Every finding on record at Kadima Rehabilitation & Nursing at Irwin

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to complete a thorough investigation to identify the extent of potential abuse for 12 of 13 residents(Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12) and failed to properly identify abuse for one of 13 residents (Resident R1). Findings include:Review of the facility policy Abuse Protection reviewed on 9/3/25, indicated all residents have a right to be free from abuse, corporal punishment, neglect, etc., Abuse is identified as the infliction of injury, unreasonable confinement, intimidation, or punishment which results in harm, pain, or mental anguish. Our facility is committed to protecting our resident s from abuse by anyone.Review of the facility policy Abuse Reporting and Investigation, reviewed on 9/3/25, indicated that the facility will conduct a thorough investigation on all reports of abuse. Upon receipt of the information, the Administrator or designee will notify the Social Service Department for psycho-social support. The resident will be protected during the investigation.During an interview on 2/3/26, at approximately 9:00 a.m., the Nursing Home Administrator stated that the investigation had been conducted on the allegation of sexual abuse for Resident R1.Review of the facility investigation did not include interviews with any other residents to identify possible other victims of the abuse for the 12 other residents that Nurse Aide (NA) Employee E1 had cared for during the night of 1/19/26, to determine the extent of the abuse. The investigation indicated that Resident R1's allegations had been unfounded. NA Employee E1 resigned from the facility.During an interview on 2/3/26, at 10:19 a.m., Resident R1 stated that NA Employee E1 had come into her room to change her after she had an incontinent episode of urine. Resident R1 stated that NA Employee E1 removed the front of her diaper wiped the sides of her front, never cleaned her then turned her onto her side, pulled off the diaper then began pressing on Resident R1's hemorrhoid in and out several times, with no rag or wipe in her hand. Resident R1 stated I don't know what she thought would happen. Resident R1 stated she did not move her bowels, however, NA Employee E1 never cleaned her, she just put on a new diaper and left. Resident R1 stated she asked NE Employee E1 to ask the nurse to come in and Resident R1 stated she told the nurse she felt violated. NA Employee E1 came returned to Resident R1's room again. Residents R1 stated that she felt assaulted. Resident R1 stated that this has never happened before That she feels safe at the facility now if the Nurse Aide no longer works there.During an interview on 2/3/26, at 12:18 p.m., the Nursing Home Administrator (NHA) confirmed Resident R1's allegation was identified as unsubstantiated for Resident R1 and that the facility did not interview any of the other 12 residents related to the allegation to identify potential other victims of Nurse Aide Employee E1's alleged sexual assault. Confirmed that the incident was not thoroughly investigated, and resident statements were not obtained regarding their care received by staff during the night shift.28 Pa. Code: 201.149(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management

Based on observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen, the stove was properly heating and that the steam table had a draining system in place that did not have a potential to cause contamination of food and food service equipment due to drainage pipe touching the ground and actual placement within a drain to sewage system. Findings include:During an observation of the dish room on 12/16/25, at 9:50 a.m., the dish machine had been identified as a low temperature, chemical machine. A Chemical verification strip had been placed during the cleaning process and identified the chemical to be at 10 ppm the indication was for the level to be at least 50 ppm. During an interview on 12/16/25, at 10:15 a.m., the Nursing Home Administrator confirmed he was not aware that the dishwasher was inoperable.During a second observation of meal service on 12/17/25, from 12:00p.m., through 1:35 p.m., the following was observed: Dietary Aide Employee E4 was plating food items, left area, made grilled cheese using gloved hands then removed gloves, wiped her hands on pants and shirt then donned new gloves and began labeling container for sandwiches. opened bun bag and cut bread then went back to making grilled cheese, which had now been holding up tray line. Staff in the kitchen had identified that the stove does not heat properly and it takes forever to heat to cook items in a timely manner. During an observation and subsequent interview on 12/17/25, at approximately 2:00 p.m., the Nursing Home Administrator and Maintenance Director Employee E1 confirmed that the steam table had a draining system in place that had a potential to cause contamination of food and food service equipment due to drainage pipe touching the ground and actual placement within a drain to sewage system. The stove in the kitchen is not in proper working condition. 28 Pa Code:201.14(a) Responsibility of Licensee

Based on a review of the resident council minutes, the grievance logs, resident group meeting information, observation and staff interview, it was determined that the facility failed to serve food that was palatable, attractive and resident preferences. Findings include:Review of seven months of resident council minutes and grievances identified residents stating that the food was cold, food often not being provided according to the posted menu, condiments not available, food items not being available.During the resident group meeting on 12/16/25 at 2:00 p.m., the resident consensus identified food often served cold, late, not providing condiments, not always get enough or what is posted.During an observation of lunch tray line service on 12/17/25, at 12:10 p.m., dietary staff were not placing sour cream on trays until the surveyor made a statement as to where the sour cream was and a box of sour cream packets were then brought to tray line. The facility failed to have enough bottom hot plate covers for all residents.During a test tray observation on 12/17/25, at 1:29 p.m., the temperatures were:Meat 80 degrees, cool to taste beans 90 degrees, cool to tasterice no temp able to be obtainedmilk 41 During an interview on 12/17/25, at 2:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to serve food that was palatable, with all item availability and condiments per resident preferences. Confirmed that the facility failed to have enough bottom hot plate covers for all residents.28 Pa. Code 211.6(b) Dietary Services.

Based on review of the resident council minutes, the grievance logs, the facility posted meal delivery schedule, observations and staff interview, it was determined that the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Findings include:Review of the resident council minutes from September through current and grievances filed from the same time frame identified the facility failed to deliver meals to residents in a timely manner and according to the posted tray delivery schedule.During an observation on 12/16/25, at 1:45 the last cart was being delivered to the A nursing unit. The delivery schedule indicated the cart delivery to be at 12:35 p.m., and hour and ten minutes late. During an observation on 12/17/25, from 12:10 p.m. through 1:20 p.m., the following was identified: Dining room was to be delivered at 12:00 p.m., it was delivered at 12:20 p.m.A wing first cart was to be delivered at 12:10 p.m., it was delivered at 12:43 p.m.B wing first cart was to be delivered at 12:20 p.m., it was delivered at 12:55 p.m.A wing second cart was to be delivered at 12:35 p.m., it was delivered at 1:10 p.m.B wing second cart was to be delivered at 12:45 p.m., it was delivered at 1:20 p.m. During an interview on 12/17/25, at 1:45 p.m., the Nursing Home Administrator confirmed that the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences and requests.

Based on review of resident and staff interviews it was determined that the facility failed to respond to resident concerns and grievances identified during council meetings and review of 5 of 6 months no grievance resolutions. Finding include: During resident group meeting on 12/18/25, at 2:00 p.m. residents indicated that they discuss the same concerns every meeting-specifically call bells, food and mealtimes, care, staff badges, and showers. Residents indicated that they do not get feedback on their concerns. During review of resident council minutes from July 2025, through November 2025, revealed 30 areas of old business (issues/complaints discussed during meetings) with interventions listed as staff educated or manager aware and for resolved no, ongoing (19/30) or yes, resolved (11/30) documented. During an interview on 12/19/25, at 11:30 a.m. Nursing Home Administrator confirmed that call bells, food, mealtimes, staff badges, showers are discussed with grievances files and the facility failed to respond to resident groups on-going concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on review of facility policy, facility documents and staff interviews it was determined that the facility failed to document, resolve, and provide responses to residents and/or their responsible party regarding concerns for 16 of 18 grievances from July 2025 through November 2025. Finding include: Review of the facility policy Grievances dated 9/3/25, indicated the resident has the right to voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished. Prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents. Review of June 2025 through November 2025 facility provided grievance log indicated there were a total of 18 resident entries and as of 12/19/25, at 11:30 a.m. sixteen of them had no date of parties being informed of findings or disposition completed. Interview on 12/19/25, at 11:30 a.m. the Nursing Home Administrator confirmed that the facility provided grievance logs indicated the facility failed to document, resolve, and provide response to residents and/or responsible party regarding concern for 16 of 18 grievances between June 2025 and November 2025. 28 Pa. Code 201.14(b) 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 resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 8 of 13 residents (Residents R2, R3, R5, R11, R14, R29, R500, R501). Findings include:During an interview on 12/16/25, at 12:30 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R2 stated, No. Resident R2 stated that call light response takes a long time.During an interview on 12/16/25, at 12:32 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R3 stated, Could be better and is worse on the off shift and weekends.During an interview on 12/16/25, at 12:35 p.m. when asked if he felt the facility maintained enough staff to care for resident needs, Resident R3 stated, Not at all. Resident R2 further stated that call light response times can be long, and he waits a long time for assistance to get out of bed.During a confidential staff interview, when asked if the staff member felt there was sufficient staff to care for resident needs, the staff member stated, not enough help to get people up and out of bed with 3-11 shift being worse.'During a confidential staff interview, when asked of the staff member felt there was sufficient staff to care for resident needs, the staff member stated, call offs are frequent thus decreasing staff, second shift is worse.During a confidential staff interview, when asked of the staff member felt there was sufficient staff to care for resident needs, the staff member stated, call offs cause us to be short, need more staff to help cover the call offs, you then have to do what you can with what you have.During a confidential staff interview, when asked of the staff member felt there was sufficient staff to care for resident needs, the staff member stated, short staffed more than not, not just because of call offs. We can't do the showers on regular scheduled days because of short staffing.During a confidential staff interview, when asked of the staff member felt there was sufficient staff to care for resident needs, the staff member stated, staffing is short because of call offs, worse on 3-11 shift, not enough more times than not.Review of a grievance filed on behalf of Resident R11, dated 5/28/25, revealed concerns documented for incontinence care, grooming, availability of fresh water, protective booties not applied, and call light availability.Review of a grievance generated from a resident council meeting dated 9/17/25, indicated staff answered call bells and immediately shut them off with a response of I'm not your aide. Review of a grievance filed on behalf of Resident R29 and R5, dated 11/7/25, indicated Resident R29 reported that staff hardly came to check on them and would shut off light without returning, Resident was not put back into bed until the 11p-7a shift and wanted to go earlier. Resident R5 reported nobody was answering their call bell, no one touched her all shift and she was soaked, wants to talk to someone.Review of a grievance filed on behalf of Resident R14, dated 7/30/25, revealed concerns documented for incontinence care and call light response times.Review of grievance log for November revealed Resident R500 and R501 were to have filed a grievance for care concerns with no grievance form provided in compilation of grievances.Review of Resident Council minutes revealed in July, September and October resident revealed that on the 3-11 shift staff were not answering call bells, staff gave residents attitude when asked who their aide was, still not answering call lights or coming in and turning them off, staff still not introducing themselves to the resident, wait time too long for call bells.During an interview on 12/19/25, at approximately 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 8 of 13 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management.28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on facility policy, observations and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of two resident shower rooms (A wing shower room).Findings Include:During an observation on 12/16/25 at 11:24 a.m., the following was identified:Resident shower room on the A wing nursing unit hall had broken floor trim exposing broken drywall leaving pieces of metal that had been lifted and bent. During an interview on 12/18/25 at 11:38 a.m., the Maintenance Director Employee E1 and the Nursing Home Administrator confirmed that the facility failed to maintain a homelike environment for one of two shower rooms (A wing shower room).28 Pa. code: 201.14 (a) Responsibility of licensee.28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c)(d) Resident rights.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for one of three residents (Residents R1). Findings include: Review of facility's policy MDS/RAI/Care Planning dated 9/3/25, indicated the facility will develop a written plan of care individualized for each resident, which identifies through an assessment process his/her strengths, problems, and needs. Review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 10/15/25, indicated diagnoses of PTSD (post-traumatic stress disorder). Review of a psychiatry note dated 11/10/25, indicated Resident R1 has a diagnosis of PTSD. Review of Resident R1's current care plan dated 10/9/25, failed to reveal a care plan with goals and interventions for PTSD. During an interview on 12/19/25, at 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Residents R1. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical record and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of three residents (Resident R66).Finding include:Review of facility policy Splint/Brace Management dated 9/3/25, previously dated 9/18/24, indicated residents will be assessed to determine a splint/brace device program to attain, maintain, and prevent decline in joint mobility.Resident R66 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS- standardized assessment of each resident's functional capabilities and health needs) dated 10/29/25, indicated the diagnoses of transient cerebral ischemic attack (temporary blockage of blood flow in brain, results in weakness, vision/speech issues, dizziness that resolves in 24-hrs), high blood pressure, contracture left hand, muscle wasting and atrophy of unspecified origin, left upper arm (loss or thinning of muscle leading to decreased strength in that extremity).Review of order summary revealed an order on 8/12/25, for resting hand splint on left hand while in bed, off for skin integrity checks and activities of daily living.During multiple observations throughout the day on 12/16/25, 12/17/25, 12/18/25 and 12/19/25, it was noted that Resident R66's brace was never placed on her left hand.During multiple observations throughout the day on 12/16/25, 12/17/25, and 12/19/25, it was noted that Resident R66's call bell was wrapped around a chair behind the head of her bed, it was on the floor behind her bed or was on the floor next to her bed.During an interview on 12/19/25, at 11:30 a.m. the Director of Nursing confirmed the facility failed to provide care and services as needed with assisted devices as ordered for Resident R66.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.29(a)(c.3)(1) Resident Rights.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medication and/or biologicals in one of two medication rooms (A Wing Medication Room). Finding include: Review of facility policy Storage of Medication dated 9/3/25, previously review 9/18/24, indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. During an observation on 12/18/25, at approximately 9:00 a.m. of the A Wing medication room the following was observed- 16 boxes (10 syringes/each) Influenzae Vaccine 2024-2025 formula- Expired 6/30/25- 1 box ( 9 syringes Influenzae Vaccine 2024-2025 formula-Expired 6/30/25- 2 boxes-Gvoke HypoPen (glucagon Injection Pen)- Expired 6/2025- 4 boxes 50% Dextrose Injection-Expired 5/2025 During a review of all residents clinical record for administration of Influenzae vaccines, no residents were found to have received the expired medications. During an interview on 12/18/25, at 2:00 p.m. with the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to properly store medication and/or biologicals in one of two medication rooms. 28 Pa. Code 211.9(a)(1)(j)(1)(k) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, clinical and facility record review, facility submitted documents and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent a fall and an elopement for two of eight residents (Resident R1 and Resident R2). Finding include:Review of facility policy, Transfer of Residents dated 9/18/24, indicated residents will be evaluated, supervised, or assisted to ensure the appropriate method of transferring a resident is identified to minimize emotional and physical trauma to the resident.Review of facility policy, Resident Elopement dated 9/18/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement is defined as a resident leaving the premises or a safe area without authorization.Review of facility policy, Elopement Drill dated 9/18/24, indicated elopement drills will be held to prepare staff to search for a resident who is missing or has eloped.Review of facility policy, Abuse Protection dated 9/18/24, indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporeal punishment, involuntary seclusion, neglect and misappropriation of property.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included aphasia (a language disorder that affects a person's ability to communicate whether by speaking, understanding, reading, or writing), muscle wasting and atrophy (shrinking and loss of muscle tissue, often resulting in decreased strength and mobility), vascular dementia (person has problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), personal history of transient ischemic attack and cerebral infarction without residual deficits (a past history of temporary disruption of blood flow to the brain, causing stroke like symptoms that resolved within 24 hours or when a portion of the brain is deprived of blood but no long-lasting neurological deficits occurred).Review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 5/6/25, indicated the diagnoses remained current.Review of and Elopement Risk Assessment completed on 2/18/25 and 4/21/25 revealed that Resident R1 was cognitively impaired, had poor decision-making skills, did not demonstrate exit seeking behaviors, and did not wander; oblivious to safety needs.Review of the physician's orders on 8/5/25, indicated prior to the incident on 7/14/25, Resident R1 was not ordered any interventions to prevent an elopement. Review of orders did show that on 7/14/25, Resident R1 was ordered a Wander Guard (device that alarms when a resident is near and exit), and to check placement every shift.Review of Resident R1's plan of care on 8/5/25, revealed prior to the incident on 7/14/25, Resident R1 did not indicate risk for elopement, nor did it have interventions in place to prevent elopement. In review of Resident R1's plan of care it was noted that on 7/14/25, a plan of care for potential for elopement and associated injury related to exit seeking behavior was initiated. The goals are for Resident R1 to remain free of injury related to elopement risk through next review period, resident will not wander out of facility through next review, and resident will remain on unit unless supervised by facility staff or responsible party through next review.Review of facility provided incident report dated 7/14/25, at 10:10 a.m. indicated resident was let out of the facility by a staff member onto the front patio at approximately 10:00 a.m. for fresh air. Resident is nonverbal and was unable to explain why he wandered down the parking lot before being found by facility staff at 10:10 a.m. Resident was wearing appropriate clothing and footwear at the time of the elopement. Head to toes RN assessment was completed with no injuries noted to resident. Resident has not been identified as an elopement risk since admission and has not exhibited exit seeking behaviors.Review of the progress notes dated 7/14/25, at 1:17 p.m. by Registered Nurse, Nursing Supervisor completed a head-to-toe assessment on return to the facility. Multiple staff were interviewed that saw the resident at the front doors to the facility, staff saw him on the patio, and then the staff member that alerted someone that he had moved off the patio.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that include vascular dementia, diabetes (blood sugar levels are either too high or too low), aphasia, and muscle weakness.Review of the MDS dated [DATE], indicated the diagnoses remained current.Review of Resident R2's clinical record revealed orders for the resident to be an assist x2 (two persons) for bed mobility on 3/22/23, and transfers to use Hoyer lift, large sling, assist x2 written on 12/19/24 and revised on 7/17/25. The resident was placed on Hospice on 12/31/24 with orders placed by Hospice personnel for their staff to follow. Resident has history of falls without injuries, his bed is in the lowest position, and he has fall mats in place.Review of facility provided incident report dated 7/16/25, at 11:36 a.m. indicated resident was being transferred from bed to shower chair by Hospice CNA (Aide) when resident became unsteady and would not let go of chair arm which prompted Hospice CNA to lower resident to the floor. Resident is an assist x2 for transfers. Investigation was immediately launched, and Hospice CNA was suspended. Registered Nurse (RN) assessment completed with resident sustaining no injuries, family notified. Facility completed an audit of all residents with transfer statuses. Education provided to nursing staff on physician orders, transfer statuses, and house education on Abuse/Neglect completed as of 8/5/25. Review of incident also revealed multiple interviews with staff that stated the Hospice CNA did not ask for assistance when transferring the resident.Review of Resident R2's clinical record progress notes on 7/16/25, at 11:36 a.m. revealed a note placed by RN stating, Hospice CNA was transferring resident to shower chair and resident would not let go of chair arm. CNA lowered resident to the floor. No injuries noted. CRNP and wife made aware. ROM all 4 extremities unhanged. Did not hit head. During an interview on 8/5/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision to prevent an elopement and to prevent a fall for two of eight residents,28. Pa. Code 201.14(a) Responsibility of licensee28. Pa. Code 201.18(b)(e)(1) Management,

