Every finding on record at Kadima Rehabilitation & Nursing at Harmony

Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, and staff interviews it was determined that the facility failed to submit a report of an allegation of staff to resident abuse and physical restraint for one of three residents reviewed (Resident R1).Findings include: Review of the facility policy Abuse Reporting and Investigation dated 4/14/26, indicated the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. The Department of Health will be notified of the alleged event by the Administrator or designee via the Electronic Event Reporting System (ERS) per regulation. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/13/26, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), and stroke (damage to the brain from an interruption of blood supply). Review of Resident R1's care plan dated 6/5/26, indicated resident has a behavior problem related to putting self on the floor. Review of facility provided witness statement, undated, and signed by Assistant Director of Nursing (ADON) Employee E1 indicated on Friday, 6/12/26, at approximately 11:40 p.m. they received a call from Registered Nurse (RN) Supervisor Employee E2 of an allegation made by Resident R2 against Nurse Aide (NA) Employee E3. Resident R2 reported they had a photo of the roommate Resident R1, appearing to be secured to a Geri-chair with a white bed sheet. They stated this occurred during the overnight shift on Thursday and claimed NA Employee E3 was responsible. Review of alleged abuse allegations submitted to the State field office did not include the allegation of abuse and physical restraint incident involving Resident R1 reported on 6/12/26. Interview on 6/29/26, at 1:22 p.m. with the Director of Nursing and Nursing Home Administrator confirmed the facility failed to submit a report of an allegation of staff to resident abuse and physical restraint for one of three residents reviewed (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by failing to provide incontinence care in a timely manner for one of four residents reviewed (Resident R105).Findings include: Review of facility policy Abuse: Protection From Abuse dated 4/14/26, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. 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 resulted in resident neglect. Review of the clinical record indicated Resident R105 was admitted to the facility on [DATE]. Review of Resident R105's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/1/26, indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking). Section H0300: Urinary Continence indicated the resident was coded 3 always incontinent of urine. Review of Resident R105's care plan dated 10/24/25, indicated the resident has bladder incontinence related to impaired mobility, possible adverse effects related to medications received and age related functional declines. Interventions include check resident as required for incontinence. Wash, rinse, and dry perineum (the anatomical region between the genitals and the anus). Change clothing as needed after incontinence episodes. Review of a facility submitted document dated 2/26/26, indicated the following: On this date, 2/26/26, this DON (Director of Nursing) was notified by staff of a concern regarding a resident's care. The reporting staff member stated that during rounds, the resident, Resident R105, was found saturated with urine and reported that he had not received incontinent care from the CNA (Certified Nurse Aide) assigned to him the prior shift. Review of a witness statement dated 2/26/26, completed by Nurse Aide (NA) Employee E18 stated, Today 2/25/26, I came in for my 10:30 p.m. - 6:30 a.m. shift and was assigned the back section of Northwest. I began my first round at arrival and upon entering Resident R105's room he was sitting up along with his roommate and both still had dinner trays in front of them, which was a sure sign they hadn't been checked sine dinner. I asked Resident R105 who his aide was and he stated NA Employee E19 and added that he hadn't been changed since 1 p.m. when a different aide was here. Resident R105's brief and insert and bed pad were all completely saturated just like the other day when she had him. Review of a typed verbal witness statement dated 2/26/26, completed by the DON, indicated Resident R105 stated, The resident reported over the past several days there were 2 days when he did not see staff regularly. He specifically recalled that on Sunday and Wednesday, he was assisted in his wheelchair in the morning and then returned to bed before the end of the day shift. He stated that the next time he was changed was by the night shift CNA and identified his CNA on afternoon shifts these days as being NA Employee E19. When asked about staff response to his call light, Resident R105 stated that he did not use the call bell during this time. He noted that staff had entered and exited his room periodically to bring meal trays, water, snacks, etc.; however, incontinent care was not provided during those times. Review of a witness statement dated 2/26/26, completed by NA Employee E19 stated, On 2/25/26 I was working on Northwest 2 p.m. - 10 p.m. and was responsible for the care of several residents, including Resident R105, Resident R11 and another resident who was experiencing persistent vomiting. I was attending to the vomiting resident, providing them with the necessary care and support while also having to mop the entire room due to infection control reasons . Dinner trays came at about 4:40 p.m. We passed dinner, I went into Resident R105's room during dinner to pick up trays after they were done and we picked up the rest of the floor's trays. I do not recall seeing anyone's lights on. After helping do rounds with the agency girl for her x2 residents I went to Resident R11's room and had a full bed change for him, like normal. Resident R105 did not at any point then (or ever really) ring to be changed, but recently he only wants done later on in the night . I then went down to room [ROOM NUMBER] to ask the resident if he was ready when I noticed him vomiting and rushed to get a hoyer (a mechanical lift), the gurney bed, and find help to spot. He got put on the bed, I cleaned all the linens and clothes up into linen bags for laundry, put his chair aside to wash later and completed his shower. He vomited again during the shower and after I was in the room trying to find someone to help transfer him back to bed . I was in a rush to attend to that resident so I may have forgotten to check on Resident R105 when his light was on when I was taking another resident to the shower room. However, passing by the beauty shop I asked the agency girl to cover my lights and she said ok, when I came out his light was off so I assumed she assisted him. When I answer lights I do what they want. I don't turn off the bell and leave so I assume that's what she did since Resident R105 didn't ring again the rest of the night. Multiple times nurses went into his room and didn't inform me of anything from Resident R105, and I was so wrapped up in the other resident's chaos that I genuinely had forgotten to ask the agency girl what he rang for. I did not receive any notification or feedback from my colleagues that Resident R105 still needed to be changed. When I exited the shower, Resident R105's light was not ringing, which led me to believe that his needs had been met. During an interview on 4/29/26, at 12:32 p.m. the DON confirmed that the facility failed to make certain each resident was free from neglect by failing to provide incontinence care in a timely manner for Resident R105. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review and resident and staff interviews it was determined that the facility failed to provide Activities of Daily Living (ADL) assistance for three of four residents reviewed (Resident R1, R2, and R3). Findings include: Based on review of facility policy Activities of Daily Living, dated 1/19/26, indicated: The facility will, based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following of activities of daily living: bathing, dressing, grooming, and oral care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1 Minimum Data Set (MDS- a periodic assessment of care needs) dated 12/17/25, indicated diagnosis of anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissue), hypertension (when the pressure in in your blood vessels is too high), and BPH (prostate to increase in size). Section GG - Functional Abilities, Question GG0130E indicted the resident was coded at a 02 for substantial/maximal assistance for shower and bath; the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Review of Resident R1 task card indicated Resident R1 is scheduled to receive a shower Wednesday and Saturday Day shift. Review of Resident R1 December 2025 shower documentation indicated no shower, or bath was provided on 3rd,6th,17th, 20th, and 27thJanuary 2026: 14th,17th,20th, and 27thFebruary 2026:4th During an interview on 2/ 23/26, at 12:57 p.m. Resident R1 indicated that he does not get showers consistently, he has to ask for them and does not always receive them, or they offered at night which is not his preference. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2 MDS dated [DATE], indicate diagnosis of malnutrition (refers to deficiencies, excesses imbalances in a person's intake of energy and/or nutrients), paraplegia (paralysis that affects your legs, but not your arms) and chronic pain syndrome (pain that last for over three months). Section GG - Functional Abilities, Question GG0130E indicated the resident was coded at a 01 for dependent helper does all of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident R2 task card indicated Resident R2 is scheduled to receive a shower Friday and Tuesday. Review of Resident R2 December 2025 shower documentation indicated no shower or bath was given on 2nd,5th,9th,16th,19th, and 23rd.January 2026: 2nd, 6th, 30th.February 2026: 3rd. During an interview on 2/23/26, at 1:31 p.m. Resident R2 indicated that he prefers showers, and does not receive them consistently, that he likes showers over bed baths. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3 MDS dated [DATE], indicated diagnosis of Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should), PVD (slow and progressive circulation disorder caused by narrowing blockage or spasms in a blood vessel), and thyroid disorder (thyroid gland does not make enough thyroid hormones). Section GG- Functional Abilities, Question GG0130E indicated the resident was coded at a 03 for partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort. Review of Resident R3 task card indicated Resident R3 is scheduled to receive a shower Wednesday and Saturday day shift. Review of Resident R3 December 2025 shower documentation indicated no shower or bath was given on : 16th, 19th, and 23rd.January 2026: 2nd, 13th, and 20th. During an interview on 2/24/26, at 11:30 a.m. Director of Nursing was informed that the facility failed to offered baths and or showers on the dates listed above and that the facility failed to provide activities of daily living for Resident R1, R2 and R3. 28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.

