl said, I can come in any of the doors, I know all the codes, I can lean on the glass. She let herself in. Only two people were nearby. LPN Employee E3 saw the gun. The girl said, I brought my sister lunch and she did have a plate of food. It took me so long to notify the police of the incident because I was getting the facts from other patients, that one gentleman who told me the gun was the size of his hand. I was also trying to gather evidence. I found the shell casing and put that in my pocket. I wanted to hand it to the police. I showed them where the shot had gone through. During a telephonic interview on 5/7/26, at 4:13 p.m. LPN Employee E3 stated, There was a CNA that I didn't know was DNR'd (do not rehire) from the facility until she said it. I asked why, she gave some reason, I don't remember. She said, Wanna see my gun? and pulled it right out, don't know where she pulled it out of. Next thing I know she's showing it. I just stood there and didn't say much. When she went to put the clip in she said, Don't worry, it's not loaded. As I said, That's how people get killed that's when the gun went off. It happened so fast. I'm still in shock about the whole thing. I can't get past it. Other nurses are saying, I would have called the cops good for you, why didn't you? I don't care if it was four hours late. After the gun went off the girl said, I'm getting the fuck out of here hurried up and left. One of the residents saw the gun, that was Resident R3. He said he came out of his room and said, Did you do the gunshot? I wasn't saying a word to anybody. She got on the elevator and I sure as hell wasn't getting on with her. I waited and went down to the first floor and told RN Supervisor Employee E2. I told her what happened and she understood. She went to the phone, I thought she was gonna call somebody, I don't know who she called or texted. Obviously she didn't talk to the NHA or anybody. The cops never came so I was kind of wondering myself why they didn't come. She [RN Supervisor Employee E2] was well aware of it and I really thought she was calling the police after I told her. That scared the crap out of me, there was a resident sitting at the table not very far away from where the bullet came out, I'm not sure if it's still on the wall. I didn't know she was DNR'd, I worked with her a million times, she's a good aide. That's ridiculous. I know people who carry guns all the time, but not into a facility. All I heard was, Well I would have called the cops I believe in going through the chain of command, that's exactly what I did, I don't think I should be in trouble at all. I was told she lawyered up. For what? Every step she took was wrong. Getting in the building, pulling out a gun, and then discharging it. She was acting normal, not aggressive or angry. I trust my supervisor, I believe in chain of command. I think it happened around 11:30 p.m. I guess. It was a blur. I told RN Supervisor Employee E2 about 15 minutes after it happened. I'm not sure how that girl got in the building. During an interview on 5/8/26, at 5:19 p.m. the NHA and DON confirmed that the facility staff failed to implement policies and procedures to notify the administrator and local law enforcement in a timely manner after a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on one of three nursing units (Third Floor Nursing Unit). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a physician order for one of four residents (Resident R1). Findings include: Review of facility policy Medication & Treatment Orders dated 4/28/26, indicated each medication administered will have a corresponding and complete physician's order. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included fracture, left femur, atrial fibrillation (irregular heart rhythm that originates in the heart's upper chambers) and malnutrition. Review of Resident R1s Medicare-5day MDS assessment (minimum data assessment)- periodic assessment of resident care needs) dated 4/27/26, indicated the diagnosis remained current. Review of Resident R1's most recent physician orders indicate Sodium Chloride Injection Solution 0.9 % (Sodium Chloride) Use 60 ml/hr intravenously every shift for AKI, hydration for 1 day, ordered on 4/28/26. Review of Resident R1's Medication Administration Record (MAR) for April indicated blank spaces 4/28/26, it was not started. During an interview on 5/7/26, at 4:15 p.m. Director of Nursing confirmed the physician order was not followed as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by failing to create a safe environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, which created an immediate jeopardy situation for all residents.Findings include: The job description for the Nursing Home Administrator specified the primary purpose of the job position is to manage the Facility with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities To follow all facility policies and apply them uniformly to all employees. The ensure the highest degree of quality care is provided to our residents at all times. The job description for the Director of Nursing specified the purpose of the job is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on findings identified in this report, the facility failed to create a safe environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, placing all residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed. During an interview on 5/7/26, at 5:47 p.m. the NHA and DON were notified that they failed to effectively manage the facility by failing to create a safe environment free of accidents when a visitor/former employee entered the facility with a loaded handgun and discharged the handgun on the Third Floor Nursing Unit, which created an immediate jeopardy situation for all residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(3)(e)(1) Management.

