Every finding on record at Kadima Rehabilitation & Nursing at Latrobe

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment by not maintaining bathrooms including base trim on the floor perimeter in the dining room and resident bathrooms, for two out of 13 residents reviewed (Resident's 8 and 9), and not ensuring that the facility was free of dust, dirt, debris, gnats, flies and dead spiders.Findings include: The facility's policy titled resident environment, dated July 17, 2026, indicated that the facility will provide a safe, clean, comfortable and homelike environment.Observations on August 10, 2026, at 10:42 a.m. in Resident 8's bathroom revealed that there was a metal floor heating unit with a large amount of rust and chipped paint on it, the toilet paper holder was severely pitted/greenish, the bathroom had an odd odor to it, and the base trim behind the toilet was pulling away form the wall. Observations of the [NAME] hall alcove on August 10, 2026, at 10:53 a.m. and 1:45 p.m. revealed that there was a moderate amount of dust, dirt, debris and food pieces along the left wall perimeter. Observations under the dining room window and window sill on August 10, 2026, at 12:00 p.m. and 1:53 p.m. revealed that there was an accumulation of dust, dirt and two dead spiders on the window sill, approximately 20 dead gnats stuck to the wall under the window and approximately three feet of base trim pulled away under the window, with multiple area of chipped paint on the wall under the window.Observations in Resident 7's room on August 10, 2026, at 11:33 a.m. revealed there was a fly on his pillow and approximately three gnats on his overbed stand. Interview with resident 7 at that time indicated that on Sunday evening August 9, 2026, he had approximately 10 gnats in his room by his bed and table. Observations in Resident 9's room on August 10, 2026, at 1:25 p.m. revealed the base trim along the outside wall under the window area was peeled away from the wall and lying on the floor exposing the wall behind it. The resident's daughter indicated that she told someone about the base trim a couple days ago and they were supposed to fix it.Interview with the Nursing Home Administrator on August 10, 2026, at 1:47 p.m. confirmed the base strip was peeled away from the wall and needed repaired.Interview with the Maintenance Director and Director Of Nursing on August 10, 2026, at 2:18 p.m. and 3:30 p.m. respectively, indicated that the peeled away base strip molding in the dining room and residents rooms, chipped paint, dust, dirt, debris and gnats, rusted heating unit and pitted toilet paper holder and bad odor, is not home like and should all be either cleaned or repaired.28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for one of 13 residents reviewed (Resident 12).Findings include: The facility's policy regarding abuse, dated July 17, 2026, indicated that anyone who witnessed an incident of suspected resident abuse, neglect, misappropriation or exploitation was to intervene immediately and stop the abuse. They were to report it to the charge nurse or supervisor immediately. All reports of alleged or suspected abuse must be reported to the Administrator immediately. The physician and responsible party would be notified of the incident/allegation. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 20, 2026, indicated that the resident was moderately cognitively impaired, had behaviors, and had diagnoses that included a stroke and depression. Information reported by the facility, dated July 21, 2026, revealed that on July 21, 2026, at 10:30 a.m. Licensed Practical Nurse 3 reported to the Nursing Home Administrator that on July 12, at 5:00 p.m. Nurse Aide 2 was providing care to Resident 12 and was overheard stated, keep your d**k in your brief. Resident 12 responded, why are you jealous? and Nurse Aide 2 responded back, I will shove it in your mouth, and you can choke on it. During an interview with Resident 12, he stated he was pissing all over the place and the staff member asked if he was putting it in his mouth.There was no documented evidence that the Nursing Home Administrator was notified immediately of the allegation that occurred on July 12, 2026. Interview with the Director of Nursing on August 10, 2026, at 12:46 p.m. confirmed that Licensed Practical Nurse 3 did not immediately report the allegation of verbal abuse to the Nursing Home Administrator. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for one of 13 residents reviewed (Resident 6).Findings include: The facility's policy related to perineal care, dated July 17, 2026, indicated that if the perineum is grossly soiled, turn the resident on side, remove any fecal material with toilet paper, then remove and discard. Change gloves if soiled and continue with perineal care. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 6, dated July 22, 2026, revealed that the resident was cognitively impaired, was usually understood and able to usually understand others, was dependent with toileting hygiene, was always incontinent of bowel, and had diagnoses including paraplegia (loss of movement and feeling in the lower half of the body) and personal history of traumatic brain injury (TBI-brain injury that is caused by an outside force). Observations of Resident 6 on August 10, 2026, at 10:24 a.m. revealed that the resident was lying in bed with dried feces spots on his bed and a suppository bulb lying on his bed. He indicated that he needed to be changed and did not ring for assistance. The resident rang his call bell at 10:26 a.m. and at 10:28 a.m., Nurse Aide 1 and Licensed Practical Nurse 4 responded to the resident's call light. At 10:32 a.m., Nurse Aide 1 gathered supplies to provide incontinent care to Resident 6. Nurse Aide 1 placed two washcloths in the resident's sink, applied soap to the washcloths and then placed the washcloths in a basin of warm water. The basin was brought to the resident's bedside. Nurse Aide 1 applied gloves, Licensed Practical Nurse 4 assisted in rolling the resident onto his right side and Nurse Aide 1 cleaned a gross amount of feces from the resident's buttocks with a washcloth. With the same dirty gloves, he pulled the dirty fitted sheet from the left side of the resident's bed and placed a clean fitted sheet to that side of the bed. He tucked the dirty sheet and dirty bed pad under the resident and tucked the clean sheet and clean bed pad under the resident. Licensed Practical Nurse 4 assisted in rolling the resident on his left side and Nurse Aide 1 cleaned the other side of resident's buttocks and upper right leg that was soiled with feces with a second washcloth. The rest of the dirty linens were removed by Licensed Practical Nurse 4 and placed directly on the floor to the right side of the foot of his bed. The clean fitted sheet and bed pads were then pulled out from under the resident by Licensed Practical Nurse 4 and pulled across the right side of his bed. Nurse Aide 1 dried the resident's buttocks and applied a barrier cream as requested by the resident and the resident then turned onto his