Based on review of the Resident Assessment Instrument User's Manual, clinical record, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set Assessments were accurate and fully completed for one of eight residents (Resident R1).Finding include:Review of the facility policy Resident Assessment/Minimum Data Set, dated [DATE], indicated the facility will conduct initially and periodically a comprehensive, accurate, and standardized reproducible assessment of each resident's functional capacity under the direction of a designated registered nurse.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS-periodic assessment of care needs) dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood.Review of Resident R1 clinical record revealed an MDS completed on 5/6/25. Review of Section B: Hearing, Speech, and Vision indicated Resident R1 was not in a persistent vegetative state/no discernible consciousness. The remainder of the questions in B0700 Makes Self Understood-Ability to express ideas and words consider both verbal and nonverbal was marked as Sometimes Understood. Review of Section C: Cognitive Patterns-Should brief interview for mental status (C0200-C0500) be conducted the resident was marked as Rarely/Never Understood. Section C- C0700 Short Term Memory OK-Seems or Appears to recall after 5 minutes the resident was marked as Memory Problem, Section C1000 Cognitive Skills for Daily Decision Making-Made decisions regarding tasks for daily life the resident was marked as Severely Impaired-Never/Rarely made decisions. Section C-BIMS was not completed. Section D: Mood not assessed with Resident Mood Interview not completed, Staff Assessment of Resident Mood completed with a severity score of 5, score should be between 00-30.During an interview on 8/5/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive MDS assessments were accurate and fully completed for one of eight residents. 28 Pa. Code: 211.5(f) Clinical Records.

Based on review of facility policies, clinical procedures and staff interviews, it was determined that the facility failed to make certain medical records on each resident are complete and accurately documented for one of eight residents. (Resident R1).Findings include:A review of the facility policy Documentation dated 9/18/24, indicated nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception, or the use of a checklist, flowcharts, or other documentation tools. Nursing documentation will provide accurate reflection of resident condition and will meet federal and state requirements.A review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included aphasia (a language disorder that affects a person's ability to communicate whether by speaking, understanding, reading, or writing), muscle wasting and atrophy (shrinking and loss of muscle tissue, often resulting in decreased strength and mobility), vascular dementia (person has problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), personal history of transient ischemic attack and cerebral infarction without residual deficits (a past history of temporary disruption of blood flow to the brain, causing stroke like symptoms that resolved within 24 hours or when a portion of the brain is deprived of blood but no long-lasting neurological deficits occurred).A review of the Minimum Data Set (MDS-periodic assessment of resident care needs) dated 5/6/25, indicated the diagnoses remained current.On 7/14/25, the resident was let out of the facility by a staff member to the front patio at 10:00 am for fresh air. Resident was found at 10:10 am approximately 75 feet down the parking lot, he is non-verbal and was unable to explain why he wandered down the parking lot.A review of the clinical record revealed that the resident does not have a follow-up note or any notes since the day of the Elopement on 7/14/25. The note from this day states resident assessment, alert and nonverbal. Temp 97.2, HR (heart rate) 64, resp (respirations) 16, bp (blood pressure) 132/74. Resident dressed in t-shirt, shorts, shoes and socks in w/c (wheelchair) with Hoyer pad underneath. Not at risk of hypo/hyperthermia. Does have scrapes to right leg. Appears to be in no pain. No anxiety or SOB (shortness of breath). There is no documentation regarding what was done for the fresh scraps to the leg, no documentation of the Elopement Risk Assessment being completed, the wander guard being placed and where (information was obtained, orders, and kardex as to wander guard placed on left lower extremity), and no documentation regarding if the resident has attempted to wander or is displaying any wander behaviors since the date of the incident.During an interview on 8/5/25, at 1:00 p.m. the Nursing Home Administrator (NHA) confirmed the above findings, and the facility failed to document a follow-up to the incident regarding the scrapes to right leg, any documentation since the date of the incident regarding any wandering behaviors, and that medical records are complete and accurately documented.28 Pa. Code: 211.5 (f)(g)(h) Clinical Records.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect for one of five residents (Resident R1). Based on review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility the facility failed to protect residents from neglect for one of five residents (Resident R1). This was identified as past non-compliance. Findings include: Review of the facility policy, Abuse Protection, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary. Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated the patient should always roll toward you not away from you. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/6/25, included diagnoses of muscle weakness, debility, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's plan of care initiated 4/13/22, indicated Resident R1 required assistance with changing position in bed due to a decrease in functional ability and physical limitations. Review of a progress note dated 6/29/25, at 4:04 a.m. indicated, Resident rolled out of bed when aide was changing sheets. Aide had resident roll to right, and he started to slide off bed. Aide grabbed the back of his gown, and he slid off bed to sitting position with his legs extended in front of him.Review of facility submitted information dated 6/69/25, indicated, On the morning of 6-29-25 at approximately 0200 (2:00 a.m.), [Resident R1] had an assisted fall out of bed. [Resident R1] was having incontinent care completed at the time of fall. The aide performing incontinent care on [Resident R1] rolled resident away from her instead of towards her. [Resident R1] rolled out of bed on the right side of bed. [Resident R1] is an assist x1 for bed mobility. Review of an employee statement written by NA Employee E2 dated 6/29/25, indicated, [Resident R1] had an assisted fall. When rolling [Resident R1] to change sheet he rolled. I was able to grab his gown so his fall was gentle. I notified nurse. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 7/4/25, included the information, Transfer status of assist x1 for bed mobility was followed however CNA rolled resident away from her while changing which prompted resident to fall out of bed. Allegation of neglect substantiated. On 6/29/25, the facility initiated a plan of correction that included:Investigation launched immediately and CNA suspended pending investigation. A registered nurse assessment was completed immediately - no injuries noted. A verbal one on one education was completed with the aide by clinical management team on the proper way to roll residents who are an assist x1 in bed as well as abuse/neglect policy. House education completed as well. Family, Adult Protective Services, and police all notified of incident. All incidents and accidents are discussed daily during IDT (inter-disciplinary team) and monthly during QAPI (Quality Assurance and Performance Improvement).On 7/15/25, five nurse aides were interviewed, and confirmed they were provided education on abuse and neglect. Review of education sign in sheets on 7/15/25, confirmed in-service on abuse and neglect was completed on 6/30/25.During an interview on 7/15/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to protect residents from neglect for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility job descriptions, personnel files, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides (NA) reviewed (NA Employee E1). Based on review of facility provided documentation, it was determined that the facility failed to have updated certifications on file for one of five Nurse Aides (NA), which allowed NA Employee E1 to work without a current certification.Review of the facility documents provided indicated that nurse aides, Must possess an active Certified Nursing Assistant Certification; having successfully completed a State approved training program and necessary examination.Review of facility submitted information dated [DATE], indicated, As part of a routine internal audit, conducted to ensure compliance with licensure requirements, it was identified that employee's [Nurse Aide Employee E1] license had expired as of [DATE]. Upon identification of the lapse, the employee was immediately removed from the schedule and was not permitted to resume duties until verification of her renewed certification was received. Review of facility provided plan of correction revealed the following: Regular monthly audits x 3 months. Automated reminders for upcoming expiration dates. Facility completed on [DATE], an audit as part of transition to a new electronic HR/payroll software, which allows for live tracking and trending of certification dates. All other licenses and certifications were found an no concerns were noted.All incidents are reviewed at daily clinical meeting and are forwarded to QAPI (Quality Assurance and Performance Improvement committee) for further review, recommendations, and audits.During interviews completed on [DATE], of five nurse aides working in the facility, all had received education and had current certifications. During an interview on [DATE], at 10:45 a.m. the Nursing Home Administrator confirmed the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed.28 Pa. Code 201.29 Personnel Policies and Procedures.

Based on review of facility documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R1).Based on review of published documents, clinical record review, facility provided documents and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R1). This was identified as past non-compliance.Findings include:Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated the patient should always roll toward you not away from you.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/6/25, included diagnoses of muscle weakness, debility, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R1's plan of care initiated 4/13/22, indicated Resident R1 required assistance with changing position in bed due to a decrease in functional ability and physical limitations. Review of a progress note dated 6/29/25, at 4:04 a.m. indicated, Resident rolled out of bed when aide was changing sheets. Aide had resident roll to right, and he started to slide off bed. Aide grabbed the back of his gown, and he slid off bed to sitting position with his legs extended in front of him.Review of facility submitted information dated 6/29/25, indicated, On the morning of 6-29-25 at approximately 0200 (2:00 a.m.), [Resident R1] had an assisted fall out of bed. [Resident R1] was having incontinent care completed at the time of fall. The aide performing incontinent care on [Resident R1] rolled resident away from her instead of towards her. [Resident R1] rolled out of bed on the right side of bed. [Resident R1] is an assist x1 for bed mobility.Review of an employee statement written by NA Employee E2 dated 6/29/25, indicated, [Resident R1] had an assisted fall. When rolling [Resident R1] to change sheet he rolled. I was able to grab his gown, so his fall was gentle. I notified nurse.Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 7/4/25, included the information, Transfer status of assist x1 for bed mobility was followed however CNA rolled resident away from her while changing which prompted resident to fall out of bed. Allegation of neglect substantiated. On 6/29/25, the facility initiated a plan of correction that included:Investigation launched immediately and CNA suspended pending investigation. A registered nurse assessment was completed immediately - no injuries noted. A verbal one on one education was completed with the aide by clinical management team on the proper way to roll residents who are an assist x1 in bed as well as abuse/neglect policy. House education completed as well. Family, Adult Protective Services, and police all notified of incident. All incidents and accidents are discussed daily during IDT (inter-disciplinary team) and monthly during QAPI (Quality Assurance and Performance Improvement).On 7/15/25, five nurse aides were interviewed, and confirmed they were provided education on bed mobility. The nurse aides were able to verbalize the correct way to roll a resident. During an interview on 7/15/25, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policies and documents, and staff interviews, it was determined that the facility failed to properly monitor equipment in the Main Kitchen creating the potential for food-borne illness. Findings include: A review of facility policies Equipment Temperature Logs dated 9/18/24, indicated that the Dietary Services Manager will use the Refrigeration and Freezer Temperature Log to record the temperatures of all refrigerators and freezers daily. The forms will be posted in the Dining Services Department and kept on file for a period of one year. A review of the Equipment Temperature Log, To Be Taken daily by the Dietary Services Manager documents dated 12/1/24 through 1/27/25 did not include documentation that temperatures were taken on the following days for the walk in and reach in coolers and freezers, and milk cooler: 1/6/25. 1/13/25. 1/16/25. 1/18/25. During an interview on 1/27/25, at 9:50 a.m., the Nursing Home Administrator and Dietary Services Manager E1 confirmed the above findings, and that the facility failed to monitor equipment temperatures creating the potential for food-borne illness. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.6(c) Dietary services.

Based on observations and interview, the facility failed to store medications in a safe and sanitary manner for one of three medication carts reviewed (A unit Long Hall, and B unit Short Hall). Findings: Review of facility policy Infection Control Plan, Program, and Committee reviewed 9/18/24, indicated the facility maintains a structured Infection Control Program focused on prevention and management of infections. During an observation on 1/28/25, at 9:10 a.m., A unit Short Hall medication cart contained six of six insulin pens in compartments unbagged, posing the risk of cross-contamination. During an interview at that time, Licensed Practical Nurse (LPN) Employee E3 confirmed the insulin pens were unbagged. During an interview on 1/28/25 at 10:00 a.m. the Director of Nursing confirmed the facility failed to prevent the risk of cross-contamination by storing insulin pens unbagged in the medication carts for A unit Long Hall medication carts. 28 Pa code 201.14(a) Responsibility of licensee 28 Pa code 211.12(d)(1) Nursing services