Based on review of facility policy, clinical records, facility documents, observations, and staff interviews, it was determined the facility failed to keep residents free from hazards and provide the necessary monitoring and supervision for residents with known suicidal ideation and history of a suicide attempt for two of three residents (Resident R1, and R2).Findings include: Review of facility policy Suicide Threats dated 11/1/25, indicated resident suicide threats must be taken seriously and immediately reported to the nurse supervisor charge nurse. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. The resident will be placed on 1:1 observation until the acute episode has been resolved if the resident is capable of self-injury. The resident shall remain on 1:1 monitoring until transfer from the facility for acute intervention or nursing assessment has identified the resident is no longer a safety risk. The charge nurse or designees shall immediately notify the resident's attending physician, and responsible party. Following the assessment of nursing staff will remove any items with which the resident could use to harm self which may include, but not limited to call bell cords (replace with tap bells), light and/or nurse call pull cords to be shorted to length no longer than eight inches or replace with wooden or plastic type, and remove all plastic trash liners (including bathroom). Review of facility policy Care Planning dated 11/1/25, indicated care planning is a tool for an interdisciplinary approach to plan the care of the resident. The purpose is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/26, revealed diagnoses of PTSD (a mental health condition that caused by an extremely stressful or terrifying event), high blood pressure, and depression. Review of documentation provided by the facility dated 1/29/26, stated: Registered Nurse responded to the unit after staff reported that Resident R1 stated, 'I want to kill myself,' while holding a fork to his neck. Resident stated he would 'push it through' if his room was not changed. Safety measures were initiated, and staff remained with the resident. Review of Resident R1's clinical record revealed a physician's order dated 1/29/26, to monitor resident for safety, behaviors or signs of distress. Has the resident displayed any behaviors this shift? Stay with resident until determined if patient needs one on one supervision. May start every 15 minute checks until seen by psych. Review of Resident R1's clinical record revealed the above order was discontinued on 2/20/26, and a new order was written that day to downgrade frequency of suicide precaution checks to every four hours. Review of Resident R1's clinical record revealed the above order was discontinued on 3/3/26, and a new order was written the same day to downgrade frequency of suicide precaution checks to every shift. Review of documentation provided by the facility on 3/5/26, stated: It appears that the situation involving Resident R1 began after the facility business office discussed he may owe facility a monthly $400 payment. Following this conversation, Nursing Administration was informed that Resident R1 expressed statements indicating he no longer wished to live, and he wished he had a gun to shoot himself. Safety measures were initiated, and staff remained with the resident. Review of Resident R1's clinical record failed to reveal documentation that resident was monitored for suicide precautions on the following shifts: 3/4/26: daylight, and evening shift 3/5/26: night, daylight, and evening shift 3/6/26: night, daylight, and evening shift 3/7/26: night, daylight, and evening shift 3/8/26: night, daylight, and evening shift 3/9/26: night, daylight, and evening shift 3/10/26: night, and daylight shift 3/12/26: night shift 3/14/26: night shift During an interview on 4/30/26, at 4:29 p.m. the Director of Nursing confirmed that the facility failed to ensure that monitoring and supervision occurred for Resident R1. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], revealed diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anxiety. Review of documentation provided by the facility, dated 4/16/26, stated: During a therapy session, Resident R2 disclosed that she has been experiencing suicidal thoughts. Resident R2 was immediately placed on 1:1 observation for safety. A full skin assessment was completed, negative findings. Physician and family made aware. All potential hazards were addressed promptly, cords were secured and utensils were replaced with plastic. Resident was sent to hospital for evaluation and treatment. Review of Resident R2's care plan updated on 4/16/26, indicated all potential hazards will be addressed promptly: cords were secured and dietary services replaced metal utensils with plastic. During an observation on 4/30/26, at 2:15 p.m. Resident R2 was lying in bed coloring pictures. The bed controller was on the bed, however the bed controller cord was not secured. During an interview on 4/30/26, at 3:30 p.m. Licensed Practical Nurse (LPN) Employee E1 and State Agency (SA) reviewed Resident R2's care plan. LPN Employee E1 confirmed that all cords should be secured according to care plan. During an interview on 4/30/26, at 3:37 p.m. LPN Employee E1 confirmed that the bed controller cord was not secured for Resident R2 and could be used to self-harm if wanted. LPN Employee E1 notified appropriate department to secure the cord. During an interview on 4/30/26, at 3:50 p.m. the Director of Nursing confirmed that the bed controller cord was not secured and that the facility failed to implement Resident R2's care plan interventions and failed to keep residents free from hazards. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to record food temperatures at the time of service in the main kitchen. Findings include: A review of the facility's food temperature log on 3/4/26, at 12:15 p.m. revealed that there was no documented evidence that the holding food temperatures were obtained at the time of of during service for breakfast and lunch to ensure that the food maintained safe internal temperatures. In an interview during this observation period, Dietary Manager Employee E7 stated confirmed that there were no recorded temperatures for breakfast or lunch and they should have been recorded. 28 Pa. Code 201.14(a)Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, clinical records, facility documents, resident and staff interviews, it was determined the facility failed to keep Resident R96 free from hazards and provide the necessary monitoring and supervision for a resident with known suicidal ideation and history of a suicide attempt for one of three residents (Resident R96). This failure created an immediate jeopardy situation. Findings include: Review of facility policy Suicide Threats dated 11/24, indicated resident suicide threats must be taken seriously and immediately reported to the nurse supervisor charge nurse. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine the resident. The resident will be placed on 1:1 observation until the acute episode has been resolved if the resident is capable of self-injury. The resident shall remain on 1:1 monitoring until transfer from the facility for acute intervention or nursing assessment has identified the resident is no longer a safety risk. The charge nurse or designees shall immediately notify the resident's attending physician, and responsible party. Following the assessment of nursing staff will remove any items with which the resident could use to harm self which may include, but not limited to call bell cords (replace with tap bells), light and/or nurse call pull cords to be shorted to length no longer than eight inches or replace with wooden or plastic type, and remove all plastic trash liners (including bathroom). Review of facility policy Accidents and Incidents-Investigating and Reporting dated 11/24, revealed all accidents or incidents occurring on the facility premises must be investigated and reported to the administrator. Should you witness an accident or find it necessary to aid a resident post-accident you should render assistance immediately. Regardless of how minor an accident or incident, it must be reported to the nursing supervisor. Do not leave an accident victim unattended unless it is necessary to summon assistance. Review of the clinical record