Based on facility policy, clinical record review, observations and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for one of six residents reviewed (Resident R5). Findings include: Review of the facility policy Abuse Protection reviewed 4/25/25, indicated the resident has the right to be free from verbal, physical, mental abuse, neglect, corporal punishment, and involuntary seclusion. Abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Involuntary seclusion is defined as separation of a resident from other residents from his/her room or confinement to his/her room against the resident's will. Review of the Resident Rights reviewed 4/25/25, indicated the resident has the right to a dignified existence and self-determination. The facility will protect and promote the rights of each residents. Residents are to be treated with dignity and respect. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included anxiety, depression, and psychotic disorder. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/24/25, indicated the diagnoses were current. Further review of the MDS, Section C: Cognitive Patterns; Question C0500 BIMS Summary Score indicated 15. Section GG: Functional Abilities; Question GG0170 Mobility D: indicated the resident was dependent-helper does all of the effort. During an observation on 6/12/24, at 12:05 p.m. Resident R5's door was closed and was heard yelling open my door repeatedly. LPN, Employee E1 was observed opening Resident R5's door and stated Don't shut her door. Nurse Aide (NA), Employee E2 stated I shut her door because she is screaming at me. She sits there and tells me what to do. LPN, Employee E1 confirmed NA, Employee E2 closed Resident R5's door. During an interview on 6/12/25, at 12:08 p.m. Resident R5 stated NA, Employee E2 knows not to shut the door. Resident R5 indicated the door was shut for about five minutes. Resident R5 stated NA, Employee E2 shut the door because the food tray cart was open and NA, Employee E2 was on their phone. During an interview on 6/12/25, at 12:16 p.m. NA, Employee E2 stated Resident R5 was screaming to get off the phone and pass the lunch trays. NA, Employee E2 confirmed she closed Resident R5's door. During an interview on 6/12/25, at 12:55 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to prevent involuntary seclusion for one of six residents (Resident R5). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents. Findings include: Review of facility policy Resident Elopement dated 4/25/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leaves of absence) and/or any necessary supervision to do so. Upon admission, residents will be assessed for elopement risk. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. Residents at risk for elopements shall have their pictures maintained for identification purposes. Residents at high risk for elopement shall not be admitted to the facility unless appropriate interventions are identified prior to admission and the facility has the ability to appropriately supervise and monitor the resident. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/16/25, indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status. Review of Resident R110's clinical record revealed an Elopement Risk Assessment completed on 3/10/25, which consisted of the following information: Risk Assessment: 1) Is the resident cognitively impaired? Yes 2) Is the resident independently mobile (ambulatory or wheelchair)? Yes 3) Does the resident have poor decision-making skills? Yes 4) Has the resident demonstrated exit seeking behavior? Yes 5) Does the resident wander oblivious to safety needs? Yes 6) Does the resident have a history of elopement? No Determination: 1) Resident is determined AT RISK for elopement. Yes 2) Plan has been implemented to ensure resident safety. Yes Score: 1.0 Category: At Risk for Elopement Review of Resident R110's care plan dated 3/11/25, indicated the resident will not wander out of facility through next review. Interventions included assist in reorientation to room and facility using verbal cues and reminders, check resident's whereabouts frequently, door alarms on at all times and answer alarms promptly, encourage group activity and attempt to keep occupied, make receptionist and other staff aware of elopement risk, notify social services for persistent attempts to leave building and not responding to redirection, photo identification on file in front lobby, put familiar items in resident's room to assist in identifying room, redirect from exits as needed based on behavior, and Wanderguard device (electronic monitoring safety bracelet) check placement and function each shift. Review of a physician order dated 3/11/25, indicated Wanderguard every evening shift check for proper function. Review of a physician order dated 3/11/25, indicated Wanderguard every shift check for proper placement. Review of an event submitted by the facility dated 3/24/25, stated, On 3/24/25 at approximately 1930 (7:30 p.m.) the Supervisor was made aware that Resident R110 was unintentionally let out by a CNA (Certified Nurse Aide). While the CNA was attending to another resident and helping them through the doorway, Resident R110 walked outside and away from CNA to another location of facility grounds. CNA was alerted that the resident walked away and immediately alerted the Supervisor. The Supervisor immediately alerted other staff to search facility grounds. Within two minutes, staff from the facility Personal Care (PC) side called the Supervisor to make her aware that Resident R110 was found knocking on their front door. Addendum - when code is entered, and the door is opened the wanderguard system does not alarm. In this instance when the staff member entered the code and opened the door to allow residents outside, Resident R110 was not close enough to the door to allow the system to alarm prior to the staff opening the door. Review of a nursing progress note dated 3/24/25, stated, Resident was let out with smokers and walked around building to door. PC called to make staff aware of situation. Floor staff went to PC to bring resident back to unit. CNA educated on the importance of knowing who can't go out at smoke times. Resident willingly returned to unit and had no injuries or distress noted. Review of a witness statement completed by Registered Nurse (RN) Employee E14 dated 3/25/25, stated, Last night on 3-11 shift, this RN was notified by staff that Resident R110 had followed the smoking residents out the door with staff for their smoke break. In less than two minutes, PC staff notified this staff that he was outside, and he was immediately accompanied into the building. He was pleasant and courteous with staff, fully assessed, VSS (vital signs stable), and Resident R110 was in good spirits. His wander guard was checked along with all doors, and he was supervised at all times, as one of the residents also noticed his walking out with the smokers and alerted the group. Physician and family notified. Review of a witness statement dated 3/25/25, completed by Nurse Aide (NA) Employee E5 stated, I was taking the residents out for smoking break and another resident, Resident R110, walk passed while I was tending to another resident while getting her out the door way. In the midst of assisting that resident over to the rest of the residents another resident informed me that Resident R110 had taken off walking away from the facility building. I instantly started running to see where he was, I didn't see him so I ran inside the building asking the nurses for help because Resident R110 had walked off. At that moment everyone set out to find out where Resident R110 had gone to. Review of a Current Smokers list provided by the facility on 5/5/25, indicated the facility has 12 residents who smoke. Resident R110 was not identified by the facility as a current smoker. During an observation on 5/6/25, at 10:37 a.m. seven residents were observed in the designated smoking area with one staff member. During this observation, while staff had the door open to allow residents outside, the wanderguard system continuously alarmed while the door was held open. During an interview on 5/6/25, at 10:44 a.m. RN Employee E13 stated, We don't have any documentation that we bring with us during smoking, we just know who smokes. They're never all out at once. During an observation on 5/6/25, at 11:18 a.m. of an Elopement Binder located at the nurse's station revealed Residents R104, R106, and R110 were identified as elopement risks. During an interview on 5/6/25, at 11:23 a.m. NA Employee E2 stated, I just started in March. The facility gave me education about their elopement policy. I know residents are an elopement risk because they have one of those bracelets. I'm not sure about a binder with elopement risks. Resident R106 tries to get out, she's the only one I know for sure. During an interview on 5/6/25, at 11:25 a.m. NA Employee E1 stated, Therapy approves smokers for safety. There is no list used for smokers, we basically know who smokes. There are too many smokers to go outside with just one person watching. When asked who elopement risks are, NA Employee E1 stated, Her and pointed to Resident R54. NA Employee E1 stated, She got outside one time with visitors about a week ago. We couldn't find her in the building another time, we all had to look for her. Review of the clinical record revealed that Resident R54 was admitted to the facility on [DATE]. Review of Resident 54's MDS dated [DATE], indicated diagnoses of high blood pressure, chest pain, and dementia (a progressive decline in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life). Review of Resident R54's clinical record revealed an Elopement Risk Assessment completed on 4/8/25, which consisted of the following information: Risk Assessment: 1) Is the resident cognitively impaired? Yes 