Based on a review of facility policy, federal regulation, and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 4 of 12 months (January 2024 through April 2024). Findings include: Review of the facility policy Admission Transfer and Discharge 9/21/23 and 9/18/24, indicated no resident will be discharged without timely notification of the resident, responsible party, or authorized representative. Review of Title 42 Code of Federal Regulations S483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. During an interview on 1/27/25, at 2:30 p.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 4 of 12 months (January 2024 through April 2024). 28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to protect residents from staff-initiated physicial abuse and involuntary seclusion. This failure resulted in a staff member restraining a resident to a wheelchair with a bed sheet and placing the resident into a dark room with the door closed unable to exit which created an Immediate Jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of facility policy Abuse: Protection from Abuse, reviewed 4/1/23, revealed that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 6/6/23, included diagnoses of osteoarthritis (degeneration of the joint causing pain and stiffness), anxiety, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5. Review of Resident R1's diagnosis list indicated unspecified dementia with agitation was added on 1/30/23, and unspecified dementia with psychotic disturbance was added on 3/3/23. Review of Resident R1's physician orders active in July 2023, included: -Quetiapine fumarate (Seroquel, an anti-psychotic medication) 25 mg, three times a day for unspecified psychosis, dated 6/26/23. -Clonazepam (Klonopin, an anti-anxiety medication) 1 mg every eight hours, as needed for agitation/ behaviors, and give one tablet by mouth at bedtime., dated 7/7/23. -Fluoxetine (Prozac, an anti-depressant medication) 40 mg daily for depression, dated 6/27/23. Review of a physician order originally dated 9/6/22, and reordered 3/2/23, and 6/26/23, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related anxiety and depression symptoms and the use of a PRN medication (Klonopin). Further review of the physician orders failed to include monitoring of behaviors related to dementia or antipsychotic use. Review of nurse aide behavior symptom documentation from 3/3/23, through 7/9/23, included behavioral disturbance documentation on 3/16/23, and 7/9/23. Review of Resident R1's plan of care active on 7/9/23, did not include a care plan developed for behavioral disturbances. Review of Resident R1's plan of care for Impaired cognitive function / dementia or impaired thought processes related to dementia initiated 4/6/22, did not include interventions for behaviors. Review of Resident R1's plan of care for psychotropic medications initiated 3/3/22, and reviewed 12/12/22, included only the intervention to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of a progress note written by Registered Nurse (RN) Supervisior Employee E1 on 7/9/23, at 10:48 p.m. stated Resident screaming/yelling/cursing throughout 7P to present. In/out of bed, in/out of hall both with and without walker, pants, and underwear. Demands to be changed every minute of so [sic], resident checked frequently for incontinence by both CNAs (NA, nurse aides) and nursing. Only one instance of soiling found. Refused all dinner. Took meds crushed. Gait becoming increasingly unsteady as resident becomes more agitated. All efforts to calm have thus far been unsuccessful. Placed in w/c (wheelchair) and brought to nursing station for safety. Multiple C/O (complaints) received by peers on the hall regarding noise. Review of documentation submitted by the facility on 7/16/23, revealed At 1:20 p.m. on 7/16/23, Licensed Practical Nurse (LPN) Employee E2 informed the Director of Nursing (DON) that on 7/9/23, she witnessed RN Employee E1 take Resident R1 into the salon room for about 20 minutes and left him alone with the door shut while he was tied to the wheelchair with his bed sheets. Then resident was moved to the conference room where he was left with the door open. LPN Employee E2 also informed the DON that resident was given medications to calm him down prior to resident being moved into the salon. Review of a facility investigation statement (undated), written by RN Supervisor Employee E1 stated, Last weekend, resident was having an extreme escalation of his usual behaviors. Continuously in/out of bed, both with and without walker and/or pants. Continuous screaming, cursing, yelling for medication, to be changed, mouth is dry, etc. All chronic behaviors for this resident, but very extreme in this instance. Resident was provided with multiple changes of pants and underwear, although he was not soiled. As soon as any staff provided care, he would begin again without pause. Per report this has been going on most of the day prior to my arrival, and he'd continue throughout the evening, and into the early hours of the night shift without pause. Resident refused to eat or rest. His gate was becoming more and more unsteady as he became more exhausted. His ability to calm became severely impaired as his mental state continue to escalate. All ordered medications had been administered by floor, nurse, and had, as yet, been wholly ineffective in reducing his anxiety, behaviors. Staff needed assistance to monitor resident in order to allow them to provide care for the rest of the unit. A rock and go wheelchair was brought from shower room and resident seated and brought to nursing station for monitoring. Staff continued with rounds. Resident continued with the same behaviors and added complaints of being cold. Bedding was brought from room and resident was covered. He continued to throw blanket and sheet off, kicking them with feet and becoming tangled while at the same time, rocking forward and attempting to get out of chair unassisted, almost falling forward on his face despite me being right next to him. Resident screamed and yelled to go back to room, related to resident that we were afraid for his safety and that he was too upset to be safe alone in room. Resident continued for several minutes screaming throwing all offerings of fluids, snacks blankets .then screamed of cold. Bedding was replaced several times and finally threaded through the cracks in the chair and snugged down/tucked in around resident in an effort to keep him covered. A sheet was run through the rear spokes of the chair and attempt to reduce the forward rock of the chair, as well as keeping, as well as keep resident from rolling chair, as was would not leave the brakes on. At no time was resident left alone or unmonitored, continued to talk with resident and encourage him to calm and try to relax. Resident began to slowly calm, and speak in a more organized manner. Was given and accepted fluids. After about 30 to 40 minutes, resident was much calmer and appeared to become sleepy. When asked if he was tired and ready to lie down, resident responded that he was. He was calm and reasonable. At this time I returned with resident to his room, checked for any incontinence, assisted him to bed, provided his glasses, fluids, tissues, and phone within reach on tray table. Provided fresh linen for bed as he had spilled fluid on his bed previously and resident transferred to bed, was positioned on pillows, and covered with multiple blanket at his request. Asked resident if he was good, he responded in the affirmative. He complained of being cold, air was turned off, he requested that I turn off the lights. I did so, placed his walker at bedside and left. Resident then rested quietly for several hours. As is common after an emotional escalation of that magnitude. He resumed as usual behavior is around 5 or 6 am, but did not evidence previous extremes. Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E2 stated, On 7/9/23, I was the nurse assigned on A-long from 7:00 a.m. to 11:00 p.m. One of the residents assigned to me (Resident R1) one was having a difficult evening and was continuously yelling out, coming to the nurses station it, insisting he be changed. His brief was changed multiple times even though it was dry in order to appease him. These attempts failed as he continued to yell out stating he need a changed. I medicated him as ordered with all p.m. medications and PRN Klonopin. Around 9:00 p.m. I observed the RN Supervisor (RN Employee E1) take medications from the top drawer of my med cart and proceed to Resident R1's room. I then observed her wheel Resident R1 up to the nurses station and tie him to his chair with a bed sheet. The sheet was wrapped around his waist and then tied to the back of the chair. The resident continued to yell out for some time. Yelling continuously and loudly to be taken back to his room. Then, RN Supervisor Employee E1 then wheeled the resident into the beauty salon and shut the door behind him, leaving Resident R1 in there alone. I went outside to take a break. I was outside for about 20 minutes. Upon returning to check the beauty salon door to see if Resident R1 was still there and safe. I noted that he was no longer there but have been moved to the DON office with the door left open. He remained there at the time of my departure at 11:00 p.m. Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E3 stated, On 7/9/23, while on duty witnessed RN supervisor (RN Employee E1) on duty, put resident (Resident R1) in a chair and placed a sheet around him and tied. Put in the ADON's office and closed the door. Resident yelling out. Resident agitated all 3-11 shift. Review of a facility investigation witness statement dated 7/16/23, written by NA Employee E4 stated, I was sitting at the nurses station charting. And (Resident R1) kept coming up, saying he was wet. Well he was changed and he was checked by three different people. He was dry. Well he still came up every couple of minutes and (RN Employee E1) said that if he doesn't go lay down, then she was going to put him in the quiet room. (Resident R1) kept coming up. So she went and got (another resident's) rock 'n go chair (tiltable wheelchair) and put him in it. She said she was going to fix it so that he can't get out. When it was time for me to leave, I walked past the DON room and saw Resident R1 sitting in the chair in the office. During a follow-up interview on 7/23/23, at 11:29 a.m. LPN Employee E2 confirmed the above statement. During a follow-up interview on 7/23/23, at 2:58 p.m. NA Employee E4 confirmed the above statement. On 7/23/23, at 5:18 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 94 residents for staff initiated physical abuse and involuntary seclusion by placing the resident into a dark room with the door closed unable to exit and the Immediate Jeopardy template was provided to facility administration. On 7/23/23, at 7:10 p.m. an acceptable Corrective Action Plan was received which included the following interventions: - RN Supervisor E1's employment was then terminated on 7/19/23 due to abuse. - Abuse training will be completed with all staff by 7/24/23 at 5:00 p.m. - Resident was immediately assessed with a head to toe done. He has been seen by a physician with no issues noted. - All staff currently working in the building were educated on the abuse policy on 7/24/23 by 6:00 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 5:00 p.m. on 7/24/23. 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. - Social Worker will audit all grievances for the past 3 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. Grievances will continue to be audited monthly at QAPI. - In-house and agency staff will be educated on abuse reporting monthly for 3 months, then yearly. New hires and new agency staff will be educated upon orientation. - Social Worker will interview residents for concerns about abuse and neglect, monthly for 3 months. During staff interviews conducted on 7/24/23, between 9:00 a.m. and 12:30 p.m. 19 staff members confirmed they received education on abuse prevention. During observations completed on 7/24/23, between 2:30 p.m. and 3:10 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 7/24/23, between 3:10 p.m. and 3:25 p.m. 13 staff members confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 7/24/23, at 3:50 p.m. when the action plan implementation was verified. During an interview on 7/24/23, at 12:40 p.m. the Nursing Home Administrator confirmed that facility failed to protect residents from staff-initiated physical abuse and involuntary seclusion. This failure resulted in a staff member restraining a resident to a wheelchair with a bed sheet and placing the resident into a dark room with the door closed unable to exit, and created an Immediate Jeopardy situation for one of 94 residents. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse and involuntary seclusion for one of three residents reviewed (Resident R1), which provided the opportunity of an additional seven days for abuse to possibly continue. This failure created an Immediate Jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse Reporting and Investigation dated 4/1/23, indicated anyone who witnesses an incident of suspected resident abuse is to intervene immediately and stop the abuse. They are to report it to the charge nurse or supervisor immediately. Review of abuse education provided to facility staff defined abuse as willful mistreatment that can be verbal, sexual, physical, or mental. The education further stated that employees of nursing homes are mandated to immediately report any suspected abuse of a recipient of care, and provided a toll-free, elder abuse hot line to report abuse. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 6/6/23, included diagnoses of osteoarthritis (degeneration of the joint causing pain and stiffness), anxiety, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5. Review of a physician order originally dated 9/6/22, and reordered 3/2/23, and 6/26/23, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related anxiety and depression symptoms and the use of a PRN medication (Klonopin). Further review of the physician orders failed to include monitoring of behaviors related to dementia or antipsychotic use. Review of Resident R1's plan of care active on 7/9/23, did not include a care plan developed for behavioral disturbances. Review of Resident R1's plan of care for Impaired cognitive function / dementia or impaired thought processes related to dementia initiated 4/6/22, did not include interventions for behaviors. Review of Resident R1's plan of care for psychotropic medications initiated 3/3/22, and reviewed 12/12/22, included only the intervention to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of a progress note written by Registered Nurse Supervisor (RN) Employee E1 dated 7/9/23, at 10:48 p.m. stated Resident screaming/yelling/cursing throughout 7P to present. In/out of bed, in/out of hall both with and without walker, pants, and underwear. Demands to be changed every minute of so, resident checked frequently for incontinence by both CNAs (NA, nurse aides) and nursing. Only one instance of soiling found. Refused all dinner. Took meds crushed. Gait becoming increasingly unsteady as resident becomes more agitated. All efforts to calm have thus far been unsuccessful. Placed in w/c (wheelchair) and brought to nursing station for safety. Multiple C/O (complaints) received by peers on the hall regarding noise. Review of documentation submitted by the facility on 7/16/23, revealed At 1:20 p.m. on 7/16/23, Licensed Practical Nurse (LPN) Employee E2 informed the Director of Nursing (DON) that on 7/9/23, she witnessed RN Employee E1 take Resident R1 into the salon room for about 20 minutes and left him alone wit the door shut while he was tied to the wheelchair with his bed sheets. Then resident was moved to the conference room where he was left with the door open. LPN Employee E2 also informed the DON that resident was given medications to calm him down prior to resident being moved into the salon. Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E2 stated, On 7/9/23, I was the nurse assigned on A-long from 7:00 a.m. to 11:00 p.m. One of the residents assigned to me (Resident R1) one was having a difficult evening and was continuously yelling out, coming to the nurses station it, insisting he be changed. His brief was changed multiple times even though it was dry in order to appease him. These attempts failed as he continued to yell out stating he need a changed. I medicated him as ordered with all p.m. medications and PRN Klonopin. Around 9:00 p.m. I observed the RN Supervisor (RN Employee E1) take medications from the top drawer of my med cart and proceed to Resident R1's room. I then observed her wheel Resident R1 up to the nurses station and tie him to his chair with a bed sheet. The sheet was wrapped around his waist and then tied to the back of the chair. The resident continued to yell out for some time. Yelling continuously and loudly to be taken back to his room. The RN Supervisor Employee E1 then wheeled the resident into the beauty salon and shut the door behind him, leaving him and him in there alone. I went outside to take a break. I was outside for about 20 minutes. Upon returning to check the beauty salon door to see if Resident R1 was still there and safe. I noted that he was no longer there but have been moved to the DON office with the door left open. He remained there at the time of my departure at 11:00 p.m. Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E3 stated, On 7/9/23, while on duty witnessed RN supervisor on duty, put resident (Resident R1) in a chair and placed a sheet around him and tied. Put in the ADON's office and closed the door. Resident yelling out. Resident agitated all 3-11 shift. Review of a facility investigation witness statement dated 7/16/23, written by NA Employee E4 stated, I was sitting at the nurses station charting. And (Resident R1) kept coming up, saying he was wet. Well he was changed and he was checked by three different people. He was dry. Well he still came up every couple of minutes and (RN Supervisor Employee E1) said that if he doesn't go lay down, then she was going to put him in the quiet room. (Resident R1) kept coming up. So she went and got (another resident's) rock 'n go chair (tiltable wheelchair) and put him in it. She said she was going to fix it so that he can't get out. When it was time for me to leave, I walked past the DON room and saw Resident R1 sitting in the chair in the office. During a follow-up interview on 7/23/23, at 11:29 a.m. LPN Employee E2 confirmed the above statement, and confirmed she was aware that she is required to report any observations of abuse. LPN Employee E2 stated that she wasn't regular staff at the facility, and she didn't feel at home to be able to report the concern. During a follow-up interview on 7/23/23, at 2:58 p.m. NA Employee E4 confirmed the above statement, and confirmed she was aware that she is required to report any observations of abuse. NA Employee E3 stated I wanted to say something, but she was the supervisor. The failure to report this instance at the time of occurrence caused the abuse to possibly continue from the date of occurrence of 7/9/23 through the initial report of 7/16/23 or seven days. On 7/23/23, at 5:18 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 94 residents, and the Immediate Jeopardy template was provided to facility administration. On 7/23/23, at 7:10 p.m. an acceptable Corrective Action Plan was received which included the following interventions: - RN Supervisor E1's employment was then terminated on 7/19/23 due to abuse. - All staff currently working in the building will be educated on the abuse policy specifically as it applies to reporting abuse by 7/23/24. by 5:00 pm. - Incoming staff will be educated by the RN Supervisor at the start of their shift today, 7/23/23. Current employees who are not presently at work will be educated by phone on the abuse policy by 5:00 pm on 7/24/2023. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Staff who received distance education will sign to acknowledge completion and understanding of education prior to next shift worked. - Nursing supervisor will conduct interviews with all residents to assure residents are free from abuse/neglect. - Social Worker will audit all grievances for the past 3 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. Grievances will continue to be audited monthly at QAPI (Quality Assurance and Performance Improvement meeting). - In-house and agency staff will be educated on reporting abuse reporting monthly for 3 months, then yearly. New hires and new agency staff will be educated upon orientation. During staff interviews conducted on 7/24/23, between 9:00 a.m. and 12:30 p.m. 19 staff members confirmed they received education on abuse reporting. During observations completed on 7/24/23, between 2:30 p.m. and 3:10 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 7/24/23, between 3:10 p.m. and 3:25 p.m. 13 staff members confirmed they received education on abuse reporting. The Immediate Jeopardy was lifted on 7/24/23, at 3:50 p.m. when the action plan implementation was verified. During an interview on 7/24/23, at 4:00 p.m. the Nursing Home Administrator confirmed that facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident physical abuse and involuntary seclusion for one of three residents reviewed, which provided the opportunity of an additional seven days for abuse to possibly continue, and that this failure created an Immediate Jeopardy situation for one of 94 residents. 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on clinical record and facility document review and staff interview, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of 94 residents. This failure created an immediate jeopardy situation for one of 94 residents (Resident R1). Findings include: Review of the facility policy, Guidelines for Caregiver Interaction with Dementia dated 4/1/23, indicated that staff will interact with residents in a manner that supports dignity and enhances residents abilities to successfully participate in life. Staff will recognize that the resident cannot always control his/her behavior. Review of the National Library of Medicine document, Sundowning in Dementia dated 12/27/16, defined sundowning as the emergence or worsening of neuropsychiatric symptoms (NPS) in the late afternoon or early evening. It represents a common manifestation among persons with dementia and is associated with several adverse outcomes (such as institutionalization, faster cognitive worsening, and greater caregiver burden). Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 6/6/23, included diagnoses of osteoarthritis (degeneration of the joint causing pain and stiffness), anxiety, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 5. Review of Resident R1's diagnosis list indicated unspecified dementia with agitation was added on 1/30/23, and unspecified dementia with psychotic disturbance was added on 3/3/23. Review of Resident R1's physician orders active in July 2023, included: -Quetiapine fumarate (Seroquel, an anti-psychotic medication) 25 mg, three times a day for unspecified psychosis, dated 6/26/23. -Clonazepam (Klonopin, an anti-anxiety medication) 1 mg every eight hours, as needed for agitation/ behaviors, and give one tablet by mouth at bedtime., dated 7/7/23. -Fluoxetine (Prozac, an anti-depressant medication) 40 mg daily for depression, dated 6/27/23. Review of a physician order originally dated 9/6/22, and reordered 3/2/23, and 6/26/23, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related anxiety and depression symptoms and the use of a PRN medication (Klonopin). Further review of the physician orders failed to include monitoring of behaviors related to dementia or antipsychotic use. Review of nurse aide behavior symptom documentation from 3/3/23, through 7/9/23, included behavioral disturbance documentation on 3/16/23, and 7/9/23. Review of Resident R1's plan of care active on 7/9/23, did not include a care plan developed for behavioral disturbances. Review of Resident R1's plan of care for Impaired cognitive function / dementia or impaired thought processes related to dementia initiated 4/6/22, did not include interventions for behaviors. Review of Resident R1's plan of care for psychotropic medications initiated 3/3/22, and reviewed 12/12/22, included only the intervention to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of Resident R1's progress notes from 1/30/23, through 7/24/23, indicated the following: -2/6/23, at 3:35 p.m. Provider visit: Pt seen today at the request of nursing for reports he was having increased behaviors over the weekend. Per the charge nurse, he was yelling out, and frequently out at the nurses' station hollering. -2/21/23, at 6:56 p.m.: Resident has come to the nurses station off and on since the beginning of the shift with either nothing on except a tee shirt or a brief and tee shirt. Several times he has not had his walker. Resident redirected. -2/21/23, at 9:09 p.m.: Resident put himself on the floor. Resident has been having increase behaviors this shift. -2/26/23, at 6:00 a.m.: Resident's wife in at this time to reason with resident and resolve his increased behaviors over the last two days. -3/2/23, at 4:53 p.m.: Seroquel increased to 100 mg three times daily. -3/10/23, at 7:42 a.m.: Resident has been coming to the nurses station frequently stating, Help me. Resident was changed and medicated. At one point in front of staff at the nurses station the resident started to get down onto the floor. Resident has been redirected several times. -3/16/23, Provider visit: Pt seen today acutely at the request of nursing for reports of increased behaviors and abdominal pain. Nursing reporting he has multiple BM's a day ongoing and continues with increased behaviors today intermittently. -3/16/23, at 6:29 a.m.: Resident was up and down the hall more than 10 times to the nurses station, stating his stomach hurts and needs to be changed, had 2 BM's this shift, right after he was changed he came back to the nurses station 3 mins later yelling at the top of his lungs to be changed again, he was check and had not went again, wife had to be called to calm patient down, he yelled and came and back of the nurses station intentionally pulled pants and pull up down, patient did not relax until his wife arrived and immediately went to sleep from 2 am to 620 am, he has currently came back out of his room several time with the same episodes, will continue to monitor. -3/16/23, at 4:10 p.m.: Resident sent to the hospital. Displaying increased aggression, profanity, and restlessness. Returned 3/17/23, with a diagnosis of a urinary tract infection. -3/23/23, 5:06 a.m.: Documented as yelling/screaming/disruptive/agitated. Provided redirection, medications, and calling wife. -3/23/23, at 8:44 p.m.: Resident comes out of room with his pants around his ankles yelling he needs changed, then yells he needs a pill, he repeats these behaviors, he is dry and medicated, redirected, one on one, RN supervisor aware -3/24/23, Provider visit: Prozac increased to 60 mg (yesterday). -3/24/23, at 8:28 p.m.: Immediately after wife left the patient started to yell that he needed changed, then yelled that he needs a pill. He came out in the hallway yelling for help. He was dry, medicated and needed redirecting several times before patient finally settled in his bed. -3/30/23, at 4:46 a.m.: Resident has been awake all night, calling out help me. Ambulating in hallways and coming up to nurse's station. Many attempts made to comfort resident, but resident remains awake. -4/12/23, at 4:45 p.m.: Resident using wheeled walker, came to nurses station with his pants and depends (disposable brief) around his ankle. -4/13/23, at 6:46 p.m.: Resident came to the nurses station with no walker, and with his pants and depends around his ankles. -6/6/23, at 1:28 a.m.: Patient yelling for nurse, PRN for anxiety is not available yet. Patient is inconsolable. Patient given drink and attempts were made to verbally soothe him. -7/5/23, at 3:36 a.m.: patient has been up and down the hall nonstop yelling help me because his stomach hurts, it has currently been since 11pm, he is stating that his stomach hurts, pt. has had a BM, BS are active, unable to redirect patient, wife was called to see if she could calm him down, she was unable to, left. Review of a progress note written by Registered Nurse (RN) Supervisor Employee E1 dated and time stated Resident screaming/yelling/cursing throughout 7P to present. In/out of bed, in/out of hall both with and without walker, pants, and underwear. Demands to be changed every minute of so, resident checked frequently for incontinence by both CNAs (NA, nurse aides) and nursing. Only one instance of soiling found. Refused all dinner. Took meds crushed. Gait becoming increasingly unsteady as resident becomes more agitated. All efforts to calm have thus far been unsuccessful. Placed in w/c (wheelchair) and brought to nursing station for safety. Multiple C/O (complaints) received by peers on the hall regarding noise. Review of documentation submitted by the facility on 7/16/23, revealed At 1:20 p.m. on 7/16/23, Licensed Practical Nurse (LPN) Employee E2 informed the Director of Nursing (DON) that on 7/9/23, she witnessed RN Supervisor Employee E1 take Resident R1 into the salon room for about 20 minutes and left him alone with the door shut while he was tied to the wheelchair with his bed sheets. Then resident was moved to the conference room where he was left with the door open. LPN Employee E2 also informed the DON that resident was given medications to calm him down prior to resident being moved into the salon Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E2 stated, On 7/9/23, I was the nurse assigned on A-long from 7:00 a.m. to 11:00 p.m. One of the residents assigned to me (Resident R1) one was having a difficult evening and was continuously yelling out, coming to the nurses station it, insisting he be changed. His brief was changed multiple times even though it was dry in order to appease him. These attempts failed as he continued to yell out stating he need a changed. I medicated him as ordered with all p.m. medications and PRN Klonopin. Around 9:00 p.m. I observed the RN Supervisor (RN Supervisor Employee E1) take medications from the top drawer of my med cart and proceed to Resident R1's room. I then observed her wheel Resident R1 up to the nurses station and tie him to his chair with a bed sheet. The sheet was wrapped around his waist and then tied to the back of the chair. The resident continued to yell out for some time. Yelling continuously and loudly to be taken back to his room. The RN Supervisor Employee E1 then wheeled the resident into the beauty salon and shut the door behind him, leaving him and him in there alone. I went outside to take a break. I was outside for about 20 minutes. Upon returning to check the beauty salon door to see if Resident R1 was still there and safe. I noted that he was no longer there but have been moved to the DON office with the door left open. He remained there at the time of my departure at 11:00 p.m. Review of a facility investigation witness statement dated 7/16/23, written by LPN Employee E3 stated, On 7/9/23, while on duty witnessed RN supervisor on duty, put resident (Resident R1) in a chair and placed a sheet around him and tied. Put in the ADON's office and closed the door. Resident yelling out. Resident agitated all 3-11 shift. Review of a facility investigation witness statement dated 7/16/23, written by NA Employee E4 stated, I was sitting at the nurses station charting. And (Resident R1) kept coming up, saying he was wet. Well he was changed and he was checked by three different people. He was dry. Well he still came up every couple of minutes and (RN Supervisor Employee E1) said that if he doesn't go lay down, then she was going to put him in the quiet room. (Resident R1) kept coming up. So she went and got (another resident's) rock 'n go chair (tiltable wheelchair) and put him in it. She said she was going to fix it so that he can't get out. When it was time for me to leave, I walked past the DON room and saw Resident R1 sitting in the chair in the office. On 7/23/23, at 5:18 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 94 residents, and the Immediate Jeopardy template was provided to facility administration. On 7/23/23, at 7:10 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: -All staff will be educated on the dementia services policy by 7/24/23, at 5:00 p.m. -RNAC will be educated to include antipsychotic care plans when appropriate 7/24/23, at 5:00 p.m. Residents: -Whole house audit completed for residents with a dx of dementia to ensure appropriate behavior tracking by NHA with nurse management team. 7/24/23, at 5:00 p.m. System Correction: -Whole house education for all departments including nursing, maintenance, therapy, housekeeping, laundry, dietary, administrative, social services, and activities from SNF including agency and hospice staff will be conducted regarding behavioral symptoms and interventions (behavior examples include: agitation, anxious behaviors, depression, insomnia, wandering, delusions, hallucinations, etc.) support for residents with dementia, types of dementia, and positive approaches for residents with dementia. -Dementia education added to in person meetings conducted by DON on 7/24/23 and to mailings/emailing by NHA with completion on 7/24/23. -Staff who received distance education will sign to acknowledge completion and understanding of education prior to next shift worked. Monitoring: -Audits will be completed by NHA 3x week for 4 weeks then weekly x 3 months for residents with dementia to ensure appropriate care plan and behavior monitoring is in place. -Results will be submitted to QAPI (Quality Assurance and Performance Improvement committee). During staff interviews conducted on 7/24/23, between 9:00 a.m. and 12:30 p.m. 19 staff members confirmed they received education on behavioral symptoms of residents with dementia. During observations completed on 7/24/23, between 2:30 p.m. and 3:10 p.m. the Director of Nursing was observed providing confirmatory education to staff who had received education via telephone, and education to agency staff prior to the start of the shift. During staff interviews conducted on 7/24/23, between 3:10 p.m. and 3:25 p.m. 13 staff members confirmed they received education on behavioral symptoms of residents with dementia. The Immediate Jeopardy was lifted on 7/24/23, at 3:50 p.m. when the action plan implementation was verified. During an interview on 7/24/23, at 12:40 p.m. the Director of Nursing confirmed that the facility failed to recognize that Resident R1's progress notes revealed behavioral disturbances in the afternoon and progressing into the night indicated sundowning, failed to develop plans of care related to behavioral disturbances and antipsychotic medication usage, and failed to adequately monitor behavioral disturbances related to dementia. At this time, the Nursing Home Administrator confirmed that facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to ensure safety for one of 94 residents. This failure created an immediate jeopardy situation for one of 94 residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code: 201.29(a)(b)(c)(i)(n) Resident rights. 28 Pa. Code 201.18(b)(1) Management.