revealed Resident R96 was admitted to the facility on [DATE]. Review of Resident R96's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/5/25, revealed diagnoses of Depression and Adjustment Disorder with depressed mood. Review of Section D0150. Resident Mood Interview revealed the resident had felt down, depressed, or hopeless nearly every day. Review of Resident R96's progress note entered by Registered Nurse, Employee E13, dated 8/12/25, at 2:59 p.m. revealed the resident was found with a phone cord wrapped around [his/her] neck. The resident was pulling on the cord and expressed I want to kill myself. and I need help. The physician was notified, and the resident was sent to hospital for further evaluation. Review of Resident R96's progress note dated 8/12/25, at 10:13 p.m. revealed the resident returned from the hospital. Review of Residents R96 care plan dated 8/13/25, indicated the resident was a suicide risk as evidence by feelings/actions which indicate suicidal ideation. Interventions included to tie down cords beneath bed, shorten call light and call bells so it's within reach but not enough to get around [his/her] neck. Review of Resident R96's physician orders revealed every 15 minutes checks (Q15 minute checks) were ordered on 8/13/25, for one day. Review of Resident R96's clinical record failed to include evidence the resident was provided Q15 minute checks as ordered on 8/13/25. During an interview on 10/27/25, at 11:05 a.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to provide evidence documentation the physician ordered Q15 minute checks were completed as ordered. Review of Resident R96's late entry progress note dated 10/18/25, entered by Registered Nurse Supervisor, Employee E2, on 10/22/25, revealed Nurse Aide (NA), Employee E1 entered Resident R96's room to complete care, and the resident wrapped the telephone cord around [his/her] neck and expressed suicidal ideation. Resident R96 expressed wanting to die, was upset and crying. Review of Resident R96's clinical record failed to include a physical assessment that was completed or Q15 minute checks or a 1:1 was implemented after Resident R96 was found with a telephone cord wrapped around their neck and expressed suicidal ideation on 10/18/25.Review of Resident R96's hospital record dated 10/19/25, instructed the residents to follow up with psychiatry within one week.Review of Resident R96 physician order dated 10/20/25, stated to see psychiatry as soon as possible.Review of Resident R96 clinical record on 10/27/25, failed to include evidence the resident was seen by psychiatry as ordered.Review of information submitted by the facility on 10/22/25, revealed a nurse aide reported when they entered Resident R96's room to complete care on 10/22/25, the resident had their telephone cord wrapped around their neck and expressed suicidal ideation. All call bells and bed controls have been secured, and the facility will purchase a cordless phone for residents to use at bedside. Residents have a continued safety care plan in place. Resident has an order for Q shift behavioral checks.During an observation on 10/27/25, at 10:09 a.m. Resident R96 was observed resting in bed with a bed controller wrapped around the positioner bar, not secured. Resident R96's bed was plugged into the wall and the cord was unsecured. The television cord was observed hanging from the television to the wall outlet, the cord was not secured. During an observation on 10/27/25, at 10:12 a.m. Resident R96's roommate was resting in bed and was wearing oxygen tubing that was connected from [his/her] nostrils to the oxygen concentrator located in-between Resident R96's bed. Resident R96's roommate bed controller and call bell cord were not secured. Resident R96's roommate had a television cord that was unsecured. During interview on 10/27/25, at 10:48 a.m. Registered Nurse Supervisor, Employee E2 confirmed Resident R96 was not assessed by a nurse after their suicide ideation on 10/18/25. During an interview on 10/27/25, at 11:05 a.m. the Director of Nursing indicated staff must stay with resident if suicidal, then an order for every 15 minutes or 1:1 is obtained. During an interview on 10/27/25, at 11:07 a.m. the Nursing Home Administrator confirmed the facility failed to provide evidence Q15 minutes checks and/or 1:1 supervision was completed for Resident R96's suicidal ideation on 10/18/25. During an observation and interview on 10/27/25, at 11:21 a.m. Licensed Practical Nurse (LPN), Employee E3 confirmed Resident R96's cords were not secured. LPN, Employee E3 stated if a resident has suicide ideation, they must be placed on Q15 minute checks for 24 to 48 hours until evaluated by psychiatric services. An incident report must be completed, and an assessment is completed by nurse or supervisor, and physician is notified. LPN, Employee E96 confirmed the facility failed to keep a resident free from hazards and provided the necessary monitoring and supervision for a resident with known suicidal ideation and history of suicide attempt (Resident R96). During a phone interview on 10/27/25, at 1:16 p.m. Nurse Aide, Employee E1 stated on 10/18/25, they went in to do care and Resident R96 was observed with a cord wrapped around their neck twice. NA, Employee E1 stated they told the residents to take it off their neck and the residents started crying. I didn't really think too much to tell anyone. NA, Employee E1 stated I told someone later that same day. NA, Employee E1 indicated RN Supervisor, Employee E2 was notified about Resident R96 while having a conversation later that day. NA, Employee E1 confirmed Resident R96 did not have Q15 minutes checks or a 1:1 supervision implemented after the incident on 10/18/25. NA, Employee E1 stated I am not aware where to document it, I never have a 1:1 in that facility. On 10/27/25, at 2:01 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed. The NHA provided the IJ Template, the facility failed to keep a resident free from hazards and provided the necessary monitoring and supervision for a resident with known suicidal ideation and history of suicide attempt (Resident R96), and a corrective action plan was requested. On 10/27/25, at 4:35 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: The facility will keep residents free from hazards and self-harm and monitor and supervise residents identified at risk for suicidal ideations. -Resident R96 will be provided with a safe environment by securing bed control cord, call bell cord, and telephone cord so cords are not accessible to resident to harm self. Roommate's cords have also been secured. The room has also been checked for any other hazardous items to ensure a safe environment. Physician orders for monitoring resident BP will be completed by nursing staff every 15 minutes to ensure resident safety. Residents will be evaluated by psychiatric services for safety on 10/27/25. Care plan will be reviewed and updated by 10/27/25. Completed on 10/27/25 by EOD. -The Director of Nursing or designee will complete a house audit by end of day 10/27/25 of all residents for suicidal ideations. A resident questionnaire on suicidal ideation will be used for all residents with a BIMS of 9 or above. Residents with a BIMS of 8 or below, a resident skin check and review of risk management to determine resident's safety. -Care plans will be updated to reflect the residents' current condition by Licensed Practical Nurse Assessment Coordinator (LNAC) or designee by end of day 10/27/25. - A house audit of environment will be completed by Environmental Services Supervisor or designee by end of day 10/27/25 to validate no hazards are identified for residents with suicidal ideations. -The NHA, DON and Regional Clinical Consultant will review and update the facility policy and procedures for Suicidal Threats and Supervision of Residents with suicidal ideations on 10/27/25 by end of day. -All staff will be re-educated before their next scheduled shift on the facility policy and procedures for Suicidal Threats, Care Plans and Supervision of residents identified with suicidal ideations on 10/28/25 by end of day. -All incidents and accidents will be reviewed daily and results reported to the Monthly Quality Assurance and Process Improvement Committee for review and frequency of audits. Resident R96 room was assessed on 10/29/25, and bed control cords, call bell cords, and telephone cords were not accessible to resident to harm self. The resident's roommate also had cords secured. Review of the physician order revealed the resident has been ordered Q15 minute safety checks on 10/27/25. Review of Q15 minute check sheet revealed facility completed Q15 minute check as ordered. The resident was evaluated by psychiatrist services on 10/27/25, and revealed the resident is not at risk of harm at that time. A house audit was completed on 10/28/25, of 100/100 residents. Residents with BIMS of 9 or above were asked a questionnaire of three questions that included if they had a history of suicidal ideation, if they are having thoughts of hurting themselves, and if so, what is their plan. Residents were also asked if they felt safe. Residents who have BIMS of 8 or below were assessed by Registered Nurse and a body check was completed. 