back in bed. Nurse Aide 1 obtained a clean pair of underwear with the same pair of dirty gloves and assisted the resident with putting on his clean underwear. Nurse Aide 1 got a plastic bag and placed the dirty linens that were on the floor into the bag. He cleaned the basin, removed his dirty gloves and washed his hands. There were no observations of Nurse Aide 1 changing his gloves after cleaning Resident 6's buttocks with gross amounts of feces, and before handling the resident's clean linens and undergarments. Interview with Nurse Aide 1 on August 10, 2026, at 10:43 a.m. confirmed that he should have changed his dirty gloves after cleaning feces from Resident 6's buttocks and before applying clean linens and undergarments and he did not, and he confirmed that the dirty linens should not have been placed directly on the floor. Interview with the Director of Nursing on August 10, 2026, at 2:11 p.m. confirmed that Nurse Aide 1 should have changed his gloves after performing incontinent care for Resident 6 and prior to applying clean linens and undergarment, and she confirmed that the resident's soiled linens should not have been placed directly on the floor. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment for two of 13 residents reviewed (Residents 2, 4 ), in the East dining room, and in three out of three shower rooms reviewed (East, [NAME] 1 and [NAME] 2). Findings include:The facility's policy titled Resident Environment, dated April 20, 2026, revealed that the policy objective was to provide a safe, clean and homelike environment for residents.Observations of Resident 2 on May 28, 2026, at 10:42 a.m. and at 4:00 p.m. revealed that the resident was sitting up in her bed with the privacy curtain closed. The curtain had multiple areas of stains of different colors and substances.Interview with the Maintenance Supervisor on May 28, 2026, at 4:00 p.m. confirmed that Resident 2's privacy curtain was dirty and not homelike. He explained that staff would contact maintenance that a privacy curtain needed laundry service. Maintenance staff would remove the curtain and then hang a clean curtain.Observations of Resident 4 on May 28, 2026, at 10:32 a.m. and at 2:18 p.m. revealed that the resident was resting in her bed with the facility fan at the foot of her bed. The fan was running and blowing air onto her body. It was noted that the fan had a moderate accumulation of dirt and debris on the grill guard.Observations in the first-floor dining area on May 28, 2026, at 9:45 a.m. revealed that a floor fan was blowing into the kitchen toward a food cart that was in the doorway to the entrance of the kitchen. The food was covered. Observations in the same dining area at 11:45 a.m. revealed that the same fan was now turned and facing into the dining area. There were approximately 10 residents in the dining area and the closest resident was approximately eight feet away from the fan. The residents were not eating at the time. At one point a resident got up and stood in front of the fan to look out the window. The fan was observed to have a very large accumulation of dirt, dust and debris on the grill guard that included a stand of hair that was approximately 13 inches long.Interview with the Assistant Director of Nursing on May 28, 2926, at 1:45 p.m. confirmed that Resident 4's fan and the dining room fan should not have been running in the facility with an accumulation of dirt and debris on them.Observations of shower rooms East, [NAME] 1 and [NAME] 2 at 4:05 p.m., 4:09 p.m. and 4:11 p.m. respectively, revealed that there was a moderate to large amount of a black removable substance noted in the bottom perimeter of the showers, approximately one to ten inches off the shower floor.Interview with the Maintenance Supervisor on May 28, 2026, at 4:15 p.m. confirmed that residents' curtains, fans and shower rooms should always be clean.Interview with the Director of Nursing on May 28, 2026, at 4:37 p.m. confirmed that the resident curtain, fans and shower rooms should have been clean, and they were not.28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on clinical record reviews, resident and staff interviews, it was determined that the facility failed to provide discharge planning for one of 13 residents reviewed (Resident 2) who planned to be discharged to go home.Findings include:A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 6, dated May 1, 2026, revealed that the resident was cognitively intact, could understand, was understood, was independent with bed mobility and required supervision, and was occasionally incontinent of bladder and continent of bowel.Observations and interview of Resident 2 on May 28, 2026, at 10:42 a.m. revealed that the resident was sitting up in her bed. She explained that she was ready to discharge home about six weeks ago, but feels like she was stuck. She has an apartment, she has care givers, she has family to assist her, and she wanted to discharge weeks ago. She did not want to leave against medical advice, because the facility would contact protective services, and she would not be provided necessary equipment or medications. Resident 2 stated that staff came in to discuss her discharge approximately six weeks ago, but then nothing happened. The social worker was not available because she was on leave. She explained that there was no reason she could not go home, and every day her bill was adding up. Interview with the Director of Therapy on May 28, 2026, at 11:07 a.m., revealed that Resident 2 has poor therapy participation, however she goes on leave of absence with her family without concern. He does not believe that the resident has a place to go, so he was not aware of any future discharge at the time.Interview with the Social Services Director on May 28, 2026, at 2:00 p.m. and 3:35 p.m., revealed that she met with Resident 2 in January, 2026 and the resident did not want to discharge at that time. She was asked to see Resident 2 with another staff member on April 17, 2026. Discharge planning was started at that time and nursing was notified to do oxygen testing. The Social Services Director revealed that she was on leave around April 25, 2026. She confirmed that Resident 2 has an apartment.There was no documented evidence in Resident 2's clinical record to indicate that any discharge planning was completed by Social Services in April 2026, when Resident 2 indicated that she was ready to discharge. A follow-up interview with Resident 2 on May 28, 2026, at 1:31 p.m. revealed that she was being discharged on June 5, 2026.Interview with the Nursing Home Administrator on May 28, 2026, at 3:40 p.m. confirmed that there was no documented evidence of discharge planning in Resident 2's clinical record until May 28, 2026.28 Pa. Code 211.10.Resident care polices

Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by providing a food item the resident was allergic to for one of three residents reviewed (Resident 1), which resulted in an anaphylactic reaction requiring hospitalization.Findings include:The facility's abuse/neglect policy, dated August 13, 2025, indicated that each resident had the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment of care, including but not limited to nutrition medication, therapies, and activities of daily living.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 2, 2026, revealed that the resident was cognitively impaired and could eat independently. An allergy report, dated October 31, 2025, indicated that Resident 1 had an allergy to tree nuts. There was no documented evidence that Resident 1's care plan included the resident's allergy to tree nuts until April 5, 2026,A nursing note for Resident 1, dated April 4, 2026, revealed that at 5:00 p.m. Registered Nurse 3 was notified that the resident had an emesis after being given chocolate and exhibited seizure like activity. Upon being returned to bed, the resident complained of abdominal pain. The resident was assessed by the registered nurse and had no stridor, facial swelling, or shortness of breath. The resident abdomen was distended and firm, and he was lethargic with a fixed stare. His respirations were shallow, he had a pulse oximetry (measures the amount of oxygen in your blood) 90% (normal is 95-100%), and 2 liters of oxygen was applied via nasal cannula (plastic tube that supplies oxygen through the nose). EMS (Emergency Medical Service) arrived and transported the resident to the hospital.Hospital records, dated April 4, 2026, revealed that the resident had a chocolate covered peanut and he did have a peanut allergy. He started developing facial swelling and shortness of breath, and was altered and short of breath upon EMS arrival. Upon transferring the resident to the stretcher, he became unresponsive and was given IM (intramuscular) epinephrine (medication used to reverse severe allergic reactions), his pulses were lost, CPR was started, and he was intubated (procedure that involves passing a tube into a person's airway to help a person breathe.) in the field. The resident was given epinephrine four more times. Upon arrival to the emergency department another ampule of epinephrine as well as Benadryl (medication used to treat allergic reactions) were given. Given the fact that the resident was on an epinephrine infusion, as well as intubated and on a ventilator, he was admitted . He was also given Solumedrol (corticosteroid used to help reduce inflammation and help with allergic reactions) intravenously. A Tryptase laboratory test (commonly used to assess mast cell activity, which plays a key role in allergic reactions and other immune responses), ordered April 4, 2026, and collected April 5, 2026, revealed that the result was 19.7 micrograms/Liter (mcg/L) (normal is less than 11mcg/L). His diagnoses were cardiac arrest, acute respiratory failure, and anaphylactic reaction (potentially life-threatening allergic reaction).A witness statement for Nurse Aide 1, dated April 4, 2026, revealed that she offered Resident 1 a piece of chocolate for Easter, not realizing it contained tree nuts. This led her to mistakenly believe that the chocolate was safe. Around ten minutes later the resident was noted to have seizure like activity in the hallway and was throwing up chocolate. She was aware of the documented allergy to tree nuts, however, was confused because she had previously seen him consuming peanut butter products such as [NAME] bars and peanut butter and jelly sandwiches that came from dietary staff without issue. At that time she became aware of the potential risks and notified the nurse on the unit. She wondered if the chocolate that she gave contained a nut due to him throwing up the chocolate and being very ill.A witness statement for Licensed Practical Nurse 2, dated April l4, 2026, revealed that the resident had a light brown emesis and stated that his stomach hurt. The registered nurse Supervisor was notified. The resident fell back into a chair and started having seizure like activity. Nurse Aide 1 reported that she had given the resident [NAME] chocolate. While the nurse was getting vital signs, the resident became more lethargic and harder to arouse. The resident's vital signs were: blood pressure- 100/68, pulse-113, respirations-20, temperature- 97.8 degrees Fahrenheit, and his pulse oximetry was 68% on room air. Oxygen was placed on the resident at 4 liters per minute and EMS arrived at that time.A review of the [NAME] Collection of Assorted [NAME] Chocolates packaging indicated that [NAME]- contained premium hazelnut and milk chocolate (contains tree nuts), Raffaello- contained crispy, creamy coconut and almonds (contains tree nuts), and Rondnoir- contained fine wafer, creamy cocoa filling, and dark chocolate heart (may contain tree nuts).Interview with the Director of Nursing on April 23, 2026, at 12:50 p.m. confirmed that at the time of the incident, Nurse Aide 1 was aware of Resident 1's allergy to tree nuts; however, provided the resident a piece of chocolate that contained a possible allergen and should not have.Interview with the Director of Nursing on May 8, 2026, at 2:32 p.m. revealed that Nurse Aide 1 gave Resident 1 a piece of chocolate candy from a [NAME] assortment box. She was unable to identify which one she gave to Resident 1.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(10 Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were not provided with foods that they were allergic to for one of three residents reviewed (Resident 1), resulting in an allergic reaction for the resident. This deficiency was cited as past non-compliance.Findings include:The facility's policy regarding a nutrition assessment, dated August 13, 2025, indicated that a nutrition assessment would be completed for each resident admitted to the facility. A nutrition assessment would be completed and include the following information: weight, height, hematologic data, nutritional intake, eating habits, food preferences and dislikes, dietary restrictions, diagnoses, other information deemed appropriate and necessary, and food allergies.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 2, 2026, revealed that the resident was cognitively impaired and could eat independently. An allergy report, dated October 31, 2025, indicated that Resident 1 had an allergy to tree nuts. There was no documented evidence that Resident 1's care plan included the resident's allergy to tree nuts until April 5, 2026,A nursing note for Resident 1, dated April 4, 2026, revealed that at 5:00 p.m. the Registered Nurse 3 was notified that the resident had an emesis after being given chocolate and exhibited seizure like activity. Upon being returned to bed, the resident complained of abdominal pain. The resident was assessed by the registered nurse and had no stridor, facial swelling, or shortness of breath. The resident abdomen was distended and firm, and he was lethargic with a fixed stare. His respirations were shallow, he had a pulse oximetry (measures the amount of oxygen in your blood) 90% (normal is 95-100%), and 2 liters of oxygen was applied via nasal cannula (plastic tube that supplies oxygen through the nose). EMS (Emergency Medical Service) arrived and transported