2) Is the resident independently mobile (ambulatory or wheelchair)? Yes 3) Does the resident have poor decision-making skills? Yes 4) Has the resident demonstrated exit seeking behavior? Yes 5) Does the resident wander oblivious to safety needs? Yes 6) Does the resident have a history of elopement? No Determination: 1) Resident is determined AT RISK for elopement. Yes 2) Plan has been implemented to ensure resident safety. Left Blank Score: 1.0 Category: At Risk for Elopement Review of Resident R54's clinical record revealed a physician's order dated 4/8/25, for a Wanderguard, which was discontinued on 4/15/25. During an observation on 5/6/25, at 11:26 a.m. Resident R54 was observed pushing on an external door and asked State Agency how to get out of the door. During an interview on 5/6/25, at 11:45 a.m. NA Employee E3 stated, Resident R54 has exit seeking behaviors. Coworkers informed me she got out the front door with visitors about a week ago. I have to redirect her often. She does not have a Wanderguard. An additional review of Elopement Binder on 5/6/25, at 11:50 a.m. confirmed that Resident R54 was not identified as an elopement risk. During an interview on 5/6/25, at 11:55 a.m. the Nursing Home Administrator (NHA) stated he was not aware that Resident R54 had gotten out of the building or if she was an elopement risk. During an interview on 5/6/25, at 12:11 p.m. the Director of Nursing (DON) stated, When Resident R54 was admitted we were told by a nurse who had Resident R54 at a prior facility that she was an elopement risk. When she was admitted , we put her as an elopement risk and put a Wanderguard on her. We watched her for a week, and she did not communicate any wants to leave, so we discontinued her Wanderguard. Elopement assessments are done at admission and quarterly. Staff are to notify the supervisor if there is a change in a resident's behavior. The Activity Director updates the elopement binder anytime there is a change. Elopement risks are reviewed daily, it's part of our clinical stand-up meeting. On 5/6/25, at 1:45 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for two of 108 residents, which resulted in an elopement from the facility, and a corrective action plan was requested. During a telephonic interview on 5/6/25, at 2:43 p.m. NA Employee E5 stated, I was letting the smokers out and he [Resident R110] must have gotten by me and I really didn't notice. One of the other residents was like, the guy left and the resident told me who it was. I immediately went to the front of the building, couldn't find him, went back in and told nurses. We never found him; he went to personal care. He got out in the midst of letting the smokers out, I was helping a resident over the little hump of the door, she couldn't push herself over in her wheelchair. He must have went around me and I didn't notice. The facility had previously given me education about elopements. At the time of the incident, I didn't know he was a wanderer. During an observation on 5/6/25, at 3:53 p.m. Resident R54 was observed attempting to get out of the facility through an external door. The Wanderguard system alarmed when Resident R54 approached the door, alerting staff of her attempt to exit the building. On 5/6/25, at 4:02 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: - The facility immediately reviewed and revised the elopement policy on 5/6/25, at 2:00 p.m. Residents: - The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement on 5/6/25, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions on 5/6/25. A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk. System Correction: - The root cause of the elopement has been determined to be lack of staff education and supervision. - The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift. - The facility immediately will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents. The facility will immediately have one staff member for every eight residents who smoke. Monitoring: - The Facility will complete a head count of all residents each shift for four weeks to ensure residents are safe and provided adequate supervision. - The Director of Nursing of Designee will review progress notes daily for four weeks to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place. - The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for frequency of audits. The facility's policy and procedures for elopements were reviewed on 5/6/25, no revisions were made. The facility's policy and procedures for smoking were reviewed and revised on 5/7/25, to reflect supervision of one staff member for every eight residents during supervised smoking. During an observation on 5/7/25, at 10:38 a.m. six residents were observed outside smoking with three staff members present. On 5/7/25, at 11:20 a.m. it was confirmed 108/108 residents were reassessed for an elopement risk. 4/108 residents were identified as at risk, and 4/4 care plans were updated to include interventions to prevent elopement. 4/4 residents were included in the elopement binders. Elopement books with 4/4 identified residents were observed at two of two nursing stations and the front desk. The residents' photos and names were listed. Review of facility documents on 5/7/25, revealed that the facility has 126 employees and that 100% had received elopement education. 59 of these employees received formal education on the policy Resident Elopement which included reporting residents with exit seeking behaviors to the supervisor and documenting all exit seeking behaviors in the clinical record. 67 of these employees had received education via telephone as they had not been working in the building. Staff are to sign when they are in the building before the start of their next shift. During employee interviews on 5/7/25, from 9:58 a.m. through 11:55 a.m. 36 employees confirmed they had received education on the facility's elopement policy and procedures, as stated above. The Immediate Jeopardy was lifted on 5/7/25, at 12:07 p.m. when the action plan implementation was verified. During an interview on 5/7/25, at 12:08 p.m. the NHA confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one resident (Resident R110) and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents who may not have been identified properly as an elopement risk. 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 observations, and staff interviews it was determined the facility failed to ensure that daily nutritional and special dietary needs for residents were met for one of four weeks (April/May 2025). Findings include: During an observation in the South Wing on 5/5/25, at 12:08 p.m. lunch trays were observed to not have any tray tickets on the trays to identify the resident, diet, or food items. During an interview on 5/5/25, at 12:08 p.m. Nurse Aide (NA) Employee E1 stated that there have not been any tray tickets on trays for about a week, and that Dietary Staff have hand-written the residents' last name, room number, and diet order on the corner of the placemat on the trays. During an interview on 5/5/25, at 12:15 p.m. Dietary Manager (DM) Employee E15 confirmed that the facility had a broken printer for approximately one week, and that the facility had not been utilizing tray tickets during that time frame, and that dietary staff was writing the residents' name, diet order, and room number on the placement. When DM Manager Employee E15 was asked how dietary staff was made aware of the information to write on the placemat, DM Employee E15 produced a printout that contained each residents' name, room number, and diet order. It did not contain food allergies, or preferences. DM Employee E15 confirmed that the facility failed to ensure that proper information regarding resident preferences and food allergies were communicated and provided. During an interview on 5/5/25, at 12:20 p.m. DM Employee E15 informed that the printer is now working and that tray tickets would now be utilized. During an interview on 5/5/25, at 1:32 p.m. Nursing Home administrator confirmed that the facility failed to ensure that daily nutritional and special dietary needs for residents were met. 28 Pa. Code: 201.12(d)(5) Nursing services 28 Pa. Code: 201.18(b)(1)(e)(1) Management

Based on observations and staff interviews, it was determined that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. (Main Kitchen). Findings include: During an observation in the Main Kitchen on 5/5/25, at 9:44 a.m. refrigeration/freezer temperature log on tray line refrigerator, revealed that the facility failed to monitor and record temperatures on 5/2/25, 5/3/25, 5/4/25, and 5/5/25. Observation also revealed that refrigeration/freezer temperature log on walk-in refrigerator, and walk-in freezer revealed that the facility failed to monitor and record temperatures on 5/3/25, and 5/4/25. During an observation on 5/5/25, at 9:45 a.m. in the walk-in refrigerator the following items were observed to have no label or date: Plastic container of cooked beef patties Plastic container of pickles Plastic container of diced potatoes Plastic container of sauerkraut Plastic container of Jello Bag of coleslaw mix During an observation on 5/5/25, at 9:46 a.m. in the cook's area a plastic container of Cheerios was observed with no label or date. During an observation in the Main Kitchen on 5/5/25, at 9:49 a.m. the meat slicer was observed to not have a cover in place to protect from contamination. During an observation in the Main Kitchen on 5/5/25, at 9:50 a.m. the stand mixer was observed to not have a cover in place to protect from contamination, and contained a thick layer of dried food particles. During an interview on 5/5/25, at 9:51 am the Dietary Manager Employee E15 confirmed that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. Pa Code 201.14(a) Responsibility of licensee. Pa Code 201.18(b)(3) Management.