3/100 residents were identified as suicidal ideation risk. 3/3 residents care plans were updated on 10/28/25, to include their suicidal ideation risk and individualized interventions to prevent harm. A final house audit was completed on 10/29/25, by NHA and DON. During an observation on 10/29/25, from 11:00 a.m. to 11:05 a.m. 3/3 residents' room no hazards were identified. Facility Suicide Threats policy was revised on 10/27/25, to include supervision of residents. A staff member must remain with the resident until the nurse supervisor/charge nurse arrives to examine residents. The resident will be placed on 1:1 observation until the acute episode has been resolved. The facility's MDS/RAI/Care Planning policy was reviewed on 10/27/25, and no changes were made. 113/113 in-house staff and the facility utilizes one staffing agency. 21/31 agency staff were educated. During in-person interviews completed on 10/29/25, from 9:37 a.m. to 10:15 a.m. 16 in-house staff members (nursing and ancillary) confirmed they were educated on the facility policy and procedures for suicidal threats, supervision, and care plans of residents. During phone interviews completed on 10/29/25, from 9:46 a.m. to 10:45 a.m. 9 staff members confirmed they were educated on suicide risks, supervision, and care planning. Facility will ensure all agency staff members verify education prior to the start of their next scheduled shift. The facility's next scheduled QA is 11/18/2025. The Immediate Jeopardy was lifted on 10/29/25, at 11:14 a.m. when the action plan implementation was verified. During an interview on 10/31/25, at 2:15 p.m. the NHA confirmed the facility failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident with known suicidal ideation and history of suicide attempt for one of three residents (Resident R96). This failure created an immediate jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, incident reports, facility documents, employee file, written employee statement, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by not providing the required assistance of two people for a safe transfer, which resulted in actual physical harm (laceration of the right posterior scalp- a deep cut on the back of the head) for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy Abuse Protection, last reviewed 7/21/22, indicated that neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including, but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect. Review of the facility policy Transfer with a Mechanical Lift (a large mechanical device designed to help caregivers lift and transfer a resident who is unable to use their legs from one place to another), last reviewed 7/21/22, indicated that the mechanical lift will be used by two staff members. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and a right below knee amputation. Review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 2/10/22, indicated that the diagnoses remained current and included Section G- Functional Status, Questions G0110B, Activities of Daily Living Assistance for Transfers which indicated that Resident R1 required extensive assistance of two or more staff members. Review of Resident R1's physician orders dated 2/16/22, indicated that Resident R1 was to be transferred with assistance of two people with a sliding board (a rigid, flat board designed to help caregivers transfer a resident who is unable to use their legs from one place to another). Review of Resident R1's care plan dated 2/18/22, indicated that Resident R1 had impaired ability to perform transfers and that the facility should provide two people with use of a sliding board to assist with safe transfers. Review of facility documents dated 3/10/23, indicated Nurse Aide (NA) Employee E1 transferred Resident R1 via mechanical lift which tipped over and Resident R1 fell to the floor. Resident was bleeding from the back of the head and was transferred to emergency room where she received staples to close the wound. NA Employee E1 was transferring Resident R1 without assistance of another person. Review of NA Employee E1's signed witness statement, dated 3/9/23, stated that NA Employee E1 was lowering resident into her chair when the Hoyer (mechanical lift) started to tip over. Review of NA Employee E1's employee file indicated that NA Employee E1 received education on Abuse, Safety and Restorative nursing training on 2/8/23. During an interview on 3/20/23, at 10:30 a.m., NA Employee E2 stated that she was on the same unit passing lunch trays when the accident occurred. She was summoned by Licensed Practical Nurse (LPN) Employee E3 to come into Resident R1's room. When NA employee E2 entered the room, she observed Resident R1 on the floor bleeding from her head and NA Employee E1 wiping blood off the floor. NA Employee E2 further explained that NA Employee E1 was transferring Resident R1 from the bed to her wheelchair by herself. It was also stated that Resident R1 only has one leg and that she is difficult to transfer due to being off balance. NA Employee E2 stated that a residents transfer orders are available in the computer under the Kardex and was able to demonstrate where it was in the computer. During an interview on 3/20/23, at 10:42 a.m., LPN Employee E4 stated that there have been no problems identified with the operation of the mechanical lift and that it does require two people for a safe transfer. During an observation on 3/220/23, at 10:56 a.m., two employees were observed coming out of a resident's room with a mechanical lift. These employees were identified as NA Employees E5 and E6. During an interview on 3/20/23, at 10:56 a.m., NA Employee E5 stated that she and NA Employee E6 were in process of getting people out of bed to eat lunch. When asked why both NA Employee E5 and E6 were working together to complete this task, NA Employee E5 stated you need two people for a Hoyer. NA Employee E5 also stated that a resident's transfer status is in the computer and can easily be verified. During an interview on 3/20/23, at 10:56 a.m. NA Employee E6 confirmed the above process and added that using two people for a mechanical lift transfer is part of their training and that they also receive yearly in-servicing on this topic. During a phone interview on 3/20/23, at 11:25 a.m., NA Employee E1 stated I don't understand what happened. I made a mistake of doing it by myself. I should have looked better than I did for help. I was just trying to get my work done. NA Employee E1 also confirmed that she had received education on requiring two people for a mechanical lift transfer prior to the incident and that she no longer works at this facility. During an interview on 3/20/23, at 2:35 p.m. NA Employee E7 stated that although Resident R1 was ordered assistance of two people for a sliding board transfer, Resident R1 refused to use it and preferred the mechanical lift even though she was terrified of it. During an interview on 3/20/23, at 2:35 p.m. NA Employee E5 also confirmed that Resident R1 preferred to use the mechanical lift and would refuse use of the sliding board. During an interview on 3/20/23, at 2:42 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that a resident was free from neglect by not providing the required assistance of two people with a sliding board for a safe transfer, which resulted in actual physical harm (laceration of the right posterior scalp) for Resident R1. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(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.