the resident to the hospital.Hospital records, dated April 4, 2026, revealed that the resident had a chocolate covered peanut and he did have a peanut allergy. He started developing facial swelling and shortness of breath, and was altered and short of breath upon EMS arrival. Upon transferring the resident to the stretcher, he became unresponsive and was given IM (intramuscular) epinephrine (medication used to reverse severe allergic reactions), his pulses were lost, CPR was started, and he was intubated (procedure that involves passing a tube into a person's airway to help a person breathe.) in the field. The resident was given epinephrine four more times. Upon arrival to the emergency department another ampule of epinephrine as well as Benadryl (medication used to treat allergic reactions) were given. Given the fact that the resident was on an epinephrine infusion, as well as intubated and on a ventilator, he was admitted . He was also given Solumedrol (corticosteroid used to help reduce inflammation and help with allergic reactions) intravenously. A Tryptase laboratory test (commonly used to assess mast cell activity, which plays a key role in allergic reactions and other immune responses), ordered April 4, 2026, and collected April 5, 2026, revealed that the result was 19.7 micrograms/Liter (mcg/L) (normal is less than 11mcg/L). His diagnoses were cardiac arrest, acute respiratory failure, and anaphylactic reaction (potentially life-threatening allergic reaction).A witness statement for Nurse Aide 1, dated April 4, 2026, revealed that she offered Resident 1 a piece of chocolate for Easter, not realizing it contained tree nuts. This led her to mistakenly believe that the chocolate was safe. Around ten minutes later the resident was noted to have seizure like activity in the hallway and was throwing up chocolate. She was aware of the documented allergy to tree nuts, however, was confused because she had previously seen him consuming peanut butter products such as [NAME] bars and peanut butter and jelly sandwiches that came from dietary staff without issue. At that time she became aware of the potential risks and notified the nurse on the unit. She wondered if the chocolate that she gave contained a nut due to him throwing up the chocolate and being very ill.A witness statement for Licensed Practical Nurse 2, dated April l4, 2026, revealed that the resident had a light brown emesis and stated that his stomach hurt. The registered nurse Supervisor was notified. The resident fell back into a chair and started having seizure like activity. Nurse Aide 1 reported that she had given the resident [NAME] chocolate. While the nurse was getting vital signs, the resident became more lethargic and harder to arouse. The resident's vital signs were: blood pressure- 100/68, pulse-113, respirations-20, temperature- 97.8 degrees Fahrenheit, and his pulse oximetry was 68% on room air. Oxygen was placed on the resident at 4 liters per minute and EMS arrived at that time.A review of the [NAME] Collection of Assorted [NAME] Chocolates packaging indicated that [NAME]- contained premium hazelnut and milk chocolate (contains tree nuts), Raffaello- contained crispy, creamy coconut and almonds (contains tree nuts), and Rondnoir- contained fine wafer, creamy cocoa filling, and dark chocolate heart (may contain tree nuts).Interview with the Director of Nursing on April 23, 2026, at 12:50 p.m. confirmed that at the time of the incident, Nurse Aide 1 was aware of Resident 1's allergy to tree nuts; however, provided the resident a piece of chocolate that contained a possible allergen and should not have.Interview with the Director of Nursing on May 8, 2026, at 2:32 p.m. revealed that Nurse Aide 1 gave Resident 1 a piece of chocolate candy from a [NAME] assortment box. She was unable to identify which one she gave to Resident 1.Following identification that Resident 1 was provided a piece of chocolate candy that caused him to have an allergic reaction and transfer to the hospital, the facility's corrective actions included:The facility transferred Resident 1 to the hospital for further evaluation and treatment. His care plan was updated to include a high risk allergy to tree nuts with an anaphylactic reaction. Dietary slips were sent to the kitchen to identify tree nuts as a high risk allergy.An audit was performed of all residents that had food allergies. Care plans were reviewed and updated with high risk food allergies and new dietary slips were sent to the kitchen identifying all high risk allergies.A system change of adding high risk food allergies to the Kardex was initiated. Education was provided to staff on food allergy safety, including referring to the Kardex, dietary slips, and care plans. Staff were not to provide any outside food until the food allergies and safety were approved by the nurse.Audits were completed daily for two weeks, then weekly for four weeks, then monthly for three months to ensure staff were following the allergy policy. Results of the audits would be reviewed by the QAPI committee.A review of the facility's corrective actions revealed that the facility was in compliance with F806 on April 8, 2026.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(10 Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect residents' food allergies for one of three residents reviewed (Resident 1). Findings include:The facility's policy regarding care plans, dated August 13, 2025, indicated that the resident would be reassessed at least quarterly, and the care plan would be reviewed by the interdisciplinary team. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 2, 2026, revealed that the resident was cognitively impaired and could eat independently. An allergy report, dated October 31, 2025, indicated that Resident 1 had an allergy to tree nuts.A nursing note for Resident 1, dated April 4, 2026, revealed that at 5:00 p.m. the Registered Nurse 3 was notified that the resident had an emesis after being given chocolate and exhibited seizure like activity. Upon being returned to bed, the resident complained of abdominal pain. The resident was assessed by the registered nurse and had no stridor, facial swelling, or shortness of breath. The resident abdomen was distended and firm, and he was lethargic with a fixed stare. His respirations were shallow, he had a pulse oximetry (measures the amount of oxygen in your blood) 90% (normal is 95-100%), and 2 liters of oxygen was applied via nasal cannula (plastic tube that supplies oxygen through the nose). EMS (Emergency Medical Service) arrived and transported the resident to the hospital.However, there was no documented evidence that Resident 1's care plan was updated to include the resident's allergy to tree nuts until April 5, 2026, which included: food allergies would be included on the dietary slip, Medication Administration Record (MAR) and Kardex, give epinephrine right away and note the time it was given, and no food would be given to the resident until verified by the nurse to ensure that there are no food allergens.Interview with the Director of Nursing on April 23, 2026, at 12:50 p.m. confirmed that Resident 1's care plan was not updated to include food allergies prior to the incident.