Based on a review of observations, clinical records, facility employee vaccination data, and staff interviews, it was determined that the facility failed to implement policies and procedures to ensure that all staff were vaccinated for COVID-19 and mitigation actions for non-vaccinated staff were implemented. This failure created an Immediate Jeopardy situation for 32 of 103 residents not up-to-date with the COVID-19 vaccination, or for whom vaccination status is unknown (Residents R1, R5, R9, R11, R12, R13, R14, R15, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R31, R32, R33, R34, R , R37, R38, R39, R40, R41, R42, R43). Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group memo (QSO-22-07-ALL) dated 12/28/21, revised 04/05/22, indicated the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents: facility employees, licensed practitioners, students, trainees, and volunteers, and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Review of the facility, COVID 19 Vaccination Policy dated 7/14/22, indicated this policy will comply with all applicable laws and is based on guidance from the CDC (Centers for Disease Control and Prevention) that all employees are required to receive vaccinations as determined by CMS (the Centers for Medicare and Medicaid Services) unless a reasonable medical or religious accommodation is approved, that the COVID-19 vaccination program applies to all employees, that the facility is responsible for maintaining an accurate record of COVID-19 vaccinations, and that any individual receiving an exemption for any reason is required to wear a surgical mask at all times within the facility and universal eye protection. A review of facility reported information on 7/29/22, indicated that the facility had residents currently infected with COVID-19. During an observation of the dining room and common areas between the nursing units on 7/30/22, beginning at 1:25 p.m. revealed: -Dietary Employee E1 entering the dining room, from the kitchen, with no mask on. During an interview on 7/31/22, at 2:15 p.m. Dietary Employee E1 confirmed she was unvaccinated. -Licensed Practical Nurse (LPN) Employee E2 walked from the nursing unit to the outside exit at the back of the dining room with no mask on. -Dietary Employee E3 observed at food preparation table with no mask on. -Nurse Aide (NA) Employee E4 observed wearing a surgical mask. At 1:34 p.m. noted to have the surgical mask below her nose. -NA Employee E5 observed wearing a surgical mask. -Registered Nurse (RN) Employee E6 observed with no mask on. -NA Employee E7 was observed wearing a surgical mask. -Maintenance Employee E8 observed wearing surgical mask below his nose. At 1:48 p.m. noted to have no mask on. -LPN Employee E9 observed wearing a surgical mask. -NA Employee E10 observed wearing a surgical mask. Vaccination record review on 7/31/22, confirmed that NA Employee E10 was unvaccinated. -NA Employee E11 observed not wearing a mask. -RN Employee E12 observed wearing a surgical mask. -LPN Employee E13 observed wearing a surgical mask. Vaccination record review on 7/31/22, confirmed that LPN Employee E13 was unvaccinated. On 7/30/22, at 2:30 p.m. the Director of Nursing was asked for a staff vaccination matrix. On 7/30/22, at 5:43 p.m. the Director of Nursing was again asked for a staff vaccination matrix. On 7/30/22, at 6:00 p.m. a staff vaccination matrix was received. Initial review of the matrix indicated that it included staff that had not been employed at the facility for over six weeks. A request was made for an updated matrix to be provided. During a review on 7/31/22, at 8:30 a.m. of the clinical records of positive residents revealed the following: -Resident R1 had a positive COVID-19 test on 7/19/22. Resident R1 was documented as being short of breath on 7/27/22. Resident R1 ceased to breathe on 7/29/22. -Resident R2 had a positive COVID-19 test on 7/21/22. Resident R2 was hospitalized on 7/30/22. -Resident R3 had a positive COVID-19 test on 7/26/22. Resident R3 was hospitalized on 7/28/22. -Additionally, 22 other residents had tested positive for COVID-19, and remained in the facility. On 7/31/22, at 10:00 a.m. an updated staff vaccination matrix was provided. During an interview on 7/31/22, at 1:10 p.m. Human Resources (HR) Employee E14 confirmed that 25 staff members on the matrix were no longer employed at the facility, and confirmed that 24 currently employed staff members were not on the vaccination matrix. HR Employee E14 further confirmed that only facility-hired and agency nursing staff were included on the matrix, that medical providers, hospice providers, and other outside vendor staff were not included. A review of the facility provided list of residents and their COVID-19 vaccination status and of the resident's clinical records revealed the following: Resident R1: No documentation that resident was vaccinated. Resident R5: Documented as unvaccinated. Resident R9: Documented as unavailable (noted to be historically vaccinated, but facility does not maintain a record). Progress notes did not include administration of a booster. Resident R11: Vaccination status was blank. Resident R12: Documented as unavailable. Progress notes did not include administration of a booster. Resident R13: Vaccination status was blank. Resident R14: Vaccination status was blank. Resident R15: Resident documented as not up-to-date with boosters. Resident R17: Vaccination status was blank. Resident R18: Documented as unavailable. Progress notes did not include administration of a booster. Resident R20: Documented as unvaccinated. Resident R21: Vaccination status was blank. Resident R22: Documented as unvaccinated. Resident R23: Vaccination status was blank. Resident R24: Documented as unvaccinated. Resident R25: Documented as unvaccinated. Resident R26: Documented as unvaccinated. Resident R27: Vaccination status was blank. Resident R28: Documented as unvaccinated. Resident R29: Documented as unvaccinated. Resident R31: Documented as unvaccinated. Resident R32: Documented as unavailable. Progress notes did not include administration of a booster. Resident R33: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 2/3/21. Resident R33 was not documented as having been diagnosed with COVID-19 from 2/3/21, through 3/3/21, to preclude second dose. Resident R34: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R34 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R36: Documented as unavailable. Progress notes did not include administration of a booster. Resident R37: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R37 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R38: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R38 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R39: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R39 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R40: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R40 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R41: Documented as unavailable. Clinical record reveals the second dose of a two-part vaccine was given on 4/19/21. Progress notes did not include administration of a booster. Resident R42: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/23/22. Resident R42 was not documented as having been diagnosed with COVID-19 from 3/23/22, through 4/20/22, to preclude second dose. Resident R43: Documented as unavailable. Clinical record reveals only first dose of a two-part vaccine was given on 3/1/21. Progress notes did not include administration of a new vaccine series. On 7/31/22, at 2:58 p.m. the Nursing Home Administrator and the Director of Nursing were made aware that Immediate Jeopardy existed for 32 of 103 residents in the facility. The Immediate Jeopardy template was provided to facility administration and a corrective action plan was requested. On 7/31/21, at 5:55 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Facility will acquire the vaccination status of staff members and residents within 24 hours to assure the facility presents a safe environment for family, staff, and residents. -A whole house audit will be conducted to assure the vaccination status is known for all residents and staff immediately. -The vaccination matrix will be updated immediately and will stay updated with all current staff and agency staff members, vendors, providers and CRNPS. -The Nursing Home Administrator will ensure the vaccination matrix remains updated moving forward, and a staff member is assigned to be stationed at the lobby entrance during normal hours of operation. -All Covid positive staff members will be included on our line listing. -Signage was placed on entrance doors on 7-31-2022, at 3:02 p.m. letting staff members and any members of the community know that there are active positive cases of covid-19 in the facility. -Staff will be educated that staff and any members of the community including vendors need to be signed in to the facility and pass the screening before they can enter the floors. -Dietary staff will be educated to wear the proper PPE in the kitchen at all times, initial education was provided to dietary staff in the facility, and will be provided to the remaining staff prior to the start of their next shift. -All departments will be educated to wear the proper PPE at all times per the zones of the building, facility staff will be educated prior to their next scheduled shift. -Nursing Home Administrator or Designee will complete an audit daily for 2 weeks then 5 times a week for 2 weeks in all departments to ensure staff are wearing appropriate Personal Protective Equipment while in the facility to ensure the safety of all residents and staff. -These audits will be forwarded to the monthly QAPI for review and frequency of audits. -Resident R3's hospitalization will be fully investigated, and documentation will be completed to assure status of resident is known. Review of the updated staff vaccination matrix on 8/1/22, at 1:34 p.m. confirmed that it was 100% complete. Facility observations on 8/1/22, from 2:00 p.m. through 4:00 p.m. confirmed that education was being provided to the oncoming shift, and the facility red, yellow, and green zones were demarcated, with instructions for the correct PPE requirements in each zone. During interviews on 8/1/22, from 2:00 p.m. through 4:00 p.m. seventeen employees confirmed they had received education on appropriate PPE, requirements of each zone, and had vaccination status confirmed. The Immediate Jeopardy was lifted on 8/2/22, at 10:00 a.m. when the action plan implementation was verified. During an interview on 8/2/22, at 2:40 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the staff vaccination matrix was not updated with current employees, confirmed that the matrix did not include vendor or outside provider employees, and that both vaccinated and unvaccinated staff were not following requirements for the proper use of personal protective equipment required in a facility COVID-19 outbreak. This failure created an Immediate Jeopardy situation for 32 of 103 residents not up-to-date with the COVID-19 vaccination, or for whom vaccination status was unknown. Infection Control CFR(s): S483.80(i)(1)(3)(iii)(iv)(vii) Previously cited: 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 2/10/21, 8/26/21, 2/23/22, 3/30/22, and 6/3/22, 6/21/22. 28 Pa. Code: 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 5/7/21, 7/14/21, 2/23/22. 28 Pa. Code 201.18(b)(3) Management. Previously cited: 2/23/22. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 2/10/21, 7/14/21, 8/26/21. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 8/31/20, 12/3/20, 2/10/21, 6/29/21, 7/14/21, and 8/26/21, 6/21/22. 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 8/31/20, 12/3/20, 2/10/21, 6/29/21, 7/14/21, and 8/26/21, 6/21/22. 28 Pa. Code: 211.12(d)(2) Nursing services. Previously cited: 2/10/21. 28 Pa. Code: 211.12(d)(5) Nursing services. Previously cited: 10/26/20, 2/10/21, 5/7/21, 6/3/21, 6/29/21, 7/14/21, 8/26/21, 6/21/22.