Based on review of facility policy, clinical records, incident reports, facility documents, employee file, a written employee statement, and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident and received adequate supervision during a transfer, which resulted in actual physical harm (laceration of the right posterior scalp- a deep cut on the back of the head) for one of three residents reviewed (Resident R1). Findings include: Review of the facility policy Transfer with a Mechanical Lift (a large mechanical device designed to help caregivers lift and transfer a resident who is unable to use their legs, from one place to another), last reviewed 7/21/22, indicated that the mechanical lift will be used by two staff members. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and a right below knee amputation. Review of Resident R1's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 2/10/22, indicated that the diagnoses remained current and included Section G- Functional Status, Questions G0110B, Activities of Daily Living Assistance for Transfers which indicated that Resident R1 required extensive assistance of two or more staff members. Review of Resident R1's physician orders dated 2/16/22, indicated that Resident R1 was to be transferred with assistance of two people with a sliding board (a rigid, flat board designed to help caregivers transfer a resident who is unable to use their legs, from one place to another). Review of Resident R1's care plan dated 2/18/22, indicated that Resident R1 had impaired ability to perform transfers and that the facility should provide two people with use of a sliding board to assist with safe transfers. Review of facility documents dated 3/10/23, indicated Nurse Aide (NA Employee E1) transferred Resident R1 via mechanical lift which tipped over and Resident R1 fell to the floor. Resident was bleeding from the back of the head and was transferred to emergency room where she received staples to close the wound. NA Employee E1 was transferring Resident R1 without assistance of another person. Review of NA Employee E1's signed witness statement, dated 3/9/23, stated that NA Employee E1 was lowering resident into her chair when the Hoyer (mechanical lift) started to tip over. Review of NA Employee E1's employee file indicated that NA Employee E1 received education on Abuse, Safety and Restorative nursing training on 2/8/23. During an interview on 3/20/23, at 10:30 a.m., NA Employee E2 stated that she was on the same unit passing lunch trays when the accident occurred. She was summoned by Licensed Practical Nurse (LPN) Employee E3 to come into Resident R1's room. When NA employee E2 entered the room, she observed Resident R1 on the floor bleeding from her head and NA Employee E1 wiping blood off the floor. NA Employee E2 further explained that NA Employee E1 was transferring Resident R1 from the bed to her wheelchair by herself. It was also stated that Resident R 1 only has one leg and that she is difficult to transfer due to being off balance. NA Employee E2 stated that a residents transfer orders are available in the computer under the Kardex and was able to demonstrate where it was in the computer. During an interview on 3/20/23, at 10:42 a.m., LPN Employee E4 stated that there have been no problems identified with the operation of the mechanical lift and that it does require two people for a safe transfer. During an observation on 3/220/23, at 10:56 a.m., two employees were observed coming out of a resident's room with a mechanical lift. These employees were identified as NA Employee E5 and E6. During an interview on 3/20/23, at 10:56 a.m., NA Employee E5 stated that she and NA Employee E6 were in process of getting people out of bed to eat lunch. When asked why both NA Employee E5 and E6 were working together to complete this task, NA Employee E5 stated you need two people for a Hoyer. NA Employee E5 also stated that a resident's transfer status is in the computer and can easily be verified. During an interview on 3/20/23, at 10;56 a.m. NA Employee E6 confirmed the above process and added that using two people for a mechanical lift transfer is part of their training and that they also receive yearly in-servicing on this topic. During a phone interview on 3/20/23, at 11:25 a.m., NA Employee E1 stated I don't understand what happened. I made a mistake of doing it by myself. I should have looked better than I did for help. I was just trying to get my work done. NA Employee E1 also confirmed that she had received education on requiring two people for a mechanical lift transfer prior to the incident and that she no longer works at this facility. During an interview on 3/20/23, at 2:35 p.m. NA Employee E7 stated that although Resident R1 was ordered assistance of two people for a sliding board transfer, Resident R1 refused to use it and preferred the mechanical lift even though she was terrified of it. During an interview on 3/2023, at 2:35 p.m. NA Employee E5 also confirmed that Resident R1 preferred to use the mechanical lift and would refuse use of the sliding board. During an interview on 3/20/23, at 2:42 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that a resident was free from a preventable accident, resulting in actual harm when Resident R1 was not provided adequate supervision of two people for a transfer which caused Resident R1 to sustain a scalp laceration. 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.