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that central venous catheters were flushed per facility policy for three of 45 residents reviewed (Resident 64, 91, 107).Findings include:The facility's policy regarding flushing central venous (midline) catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated August 13, 2025, indicated that the catheter was to be flushed before and after it was used to administer medication and was to be documented in the medical record.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated December 29, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs and was receiving care after joint replacement surgery. Physician's orders for Resident 64 dated March 14, 2026, included for the resident to receive two grams of Cefazolin (an antibiotic) intravenously every eight hours for aftercare following joint replacement surgery for six weeks. Review of the Medication Administration Record (MAR) for Resident 64 dated March 2026, revealed that two grams of Cefazolin was administered every eight hours from March 14 at 8:00 a.m. through March 19 at 8:00 a.m., however there was no documented evidence that the residents PICC (Peripherally Inserted Central Catheter- a long, thin, flexible tube inserted into a peripheral vein, usually in the upper arm, and threaded to a large vein near the heart) was flushed before and after the administration of the antibiotic. Interview with the Director of Nursing on March 19, 2026, at 10:58 a.m. revealed that there was no documented evidence that Resident 64's central venous catheter was flushed before and after the administration of medication. A quarterly MDS assessment for Resident 91, dated March 3, 2026, revealed that the resident was cognitively intact, was independent with his daily care needs and had a diagnosis of pneumonia (infection that inflames the air sacs of the lungs).Physician's orders for Resident 91, dated February 25, 2026, included orders for 1 gram (gm) of Vancomycin (an antibiotic) to be administered intravenously once a day for pneumonia.Review of Resident 91's Medication Administration Records (MAR's) for February and March 2026 revealed no documented evidence that Resident 91's midline catheter was flushed before and after the administration of the antibiotic.A nursing note for Resident 107, dated March 11, 2026, at 5:00 p.m. revealed that the resident was a new admission, was cognitively intact, required assistance for her daily care needs and had a diagnosis of pneumonia.Physician's orders for Resident 107, dated February 12, 2026, included orders for 500 milligrams (mg) of Vancomycin (an antibiotic) to be administered intravenously once a day for pneumonia.Review of Resident 107's MAR for March 2026 revealed no documented evidence that Resident 91's midline catheter was flushed before and after the administration of the antibiotic.Interview with the Director of Nursing on March 18, 2026, at 2:33 p.m. confirmed that there was no documented evidence that Residents 91 and 107's midline catheter was flushed before and after the administration of medication.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 45 residents reviewed (Resident 72).Findings include:The facility policy for the flow of care dated April 15, 2025, indicated that care will be provided to residents, as needed 24 hours a day to attain and maintain the highest level of functioning. The provision of targeted care needs shall be documented on Care Tracker/Point of Care/ADL Flow Records. The charge nurse and/or the unit manager will be responsible for evaluating compliance with flow of care expectations and providing education or intervention as needed to assure the needs are met on an ongoing basis. Step 11 in the flow of care for evening shift includes providing baths and showers. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 72 , dated January 19, 2026, indicated that the resident was able to make himself understood and was able to understand others, required assistance from staff for daily care needs including showering, and had a diagnosis of dementia. Care plan for Resident 72 dated September 17, 2025, indicated that the resident had a self-care performance deficit related to dementia, he requires staff participation with bathing, and was to get showers twice weekly on daylight shift. A review of the nurse aide bathing documentation for Resident 72 dated December 2025, January 2026, February 2026, and March 2026, revealed that the resident preferred Wednesday and Saturday evening showers and the resident may refuse showers. If he refuses, educate and document the refusal and then offer a bed bath. Documentation revealed that the resident received bed baths on December 6, 10, 13, 17, 24, 27, and 31, January 24. There was no evidence that the resident was offered or refused a shower on these dates. Review of the bathing documentation also revealed that on January 7, 14, 17, and 21, and February 11 and 25, the shower was documented as not applicable. There was no evidence that the resident was offered, provided or refused a shower on these dates. There was no documentation that a shower was offered, provided or refused on March 7. An interview with Resident 72 on March 16, 2026, at 10:15 a.m. revealed that the resident was not always offered a shower twice a week and does not recall refusing showers. Interview with the Director of Nursing on March 19, 2026, at 11:09 a.m. revealed there was no documented evidence that Resident 72 was offered or provided showers according to his care schedule during the above-mentioned dates.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies, manufacturer's prescribing information, facility's medications not to be crushed list, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent. Findings include: The facility's policy regarding medication administration, dated August 13, 2025, revealed that medications were to be administered in accordance with good nursing principles and practices and in order to ensure the safe, accurate and timely administration of medications. All drugs, devices and related materials will be administered in accordance with federal and state laws and regulated.The facility's list of medications not to be crushed, revised August 13, 2025, revealed that metformin extended release (ER), Myrbetriq ER, and propranolol hydrochloride (HCL) were not be crushed.Physician's orders for Resident 32, dated January 17, 2025, included an order for the resident to receive 20 milligrams (mg) Propranolol hydrochloride (HCL) three times a day, an order dated October 30, 2025 for the resident to receive 500 mg Metformin hydrochloride extended release (ER) two times a day, and an order dated December 13, 2025 for the resident to receive 25 mg Myrbetriq one time a day.Observations of medication administration for Resident 32 on March 19, 2026, at 08:45 a.m. revealed that Licensed Practical Nurse 9 prepared the resident's medication, including propranolol