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 to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which created an Immediate Jeopardy situation for two of 108 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 prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which placed the 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 5/7/25, at 12:08 p.m. the NHA and DON confirmed that they failed to effectively manage the facility to prevent the elopement of a resident and failed to properly identify a resident's risk for elopement, which created an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for four of ten residents (Residents R2, R55, R74, and R89). Findings include: Review of facility policy MDS/RAI/Care Planning dated 4/25/25, indicated the Resident Assessment Instrument (RAI) and Care Planning Process provide a tool for interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. The RAI is a process that defines an interdisciplinary approach to resident assessment and plan of care to help the resident attain the highest practicable functional level. The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions: - Section A1500: Preadmission Screening and Resident Review (PASRR): code 1, yes if: PASSR Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Section J1300: Current Tobacco Use: code 1, yes if: the resident or any other source indicates that the resident used tobacco in some form during the 7-day look-back period. - Section N0415: High-Risk Drug Classes: Use and Indication, Question N0415E1 - Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 day). Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness. Review of Resident R1's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/5/17, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Review of a letter from The Department of Human Services, dated 1/4/17, indicated Resident R2 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services. Review of Resident R2's annual comprehensive MDS dated [DATE], Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R2 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE]. Review of Resident R55's admission MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia, and depression. Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Question J1300 indicated the resident was coded 0 No for Current Tobacco Use. Review of Resident R55's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/31/25, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II). Review of a letter from The Department of Human Services, dated 2/14/25, indicated Resident R55 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services. During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R55 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Review of a physician order dated 4/15/25, indicated OK to smoke per facility protocol. Review of Resident R55's Smoking Safety Screening assessment dated [DATE], indicated the resident smokes 5-10 cigarettes a day and was safe to smoke with direct supervision. Review of a nursing progress note dated 4/15/25, stated, While out smoking this evening, the resident was arguing with another resident about the Vietnam War, insisting that he was fighting against Americans. This caused quite a disruption in the smoking time for residents as there are veterans in the group. The CNA (Certified Nurse Aide) that took them out reported that this resident kept getting louder and more aggressive with his argument. Review of the clinical record indicated Resident R74 was admitted to the facility on [DATE]. Review of Resident R74's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and muscle weakness. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period. Review of Resident R74's clinical record failed to include a physician order for an anticoagulant medication. Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE]. Review of Resident R89's quarterly MDS dated [DATE], indicated diagnoses of hyperkalemia (high levels of potassium in the body), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period. Review of Resident R89's clinical record failed to include a physician order for an anticoagulant medication. During an interview on 5/9/25, at 10:56 a.m. Licensed Practical Nurse Assessment Coordinator Employee E9 confirmed that the facility failed to ensure that Minimum Data Se assessments accurately reflected the resident's status for four of ten residents as required. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12(c)(d)(5) Nursing services.

Based on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102). Findings include: Review of the facility's Social Service Job Description indicated the social worker will develop a community resource file and establishes contact with new providers. Refer resident/family member to appropriate social service agencies when facility does not provide services or needs of resident. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section C- Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of two: severe cognitive impairment. Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses because he had problems with the grandson, and he needed a guardian. Interview on 5/8/25, at 1:10 p.m. the Nursing Home Administrator indicated the previous company quit paying the attorneys and they were in the process of establishing a new contract with another and verified there was a delay in getting Resident R41 a guardian. Review of the admission record indicated Resident R102 was admitted to the facility on [DATE]. Review of Resident R102's MDS dated [DATE], indicated the diagnoses of manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), psychotic disorder (a mental disorder characterized by a disconnection from reality), and borderline intellectual functioning. Section C - Brief Interview for Mental Status indicated a score of three: severe cognitive impairment. Upon admission agreement sign in review process on 5/9/25, it was discovered that Resident 102's admission sign in agreement was not completed from 7/19/24. Interview on 5/9/25, at 11:00 a.m. the Nursing Home Administrator indicated Resident R102 is also on the list for needing a guardian and did not currently have one and confirmed the admission agreement sign in was never completed, and provided a General Notes Report on Resident R102 that indicated the following: -7/22/24, Medical Assistance 103 Admission sent (MA 103 must be completed by the facility or the resident's attending physician when a medical assistance applicant is admitted to the facility or converts to medical assistance, and when services are no longer required). -8/9/24, Received CAO (County Assistance Office) request for more information. -8/15/24, application sent without documents. -9/4/24, denial received need resources and a complete application. Needs appealed by 9/25/24. -9/20/24, Appeal sent to CAO 10/9/24, Rep payee (a representative payee is someone appointed by the Social Security Administration (SSA) to manage Social Security benefits for individuals who are unable to manage their own money) sent 10/22/24, Resident needs a guardian. Need all resources. Resident cannot sign. Was at a personal care home that closed. 11/26/24, received approval 11/21/24. 5/8/25, spoke to private vendor about guardianship. Private vendor will reach out to law firm to file a petition for guardianship. Interview on 5/9/25, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102) 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.16 (a)(1) Social services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart). Findings include: Review of facility policy Storage of Medications dated [DATE], indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Compartments containing medications are locked when not in use. During an observation on [DATE], at 12:42 p.m. of the North Hall Medication Cart indicated the following medications not dated upon opening or expired: -Resident R112's albuterol nebulizer (a medication used to prevent and treat narrowing of the airways in the lungs) -Resident R72's timolol eye drops (used for glaucoma) were dated [DATE], and should have been expired by 28 days and discarded. -Resident R12's albuterol nebulizer -Resident R7's albuterol nebulizer Interview on [DATE], at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the medications were not dated upon opening or expired. During an observation on [DATE], at 8:49 a.m. the North Medication Cart was observed outside of resident room [ROOM NUMBER] with the cart unlocked and unattended. During an interview on [DATE], at 8:52 a.m. Registered Nurse (RN) Employee E7 confirmed the North Medication Cart was unlocked and unattended and that the facility failed to properly secure a medication cart while not in use. During an observation on [DATE], at 9:13 a.m. of the North [NAME] Hall Medication Cart indicated the following medication not dated upon opening or expired: -Resident R29's albuterol nebulizer Interview on [DATE], at 9:13 a.m. LPN Employee E21 confirmed the medication was not dated upon opening as required. During an observation on [DATE], at 11:14 a.m. of the Split Hall Medication Cart indicated the following medications not dated upon opening: - Resident R33's Albuterol inhaler - Resident R73's Albuterol inhaler During an interview on [DATE], at 11:14 a.m. LPN Employee E8 confirmed the above observations and that the facility failed to properly store medications in the Split Hall Medication Cart. Interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart). 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63) Findings include: Review of the facility policy Confidentiality dated 4/25/25, indicated that to protect resident's privacy and dignity, the staff should not enter rooms without knocking except in an emergency. During an observation on South Wing on 5/5/25, at 12:03 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 18's room without knocking or requesting permission to enter. During an observation on South Wing on 5/5/25, at 12:05 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 63's room without knocking or requesting permission to enter. During an interview on 5/5/25, at 12:05 p.m. NA Employee E1 confirmed that she failed to knock prior to entering Resident R18, and R63's rooms which failed to protect and value the residents' private space. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(a)Resident Rights.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (North Medication Cart). Findings include: Review of facility policy Confidentiality dated 4/25/25, indicated the resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Access to resident medical records will be limited to the staff and consultants providing services to the resident. During an observation on 5/6/25, at 11:20 a.m. the North Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information. During an interview on 5/6/25, at 11:20 a.m. Registered Nurse Employee E4 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(c.3) Resident Rights. 28 Pa. code: 211.5(b) Medical records. 28 Pa. Code: 211.12(d)(1)(3) Nursing services.

Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). Findings Include: Review of the facility policy Resident Environment dated 4/25/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During observations of the North nursing unit on 5/5/25, at 9:45 a.m. the following was observed: -Resident R106 in room [ROOM NUMBER]-D, indicated the perimeter of the wall to the left of the entrance door was dirty with built up grime, the floor mat beside the bed was dirty with white and gray markings and smudges, the perimeter of the wall under the heating element was corroded with built up grime, the bathroom had five visibly cracked floor tiles. -Resident R102 in room [ROOM NUMBER]-D, indicated a bathroom with three visibly cracked floor tiles around the base of the commode. -Resident R64 in room [ROOM NUMBER]-B, indicated gnats flying around the bedside table that had an old meal tray from breakfast still there. The perimeter of the wall under the heating element was corroded with built up grime, and there was an air condition unit sitting on the floor in the corner of the room. Tour and interview with the Nursing Home Administrator (NHA), on 5/5/25, at 10:05 a.m. the NHA confirmed the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64). 28 Pa. code: 201.14 (b) Responsibility of licensee. 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights.

Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64). Findings include: The facility's policy Abuse Protection dated 4/25/25, indicated each resident has the right to be free from abuse. Abuse means the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, denial of food or privileges. Review of admission record indicated Resident R64's was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an internal fixation device of bones, and chronic pain. Section C indicated a BIMS score of 15 (Brief Interview for Mental Status - a screening test that aides in detecting cognitive impairment). A total score of 13 -15, indicated cognitively intact. Review of Resident R64's care plan on 5/9/25, at 12:30 p.m. indicated resident has pain related to osteoarthritis (flexible protective tissue at the ends of bones, cartilage, wears down and worsens over time), lymphedema (swelling in arm or leg caused by a lymphatic system blockage), chronic osteomyelitis (inflammation of bone caused by infection), and mechanical complication of internal fixator device of bone. Goal indicated the pain will be resolved within one hour of intervention. Administer pain medications per physician order and note the effectiveness. Acknowledge presence of pains and discomfort. Listen to resident's concerns. Review of Resident R64's physician orders indicated the following medications for pain; -Order dated 2/12/25, indicated gabapentin (medication for chronic nerve pain) 300 milligrams (mg) three times daily. -Order dated 4/16/25, indicated acetaminophen (medication that treats mild aches and pain) 650mg every eight hours. -Order dated 4/17/25, indicated oxycodone (a potent narcotic for pain)/acetaminophen 7.5mg/325mg every six hours. Review of Resident R64's medication administration record indicated resident was receiving medications as prescribed. Observation of Resident R64 on 5/5/25, at 10:00 a.m. indicated resident lying in bed with a visibly enlarged and disfigured left ankle wrapped heavily in an ACE wrap (elastic bandages). Interview on 5/5/25, at 10:00 a.m. Resident R64 indicated he injured his left ankle over four years ago and has had terrible pain and complications ever since. Resident indicated the doctors here won't give me my medicines every four hours and that he really needed them every four hours as the terrible pain returns too soon with the medications being every six hours. Review of Certified Registered Nurse Practitioner (CRNP) Employee E17's palliative care consultation dated 5/7/25, at 1:41 p.m. indicated Reason for Palliative Consultation chronic pain from osteomyelitis of left foot/ankle, debility and behavioral disturbance. Further review of CRNP Employee E17's consultation indicated Resident R64's mood was stable that morning, although he did have a verbal outburst with aggression/chair throwing over the weekend. Resident was upset with staff that his pain medication was not given 30 minutes early as staff had competing priorities. CRNP Employee E17 indicated I discussed at length with resident that it is never ok to treat staff that way, we do not tolerate verbal abuse and will reduce pain medications in future if this behavior persists. Interview on 5/9/25, at 10:48 a.m. the Assistant Director of Nursing (ADON) Employee E10 and the Nursing Home Administrator were notified by survey agency of the CRNP Employee E17's palliative consultation and the intimidation, threatening to decrease pain medications as mental abuse and threats of punishment or deprivation of services. Interview on 5/9/25, at 10:49 a.m. the NHA confirmed that the consultation note indicated a form of intimidation and threatening to deprive Resident R64 of pain medications was not appropriate. Interview on 5/9/25, at 1:30 p.m. the NHA confirmed the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, resident council interview, resident and staff interviews it was determined that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office for one of five sampled residents (Resident R96). Findings include: The facility Abuse reporting and investigation policy dated 11/1/24 and last reviewed 4/25/25, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. Abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Mental abuse includes humiliation, harrassment, threats of punishment, or deprivation. Department of Health will be notified of an alleged event by the Administrator. Review of Resident R96's admission record indicated that he was originally admitted on [DATE]. Review of Resident R96's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 2/2/25, indicated that he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning). Review of Resident R96's care plans dated 5/6/25, indicated to gently redirect activities when Resident R96 makes inappropriate actions. Review of Resident R96's Nurse practitioner note dated 4/25/25, indicated that Resident 96 stated his mood is ok and he began complaining about some issues such as bathroom had poop all over it and sometimes they are mean to me referring to staff. Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 8:28 p.m. Resident R96 was screaming profanities and racial slurs at staff. Staff approached resident in hallway by his room asked him to stop yelling and he continued to yell about the staff. Staff escorted him to his room and offered emotional support he was not accepting of support and told staff to get the f out of his room. Staff left his room and he then slammed the door. Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 9:33 p.m. Resident R96 continued to come out of his room and verbally attack staff. He was witnessed on the floor in the hallway and he was screaming profanities and racial slurs; he stated that he is going to call the police on staff. He then began to throw the battery to the hoyer lift at staff. Emotional support was offered but he replied with f- you. He then went to the end of west hall in his wheelchair and was trying to pull the fire alarm. Staff called EMS and the police for assistance. Police arrived and Resident R96 calmed down and voluntarily went with EMS to hospital for a psychological evaluation. Review of Resident R96's Nurse practitioner note dated 4/29/25, indicated that Resident R96 was observed in his wheelchair. He sated they still don't treat me right referring to staff. He further stated they pick on me. I ask them for things and they taunt me. Resident R96 had significant behaviors on Saturday which required a 911 call and transfer to the hospital for evaluation. During a resident council group interview on 5/7/25, at 1:02 p.m. Resident R53 voiced a concern with staff to resident intimidation. During an interview on 5/8/25, at 9:43 a.m. Resident R53 stated the following: yes, there was an incident. It occurred next to us. There was a bathroom problem. Older gentleman had issues; it was Resident R96. It does not take much to trigger him. The bathroom was cleaned around 5:00 p.m. to 6:00 p.m. The bathroom was a mess again and an African-American female agency aide was asked to clean it and she refused. Resident R96 got mad and threw food. Then they (Resident R96 and the unidentified staff person) started swearing back and forth at one another. Resident R96 was later sent to the hospital to evaluate for mental illness. The toilet was not cleaned until the next day. The people here know about it. During an interview on 5/8/25, at 9:52 a.m. information relayed to Nursing Home Administrator (NHA) and the NHA stated that it sounded familiar and he will provide documentation. Review of reports and facility documents submitted to the local State field office from 2/1/25 to 5/7/25 did not include a report related to Resident R96's allegation of emotional abuse. During an interview on 5/8/25, at 1:09 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office involving Resident R96 as required. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R3, and R110). Findings include: Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/28/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood). Review of the clinical record indicated Resident R3 was transferred to the hospital on 4/28/25. Review of Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Interview with the Director of Nursing on 5/9/25, at 10:00 a.m. confirmed Resident R3's clinical record did not contain the required information prior to transferring to the hospital. Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE]. Review of Resident R110's MDS dated [DATE], indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status. Review of the clinical record indicated Resident R110 was transferred to the hospital on 4/12/25. Review of Resident R110's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 5/9/25, at 11:55 a.m. the Assistant Director of Nursing (ADON) Employee E10 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents as required. 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, observation and interviews it was determined that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16). Findings include: A review of the facility policy Controlled Medications dated 4/25/25, indicated when a controlled drug is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the dose is actually administered. Observation of medication storage on 5/7/25, at 12:42 p.m. of the North Medication Cart, it was discovered that the random narcotic count for accurate record keeping was inaccurate. Interview on 5/7/25, at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, the count is not going to be correct, because I gave the medications this morning. I signed them on the medication administration record (MAR), but not yet on the narcotic accountability record. Review of Admission Record indicated Resident R14 was admitted to the facility on [DATE]. Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/25, indicated diagnoses of high blood pressure, anxiety and depression. Review of Resident R14's physician order dated 4/8/25, indicated to give clonazepam (a controlled substance that treats anxiety) 0.5 milligrams (mg) three times daily. Review of Resident R14's MAR for 5/7/25, indicated the clonazepam was signed off by LPN Employee E6 as administered per orders. Observation and interview with LPN Employee E6 on 5/7/25, at 12:44 p.m. Resident R14's card of clonazepam had 47 pills in it and the narcotic accountability log indicated there should have been 48 pills, due to LPN Employee E6 not immediately documenting it after it was given. Review of Admission Record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated the diagnoses of heart failure (heart does not pump blood as well as it should), high blood pressure, and anxiety. Review of Resident R16's physician order dated 12/31/24, indicated lorazepam (a controlled substance that treats anxiety) 0.5mg three times daily. Review of Resident R16 MAR for 5/7/25, indicated the lorazepam was signed off by LPN Employee E6 as administered per orders. Observation and interview with LPN Employee E6 on 5/7/25, at 12:46 p.m. Resident R16's card of lorazepam had 20 pills in it and the narcotic accountability log indicated there should have been 21 pills, due to LPN Employee E6 not immediately documenting it after it was given. During an interview 5/7/25, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16). 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for an edema (swelling) glove for one out of three residents (Resident R35). Findings include: Review of the facility policy Quality of Care: Attain and Maintain dated 4/25/25, indicated each resident must receive and the facility will provide the necessary services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Review of the admission record indicated Resident R35 was admitted on [DATE]. Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/29/25, indicated the diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness). Review of Resident R35's physician order dated 2/21/25, indicated resident to wear right edema glove on with morning care off with evening care. Review of Resident R35's care plan dated 4/3/25, indicated resident to wear right edema glove on with morning care off with evening care. Observation on 5/7/25, at 1:00 p.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered. Observation on 5/9/25, at 10:00 a.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered. Interview on 5/9/25, at 10:05 a.m. Nurse Aide (NA) Employee E18 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling. Interview on 5/9/25, at 10:09 a.m. NA Employee E19 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling. Interview on 5/9/25, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed on the computer that Resident R35 was ordered to have a right-hand edema glove on and confirmed he did not have it on as ordered. Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to follow a physician order for an edema glove for one out of three residents (Resident R35). 28 Pa. Code 201.18(b)(1)(2)(3) Management. 28 Pa. Code 211.10(a)(c.)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41). Findings include: Review of the facility policy Vision and Hearing dated 4/25/25, indicated the facility will ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. Interview on 5/6/25, at 9:40 a.m. Resident R41 asked survey agency to read the menu for lunch as he could not read it. Resident indicated he used to have glasses but has not had a pair in a long time. Review of the admission record indicated Resident R41 was admitted to the facility on [DATE]. Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section B1200 corrective lenses indicated Yes. Review of Resident R41's eye care chart note dated 11/30/23, indicated resident presents for evaluation of cataracts (clouding of the normally clear lens of the eye) in the right and left eye. It affects both eyes and the symptom is constant. The condition is moderate. No treatment at this time, monitor for progression. New glasses will be ordered pending insurance/payer approval. Review of Resident R41's eye care chart note dated 8/15/24, indicated the assessment showed age-related nuclear cataract of both eyes. Plan - after education and discussion, the patient would like to be referred out for cataract surgery. Return to clinic in two to four months for follow up. Review of Resident R41's progress note dated 10/8/24, indicated resident returned back from ophthalmology appointment in stable condition but unable to be seen due to insurance issues as per physician's office. Review of Resident R41's optometry note dated 3/10/25, indicated cancelled visit. Resident did not have cataract surgery and does not need to be seen. Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses. Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41). 28 Pa. Code: 211.10(a)(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, clinical records, facility investigation, resident and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent injuries for two of four residents (Resident R3 and R1). This failure caused Resident R3 to have an unsupervised fall causing head trauma, abrasion of nose and fracture of nasal bone and Resident R3 was unsupervised smoking and suffered a burn. Resident R1suffered a fall during care and sustained blunt force injuries of the head and cervical spine from the fall which resulted in the death of Resident R1. This failure created an Immediate Jeopardy situation for two of four residents (Resident R3 and R1). Findings include: Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the facility policy Anticoagulant Therapy Monitoring reviewed 11/1/23, indicated proper management for anticoagulant therapy is to monitor for signs and symptoms of adverse effects and develop a care plan for resident's receiving anticoagulant therapy. Review of the facility policy Falls Protocol reviewed 11/1/23, indicated residents determined to be at a high risk for falls will have specific risk factors identified and incorporated into the resident's care plan. Review of the facility policy Smoking Policy dated 8/16, last reviewed 11/1/23, indicated upon admission, residents who smoke will be reviewed for safety with independence in smoking. Residents who require supervision will be reviewed by the interdisciplinary team to determine appropriate interventions to allow them to smoke in the safest manner possible. Interventions will be individualized based on the needs of the resident. These interventions will include but not limited to; wearing a smoking apron, smoking only when supervised by staff or a responsible party. It stated the facility will make every effort to honor the request of those residents who are supervised with smoking by taking the residents out at their request. The facility may implement smoking times at their discretion based on facility needs. This may include posted smoking times and supervised group smoking. All staff are expected to assist in supervised smoking; it is not the only responsibility of nursing staff. Cognitive status will be identified through the use of the cognitive performance scale. A score of 3 or greater indicates the resident is cognitively impaired. To ensure safety of all residents, smoking supplies for all residents will be kept locked in the medication cart and provided to the resident upon request. Review of the facility policy Transfer/Lift Policy dated 3/21/16, last revised 1/4/24, indicated all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 9/8/23, included diagnoses of stroke (the sudden death of brain cells in a localized area due to inadequate blood flow), diabetes (condition that happens when your blood sugar is too high), and high blood pressure. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R3's score to be 3 severe impairment. Review of Resident R3's care plan dated 9/26/23, indicated the resident will remain free from falls. It was indicated a fall risk assessment was to be completed per protocol. Review of Resident R3's NSG-MORESE FALL SCALE (PCC) dated 9/11/23, indicated the resident was a moderate risk for falling. Review of Resident R3's progress note dated 10/24/23, entered by, the former Director of Nursing, Employee E10 stated The resident was outside in his wheelchair and went to the right of the facility entrance. The resident was too close to the sidewalk and curb area of the facility parking lot. The resident one wheel of his wheelchair (left wheel) went off the curb and the resident were off balance and attempted to compensate. He then fell forward onto his left hand, right hand and his face that caused two abrasions to his bridge of his nose. Residents glasses bend from this incident. Resident had epistaxis (nosebleed) that was cleansed, and ice was applied. Resident taking 75 mg Clopidogrel (blood thinner used to prevent heart attacks and strokes in persons with heart disease) daily with a daily 81 mg Aspirin (a nonsteroidal anti-inflammatory drug used to reduce pain, fever, and/or inflammation, and as an antithrombotic (drug that reduces risk of blood clots)). Coagulation status is causing his nose to bleed, occlusive dressing gauze placed in nares to coagulate the resident's active nosebleed. Will complete Neurological checks and vitals to assess if baseline deviates. Review of Resident R3's progress note dated 10/24/23, at 2:08 p.m. it was indicated the physician was notified and the resident was ordered to pack the left nostril with gauze & apply ice to effected area. Review of Resident R3's progress note dated 10/24/23, 4:21 p.m. indicated the resident's nose continued to bleed after the fall outside earlier. It was indicated the resident refused to go to hospital previously but was now agreeable to be transferred to the hospital for further evaluation. Review of Resident R3's hospital Patient Summary dated 10/24/23, indicated the resident sustained blunt head trauma, abrasion of nose, fracture of nasal bone from an accidental fall. The resident nose was packed, and he was ordered to follow up with ENT (Ear, Nose, and Throat) doctor. The resident returned back to the facility. During an interview on 1/24/24, at 2:56 p.m. the DON confirmed the facility failed to thoroughly investigate and provide adequate supervision which resulted in actual harm, resulting in Resident R3's nose fracture (Resident R3). Review of Resident R3's care plan dated 11/3/20, stated the