Based on Centers for Medicare & Medicaid Services (CMS) guidance, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 in the month of July 2022, for 30 of 30 unvaccinated employees (Employees E13 through E42). Findings include: Review of Centers for Medicare and Medicaid Services (CMS) document QSO-20-38-NH Revised 3/10/22, indicated routine staff testing frequency for staff who are not up to date on their vaccinations should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing. This memorandum indicated that facilities in counties with a high transimission rate should test their staff who are not up-to-date (a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible) twice per week. Review of the Centers for Disease Control (CDC) guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, indicated in nursing homes, health care personnel who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: in counties with substantial to high community transmission, these healthcare personnel should have a [CONDITION(S)] test twice a week. Review of the county community transmission rate revealed that the county community transmission rate of high from 06/24/22, through 8/3/22. Review of the facility provided staff testing records for the month of July 2022, indicated the following for unvaccinated employees: -Employee E13 had one test on 7/19/22, resulting negative. -Employee E14 had no testing documented. -Employee E15 had one test on 7/28/22, resulting positive. -Employee E16 had no testing documented. -Employee E17 had two tests, on 7/20/22, and 7/24/22, both resulting positive. -Employee E18 had no testing documented. -Employee E19 had one test on 7/17/22, resulting negative. -Employee E20 had no testing documented. -Employee E21 had one test 7/21/22, with no results noted. -Employee E22 had one test 7/21/22, with no results noted. Review of the staff positive list indicated that Employee E22 was positive on 7/24/22. -Employee E23 had three tests on 7/14/22, 7/25/22, and 7/28/22, all resulting negative. Employee E23 was positive on 8/1/22. -Employee E24 had one test on 7/19/22, resulting negative. -Employee E25 had one test on 7/18/22, resulting negative, and one test on 7/21/22, with no result noted. Review of the staff positive list indicated that Employee E25 was positive on 7/24/22. -Employee E26 had two tests, on 7/18/22, and 7/21/22, both resulting negative. -Employee E27 had one test on 7/17/22, resulting negative. -Employee E28 had no testing documented. -Employee E29 had one test on 7/12/22, resulting negative, and one test on 7/21/22, with no result noted. -Employee E30 had no testing documented. -Employee E31 had two tests, on 7/1/22, and 7/3/22, both resulting negative. -Employee E32 had one test on 7/17/22, resulting negative. -Employee E33 had no testing documented. -Employee E34 had two tests, on 7/18/22, and 7/21/22, both resulting negative. -Employee E35 had two tests, on 7/18/22, and 7/21/22, both resulting negative. -Employee E36 had no testing documented. -Employee E37 had no testing documented. -Employee E38 had no testing documented. -Employee E39 had one test on 7/30/22, resulting negative. -Employee E40 had one test on 7/27/22, resulting negative. -Employee E41 had three tests on 7/17/22, 7/27/22, 7/28/22, and 7/29/22, all resulting negative. -Employee E42 had no testing documented. During an electronic communication on 8/4/22, at 8:45 a.m. the Nursing Home Administrator confirmed that the facility did not have any further testing to provide for review. During an interview on 8/9/22, at 12:53 p.m. the Nursing Home Administrator confirmed that the facility failed to follow the COVID-19 testing guidelines for staff based on the county level of community transmission of COVID-19 in the month of July 2022, for 30 of 30 unvaccinated employees.

Based on review of infection control documentation and staff interview, it was determined that the facility failed to have one or more individuals serving as the Infection Preventionist, responsible for the facility's infection prevention plan during an outbreak of Covid-19. This failure resulted in the actual harm of eight of 17 unvaccinated residents becoming positive with COVID-19 (Resident R5, R11, R13, R14, R17, R21, R22, and R30). Review of the Centers for Disease Control (CDC) guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 2/2/22, indicated facilities should assign one or more individuals with training in infection prevention and control (IPC) to provide on-site management of the IPC program. This should be a full-time role for at least one person in facilities that have more than 100 residents. During an interview on 7/30/22, at 4:25 p.m., Corporate Regional Nurse Employee E43 confirmed that she had been acting Director of Nursing between 6/13/22, and 7/11/22, and was not often in the building. During a confirmatory interview conducted on 8/18/22, at 2:30 p.m. Corporate Regional Nurse Employee E43 confirmed that while having Infection Preventionist cerification, during that timeframe she was covering only the Director of Nursing position. Review of the facility provided list of COVID-19 positive staff members confirmed that the Director of Nursing tested positive for COVID-19 on 7/22/22, and was off of work through 7/29/22. During that time, Corporate Regional Nurse Employee E43 was covering the Director of Nursing position. During an electronic communication on 8/5/22, at 12:53 p.m. the Nursing Home Administrator confirmed that the facility failed to have an Infection Preventionist (IP) since 6/13/22, and further confirmed they tentatively have an Assistant Director of Nursing beginning employment on 8/16/22, who will have IP certification. Review of facility provided infection control documentation completed during the survey dating 7/30/22, through 8/8/22, revealed the following: -Resident Immunizations: 13 of 17 unvaccinated residents failed to have documentation indicating that they (or their representatives) were provided education on the risks and benefits, and the opportunity to receive the COVID-19 vaccination. Record review of the 17 residents not vaccinated revealed that R5, R11, R13, R14, R17, R21, R22, and R30 were subsequently diagnosed as positive with COVID-19 between 7/17/22, and 8/4/22. -Resident vaccination matrix: Received two versions, first with 83 of 103 residents on it. Second version did not document a vaccination status for six of 103 residents, and 17 of 103 residents were unvaccinated. -Resident testing: Resident testing was requested for the month of July. The facility provided testing only from 7/18/22, through 8/1/22. The Nursing Home Administrator confirmed on 8/4/22, at 8:45 a.m. that no further testing documentation was available for review. -Staff vaccination matrix: Received two versions, first staff vaccination matrix received was noted to be greater than six weeks out of date. Second was noted to not include newly hired employees (24), and did not include vendor employees. -Staff testing: Review of thirty unvaccinated employees failed to indicate twice weekly testing for 30 of 30 employees. -Facility infection control practices: On 7/30/22, 13 of 16 staff members were noted to not be using appropriate personal protective equipment. Eleven of 16 rooms with residents diagnosed with COVID-19 residing in them had the doors open. Two residents not diagnosed with COVID-19 remained in the same room as two residents diagnosed with COVID-19 residents, resulting in one resident (Resident R5) becoming positive for COVID-19. -Reporting of COVID-19: Five of 27 positive resident cases and zero of eight positive staff cases of COVID-19 reported to the state licensing agency. During an interview on 8/9/22, at 12:53 p.m. the Nursing Home Administrator confirmed that the facility failed to have one or more individuals serving as the Infection Preventionist, responsible for the facility's infection prevention plan during an outbreak of Covid-19. This failure resulted in the actual harm of eight of 17 unvaccinated residents becoming positive with COVID-19. Refer to F880, F886, F887, and F888 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 2/10/21, 8/26/21, 2/23/22, 3/30/22, and 6/3/22, 6/21/22. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 5/7/21, 7/14/21, 2/23/22. 28 Pa. Code 201.18(b)(3) Management. Previously cited: 2/23/22. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 2/10/21, 7/14/21, 8/26/21. 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 8/31/20, 12/3/20, 2/10/21, 6/29/21, 7/14/21, and 8/26/21, 6/21/22. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited: 8/31/20, 10/26/20, 12/3/20, 2/10/21, 8/26/21.

Based on review of facility documentation, clinical records and staff interview it was determined that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for 17 of 17 unvaccinated residents (Resident R5, R11, R13, R14, R17, R21, R22, R30, R23, R29, R24, R25, R31, R20, R26, R27, and R28). This failure resulted eight of 17 unvaccinated residents becoming positive with COVID-19 (Resident R5, R11, R13, R14, R17, R21, R22, and R30) and in the actual harm of six of the eight positive residents having symptoms of COVID-19 (Resident R5, R11, R13, R14, R21, and R22). Review of facility provided infection control documentation from 7/30/22-8/2/22, revealed the following: Resident vaccination matrix requested on 7/30/22. Received on 7/31/22, as a list of resident names, some with notations of vaccination status. Facility census was 103 upon entry to the facility of 7/30/22, only 83 names on the listing of resident vaccination status. A second listing of resident vaccination status was received 8/1/22: -Six residents have no status listed. -Four residents have a status of unavailable (noted to be historically vaccinated, but facility does not maintain a record). -Twelve residents have a status of partially vaccinated (vaccinated, not up to date). -Four residents have a status of refused. -Seven residents have a status of unvaccinated (no differentiation provided how this differed from refused). -72 Residents documented as vaccinated. Record review of 17 residents not vaccinated revealed the following: Resident R5 vaccination status in the resident vaccination matrix was documented as unvaccinated. Review of Resident R5's progress notes from 11/24/21, through 8/1/22, failed to reveal Resident R5 being offered or educated on the COVID-19 vaccine. Resident R5 tested positive for Covid-19 on 8/1/22. Review of a nurse practitioner note on 8/1/22, at 9:13 p.m. indicated that Resident R5 had a non-productive cough, and reported feeling of thick mucous in his throat that he cannot seem to get up. Resident R11 vaccination status in the resident vaccination matrix was blank. Review of Resident R11's progress notes from 7/1/22, through 7/26/22, failed to reveal Resident R11 being offered or educated on the COVID-19 vaccine. Resident R11 tested positive for COVID-19 on 7/26/22. Review of a nurse practitioner note on 7/28/22, at 4:46 p.m. indicated that Resident R11 had COVID-19 related symptoms of loose stools, nausea, and abdominal cramps. A new order for [MEDICATION(S)] (medication used to prevent and treat nausea and vomitting) was ordered on 7/28/22. Resident R13's vaccination status in the resident vaccination matrix was blank. Review of Resident R13's progress notes from 6/27/22, through 7/21/22, failed to reveal Resident R13 being offered or educated on the COVID-19 vaccine. Resident R13 tested positive for COVID-19 on 7/21/22. Review of a progress note on 7/21/22, at 3:52 a.m. indicated that Resident R13 had two loose stools, a cough, and complained of all-over pain. Resident R13 was receiving hospice services (end of life care), and ceased to breathe on 8/9/22. Resident R14's vaccination status in the resident vaccination matrix was blank. Review of Resident R14's progress notes from 6/22/22, through 7/21/22, failed to reveal Resident R14 being offered or educated on the COVID-19 vaccine. Resident R14 tested positive for COVID-19 on 7/21/22. Review of a nurse practitioner note on 7/21/22, at 1:18 p.m. indicated that Resident R14 reported a sore throat and a moist cough for two days. Resident R17's vaccination status in the resident vaccination matrix was blank. Review of Resident R17's progress notes from 5/27/22, through 7/21/22, failed to reveal Resident R17 being offered or educated on the COVID-19 vaccine. Resident R17 tested positive for COVID-19 on 7/21/22. Resident R21's vaccination status in the resident vaccination matrix was blank. Review of Resident R21's progress notes from 6/5/21, through 7/17/22, failed to reveal Resident R21 being offered or educated on the COVID-19 vaccine. Resident R21 tested positive for COVID-19 on 7/17/22. Review of a nurse practitioner note on 7/18/22, at 4:04 p.m. indicated that Resident R14 reported a sore throat. Review of a progress note dated 7/19/22, at 4:30 a.m. indicated Resident R21 had an oxygen saturation of 88% (normal level between 95-100%, 88-92 % for residents with [CONDITION(S)], a group of progressive lung disorders characterized by increasing breathlessness) and audible congestion with wheezes (high-pitched whistling sound made while breathing). Review of all oxygen saturations documented in the clinical record indicated 88% is the lowest documented since Resident R21 was admitted on [DATE]. Resident R22's vaccination status in the resident vaccination matrix was documented as unvaccinated. Review of Resident R22's progress notes from 11/12/21, through 7/21/22, failed to reveal Resident R22 being offered or educated on the COVID-19 vaccine. Resident R22 tested positive for COVID-19 on 7/21/22. Review of a nurse practitioner note on 7/21/22, 12:03 p.m. indicated that Resident R14 reported a sore throat and dry cough. Review of a progress note on 7/21/22, at 12:30 p.m. indicated Resident R14 complained of a runny nose. Resident R30's vaccination status in the resident vaccination matrix was documented as unvaccinated. Review of Resident R30's progress notes from 6/23/21, through 8/4/22, failed to reveal Resident R30 being offered or educated on the COVID-19 vaccine. Resident R30 tested positive for COVID-19 on 8/4/22. Resident R23's vaccination status in the resident vaccination matrix was blank. Review of a progress note on 1/12/21, at 12:05 p.m. indicated that Resident R23 wanted to receive the vaccine. Review of the Medication Administration Records (MARs) from January 2021, through July 2022, failed to indicate that Resident R23 received the COVID-19 vaccine. Resident R29's vaccination status in the resident vaccination matrix was blank. Review of a progress note on 6/4/21, at 3:18 p.m. indicated that Resident R29 was considering receiving the vaccine. Review of the MARs from January 2021, through July 2022, failed to indicate that Resident R29 received the COVID-19 vaccine, and progress notes from 6/5/21, through 8/1/22, failed to reveal if Resident R29 was provided an additional opportunity to receive the vaccination or education on refusing. Resident R24's vaccination status in the resident vaccination matrix was documented as refused. Review of Resident R24's progress notes from 1/24/22, through 8/1/22, failed to reveal Resident R24 being offered or educated on the COVID-19 vaccine. Resident R25's vaccination status in the resident vaccination matrix was documented as refused. Review of Resident R25's progress notes from 1/31/22, through 8/1/22, failed to reveal Resident R25 being offered or educated on the COVID-19 vaccine. Resident R31's vaccination status in the resident vaccination matrix was documented as unvaccinated. Review of Resident R31's progress notes from 1/24/22, through 8/1/22, failed to reveal Resident R31 being offered or educated on the COVID-19 vaccine. Review of progress notes indicated that Residents R20, R26, R27, and R28 all refused the COVID-19 vaccine on 6/24/21, and no further documentation was noted that they were offered again. During an interview on 8/9/22, at 12:53 p.m. the Nursing Home Administrator confirmed that the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for 17 of 17 unvaccinated residents. This failure resulted in the actual harm of eight of 17 unvaccinated residents becoming positive with COVID-19. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 2/10/21, 8/26/21, 2/23/22, 3/30/22, and 6/3/22, 6/21/22. 28 Pa. Code 201.18(b)(1) Management. Previously cited: 5/7/21, 7/14/21, 2/23/22. 28 Pa. Code 201.18(b)(3) Management. Previously cited: 2/23/22. 28 Pa. Code 201.18(e)(1) Management. Previously cited: 2/10/21, 7/14/21, 8/26/21. 28 Pa. Code: 211.12(d)(1) Nursing services. Previously cited 8/31/20, 12/3/20, 2/10/21, 6/29/21, 7/14/21, and 8/26/21, 6/21/22. 28 Pa. Code: 211.12(d)(3) Nursing services. Previously cited: 8/31/20, 10/26/20, 12/3/20, 2/10/21, 8/26/21.