HCL, metformin ER, and Myrbetriq ER, by crushing them and then proceeded to administer the crushed medications to the resident. Interview with Licensed Practical Nurse 9 on March 19, 2026, at 08:50 a.m. revealed that she was unaware that she should not crushed the propranolol HCL, metformin ER, or the Myrbetriq ER and that the medication package should have indicated do not crush for any medication that is not to be crushed. Interview with the Director of Nursing on March 19, 2026 at 11:35 a.m. revealed that the medication package should have said do not crush, and that the nurse should not have crushed them.Facility policy regarding specific medication administration procedures for oral inhalation administration, dated August 13, 2025 indicated that when administering a steroid inhalers staff are to provide the resident with cup of water and instruct them to rinse their mouth and spit the water out.The Manufacturer's prescribing information for Breo Ellipta, a sterioid inhaler, dated May 2023, indicated that Breo Ellipta can cause serious side effects, including fungal infection in your mouth or throat (thrush). The user should rinse their mouth with water without swallowing after using Breo Ellipta to reduce your chance of getting thrush.Physician's orders for Resident 88, dated September 7, 2025, included an order for the resident to receive 100-25 micrograms per actuation (mcg/act) Breo Ellipta inhalation aerosol powder once a day.Observations of medication administration for Resident 88 on March 17, 2026, at 9:30 a.m. revealed that Licensed Practical Nurse 10 administered the Breo Ellipta inhaler, but did not offer for the resident to rinse his mouth after use.Interview with Licensed Practical Nurse 10 revealed that she did not offer Resident 88 to rinse and spit after administering the Breo Ellipta, and she should have. Interview with the Director of Nursing on March 19, 2026 at 9:58 a.m. revealed that Licensed Practical Nurse 10 should have offered for Resident 88 to rinse his mouth after use of the inhaler.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain resident dignity for one of 45 residents reviewed (Residents 27). Findings include:The facility's policy titled personal privacy, dated August 13, 2025, indicated that the facility staff will treat residents in a manner that maintains the privacy of their bodies. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 20, 2026, revealed that the resident was sometimes understood, sometimes understood others, was moderately cognitively impaired, and required assistance from staff for daily care needs.Observations of Resident 27 on March 17, 2026, at 3:15 p.m. revealed that he was sitting in a wheeled shower chair while staff pushed him approximately 30 feet from the shower room down the first floor hall to his room. Resident 27 had a folded sheet/blanket across his lap, his chest, back, upper thighs and legs were exposed. Interviews with Nurse Aide 1 and the Regional Clinical Consultant 2 on March 17, 2026, at 3:23 p.m., indicated that he should not have transferred the resident through the hall with only a folded sheet on his lap leaving most of his body exposed. Interview with the Nursing Home Administrator on March 17, 2026, at 3:50 p.m., indicated that staff should have provided for Resident 27's dignity as he was transferred threw the hall, and they did not. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plan of corrections for an annual survey ending December 10, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 19, 2026, identified repeated deficiencies related to quality care, IV fluids, and labeling drugs.The facility's plan of correction for a deficiency regarding accurate MDS assessments, cited during the survey ending December 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided.The facility's plan of correction for a deficiency regarding development of care plans, cited during the survey ending December 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F694, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's IV fluids were administered appropriately.The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending December 10, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that drugs were labeled appropriately.Refer to F684, F694, F761.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on a review of the facility policies, the facility's list of medications that are not to be crushed, as well as observations and staff interviews, it was determined that the facility failed to label medications with the appropriate instructions for administration for one of 45 residents reviewed (Resident 32).Findings include:The facility's policy regarding medication administration, dated August 13, 2025, revealed that medications were to be administered in accordance with good nursing principles and practices and in order to ensure the safe, accurate and timely administration of medications. All drugs, devices and related materials will be administered in accordance with federal and state laws and regulated.The facility's list of medications not to be crushed, revised August 13, 2025, revealed that propranolol HCL, metformin hydrochloride (HCL) extended release (ER), and Myrbetriq ER were not be crushed.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated February 3, 2026, revealed that the resident was cognitively impaired, required assistance from staff for all his daily care needs, and had diagnoses that included diabetes, overactive bladder, and heart disease. Physician's orders for Resident 32, dated January 17, 2025, included an order for the resident to receive 20 milligrams (mg) Propranolol HCL three times a day, an order dated October 30, 2025 for the resident to receive 500 mg Metformin HCL ER two times a day, and an order dated December 13, 2025 for the resident to receive 25 mg Myrbetriq ER on e time a day.Observations of medication administration for Resident 32 on March 19, 2026, at 08:45 a.m. revealed that Licensed Practical Nurse 9 prepared the resident's medication, including propranolol HCL, metformin HCL ER, and Myrbetriq ER, by crushing them and then proceeded to administer the crushed medications to the resident. Interview with Licensed Practical Nurse 9 on March 19, 2026, at 08:50 a.m. revealed that she was unaware that she should not crushed the propranolol HCL, metformin HCL ER, or the Myrbetriq ER and that the medication package should have indicated do not crush for any medication that is not to be crushed and those ones did not. Interview with the Director of Nursing on March 19, 2026 at 11:35 a.m. revealed that the medication package should have said do not crush, however, the pharmacy does not label the medications do not crush until the physician orders that. 28 Pa. Code 211.9(a)(1) Pharmacy services