Based on review of facility policies, clinical records and facility documentation, observations and staff interviews, it was determined that the facility failed to make certain that adequate assistance was provided during transfer for one of ten residents which resulted in actual harm (Resident R1). Findings include: Review of the facility policy Abuse Protection last reviewed 5/28/19, indicated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Review of the facility policy Transfer of Residents last reviewed 5/28/19, indicated that residents will be evaluated, supervised or assisted to ensure the appropriate method of transferring a resident is identified to minimize emotional and physical trauma to the resident. The Admission Record Report indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].(a person's body shakes rapidly and uncontrollably). The Admission Minimum Data Set assessment (MDS-periodic assessment of care needs) dated 5/17/19, indicated Resident R1 was alert, oriented and able to make decisions, required the extensive assistance of two or more persons with transfers, bed mobility and personal hygiene and required the extensive assistance of one with dressing. The care plan dated 5/17/19, indicated that Resident R1 requires assistance with dressing, personal hygiene, walking, transferring, toileting, changing position in bed and eating related to decrease in functional ability. The care plan indicated that Resident R1 required assistance of two for transfers. The physical therapy evaluation and plan of treatment forms dated 5/7/19, identified Resident R1 appears to be contracted into extension due to bed bound since (MONTH) or resisting due to dementia when assessing range of motion (movement around a joint or body part) of lower extremities (limbs), weakness, unsteadiness on feet, difficulty walking and fall risk. The occupational therapy evaluation and plan of treatment forms dated 5/7/19 identified Resident R1 dependent for activities of daily living (ADLs-which included bed mobility, transfer needs and personal hygiene). Resident R1 demonstrated decreased safety awareness and anxiousness during bed mobility and other tasks due to pressure sores A physician's order dated 6/6/19, indicated that Resident R1 required the assist of two (staff) for transfers. A nurse's note dated 7/17/19, at 7:40 a.m. indicated Called to room at 5:30 a.m. Aid on duty slid resident to floor. Called for nurse to assess and found resident left leg was twisted and very painful. Called 911. Call to MD. Resident sent to St. Margaret's Hospital. A nurse's note dated 7/17/19 at 4:51 p.m. indicated spoke with St. Margaret's Hospital. Patient has a fracture of left femur and was transferred to Presbyterian Hospital. A review of the facility investigation of Resident R1's 7/17/19, fall from the bed indicated that the nurse instructed nursing assistant (NA) Employee E1 to wash and dress Resident R1 and leave resident in bed. NA, Employee E1 attempted to transfer Resident R1 from her bed to her wheelchair. NA Employee E1 said that her legs twisted so she lowered there resident to the floor. Resident R1 was assessed by the nurse and was found to have internal rotation of her left leg and complained of severe hip pain. Resident R1 was transferred to the hospital. Xray report from the hospital showed a subtrochanteric [MEDICAL CONDITION] femur. NA Employee E1 worked through a staffing agency. A review of the acute care records dated 7/17/19, at 7:57 a.m. indicated that as a result of fall while transferring to wheelchair, Resident R1 was diagnosed with [REDACTED]. In a handwritten statement signed by NA Employee E1, and dated on 7/17/19, stated that she was getting Resident R1 up for [MEDICAL TREATMENT] and while getting her out of bed, Resident R1 twisted her legs and she could not get her in the chair so she laid her down on the floor and called for help. During an interview on 8/6/19, at 8:00 a.m. the Director of Nursing confirmed that the facility failed to make certain that Resident R1 was provided appropriate assistance with transfer which resulted in actual harm to the resident. The facility failed to make certain that Resident R1 was provided appropriate assistance with transfer resulting in actual harm. 42 CFR 483.25(d)Accidents 28 Pa. Code 201.14(a) Responsibility of Licensee. Previously cited 3/21/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 3/21/18, 10/22/18. 28 Pa. Code 201.18(b)(3) Management. 28 Pa. Code 201.29(a)(d)(j) Resident rights. 28 Pa. Code 201.29(c) Resident rights. 28 Pa. Code 211.10(a)(c)(d) Resident care policies. Previously cited 11/21/18.