Based on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure resulted in actual harm of one of seven residents who remained in a room with a COVID-19 positive resident becoming positive and symptomatic of COVID-19 (Resident R5). Findings include: Pennsylvania Health Alert Network (PA-HAN) - 627, Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities for outbreaks and exposure to COVID-19 (a contagious [CONDITION(S)] disease that can cause a variety of symptoms, including breathing problems, fever, and cough) dated 2/15/22, indicated for residents positive with COVID-19: the use of a private room with a private bathroom or with another resident with laboratory-confirmed COVID-19, and to restrict the resident to their room with the door closed. Instructions in this HAN indicate to refered to archived PA-HAN 570 for recommendations related to the implementation of zone-based guidance. PA-HAN - 570, Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities for outbreaks and exposure to COVID-19 dated 5/10/21, indicated the use of an N95 or equivalent or higher level respirator and eye protection. Review of the facility policy Infection Control COVID 19 Skilled Nursing and Rehabilitation Facilities dated 7/14/22, indicated red zone guidelines of: a gown is required at all times while on the red unit, gloves and eye protection is to be worn with all resident contact, and N-95 respirators are to be worn at all times in the red zone. The policy indicated yellow zone guidelines of: gowns, gloves, and eye protection for resident contact, and N-95 respirators are to be worn at all times in the yellow zone. Review of Centers for Disease Control (CDC) recommendation Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/22, indicated for the facility to ensure everyone is aware of recommended IPC (infection prevention and control) practices in the facility by posting a visual alert (e.g., signs, posters) at the entrance and in strategic places with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Review of daily census information indicated that Resident R4 and R5 were roommates. Review of COVID-19 test results indicated that Resident R4 resulted as positive on 7/23/22. Both residents remained in the same room, with Resident R5 then testing as positive for COVID-19 on 8/1/22. Review of a nurse practitioner note on 8/1/22, at 9:13 p.m. indicated that Resident R5 had a non-productive cough, and reported feeling of thick mucous in his throat that he cannot seem to get up. Review of facility room assignments indicated the availability of four open beds in rooms on 7/23/22, of the same gender as Resident R5 with roommates who were up to date on their COVID-19 vaccinations. Review of daily census information indicated that Resident R19 and R20 were roommates. Review of COVID-19 test results indicated that Resident R19 resulted as positive on 7/26/22. Both residents remained in the same room. Review of facility room assignments indicated the availability of four open beds in rooms on 7/23/22, of the same gender as Resident R20 with roommates who were up to date on their COVID-19 vaccinations. During an observation of the dining room and common areas between the nursing units on 7/30/22, beginning at 1:25 p.m. revealed: -Dietary Employee E1 entering the dining room, from the kitchen, with no mask on. During an interview on 7/31/22, at 2:15 p.m., Dietary Employee E1 confirmed she was unvaccinated. -Licensed Practical Nurse (LPN) Employee E2 walked from the nursing unit to the outside exit at the back of the dining room with no mask on. -Dietary Employee E3 observed at food preparation table with no mask on. -Nurse Aide (NA) Employee E4 observed wearing a surgical mask. At 1:34 p.m. noted to have the surgical mask below her nose. -NA Employee E5 observed wearing a surgical mask. -Registered Nurse (RN) Employee E6 observed with no mask on. -NA Employee E7 was observed wearing a surgical mask. -Maintenance Employee E8 observed wearing surgical mask below his nose. At 1:48 p.m. noted to have no mask on. -LPN Employee E9 observed wearing a surgical mask. -NA Employee E10 observed wearing a surgical mask. Vaccination record review on 7/31/22, confirmed that NA Employee E10 was unvaccinated. -NA Employee E11 observed not wearing a mask. -RN Employee E12 observed wearing a surgical mask. -LPN Employee E13 observed wearing a surgical mask. Vaccination record review on 7/31/22, confirmed that LPN Employee E13 was unvaccinated. During an interview on 7/30/22, at 1:50 p.m. Registered Nurse Employee E12 stated that both nursing units were red zones, the common areas of the lobby and dining areas were yellow zones, and that the facility was in a COVID-19 outbreak. During observations conducted on 7/30/22, beginning at 2:09 p.m. revealed the following residents' room doors open: -Signage at the entrance to both nursing units indicating that the nursing units were considered red zones. -Resident R6, diagnosed three days previously. -Resident R7, diagnosed four days previously. -Resident R8, diagnosed four days previously. -Resident R9, diagnosed four days previously. -Resident R19, diagnosed four days previously. -Resident R10, diagnosed five days previously. -Resident R11, diagnosed five days previously. Additionally, the room doors for Residents R2, R12, R13, R14, R15, R16, R17, and R18 were open. These residents were between 7-9 days after a positive test. The clinical record failed to indicate if after seven days negative [CONDITION(S)] tests were used to end isolation early. During observations completed throughout the day on 7/31/22, all the above doors were now closed. During observations conducted on 8/2/22, beginning at 12:10 p.m. revealed the following residents' room doors open: -Resident R5, diagnosed on e day previously. -Resident R7, diagnosed seven days previously. -Resident R10, diagnosed seven days previously. -Resident R19, diagnosed seven days previously. During an interview on 8/9/22, at 12:53 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain an infection prevention and control program by failing to follow infection control guidelines from the CDC and the PA DOH to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic. This failure resulted in actual harm of one of seven resident who remained in a room with a COVID-19 positive resident. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 2/10/21, 8/26/21, 2/23/22, 3/30/22, and 6/3/22, 6/21/22. 28 Pa. Code:201.18(e)(6) Management. Previously cited: 8/26/21. 28 Pa. Code:211.12(a) Nursing services. Previously cited: 8/26/21. 28 Pa. Code:211.12(c) Nursing services. Previously cited: 8/26/21, 2/23/22. 28 Pa. Code:211.12(d)(1) Nursing services. Previously cited 8/31/20, 12/3/20, 2/10/21, 6/29/21, 7/14/21, and 8/26/21, 6/21/22. 28 Pa. Code:211.12(d)(2) Nursing services. Previously cited: 2/10/21. 28 Pa. Code:211.12(d)(3) Nursing services. Previously cited: 8/31/20, 10/26/20, 12/3/20, 2/10/21, 8/26/21. 28 Pa. Code:211.12(d)(4) Nursing services. Previously cited: 8/26/21.

Based on review of facility policy, closed clinical records, facility documents and staff interviews, it was determined that the facility failed to ensure that food was served in a form to meet the individual needs of one of four residents sampled (Closed Resident CR1), which resulted in actual harm of choking and acute [CONDITION(S)] requiring transfer to the hospital for admission and treatment. Findings include: Review of facility policy Level 1 Dysphagia Pureed, indicated this diet consists of food that are pureed, homogenous and cohesive. Foods should be pudding like. Foods that require bolus formation, controlled manipulation and chewing are not allowed. Recommended pureed fruits, avoid whole fruits. Review of Resident CR1's Minimum Data Set (periodic review of care needs) dated 9/1/21, indicated the resident was admitted to the facility on [DATE], and their current diagnoses included alzheimers, [CONDITION(S)] and seizures. Review of Resident CR1's Speech Therapy Evaluation and Plan of Treatment dated 11/4/21, indicated swallowing strategies will include 100% supervision for all meals, was ordered a pureed diet and now taking liquids via spoon. Review of Resident CR1's physician orders dated 11/4/21, indicated the resident was ordered a pureed diet, with nectar consistency fluids, liquids via spoon. Review of Resident CR1's progress note dated 11/4/21, at 6:11 p.m. indicated the nurse was called to the room by a Nurse Aide (NA), who stated that something was wrong, resident sitting upright in bed unable to breath, resident was alert to her name, and able to make eye contact when her name was spoken. This nurse performed the hiemlich maneuver, after one second the resident was breathing, and spitting particles of an orange out. Review of Resident CR1's progress note dated 11/4/21, at 6:48 p.m. indicated that resident left to hospital via ambulance due to aspiration and continuously choking. Review of Resident CR1's progress note dated 11/4/21, at 6:50 p.m. indicated that the resident was coughing with labored breathing after eating some of her dinner. Review of Resident CR1's physician order dated 11/4/21, indicated send resident out to the hospital. Resident with probable aspiration on food. Resident continuously coughing. During an interview on 11/16/21 at 12:25 p.m. NA Employee E1 confirmed that the resident had whole segments of oranges on her tray, that she gave Resident CR1 a little piece of orange and Resident CR1 swallowed it. During an interview on 11/16/21, at 12:50 p.m. Licensed Practical Nurse Employee E2 confirmed that she was assigned to another hall when she heard yelling, she then went to Resident CR1's room, found resident choking and gagging, she pushed resident forward on bed, gave three back slaps, then performed the hiemlich, and a piece of orange popped out. During an interview on 11/16/22, at 11:40 a.m. Dietary Manager Employee E3, confirmed that Dietary Aide Employee E4 placed whole segmented oranges on Resident CR1's tray during tray line on 11/4/21. During an interview on 11/16/22, at 2:42 p.m. and 2/3/22, at 10:21 a.m. the Nursing Home Administrator and Director of Nursing confirmed that Resident CR1 received the wrong food (whole segments of an orange) that was not in the form to meet the resident's needs for safe swallowing to prevent the resident from choking, that Dietary Aide Employee E3 placed whole segments of oranges on the tray. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 8/26/21 and 2/10/21 29 Pa. Code 201.18 (b)(1) Management Previously cited 5/7/21 29 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 207.2(a) Administrator Responsibility Previously cited 8/26/21, 7/14/21, and 2/10/21 28 Pa. Code 211.6 (c) Dietary Services. 28 Pa. Code 211.12 (c)(d)(1) Nursing services Previously cited 8/26/21, 7/14/2, 6/29/21, 5/7/21, 2/10/21, 12/30/20, 8/31/20, 7/21/20 and 3/13/20 28 Pa. Code 211.12 (c)(d)(5) Nursing services Previously cited 8/26/21, 7/14/2, 6/29/21, 6/3/21, 5/7/21, 2/10/21, 10/26/20, 9/23/20, 8/31/20, 7/21/20 and 3/13/20