resident is dependent on staff for activities and his preferred activities included going outside during supervised smoking times. Review of Resident R3's care plan dated 9/28/19, revised on 5/5/23, indicated the resident must not be left unattended while smoking, ask staff to light smoking material, wear a smoking apron, be supervised, and place smoking materials at nurses' station for storage. Review of Resident R3's NSG_SMOKING SAFETY SCREENING V1 assessment dated [DATE], indicated the resident smokes 5-10 cigarettes per day. It was indicated the resident must be provided supervision and a smoking apron while smoking. Review of Resident R3's progress note dated 10/24/23, at 11:36 p.m. entered by Licensed Practical Nurse (LPN), Employee E11 indicated the resident returned to the facility and was demanding to go outside and smoke. No further action was documented. Review of Resident R3's progress note dated 10/25/23, at 10:45 p.m. entered by LPN, Employee E11. stated Resident let himself outside to have a cigarette, this writer instructed him to not go outside, it was not time to smoke, instructed him of the designated smoking times for the facility, resident shrugged his shoulders and went outside to smoke anyway. Resident stated, There's no reason why I can't smoke when I want resident refuses to follow rules. Review of Resident R3's progress note dated 10/26/23, at 1:50 a.m. entered by LPN, Employee E11 stated Resident continues to be non-compliant with the smoking policy, resident has gone outside to smoke several times this shift. Resident states, I'm [AGE] years old, I don't have rules. Review of Resident R3's progress note dated 10/29/23, at 12:14 a.m. entered by LPN, Employee E11 stated Resident came up to the nurses station and said he was going outside for a quick smoke, this writer explained to him once again it's not his designated smoking time, he cannot go outside at this hour to smoke, resident said, Look the other way then, cause I'm going out resident currently outside smoking, non-compliant with the smoking policy. Review of Resident R3's progress note dated 10/29/23, at 12:16 a.m. entered by LPN, Employee E11 stated the Registered Nurse (RN) Supervisor was notified of the resident's non-compliance with smoking policy. Review of Resident R3's progress note dated 10/29/23, at 12:30 a.m. entered by RN, Employee E12 stated resident observed outside front doors sitting in wheelchair smoking. Spoke with resident and reminded of smoking policy. Resident advised that continued non-compliance of smoking policy can result in loss of smoking privilege. Resident unreceptive at this time. Review of Resident R3's progress noted dated 11/2/23, at 2:29 a.m. entered by LPN, Employee E11 stated Resident continues to go outside and smoke, resident is aware of the smoking policy, resident continues to be non-compliant, RN supervisor aware. Review of Resident R3's progress note dated 11/2/23, at 2:35 a.m. entered by RN, Employee E12 stated staff observed resident sitting in wheelchair smoking outside front door. Looked for resident outside. Per staff report, resident abruptly went back inside after dropping his lit cigarette on his right leg. Staff further reports resident yelling and brushing lit cigarette off right leg and continuing to slap and pat right leg with both hands to put out burning hole in pants. Review of Resident R3's progress note dated 11/2/23, at 2:43 a.m. entered by RN, Employee E12 indicated the resident refused to be assessed and stated, leave me alone, I'm fine. During an interview on 1/25/24, at 9:34 a.m. LPN, Employee E4 stated Resident R3 wants to smoke outside often, and if he comes up to her, she will take a few minutes to go out with him. LPN, Employee E4 stated Resident R3 is never to be left alone while smoking and he should wear a smoking apron. During an interview on 1/25/24, at 10:19 a.m. Resident R3 stated I go out to smoke by myself all the time. During an interview on 1/25/24, at 10:35 a.m. with the DON and Registered Nurse Assessment Coordinator (RNAC), Employee E12, the DON stated staff try to supervise him when he goes outside, however he goes around the corner where he is not visible. RNAC, Employee E12 stated he occasionally will sneak around, and staff try to bring him back in or sit with him. RNAC, Employee E12 stated we also have changed our codes a couple times, because he picks up and learns the code and watches and that's how he gets out. The DON confirmed the facility failed investigate Resident R3's incident that occurred on 11/2/23, and to make certain each resident received adequate supervision and assistance which resulted in harm (Resident R3). Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's MDS dated [DATE], included diagnoses of anxiety, depression, bipolar disorder (mental illness characterized by extreme mood swings), psychotic disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), dementia (a group of symptoms that affects memory, thinking and interferes with daily life.), and muscle weakness. Review of Resident R1's care plan dated 11/6/18, indicated the resident was a high risk for falls due to muscle weakness, debility, psychotropic medication use (medications that alter mood, perceptions, and behavior), and abnormalities of gait and mobility. It was indicated the resident must receive an extensive assist of two persons for bed mobility. Review of Resident R1's Kardex dated 1/3/24, failed to indicate the resident required an assistance of two people for bed mobility. Review of Resident R1's physician order dated 3/5/19, indicated to administer 2.5 mg of Eliquis (blood thinner) two times a day for atrial fibrillation (irregular heartbeat). Review of Resident R1's care plan dated 11/7/21, indicated the resident was on anticoagulant therapy and interventions included to avoid activities that could result in injury, and take precautions to avoid falls. Review of Resident R1's progress notes dated 1/3/24, entered by RN Supervisor, Employee E5 at 9:45 p.m. stated Resident fell out bed while being changed by the nurse aide. Resident's forehead and nose and was bleeding profusely from the laceration and bleeding a small amount from her nose. Staff LPN had stopped the bleeding with a bath towel. Resident was sitting in an upright position on the floor, with a large amount of blood on the floor, upon RN assessment, resident was talking as she normally does, she was complaining pain to her head. She was answering questions appropriately, Heart Rate 88, pulse ox (measure amount of oxygen in blood) 98%, was unable to get an accurate blood pressure reading resident was irritated with the blood pressure cuff saying it was pinching her. EMS (Emergency Medical Services) arrived and assisted with transferring the resident from the floor to the stretcher. EMS checked resident ' s pupil response and pupils responded within normal limits. Resident was sent to emergency room . Review of Resident R1's progress note dated 1/4/24, entered by RN Supervisor, Employee E5, at 3:01 a.m. indicated they received a call from the hospital's social worker and wanted to get more information on what happened to the resident because he was unsure of the events and had not got a report from the ambulance. It was indicated that the events the nurse aid told her was that she was changing the resident and she rolled her and her resident fell off the bed and landed face first. It was indicated the resident was not doing well and the recently was comfort measures only. Review of Resident R1's Emergency Department Note dated 1/3/24, indicated the resident was brought in for evaluation for a fall from a bed. When the resident arrived, she was hypoxic (deficiency in the amount of oxygen reaching the tissues) on room air in the 80's and was having a lot of nasal congestion. It was indicated the resident was on Eliquis and was observed to have multiple areas of ecchymosis (bruising that occurs when blood leaks from a broken capillary into surrounding tissue under the skin), facial ecchymosis, nasal bleeding, and large forehead laceration which is oozing. It stated, after examination it was noted the patient has left both-bone lower leg fractures, nasal bone fractures, and potential ligamentous (painful conditions caused by tearing or overstretching the ligament) injury of her cervical spine. It was indicated Resident R1 was transferred to a trauma center for further treatment and evaluation. Review of Resident R1's progress note dated 1/4/24, 2:46 p.m. stated per the legal guardian the resident ceased to breath in the hospital. Review of Resident R1's death certificate dated 1/7/24, indicated the resident cause of death was blunt force injuries of the head and cervical spine from a fall from bed. It was indicated the resident ceased to breath on 1/4/24. Review of Resident R1's investigation report dated 1/4/24, indicated it was determined NA, Employee E6 failed to follow proper protocol/procedures when rolling resident in bed, resident was rolled away from nurse aide at time of fall. During an interview on 1/25/24, at 9:36 a.m. LPN, Employee E5 confirmed when turning a resident in bed, you must always roll them towards you and not away. It was indicated a resident's transfer status and level of assistance should be verified in the clinical record, and the facility also implemented a color-coded dot system on all the resident's doors so staff can know how to transfer a resident easily. LPN, Employee E5 stated if a staff member is unsure of the level of assistance a resident requires, they can just ask, and anyone can show them. During an interview on 1/25/24, at 1:31 p.m. NA, Employee E7 stated when she arrived in Resident R1's room to help, Resident R1 was on the ground and blood was everywhere. It was indicated the resident rolled out of bed and her forehead was observed to be bashed in and her fingers were messed up. NA, Employee E7 stated she was unsure what happened, and that the facility typically has three nurse aides that work that unit, however that day they only had two. NA, Employee E7 stated when assisting a resident who requires the assistance of two people, staff must never transfer them