Based on review of clinical and facility records and staff interviews, it was determined that the facility failed to provide supervision at all times during a resident outing which resulted in actual harm for one of five residents (Resident R1). Findings include: Review of the facility Admission Progress Note dated 7/9/15, indicated that Resident R1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., [DIAGNOSES REDACTED] with shunt (abnormal accumulation of cerebrospinal fluid in the brain with a tube to drain), visual impairment, [DIAGNOSES REDACTED], chronic obstructive pulmonary disease (is a progressive disease that makes it hard to breath), chronic bronchitis (an inflammation of the bronchial tubes), anxiety and agitation. Review of the admission Minimum Data Set assessment (MDS- an assessment of resident care needs) dated 7/16/15, revealed that Resident R1 was cognitively impaired with long and short term memory impairment and required extensive assistance with care. Review of the physician's orders dated 7/9/15 through 8/31/15, indicated that Resident R1 did not have a current physician's order for a therapeutic leave of absence (to leave the facility grounds on outings, special events, going for rides, over night stays). Review of the plan of care dated 11/25/14 through 10/28/15, indicated that Resident R1 had poor safety awareness, had a history of [REDACTED]. Review of the Psychological Progress Note dated 7/29/15, indicated that Resident R1 was anxious, confused, irritable, depressed and had mood swings. Review of information submitted by the facility, dated 8/18/15, at 4:48 p.m., indicated that on 8/17/15, at 4:30 p.m., Resident R1 was taken on an activity outing, tumbled from their wheelchair, struck their head on rocks bordering a lake and sustained a head laceration. Resident R1 was given first aid and transported to the hospital. A review of a witness statement indicated that on 8/17/15, the date of the occurrence, at 3:40 p.m., five residents went on an activity outing, including Resident R1, with one staff member, the Activities Director, Employee E1. Resident R1 was in their wheelchair parked on the paved walkway with the brakes on near a decline with a grade steep enough that the wheelchair could go down by itself without being pushed. Resident R3, in self-propelled wheelchair, parked on the paved walkway and Resident R2 who was ambulatory left the group to scare away geese. Residents R4 and R5 were on a very slight incline in their self propelled wheelchairs to feed some ducks. The facility documentation (diagram outlining where residents were located) indicated that the residents were not close together. Employee E1 had her back towards Resident R1, and was focused on Resident R2 who was walking rapidly towards the geese, to scare them away. Employee E1 was trying to get Resident R2 to stop and not fall. When Employee E1 turned her head toward Resident R1, she saw the resident's wheelchair rolling down the hill (on a much steeper grade), observed the wheelchair hit some rocks and the resident fell out of the wheelchair into a bed of cattails among rocks and boulders at the edge of the pond. Employee E1 left Resident R1 laying at the pond's edge to obtain a personal cell phone from her purse (the location of the phone is not documented). Employee E1 then returned down over the bank of the pond to be with Resident R1 to call for assistance. There was no mention in the facility documentation as to where Residents R2, R3, R4 and R5 were or what they were doing when Employee E1 was attending to the resident who was bleeding from a head wound and was trying to call on the cell phone for help. The facility documentation indicated that there was very poor cell phone reception and that after 31 attempts to call for assistance (911 twenty times and the facility eleven times) during an unknown time frame, 911 was finally reached and an ambulance was dispatched to the park for Resident R1 to receive assistance. Resident R1 was transported to the hospital without facility staff. Review of the hospital Emergency Department note dated 8/17/15, indicated that Resident R1 had sustained a, large scalp laceration that measured 15 centimeters (6 inches) in length on the left lateral (side) of the head with some exposed galea aponeurosia (a tough layer of dense fibrous tissue which covers the upper part of the skull) and exposed calvarium (portion of a skull including the braincase). Resident R1 required multiple sutures including the galea aponeurosia layer, deep dermal (sensitive connective tissue layer below the epidermis) tissue layer and the epidermis (outermost layer) of the skin. Review of the facility policy titled, Resident Outings dated 11/30/14, revealed that the Executive Director must approve all trips from the facility and must be notified when the group leaves the building and the residents must sign out on the activity log. Interviews on 8/30/15, at 2:00 p.m., with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed that they were not aware that the five residents had left the building on an outing, that they did not approve the trip for these five residents, that the sign out log sheet was not available for review and that Resident R1 did not have a current leave of absence order signed by the physician. The NHA and DON also confirmed that Resident R1 was physically and mentally challenged, the resident had poor safety awareness and was a fall risk with multiple falls, that the outing contained only one staff member, that the staff member was not provided with a means to communicate in the event of an emergency and had to use her own phone that had poor reception and that the activity staff failed to assure that Resident R1 and the remaining four residents remained safe at all times. 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 1/22/15, 7/31/14. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 6/11/15, 4/17/15, 4/15/15, 3/19/15, 1/22/15, 11/7/14, 7/31/14, 5/27/14. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 6/11/15, 4/17/15, 3/19/15, 1/22/15, 7/31/14, 5/27/14. 28 Pa. Code: 201.18(e)(1) Management. Previously cited 8/13/15, 6/11/15, 4/17/15, 3/19/15, 1/22/15, 7/31/14, 5/27/14. 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited 6/11/15, 4/17/15, 1/22/15, 7/31/14, 5/27/14. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 3/19/15, 1/22/15, 7/31/14, 5/27/14. 28 Pa. Code: 211.11(a)(d) Resident care plan. Previously cited 7/31/14, 5/27/14. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 8/13/15, 6/26/15, 6/11/15, 4/17/15, 3/19/15, 1/22/15, 11/7/14, 7/31/14, 5/27/14.