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 45 residents reviewed (Resident 42). Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated December 12, 2025, revealed that the resident was cognitively impaired and required extensive assistance from staff for care. Observations on March 18, 2026 at 9:30 a.m. revealed that Nurse Aide 8 pushed resident 42 from her room out into the hallway with her legs dangling and no leg rests on the chair.Interview with Nurse Aide 8 on March 18, 2026 at 9:30 a.m. revealed that she pushed Resident 42 without leg rests because she could not find any in the resident's closet.Interview with the Director of Nursing on March 18, 2026 at 11:35 a.m. confirmed that Resident 42 should have had leg rests on her wheelchair while being transported. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for one of 45 residents reviewed (Resident 3).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 7, 2026, revealed that the resident was cognitively impaired and was frequently incontinent of bowel movements. Physician's orders for Resident 3, dated January 2, 2026, included orders for the resident to receive 4 ounces of prune juice as needed for no bowel movement in two days and was to be administered every shift until the resident had a bowel movement; 30 milliliters of Milk of Magnesia as needed for no bowel movements for three days; a 10 milligram bisacodyl suppository rectally as needed for no bowel movement for four days; and a Fleets enema to be given rectally as needed if the resident did not have a bowel movement in 12 hours after the bisacodyl suppository.Review of Resident 3's bowel records for February 2026 revealed that there was no documented evidence that the resident had a bowel movement from February 2 through 6 and February 15 through 20, 2026. Review of the February 2026 MAR's for Resident 3 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician. Interview with the Director of Nursing on March 19, 2026, at 10:58 a.m. confirmed that the physician's orders for bowel medications were not followed for Resident 3. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for two of 45 residents reviewed (Resident's 65 and 72). Findings include:The facility's policy regarding care plans, dated [DATE], indicated that nursing staff and/or the interdisciplinary team were to initiate and/or update care plans for the resident as warranted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated February 3, 2026, indicated that the resident was moderately cognitively impaired, required extensive assistance from staff for daily care tasks, and had diagnoses that included cerebral palsy and intellectual disorders.A review of Resident 65's clinical record revealed that from the date of her admission, [DATE], until [DATE], the resident was a Full Code (provide cardiopulmonary resuscitation (CPR). On [DATE], her code status was changed to Do Not Resuscitate (do not provide cardiopulmonary resuscitation). On February 17, 2026, the resident experienced shortness of breath, congestion and an increased heart rate. The resident's mother was updated regarding her change in condition and verbally changed her daughters No Code status to Full Code. The resident was transferred to the hospital where she was admitted . A review of Resident 65's Provider Orders for Life Sustaining Treatments (POLST) revealed that on [DATE], the Nurse practitioner and resident's mother signed the form stating the resident was a Full Code Physician's orders regarding advanced directives for Resident 65, dated [DATE], indicated that she was a Full Code (provide cardiopulmonary resuscitation if she ceases to breath).Resident 65's current care plan, revised [DATE], indicated that the resident's code status was Do Not Resuscitate.Interview with the Licensed Practical Nurse Assessment Coordinator 7 on [DATE], at 10:29 a.m. confirmed that resident 65's care plan was not updated when her health status changed and/or when the POST was signed on [DATE].Interview with the Director of Nursing on [DATE], at 10:45 a.m. confirmed that Resident 65's care plan was not updated to reflect the current code status which is a full code, and it should have been. A quarterly MDS assessment for Resident 72 dated [DATE], indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnosis that included dementia. Care plan for Resident 72 dated [DATE], indicated that the resident was taking antipsychotic (medication used for the treatment and management of symptoms associated with various psychiatric disorders) medication for management of dementia with behaviors. An intervention dated [DATE], included that the resident was to be checked every 15 minutes related to physical aggression. There was no documented evidence that 15-minute checks were being completed. Care plan for Resident 72 dated [DATE], indicated that the resident was at risk for inappropriate verbal and physical aggressive behaviors related to dementia and an intervention dated [DATE], included that the resident was to have one-on-one observation(continuous monitoring of a patient by a staff member to ensure safety) related to increased anxiety. There was no documented evidence that one-on-one observation was being completed. An interview with the Director of Nursing on [DATE], at 11:09 a.m. confirmed that Resident 72 was no longer receiving checks every 15 minutes and was no longer receiving one-on-one observation, however the care plan was not revised when these interventions were resolved and should have been. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment by not maintaining ceiling heating ventilation and air conditioning units (HVAC), and not providing a clean wheelchair for one of 45 residents reviewed (Residents 5). Findings include: The facility's policy titled resident rights, dated August 13, 2025, indicated that the resident has a right to a safe, clean, comfortable and homelike environment.Observations on March 16, 2026 at 9:58 a.m. of the East Hall heating and air conditioning unit revealed that the unit had a thick layer of dust accumulated on the filters and that it was making a rattling noise. Observations of the [NAME] 1 hall heating and air conditioning unit on March 16, 2026 at 10:42 a.m. revealed that the unit had a thick layer of dust on the filters.Observations of the [NAME] 2 hall heating and air conditioning unit revealed that there was a thick layer of dust on the filters and that the filters were hanging out of the unit.Interview with the Maintenance Director on March 18, 2026 at 9:22 a.m. revealed that the heating and air conditioning units needed cleaned. He stated that he cleans them monthly, however, that the filters needed vacuumed. Observations of Resident 5's wheelchair on March 19, 2026, at 12:41 p.m. revealed that the metal frame and the top of the back rest cushion had a large amount of brownish/white removable dust on it.Interview with the Maintenance Assistant 3 on March 19, 2026, at 12:50 p.m. indicated that he thought housekeeping cleaned the chairs. Interview with the Nurse Aide 4 on March 19, 2026, at 12:58 p.m. confirmed that Resident's 5's wheelchair was dirty and should have been cleaned. He revealed that the facility used to have a staff member that was responsible for hosing them down outside, but about a year or two ago he left, and now I don't see anyone doing that anymore.Interview with Housekeeping Employee 5 on March 19, 2026, at 1:07 p.m. indicated that they clean frequently used touch points, night stands, bed frames, over the bed lights window ceils, trash cans and the bathroom. She indicted that if she was deep cleaning a room and saw a wheelchair was dirty then she would clean it.Interview with the Van Driver/Floor Technician 6 on March 19, 2026, at 1:15 p.m. indicated that he drove the van and was responsible for cleaning and maintaining the floors, he indicated that he thought possibly that the night nurse aides cleaned the chairs. Interview with the Assistant Director of Nursing on March 19, 2026, at 1:25 p.m. confirmed that the maintenance department and housekeeping share the responsibility of maintaining the cleanliness of the facility wheelchairs. She indicated that the removable dust, dirt and debris on Resident 5's wheelchair should not have been there, and it should have been cleaned. 