Based on review of policies, clinical records, and facility investigation information, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from sexual and physical abuse for one of 26 residents reviewed (Resident 6), resulting in Resident 6 being sexually abused and manually choked by Resident 3. Findings include: The facility's policy regarding abuse prevention, dated (MONTH) 19, (YEAR), indicated that each resident had the right to be free from verbal, mental, sexual, physical, and mental abuse, and sexual abuse included, but was not limited to, sexual harassment, sexual coercion, or sexual assault. Physical abuse included hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated (MONTH) 6, (YEAR), indicated that the resident was able to make himself understood, was able to understand others, was cognitively impaired, had [DIAGNOSES REDACTED]. Resident 3's care plan regarding inappropriate sexual behavior, initiated on (MONTH) 24, (YEAR), included interventions of constant supervision in recreation programs, determining the cause and previous sexual history and documenting it, determining what triggered or lead up to the behavior, and to document a summary of each episode. Nursing notes for Resident 3 revealed that he exhibited the following verbal, physical, and/or sexually inappropriate behaviors toward staff and other residents: -November 4, (YEAR) - Resident 3 grabbed a nurse by the vagina and the breast. -November 5, (YEAR) - Resident 3 was agitated off and on all shift, wheeled himself into a room across the hall from his own, and was swearing at no one in particular. -November 13, (YEAR) - Resident 3 was observed several times masturbating in his room and made the statement to Licensed Practical Nurse 1, Hey good lookin, come get in bed with me, and was running his hand up and down the front of his brief. -November 27, (YEAR) - While Licensed Practical Nurse 1 attempted to administer a.m. medications, Resident 3 told the nurse, Show me your t**s. As Licensed Practical Nurse 1 attempted to administer the medications, Resident 3 lunged toward her with his hand out, attempting to grab her by the crotch. -November 27, (YEAR) - Resident 3 attempted to grab a nurse aide by the crotch, telling her that he wanted to lick her. -December 18, (YEAR) - Resident 3 invaded the personal space of staff and other residents. -December 24, (YEAR) - Resident 3 was walking the hallways naked. -December 24, (YEAR) - Resident 3 had sexual behaviors that were out of control. The resident went in and out of residents' rooms exposing himself, touching himself, touching nursing staff, and verbally asking for sex from nursing staff. There was no documented evidence that despite ongoing sexually inappropriate behaviors, Resident 3's care plan was revised with new interventions to prevent the behaviors toward residents and staff, and to protect residents from potential abuse. The only change to the resident's care plan was an intervention added (MONTH) 25, (YEAR), to follow-up with psych services, related to anxiety and hypersexuality. Nursing notes revealed that Resident 3 continued to have sexually inappropriate behaviors as follows: -December 27, (YEAR) - Resident 3 wandered in and out of other residents' rooms not always fully dressed. He was very confused, was looking for his wife, was not sure what he needed to do and said things like, You want to kill me? -January 9, 2019 - Resident 3 was out of his room many times with his penis in his hand. Multiple attempts were made by the resident to get staff to touch his penis, he made multiple sexual innuendos to staff when they attempted to get him to return to bed, and he was found standing outside a female resident's room with his penis in his hand. There was no documented evidence that any additional interventions were initiated to prevent Resident 3's sexually inappropriate behaviors and protect residents from potential abuse. A nursing note dated (MONTH) 14, 2019, revealed that Resident 3 was verbally and sexually inappropriate with Resident 6. Resident 3 was escorted from Resident 6's room, and approximately five minutes later Resident 3 was found in Resident 6's room choking Resident 6. The licensed practical nurse had to remove Resident 3's hands from Resident 6's neck and Resident 3 was being verbally abusive to staff while this was being done. An incident report, dated (MONTH) 14, 2019, included a typed note with Licensed Practical Nurse 2's name on it, which indicated that the nurse heard a resident's voice screaming out on the unit and when she entered Resident 6's room, she observed Resident 3 with his pants and undergarments pulled down to his ankles, holding and shaking his penis, and asking Resident 6, S**k my d**k, play with it. Resident 6 continued to yell out from his bed, attempting to hide under the covers. Resident 3 was redirected back to his room. There was no documented evidence, including in the investigation documents and nursing notes, that the facility took any action to protect Resident 6 after Resident 3 was found in his room with his pants and undergarments down at his ankles and exhibiting sexually inappropriate behaviors toward Resident 6. The incident report, dated (MONTH) 14, 2019, revealed that a few minutes after Resident 3 was removed from Resident 6's room, Licensed Practical Nurse 2 again heard a male voice screaming on the unit and found that Resident 3 had reentered Resident 6's room and had both of his hands around Resident 6's neck, choking him while he lay in bed. Resident 3 was redirected to let go of Resident 6; however, redirection was ineffective and Resident 3 refused to let go. Resident 3's hands were removed by Licensed Practical Nurse 2. Resident 3 refused to leave Resident 6's room and had to be assisted back to his own room. A quarterly MDS assessment for Resident 6, dated (MONTH) 10, (YEAR), indicated that the resident was able to make himself understood, was able to understand others, and had [DIAGNOSES REDACTED]. Interview with Resident 6 on (MONTH) 4, 2019, at 3:20 p.m. confirmed that a man came into his room, was yelling at him, and then started choking him around his neck. He stated that staff came into the room and removed the man from his room and he does not want the man to come into his room. Interview with the Assistant Director of Nursing and the Director of Nursing on (MONTH) 5, 2019, at 11:30 a.m. confirmed that there was no documented evidence that any interventions were initiated to protect Resident 6 after Resident 3 was first removed from his room following the episode of sexual abuse, and prior to Resident 3 re-entering Resident 6's room and choking him. Interview with the Nursing Home Administrator and Registered Nurse 3, a Clinical Consultant for the facility, on (MONTH) 5, 2019, at 1:35 p.m. confirmed that no interventions to protect Resident 6 were initiated after Resident 3 was removed from Resident 6's room the first time. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/11/19, 12/18/18, 7/19/18, 1/19/18, 9/28/17, 7/13/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/18/18, 5/21/18, 9/28/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 9/28/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 12/18/18, 7/19/18, 1/19/18, 12/28/17, 9/28/17, 7/13/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/17/18, 7/19/18, 5/21/18, 1/19/18, 12/28/17, 9/28/17, 8/15/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 12/26/18, 12/17/18, 7/19/18, 5/21/18, 1/19/18, 12/28/17, 9/28/17, 8/15/17, 7/13/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/11/19, 12/26/18, 12/17/18, 10/12/18, 7/19/18, 5/21/18, 1/19/18, 12/28/17, 9/28/17, 8/15/17, 7/13/17.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for two of 21 residents reviewed (Residents CR2, R4) resulting in deterioration of two pressure ulcers for Resident CR2. Findings include: The facility's policy regarding pressure sores (skin breakdown caused by pressure), dated May 18, 2017, revealed that a resident with a pressure ulcer would be treated as ordered by the physician to facilitate healing. The pressure ulcer was to be dressed with the prescribed dressing, was to be measured at least weekly, and the type of dressing applied was to be on the resident's Treatment Administration Record (TAR). The policy also indicated that the diet of the resident with a pressure ulcer was to contain nutrients adequate to support healing. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR2, dated May 31, 2017, revealed that the resident was alert and oriented, required extensive assistance with bed mobility and transfers, and was admitted with one Stage II pressure ulcer (a superficial open area in the top layer of skin), and one Stage III pressure ulcer (a deeper pressure ulcer with full thickness tissue loss). An admission nursing screening, dated May 24, 2017, revealed that Resident CR2 was admitted to the facility with pressure ulcers on the left buttock measuring 1.0 x 1.0 centimeters (cm) and 2.0 x 1.0 cm, on the right buttock measuring 3.0 x 2.0 cm and 2.0 x 1.0 cm, on the left gluteal fold (area where the buttocks meets the upper thigh) measuring 3.0 x 5.0 cm, on the right gluteal fold measuring 3.0 x 2.0 cm, and on the sacrum (area at the base of the spine) measuring 2.0 x 1.0 cm. The resident's care plan, dated May 26, 2017, did not address wound care for wounds on the gluteal folds, but indicated that wound care was to be provided to pressure sores on the left and right ischium (very close anatomically to the gluteal folds) and to the open wounds on the buttocks. Physician's orders for Resident CR2, dated May 24, 2017, included an order for [REDACTED]. May and June 2017 revealed that there was no documented evidence that a treatment was ordered to the open area on the sacrum. There was also no documented evidence that Resident CR2's wounds on the left and right ischium, left and right buttocks, and sacrum were measured weekly after May 24, 2017, in accordance with the facility's policy. Resident CR2's wound records, dated June 2, 2017, revealed that the resident had a Stage II pressure ulcer on the coccyx (tailbone) that measured 7.5 x 4.0 x 0.1 cm. A physician's progress note, dated June 2, 2017, revealed that the resident had severe pain to the pressure wound on the buttock that was constant, worse with pressure, sharp, non-radiating and ongoing severely for three days. An order was received to consult a wound care specialist and start [MEDICATION NAME] (a narcotic medication used to treat moderate to severe pain), as needed for pain. Physician's orders and TAR's for June 2017 revealed no documented evidence that a treatment to the wound on the coccyx was ordered, and there was still no documented evidence that a treatment for [REDACTED]. A wound care specialist's evaluation, dated June 6, 2017, revealed that Resident CR2 had a Stage III pressure ulcer on the coccyx that measured 7.0 x 15.0 x 0.2 cm (increased in size and depth from June 2, 2017). The wound started at the coccyx and extended to the right upper buttock. The resident also had a Stage III pressure ulcer on the sacrum that measured 7.0 x 6.0 x 0.2 cm (an increase in size and depth from May 24, 2017) and needed surgical debridement (surgical removal of dead tissue). Recommendations were made for treatments to all of the resident's wounds, including to apply Leptospermum honey (a dressing that contains medical-grade honey) to the pressure ulcer on the coccyx daily, Santyl to the pressure ulcer on the sacrum daily, and to obtain a hemoglobin A1c (test to check average blood sugar levels over 2-3 months), and a [MEDICATION NAME] level (test used to measure protein levels in the blood and identify malnutrition). Review of physician's orders and TAR's for June 2017 revealed that there was no documented evidence that these recommendations made by the wound specialist were ordered and implemented. Therefore, there were no orders for treatments to the pressure ulcers on the resident's sacrum and coccyx. A nursing note for Resident CR2, dated June 11, 2017, revealed that the resident's dressings were changed on the buttocks and there was a green, foul smelling drainage. The note indicated that the wound was necrotic (containing dead tissue), the supervisor was notified, and an order was received to culture the wound. A culture report, dated June 12, 2017, revealed that the resident had an infection in the wound on the sacral area. A nursing note, dated June 12, 2017, revealed that the wound on the coccyx had a foul odor and drainage, and was deep and black in color. A wound care specialist evaluation for Resident CR2, dated June 13, 2017, revealed that the pressure ulcer on the resident's coccyx measured 8.0 x 9.0 x 0.2 cm and was starting to merge with the sacrum and extend to the bilateral (both) upper buttocks. The pressure ulcer on the sacrum was now a Stage IV (a deep wound that exposes bone or muscle tissue), measured 13.0 x 9.0 x 0.2 cm, and had some green drainage and copious (large) amounts of purulent (containing pus) drainage. The note indicated that the wound deteriorated due to infection and nutritional compromise, and it reached the muscle most likely due to the resident spending more than four hours sitting for [MEDICAL TREATMENT]. A recommendation was made to apply Leptospermum honey to the pressure ulcer on the coccyx daily, and 1 percent acetic acid (solution used to prevent infection), Santyl and calcium alginate (absorbent dressing) to the pressure ulcer on the sacrum daily. Physician's orders for Resident CR2, dated June 13, 2017, included orders for changes to the treatments for the wounds on the left and right ischium. There were no orders for treatment to the coccyx and sacral wounds, and the resident's TAR's for June 2017 revealed that there was no documented evidence that Leptospermum honey was applied to the coccyx wound, or that the acetic acid, Santyl and calcium alginate were applied to the sacral wound as recommended by the wound specialist. A laboratory report for Resident CR2, dated June 15, 2017, which was nine days after the wound specialist's recommendations, revealed that the resident's [MEDICATION NAME] level was less than 3 milligrams per deciliter (mg/dL) (normal range is around 17-40 mg/dL). There was no documented evidence that the dietitian and the physician were notified about the resident's low [MEDICATION NAME] level until June 19, 2017, when an order was received to increase a previously ordered liquid protein supplement from twice daily to four times a day. Interview with the Director of Nursing on July 12, 2017, at 1:00 p.m. confirmed that there was no documented evidence that the treatment recommendations made by the wound specialist on June 6, 2017, were implemented. She also confirmed that the Resident CR2's [MEDICATION NAME] level was not drawn timely. Interview with the Regional Director of Clinical Services on July 13, 2017, at 1:00 p.m. confirmed that there were no physician's orders to treat Resident CR2's pressure ulcers on the coccyx and sacrum. She indicated that each individual wound should be identified and have an order for [REDACTED]. Physician's orders for Resident R4, dated May 25, 2017, included an order for [REDACTED]. for further skin breakdown. As of July 13, 2017, the care plan was not updated to include an alternating air mattress as ordered by the physician. Observations on July 10, 2017 at 4:54 p.m.; July 11, 2017 at 10:07 a.m. and 2:00 p.m.; July 12, 2017 at 9:33 a.m., 11:37 a.m. and 1:44 p.m.; and July 13, 2017 at 10:00 a.m., revealed that Resident R4's bed was equipped with a regular mattress and not an alternating air mattress as ordered by the physician. Interview with the Regional Director of Clinical Services on July 13, 2017, at 10:18 a.m. confirmed that Resident R4's bed was not equipped with an alternating air mattress and that her care plan was not updated to include the air mattress. 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 6/1/17, 3/31/17, 8/5/16, 2/11/16. 28 Pa. Code 211.10(a) Resident care policies. Previously cited 3/31/17. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 3/31/17. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/31/17, 9/15/16, 8/5/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 6/1/17, 4/13/17, 3/31/17, 9/15/16, 2/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/1/17, 4/13/17, 3/31/17, 1/11/17, 11/25/16, 11/18/16, 10/27/16, 9/28/16, 9/15/16, 8/11/16, 8/5/16, 7/7/16, 2/11/16.

Based on clinical record reviews and facility investigation reports, as well as staff interviews, it was determined that the facility failed to prevent neglect from occurring during a transfer for one of 18 residents reviewed (Resident R17), which resulted in a fracture for the resident. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R17, dated February 3, 2017, indicated that the resident was cognitively impaired, could usually understand others and make herself understood, required the extensive assistance of two persons for transfers, and had limited range of motion of her upper and lower extremities. A social service note, dated March 30, 2017, indicated that Resident R17 was able to communicate her basic needs to her caregivers and was able to recall circumstances involving her care on an ongoing basis. The resident's care plan, revised February 7, 2017, indicated that Resident R17 was to be transferred with a Sabina lift (a mechanical lift that requires the resident to stand and bear partial weight) and the assistance of two staff members. Nursing notes for Resident R17, dated March 5, 2017, at 1:53 a.m. revealed that the resident was medicated with Tylenol (used to treat mild pain) for complaints of left knee and leg pain. At 2:07 a.m. the resident complained of discomfort to the left knee and stated that earlier today (March 4, 2017) when being transferred from the chair to bed with a Sabina lift, she felt discomfort in the left knee. The resident's left knee was swollen, warm and tender to the touch. physician's orders [REDACTED]. A nursing note for Resident R17, dated March 6, 2017, at 11:56 a.m. revealed that the resident complained of pain in the left lower extremity, which was very warm, very painful, with some [MEDICAL CONDITION] (swelling) present. An X-ray report, dated March 6, 2017, revealed that the resident had a non-displaced (fracture is in line) [MEDICAL CONDITION] tibia (bone of the lower leg near the ankle area). The facility's investigation report, dated March 8, 2017, revealed that Resident R17 stated that Nurse Aide 9 transferred her by physically lifting her up and transferring her to bed, and that is how she hurt her ankle. A written statement from Nurse Aide 9, dated March 8, 2017, indicated that Nurse Aides 9 and 10 transferred Resident R17 with the Sabina lift and she complained of pain. However, a written statement from Nurse Aide 10 revealed that she did not assist with any transfers of Resident R17 on March 4, 2017. A written statement by the Assistant Director of Nursing, dated March 30, 2017, revealed that after reviewing all of the statements from employees who worked on March 4, 2017, it was determined that no one assisted Nurse Aide 9 with a transferring Resident R17 on March 4, 2017. Interviews with the Assistant Director of Nursing and the Regional Director of Clinical Services on March 21, 2017, at 3:15 p.m. revealed that according to Resident R17's and Nurse Aide 10's statements, Nurse Aide 9 did not follow the resident's care plan for transferring the resident. 42 CFR 483.12(b)(1)-(3) Prohibit Mistreatment/Neglect/Misappropriation. Previously cited 8/5/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/21/17, 8/11/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/11/17, 11/25/16, 11/18/16, 10/27/16, 9/15/16, 8/11/16, 8/5/16, 7/7/16, 2/11/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 9/15/16, 2/11/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 1/11/17, 11/25/16, 10/27/16, 9/15/16, 8/5/16, 2/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/11/17, 11/25/16, 11/18/16, 10/27/16, 9/28/16, 9/15/16, 8/11/16, 8/5/16, 7/7/16, 2/11/16.