Based on observations, review of facility and clinical documentation and staff interviews, it was revealed that the facility failed to develop and implement effective interventions to provide a safe environment for cognitively impaired residents with known exit seeking behaviors for two of five residents reviewed (Residents R1 and R2), resulting in actual harm for one of five residents reviewed (Resident R1). Findings include: The facility policy entitled, "Elopement Risk," last reviewed [DATE], indicated that residents assessed as an elopement risk will have the care plan outlined with interventions and desired outcomes. It also stated that the care plan will be reviewed and revised following attempts to leave the facility. Review of the facility plan of correction dated [DATE], indicated motion sensor alarm units would be applied to the Third Floor Stairwell emergency exit doors. It further indicated that residents noted with increased exit seeking behaviors will have a staff member sit with the resident at all times until the behavior subsides or a more appropriate placement can found. During multiple observations on [DATE], [DATE], and [DATE], no motion sensor alarms were noted on any emergency exit doors in the facility. During an interview on [DATE], at 9:50 a.m., the Maintenance Director, Employee E8, confirmed that the motion sensor alarms were no longer in use, but he did not recall when they were removed from the exit doors. A review of daily staffing sheets from [DATE], through [DATE], did not indicate the use of extra staff to be utilized to sit with any residents. A review of quarterly Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated [DATE], revealed that Resident R2 had severe cognitive impairment and independently moved about the unit in a wheelchair. During an interview on [DATE], at 10:00 a.m., Housekeeping Employee E9, indicated that in [DATE], she witnessed an incident in which the door alarm sounded and Resident R2 was found to have opened the emergency exit doorway of the North Wing Stairwell. Employee E9 stated that the only reason the resident did not fall was that her wheelchair became stuck in the doorway. Review of the nursing notes dated [DATE], at 2:15 p.m., revealed that Resident R2 was found holding on to the exit door on the North Hallway and that the Assistant Director of Nursing (ADON) was notified. During an interview on [DATE], at 2:30 p.m., Licensed Practical Nurse, Employee E4, confirmed that an incident occurred on [DATE], in which Resident R2 had opened the third floor North Hallway exit door but did not fall into the stairwell because one of the wheels on his/her wheelchair became stuck in the door. Employee E4 confirmed that she had spoken to the ADON and the Director of Nursing (DON) at that time to report this incident. A review of the quarterly MDS dated [DATE], revealed that Resident R1 had severe cognitive impairment and independently moved about the unit in a wheelchair. Review of a nursing note dated [DATE], indicated that Resident R1 was highly agitated, wanting to leave the facility, and was banging on the North Hallway exit door. Review of a psychiatric progress note dated [DATE], stated that Resident R1 was, "wanting to get out." On [DATE], the psychiatrist recommended for Resident R1's Risperdal to be increased to 0.25 mg three times daily. Review of the plan of care dated [DATE], indicated that Resident R1 was cognitively impaired, was able to propel the wheelchair independently, and that he/she, "seems to be exit seeking." The elopement risk care plan for Resident R1 indicated to observe for exit seeking behavior, use diversion techniques when exit seeking and to re-direct the resident from doors and exits as needed. There were no changes made to the elopement care plan when care plan review occurred on [DATE] and [DATE]. Review of a physician's progress note dated [DATE], indicated that Resident R1 was cognitively impaired as to time, place, person, and was unable to follow verbal cues. A review of an electronic event report dated [DATE], at 8:12 a.m., revealed that on [DATE], at 10:20 a.m., Resident R1 was found at the bottom of the third floor North Wing Stairwell, after staff heard the exit door alarm sound. The [DATE], event report indicated that Resident R1 was found to be unresponsive, with a laceration (a deep cut or tear in the skin or flesh) to his/her head, and required cardio-pulmonary resuscitation (lifesaving procedure to restore and maintain breathing and circulation), which was initiated due to the absence of vital signs. Resident R1 was transported to the hospital where he/she subsequently expired. During an observation on [DATE], at 9:40 a.m., the third floor emergency exit door operation was tested . The door alarm initiated when the bar on the door was pushed and continued to alarm for 15 seconds, at which time the door lock released. During an interview on [DATE], at 9:51 a.m., Employee E8, confirmed that the exit doors sound an alarm when pressure is applied to the bar on the doors and then the doors open (unlock) after a 15 second delay. During an interview on [DATE], at 1:47 p.m., the DON indicated that the staff responded immediately after the door alarm sounded on [DATE], but the time between the initiation of the alarm and the release of the door lock was insufficient to allow staff to reach Resident R1 and prevent the fall. The DON indicated that, "it happened too fast." Refer to F490 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited [DATE], [DATE]. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code: 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of clinical and facility records and staff interviews, it was determined that the facility failed to provide supervision during a resident transport which resulted in actual harm for one of four residents reviewed (Resident R1). Findings include: Review of the facility Physician Admission Progress Notes dated 6/25/14, indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Social Services Admission Evaluation dated 6/25/14, indicated Resident R1 was known to wander and had behaviors including non-compliance with care. Review of Psychological Diagnostic Interview notes dated 6/25/14, indicated Resident R1 was screaming and had frantic delirium (agitated confusion), may have had a suicide attempt in the past and was experiencing sadness and an inability to sleep. Review of a physician's orders [REDACTED]. Review of the Plan of Care dated 7/01/14, indicated Resident R1 had identified behavior problems which included ineffective coping skills and impulse control, insufficient safety awareness and a history of elopement. Review of Psychological Progress Notes dated 7/03/14, indicated Resident R1 was belligerent, uncooperative and that Resident R1 was, "putting self in danger and required a power of attorney (person responsible for decision making)". Review of an electronic event report submitted on 7/10/14, at 9:30 a.m., indicated that Resident R1 was picked up from the facility for transport. Resident R1 unbuckled her safety belt, opened the passenger side door and jumped from the moving vehicle. Review of the hospital Emergency Department Note dated 7/10/14, at 12:00 a.m., indicated Resident R1 had been injured when jumping from a wheelchair van and had sustained lacerations and multiple abrasions (scraped tissue) of the face and laceration of the liver. Review of the facility Transportation Request Form indicated Resident R1 was to be scheduled for ambulance transport to a physician's office appointment on 7/10/14, and noted "needs escort" on the top of the form. During an interview on 7/28/14, at 9:55 a.m., Licensed Practical Nurse, Employee E1, stated that she had told Unit Clerk, Employee E2, (responsible for scheduling the physician appointments) that Resident R1 required an escort while out of the facility due to his/her behaviors. During an interview on 7/28/14, at 10:17 a.m., Staffing Coordinator, Employee E3, confirmed that she scheduled the ambulance service to transport Resident R1 on 7/10/14, and that she was told by the nursing staff that the resident required an escort. Employee E3 confirmed that the facility failed to provide an escort to accompany Resident R1 during the ambulance trip on 7/10/14. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 4/25/14, 11/12/13. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 9/4/13, 11/12/13 and 12/4/13. 28 Pa. Code: 207.2(a) Administrator's responsibility. Previously cited 4/25/13 and 11/12/13. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 4/25/13, 11/12/13 and 11/26/13. 28 Pa. Code: 211.11(a)(d) Resident care plan. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 4/25/13, 9/4/13, 11/26/13 and 12/4/13.