alone. NA, Employee E7 stated she has asked staff from another unit or a nurse for help if she needs assistance. During an interview on 1/25/24, at 1:40 p.m. LPN, Employee E8 stated she just finished administering Resident R1 her evening medications and was going to lay the head of her bed back when NA, Employee E6 came in and stated, just to leave her go, I was going to assist her with getting ready for bed. LPN, Employee E8 stated she was still outside then door when NA, Employee E6 came out of the room and was speechless a few minutes later. When LPN, Employee E8 entered Resident R1's room, it was indicated the resident was found on the floor, laying on her left side saying, help me. LPN, Employee E8 indicated there was a large amount of blood present and the bed was observed to be pretty high. LPN, Employee E8 stated I was a nurse aide for [AGE] years, normally when changing them, the bed is lifted to the waistline. LPN, Employee E8 indicated NA, Employee E6 was not that tall and was trying to figure out why the bed was lifted that high. LPN, Employee E8 stated I was literally just in there and she never asked for assistance, I was standing right outside the door, mind you I've been helping them all day. LPN, Employee E8 stated It wouldn't have been an issue if she asked for help. During an interview on 1/25/24, at 1:46 p.m. NA, Employee E6 stated she was changing Resident R1 in bed with the bed elevated and rolled her away from herself. It was indicated as NA, Employee E6 tucked the brief under Resident R1, she accidently fell out of bed. NA, Employee E6 indicated Resident R1 fell face down and when she ran around the bed to the other side there was blood observed under the resident's head. NA, Employee E6 confirmed a resident's level of assistance is found in the care plan and charting. It was indicated the resident ' s care plan indicated the resident required an assist of two people for bed mobility, however Resident R3's Kardex failed to specify the number of people needed for bed mobility. During an interview on 1/25/24, at 1:40 p.m. RN Supervisor, Employee E5 stated when she entered Resident R1's room she was sitting up and staff were holding pressure to her head with a towel. RN Supervisor, Employee E5 stated she should have got help to roll her and I know sometimes when short staffed, they don't always do that. During a phone interview on 1/25/24, at 2:26 p.m. Protective Service Specialist, Employee E9 indicated it was reported the doctors at the hospital had a concern how Resident R1 received her injuries. It was indicated the injuries did not align with statement. Protective Service Specialist, Employee E9 indicated hospital records revealed a nasal and tibia fracture and spinal injury. On 1/25/24, at 12:40 p.m. the Nursing Home Administrator and Director of Nursing were provided the IJ template that made the facility aware that an Immediate Jeopardy situation existed for the facility. The facility failed to provide adequate supervision for two of four residents (Resident R3 and R1), which resulted in actual harm. This occurred when the facility failed to provide Residents R1 and R3 the needed supervision to prevent injuries and death. This failure created an Immediate Jeopardy situation for two of four residents (Resident R1 and R3). On 1/25/24, at 6:08 p.m. an acceptable Corrective Action Plan was accepted which included the following interventions: -The DON or Designees will complete a house audit to identify residents transfer status, level of assistance and supervision. Resident care plans will be reviewed and revised and updated appropriately to reflect resident's current condition. This is to be completed by 1/26/24. -The Administrator will perform a quality assurance and performance improvement (QAPI) meeting to review and revise policy and procedures for smoking, supervision, and transfer and level of assistance for resident care. -The Nursing Home Administrator or designees will immediately change the codes to all the doors of the exterior of the building and signage placed at all exterior doors indicating no resident to be outside unaccompanied. This will be completed by 1/25/24. -The smoking. newly developed supervision policy, and transfer/level of assistance training will be completed with all staff by 1/26/24, at 3:00 p.m. - Incoming staff will be educated by the RN Supervisor at the start of their shift today. Current employees who are not presently at work will be educated by phone on the abuse policy by 3:00 p.m. on 1/26/24. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Staff who received distance education (telephone and email) will sign to acknowledge completion and understanding of education prior to next shift worked. - The Director of Nursing will complete audits of 15 residents ADL (activities of daily living) care with observations weekly for four weeks, then monthly for three months to validate physician orders for care are followed and staff are aware of resident safety and level of assistance when turning or repositioning a resident in bed. Audits will be completed for smoking times, safety compliance and supervision of residents twice daily for 4 weeks and then five times a week for 3 months. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits. The NHA changed all the exterior door codes on 1/25/24, and the previous codes were deleted. Signage was observed at all exterior doors indicating no resident to be outside unaccompanied. During staff interviews conducted on 1/26/24, between 11:49 a.m. and 12:35 p.m. 19 staff members confirmed they received education on proper transfer and level of assistance. Smoking, and supervision. During staff interviews conducted on 1/26/24, between 12:45 p.m. and 1:29 p.m. 6 staff members confirmed they received education on proper transfer and level of assistance. Smoking, and supervision. 101 of 102 in-house staff were educated on the smoking, newly developed supervision policy, and transfer/level of assistance training. 12 of 12 agency staff were educated on-site from 1/25/24, through 1/26/24, and all ongoing education will be provided to them via phone or on-site prior to the start of their shift. 111 of 111 resident clinical records reviewed on 1/26/24, between 1:32 p.m. through 2:24 p.m. indicated residents' level of supervision, transfer status, level of assistance for care was up to date, accurate, and identified. 10 of 10 resident care plans reviewed, appropriately reflected the resident's transfer status and level of assistance. For residents who are admitted to the facility after 1/26/24, occupational and physical therapy will evaluate the residents within 48 hours of admission. The transfer and level of assistance orders will be entered by the nurse, and care plans will be updated by Registered Nurse Assessment Coordinator (RNAC) or Licensed Practical Nurse Assessment Coordinator (LPNAC). A supervised smoking audit was conducted by RN Supervisor, Employee E13 on 1/26/24, at 10:00 a.m. and 1/26/24, at 1:30 p.m. The facility was complying. The Immediate Jeopardy was lifted on 1/26/24, at 3:29 p.m. when the action plan implementation was verified. During an interview on 1/26/24, at 4:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide adequate supervision for two of four residents (Resident R1 and R3), which resulted in actual harm. This occurred when the facility failed to provide Residents R1 and R3 the needed supervision to prevent injuries and death. This failure created an Immediate Jeopardy situation for two of four residents (Resident R1 and R3). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of clinical records, facility policy, an incident report and staff interview, it was determined that the facilty failed to assure that a resident was free from mistreatment or neglect when the staff failed to provide a safe transfer in a manner that protected a resident from injury. The incident resulted in actual harm for one of five residents reviewed (Resident R2). Findings include: The facility's, Abuse Reporting and Investigation policy dated 12/29/15, indicated neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 12/12/15, indicated that Resident R2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. MDS Section G0110B Transfer, was coded 3/3, which indicated that he/she requires the extensive assistance of two staff to get in and out of bed and in and out of a scoot chair (a mobility chair designed to reduce the risk of falls for wheelchair users who propel themselves with their feet that did not include foot rests) and Sections G0110C and D, Walk in Room or Corridor, was coded 8/8, which indicated that the resident was not ambulatory. Sections G0400A and G0400B, Range of Motion, was coded 2/2, which indicated limited use of both arms and both legs. Review of the information dated 12/2/15, submitted by the facility, disclosed an incident that had occurred on 12/2/15 at 11:00 a.m. The report revealed that Activity Aide, Employee E5, transported Resident R2 back to the resident's room in a scoot chair,without foot or leg rests, and instructed the resident to hold his/her legs up. While being pushed, Resident R2 was unable to maintain his/her feet in an elavated position. Resident R2 lowered his/her feet down to the floor while being transported causing his/her feet to go backward under the scoot chair. Resident R2 immediately complained of pain yelling, my ankle, my ankle. The Registered Nurse was informed of the incident and immediately assessed Resident R2, finding a hematoma (a localized collection of blood outside the blood vessels) to the right ankle and pain upon touch. The physician was notified and an x-ray of the right foot was ordered and completed on 12/2/15, which revealed an acute (recent) non-displaced fracture of the lateral malleolus (ankle). During an interview on 1/29/15 at 12:15 p.m., the Nursing Home Administrator confirmed that during transportation, Employee E5 failed to provide a safe transport, resulting in actual harm to Resident R2. 28 Pa. Code: 201.18(b)(1)(2)(3) Management. Previously cited 2/26/15. 28 Pa. Code: 201.29(a)(c)(d) Resident rights. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited 2/26/15.