Based on clinical record reviews and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that safe methods were used when transferring one of 18 residents reviewed (Resident R17), which resulted in a fracture for the resident. The facility also failed to ensure that interventions to prevent falls were in place as planned for one of 18 residents reviewed (Resident R3), resulting in a fall with a laceration that required sutures to repair. The facility also failed to ensure that interventions were developed and/or implemented for one of 18 residents reviewed (Resident R5) who had exit-seeking behaviors and a history of elopements. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R17, dated February 3, 2017, indicated that the resident was cognitively impaired, could usually understand others and make herself understood, required the extensive assistance of two persons for transfers, and had limited range of motion of her upper and lower extremities. A social service note, dated March 30, 2017, indicated that Resident R17 was able to communicate her basic needs to her care givers and was able to recall circumstances involving her care on an ongoing basis. The resident's care plan, revised February 7, 2017, indicated that Resident R17 was to be transferred with a Sabina lift (mechanical lift that requires the resident to stand and bear partial weight) and the assistance of two staff members. Nursing notes for Resident R17, dated March 5, 2017, at 1:53 a.m. revealed that the resident was medicated with Tylenol (used to treat mild pain) for complaints of left knee and leg pain. At 2:07 a.m. the resident complained of discomfort to the left knee and stated that earlier today (March 4, 2017) when being transferred from the chair to bed with a Sabina lift, she felt discomfort in the left knee. The resident's left knee was swollen, warm and tender to the touch. physician's orders [REDACTED]. A nursing note for Resident R17, dated March 6, 2017, at 11:56 a.m. revealed that the resident complained of pain in the left lower extremity, which was very warm, very painful, with some edema (swelling) present. physician's orders [REDACTED]. The X-ray report, dated March 6, 2017, revealed that the resident had a non-displaced fracture (fracture is in line) of the distal tibia (bone of the lower leg near the ankle area). The facility's investigation report, dated March 8, 2017, revealed that Resident R17 stated that Nurse Aide 9 transferred her by physically lifting her up and transferring her to bed, and that is how she hurt her ankle. A written statement from Nurse Aide 9, dated March 8, 2017, indicated that Nurse Aides 9 and 10 transferred Resident R17 with the Sabina lift and she complained of pain. However, a written statement from Nurse Aide 10 revealed that she did not assist with any transfers of Resident R17 on March 4, 2017. A written statement by the Assistant Director of Nursing, dated March 30, 2017, revealed that after reviewing all of the statements from employees who worked on March 4, 2017, it was determined that no one assisted Nurse Aide 9 with transferring Resident R17 on March 4, 2017. Interviews with the Assistant Director of Nursing and the Regional Director of Clinical Services on March 21, 2017, at 3:15 p.m. revealed that according to Resident R17's and Nurse Aide 10's statements, Nurse Aide 9 did not follow the resident's care plan for transferring the resident. A comprehensive admission MDS assessment for Resident R3, dated February 10, 2017, indicated that the resident was confused, required the extensive assistance of one person for transfers, and had limited range of motion of her upper and lower extremities. An incident report and nursing note for Resident R3, dated February 13, 2017, revealed that the resident was ambulating (walking) back from the bathroom, lost her balance, and fell on to the fall mat beside the bed. The resident had a raised area on her occipital area (the back of her head). The report indicated that the resident turned her alarm off (sounds to alert staff when the resident is attempting to get up) and got up unassisted. The resident's care plan, dated February 13, 2017, revealed that staff were to keep the resident's alarm box out of her reach. An incident report and nursing note for Resident R3, dated February 22, 2017, revealed that the resident was attempting to get to the bathroom from her bed without calling for assistance. She removed her alarm from the bed and fell on her buttocks. There was no documented evidence that any new interventions were put into place to prevent the resident from removing her alarm or to prevent further falls for the resident. An incident report and nursing note for Resident R3, dated February 25, 2017, revealed that the resident was sitting on her bed and had a 10 centimeter (cm) laceration to the occipital area. Her bed alarm was found folded up and sitting at the top of her bed. The resident stated that she got up unassisted and fell to the floor. A nursing note, dated February 25, 2017, revealed that the resident was sent to the hospital and required four staples to close the laceration to the occipital area. There was no documented evidence that any new interventions were put into place to prevent the resident from removing her alarm or to prevent further falls for the resident. Interview with the Regional Director of Clinical Services on March 7, 2017, at 2:00 p.m. revealed that she was not aware that Resident R3 had so many falls, and she confirmed that interventions should have been in place to prevent falls for the resident. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R5, dated February 10, 2017, revealed that the resident was admitted to the facility on [DATE], and was confused. A nursing note for Resident R5, dated February 23, 2017, at 6:25 p.m. revealed that the resident was at the main entrance of the facility and was stopped from exiting the facility by the receptionist. The resident indicated that she intended to leave the facility. Resident R5's current care plan, dated February 24, 2017, revealed that a new care plan was developed for the resident's potential for elopement and associated injury related to exit-seeking behavior. Interventions included to assist in orientation to the resident's room and facility, to check the resident for the presence of a legible identification bracelet, to check the resident's whereabouts frequently, for door alarms to be on at all times and answered promptly, to make staff aware of the resident's elopement risk, to provide diversional activities when exit seeking, and to redirect the resident away from exits when needed based on her behavior. A nursing note for Resident R5, dated February 26, 2017, at 8:30 p.m. revealed that the resident exited the facility twice during the shift, and she was placed on safety checks for frequent monitoring of her whereabouts. The note did not indicate how often the safety checks were to be completed, and there was no documented evidence that this new intervention, or any other new interventions, were added to the resident's care plan. The resident's clinical record revealed that the only documented safety checks were completed on February 27, 2017, at 2:16 a.m. and 6:55 a.m., and February 28, 2017, at 3:10 a.m. A nursing note for Resident R5, dated February 28, 2017, at 8:47 p.m. revealed that the resident exited the facility during the shift. The note indicated that the resident was on safety checks for monitoring of her whereabouts, and she was taken to the nursing station for observation. However, review of the resident's care plan revealed that there were no new interventions added to the plan related to the resident's continued exit-seeking behaviors. A nursing note for Resident R5, dated March 1, 2017, at 1:29 a.m. revealed that a door alarm alerted staff that the resident was outside the door to the C wing and she was brought back into the facility. Nursing notes indicated that safety checks were completed on March 1, 2017, at 3:31 a.m.; March 2, 2017, at 3:35 p.m.; and March 3, 2017, at 3:31 a.m. However, there was no documented evidence that new interventions were added to the resident's care plan regarding elopements and exit-seeking behaviors. A nursing note for Resident R5, dated March 3, 2017, at 2:08 p.m. revealed that the resident was brought back into the building after exiting and had been in her wheelchair in the parking lot. The note indicated that the facility would implement every 15-minute checks. However, review of the resident's care plan revealed that this new intervention was not added to the plan. A nursing note for Resident R5, dated March 8, 2017, indicated that at 4:00 p.m. the resident was noted by a staff member to be in the parking lot pushing her wheelchair around. Review of the resident's every 15-minute checklist for this date and time revealed that it was documented that the resident was in bed at the time she was noted to be in the parking lot. There was no documented evidence that Resident R5's care plan regarding exit-seeking behaviors and elopement risk that was initiated on February 24, 2017, was updated to include every 15-minute safety checks and frequent visual safety checks until March 10, 2017. When the resident's exit seeking behaviors and elopements continued, indicating that the resident's care plan was ineffective, there was no documented evidence that new interventions to prevent elopement and/or exit-seeking behaviors were developed and implemented. Review of documentation for Resident R5's 15-minute safety checks for March 5, 2017, revealed that the checklist that was used did not indicate that the resident's location was monitored from 3:15 a.m. through 6:45 a.m., and on March 6, 2017, the resident's location was not monitored from 3:15 p.m. through 6:00 p.m. The checklist for March 7, 2017, revealed that the resident's location was not monitored from 8:45 p.m. through 10:45 p.m., and on March 8, 2017, there was no documented evidence that the resident's whereabouts were monitored from 7:00 p.m. through 10:45 p.m. Interview with the Assistant Director of Nursing on March 11, 2017, at 3:15 p.m. confirmed that staff should have monitored Resident R5's whereabouts, and the checklist indicated that staff did not do this on the above dates and times. She confirmed that the 15-minute check, dated March 8, 2017, at 4:00 p.m., which indicated that the resident was in bed at the time that she was found to be in the facility parking lot, was incorrect. She also confirmed that prior to the implementation of the safety checklists, there was no documented evidence that staff frequently checked the resident's whereabouts. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 7/7/16, 2/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 1/11/17, 11/25/16, 11/18/16, 10/27/16, 9/28/16, 9/15/16, 8/11/16, 8/5/16, 7/7/16, 2/11/16.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders for two of 12 residents reviewed (Residents CR3 and R12), resulting in physical harm for one resident (Resident CR3). Findings include: Hospital reports for Resident CR3, dated August 6 and 8, 2016, revealed that the resident had a minimally angled fracture (a fracture in which the fragments of bone are at angles to one another) of the left arm, and the plan was to immobilize the shoulder at all times and in 3 to 4 weeks do passive range of motion (movement of a joint with assistance), and in six weeks do active range of motion (movement of a joint independently). A hospital discharge summary, dated August 9, 2016, revealed that the resident was to have no weight bearing of the left upper extremity (arm) and was to keep the left upper arm in an immobilizer at all times. Admission physician's orders for Resident CR3, dated August 9, 2016, revealed that the resident was to have no weight bearing of the left upper extremity and was to keep the left upper extremity in an immobilizer at all times. A consultation report for Resident CR3, dated August 19, 2016, revealed that the resident had a follow-up appointment with the orthopedic physician (bone specialist), and the physician's report indicated that despite discharge orders for the immobilizer to be on at all times, it was removed several times a day, and according to the resident and her family, the left arm had been moved around. An X-ray showed that the aligned (ends of bones lined up straight) surgical neck fracture was significantly displaced (ends of bones do not line up straight). The decision was made to try closed reduction (procedure for putting the pieces of a broken bone back into the right position without surgery) under anesthesia. Interview with Nurse Aide 2 on September 13, 2016, at 3:05 p.m. revealed that she removed the neck strap of Resident CR3's left arm immobilizer strap so she could assist the resident with changing out of her shirt and into a gown at night. Interview with Physician Assistant 3, who worked for Resident CR3's orthopedic physician, on September 14, 2016, at 3:12 p.m., confirmed that the resident's left arm immobilizer should not have been removed at any time, and removing the immobilizer caused the fracture to become displaced, which resulted in the resident having closed reduction under anesthesia. Interview with Registered Nurse 1 on September 14, 2016, at 3:35 p.m. confirmed that Resident CR3's immobilizer was to be kept on the left upper arm at all times and was not to be removed. She indicated that if the physician wanted the immobilizer to be removed this would have been included in the order. Upon interview with Resident R12 on September 13, 2016, at 1:54 p.m. the resident stated that the facility's staff were not completing her dressing changes as ordered by the physician. Physician's orders for Resident R12, dated September 1, 2016, included orders for the resident to receive [MEDICATION NAME] (an absorbent dressing containing honey) every other day to trauma wounds on the left outside ankle and the back of the right leg, and to the left ischium (hip) for a failed surgical skin repair. The resident's Treatment Administration Record (TAR) for September 2016, revealed that the wound dressings were not completed on September 5 and 7, 2016. Interview with the Assistant Director of Nursing September 14, 2016, at 6:30 p.m. confirmed that there was no documented evidence that Resident R12's wound dressings were completed as ordered on the above days. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 10/23/15, 7/10/15, 1/8/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/5/16, 2/11/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/5/16, 10/23/15, 1/8/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/11/16, 8/5/16, 7/7/16, 2/11/16, 10/23/15, 7/10/15, 1/8/15.

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure a resident's right to personal privacy during the provision of care for one of six residents reviewed (Resident R1), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: The facility's policy regarding resident rights, dated January 4, 2016, indicated that the resident had the right to a dignified existence and the facility was to protect and promote the resident's right to privacy in treatment and personal care. The facility's employee handbook, undated, indicated that employees were to refrain from having their cell phones at work, except during their authorized breaks, and that cell phones were prohibited on the nursing units and their use may be considered abuse. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated July 7, 2016, indicated that the resident was able to make her needs known, was able to recall with no cueing required, was ambulatory, and required limited assistance with her bathing. Review of information dated August 7, 2016, submitted by the facility indicated that Resident R1 was taking a whirlpool bath on August 6, 2016, between 2:00 p.m. and 3:00 p.m., at which time Nurse Aides 2 and 3 were present and pictures of the resident, who was unclothed, were taken on the nurse aides' cell phones, which was witnessed by Nurse Aide 1. Investigative interview statements by Resident R1, dated August 7, 2016, and Nurse Aide 1, dated August 8, 2016, confirmed that Nurse Aides 2 and 3 had their cell phones out during Resident R1's bath, and Nurse Aide 2 was the one who showed Resident R1 pictures of herself, unclothed in the whirlpool tub. Interview with Resident R1 on August 8, 2016, at 2:40 p.m. revealed that she was shown pictures of herself unclothed on Nurse Aide 2's cell phone, and although Nurse Aide 3 had her cell phone out during the time the pictures were taken, she did not see any pictures from her phone. The resident indicated that at first she laughed because her head was changed to look like a basketball. During the interview the resident was tearful and repeatedly indicated that she did not like the nurse aides having pictures of her butt naked and that she told them to delete the pictures, but she was not sure if the pictures were deleted or not. An interview with the Nursing Home Administrator on August 8, 2016, at 11:30 a.m. revealed that employees were not to have or use their personal cell phones while on the nursing units. On August 8, 2016, at 4:15 p.m. the Nursing Home Administrator was informed that the mental health and safety of residents were in Immediate Jeopardy due to mental abuse by employees and not ensuring the privacy of a resident's body during the provision of care by utilizing personal cell phones to allegedly take photos of the resident while unclothed. The facility submitted and implemented a plan to ensure residents' privacy and protection from mental abuse by interviewing residents to ensure that their privacy was not compromised, and providing education regarding abuse to all employees prior to the start of their shifts, which included social media use. The facility educated the majority of their employees on August 8 and 9, 2016, and the Immediate Jeopardy was removed on August 9, 2016, at 12:43 p.m. 28 Pa. Code 201.29(j) Resident rights. Previously cited 2/11/16, 7/10/15, 1/8/15.

Based on review of clinical records and investigation documentation, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of six residents reviewed (Resident R1), resulting in Immediate Jeopardy to the resident's mental health and safety. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated July 7, 2016, indicated that the resident was able to make her needs known, was able to recall with no cueing required, was ambulatory, and required limited assistance with her bathing. Review of information dated August 7, 2016, submitted by the facility indicated that Resident R1 was taking a whirlpool bath on August 6, 2016, between 2:00 p.m. and 3:00 p.m., at which time Nurse Aides 2 and 3 were present and pictures of the resident, who was unclothed, were taken on the nurse aides' cell phones, which was witnessed by Nurse Aide 1. Investigative interview statements by Resident R1, dated August 7, 2016, and Nurse Aide 1, dated August 8, 2016, confirmed that Nurse Aides 2 and 3 had their cell phones out during Resident R1's bath, and Nurse Aide 2 was the one who showed Resident R1 pictures of herself, unclothed in the whirlpool tub. Interview with Resident R1 on August 8, 2016, at 2:40 p.m. revealed that she was shown pictures of herself unclothed on Nurse Aide 2's cell phone, and although Nurse Aide 3 had her cell phone out during the time the pictures were taken, she did not see any pictures from her phone. The resident indicated that at first she laughed because her head was changed to look like a basketball. During the interview the resident was tearful and repeatedly indicated that she did not like the nurse aides having pictures of her butt naked and that she told them to delete the pictures, but she was not sure if the pictures were deleted or not. Interview with the Nursing Home Administrator on August 8, 2016, at 11:30 a.m. revealed that employees were not to have or use their personal cell phones while on the nursing units. On August 8, 2016, at 4:15 p.m. the Nursing Home Administrator was informed that the mental health and safety of residents were in Immediate Jeopardy due to mental abuse by employees and not ensuring the privacy of a resident's body during the provision of care by utilizing personal cell phones to allegedly take photos of the resident while unclothed. The facility submitted and implemented a plan to ensure residents' privacy and protection from mental abuse by interviewing residents to ensure that their privacy was not compromised, and providing education regarding abuse to all employees prior to the start of their shifts, which included social media use. The facility educated the majority of their employees on August 8 and 9, 2016, and the Immediate Jeopardy was removed on August 9, 2016, at 12:43 p.m. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/5/16, 7/7/16, 2/11/16. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/5/16.

Based on review of training records, clinical records, and investigative information, as well as staff interviews, it was determined that the facility failed to ensure that staff followed training to prevent resident abuse and neglect, which resulted in harm for one of six residents reviewed (Resident R6). Findings include: The facility's training regarding preventing and identifying abuse, dated July 8, 2016, revealed that staff were to back off and give agitated residents time to calm down and to call for assistance to manage the situation. The training records showed that Nurse Aide 3 attended the training. A nursing note for Resident R6, dated July 29, 2016, revealed that the resident's fifth finger was swollen and purple and green. The facility's investigation documentation, dated July 29, 2016, revealed that Nurse Aide 3 reported that Resident R6 was incontinent of bowel and would not open her legs, but she continued to provide care to the resident as the resident continued to be combative and scream. The nurse aide indicated that the resident began to pull her hair and when she tried to remove the resident's hand from her hair, she heard a popping noise. The investigation revealed that Nurse Aide 4 heard Nurse Aide 3 state, Stop pulling my hair, and Nurse Aide 4 asked Nurse Aide 3 if she needed help, but Nurse Aide 3 said that she did not need help. An X-ray report for Resident R6, dated July 30, 2016, revealed that the resident had a fractured fifth finger. An interview with the Nursing Home Administrator on August 3, 2016, at 3:44 p.m. confirmed that Nurse Aide 3 continued to provide care when Resident R6 was resistive and declined help when offered, which resulted in the nurse aide causing a fractured finger for Resident R6. The Nursing Home Administrator confirmed that Nurse Aide 3 was trained to back off and/or call for assistance when residents were resistive to care. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/7/16, 2/11/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/7/16, 2/11/16, 10/23/15, 7/10/15, 1/8/15.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided to promote healing of pressure ulcers for one of six residents reviewed (Resident R3). Findings include: The facility's policy regarding physician notification, dated January 4, 2016, indicated that staff were to notify the physician when the resident developed a pressure ulcer. The facility's policy regarding weekly wound documentation, dated January 4, 2016, revealed that all wounds were to be measured weekly and recorded. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R3, dated May 22, 2016, indicated that the resident was dependent for bed mobility, was incontinent of bowel, required assistance with toileting, and had no pressure ulcers. Review of information submitted by the facility, dated June 29, 2016, indicated that Resident R3 was removed from the bed pan at 6:30 p.m. and reported that he had been on the bed pan since the end of the 7:00 a.m. to 3:00 p.m. shift, a minimum of three and a half hours. The information revealed that the resident had dark red lines (Stage I pressure area) that outlined the bed pan and a few hours later the lines were still evident and appeared darker as bruising. However, there was no documented evidence that the physician was notified about the area or that the area was measured and documented every week. There was also no documented evidence that any new interventions were put into place to prevent further skin breakdown from the bedpan. A nursing note for Resident R3, dated July 14, 2016, revealed that the resident had a Stage II pressure area (open, superficial areas) on the right posterior thigh that measured 0.8 x 1.0 x 0.1 centimeters (cm) and a Stage II pressure area on the right upper butt that measured 0.3 x 1.2 x 0.1 cm. A physician's orders [REDACTED]. Interview with the Director of Nursing on August 3, 2016, at 4:30 p.m. confirmed that the newly developed open areas on the right posterior thigh and right upper butt were in the same areas where the outline of the bedpan was present on June 29, 2016. Interviews with the Director of Nursing and the Assistant Director of Nursing on August 4, 2016, at 11:25 a.m. confirmed that the Stage I areas that developed on June 29, 2016, were not assessed, the physician was not notified about the areas on June 29, 2016, and there was no documented evidence that the areas were monitored since June 29, 2016. 42 CFR 483.25(c) Treatment/services to Prevent/heal Pressure Sores. Previously cited 2/11/16. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/23/15, 1/8/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/7/16, 2/11/16, 10/23/15, 7/10/15, 1/8/15.