28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of five residents reviewed (Residents 2,3,5).Findings include: The facility's policy regarding medication administration, dated May 14, 2025, indicated that nursing staff who administer medications to residents shall record and sign on the individual medication record of each resident the medication, dosage and time the medication was administered. Documentation is to be done immediately after the administration. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 20, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was at risk for pain related to spinal stenosis and discitis (inflammation and infection in the disc space in the spine).Physician's orders for Resident 2, dated October 20, 2025, included an order for the resident to receive 5-325 mg of Percocet (a narcotic pain medication) every six hours as needed for chronic back pain.Review of the controlled drug record for Resident 2, dated October 2025, revealed that one 5-325 mg tablet of Percocet was signed out on October 24, 2025, at 3:30 p.m. and October 25, 2025, at 9:00 a.m. However, there was no documented evidence in Resident 2's clinical record, including the MAR, that the signed-out doses of Percocet were administered to the resident on the above-mentioned dates and times. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 27, 2025, revealed that the resident was cognitively intact, required assistance for care needs, was at risk for pain related to spinal stenosis and diabetic neuropathy, was recently admitted to hospice, and was taking an opioid medication (medications with the potential to be abused, used to treat pain).Physician's orders for Resident 3, dated January 10, 2026, included an order for the resident to receive 10 milligrams (mg) of Morphine (a narcotic pain medication) under the tongue, every two hours as needed, for pain or respiratory distress.Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 3, dated January, 2026, revealed that a 10 mg tablet of Morphine was signed out on January 10 at 8:00 a.m., 1200 p.m. and 4:00 p.m. However, there was no documented evidence in Resident 3's clinical record, including the Medication Administration Record (MAR), that the signed-out doses of Morphine were administered to the resident on the above-mentioned dates and times. An admission MDS assessment for Resident 5, dated December 29, 2025, revealed that the resident was cognitively intact, had pain occasionally, was taking a routine and as needed pain medication, and was taking an opioid medication.Physician's orders for Resident 5, dated December 29, 2025, included an order for the resident to receive 5-325 mg of Percocet (a narcotic pain medication) every 12 hours as needed for pain.Review of the controlled drug record for Resident 5, dated December 2025 and January 2026, revealed that one 5-325 mg tablet of Percocet was signed out on December 28, 2025, at 6:15 p.m. and January 5, 2026, at 10:30 a.m. However, there was no documented evidence in Resident 5's clinical record, including the MAR, that the signed-out doses of Percocet were administered to the resident on the above-mentioned dates and times.Interview with the Director of Nursing on January 14, 2026, at 3:57 p.m. confirmed that there was no documented evidence in Residents 2, 3 and 5's clinical records to indicate that the signed-out doses of narcotics were administered to the residents on the above-mentioned dates and times.28 Pa. Code 211.9(a)(1) Pharmacy Services.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for two of 33 residents reviewed (Residents 4 and 84). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of paraplegia (the partial or complete paralysis of the lower half of the body, including both legs), and had an ostomy (a surgically created opening in the abdomen- part of the body between the chest and the hips). Care plan for Resident 4 dated September 11, 2025, indicated that the resident had a colostomy (opening on your abdomen that connects your colon (large intestine) to the outside of your body) and staff were to change the colostomy appliance as necessary. A nurse's note for Resident 4, dated October 30, 2025, at 11:59 p.m. indicated that the resident had soft brown stool noted in his colostomy. Review of physician's orders and treatment administration records for Resident 4 revealed there was no documented evidence that colostomy care was being provided to the resident. Interview with the Nursing Home Administrator on November 5, 2025, at 11:25 a.m. confirmed that there was no documented evidence that colostomy care was being provided to Resident 4. Review of the clinical record for Resident 84 indicated that he was admitted to the facility on [DATE]. Physician's orders for Resident 84, dated October 28, 2025 included an order for the resident to have ostomy care every shift. Observations of Resident 84 on November 3, 2025, at 11:08 a.m. revealed that the resident had a colostomy bag in place. He stated the staff usually empty the bag at least once a shift, but sometimes he has to ask them to do so sooner. There was no physician's order for changing the ostomy appliance or emptying the colostomy for Resident 84. There was no care plan in place for Resident 84's colostomy. Interview with the Director of Nursing on November 6, 2025, at 2:41 p.m. confirmed that there were no physician's orders in place regarding changing the colostomy appliance or emptying the colostomy. There was also no care plan in place for the colostomy and there should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained as free from accident hazards as possible for one of 12 residents reviewed (Resident 1) who used a wheelchair, resulting in a fracture. Findings include: The facility's transportation policy, dated November 24, 2024, revealed that all employees who operate a vehicle would receive, upon hire, training in bus/van policies, procedures, and operations. Additionally training was to be provided on a regular basis. Both staff clients were to wear a seatbelt at all times when the vehicle was in operation and clients in wheelchairs were to be secured with the use of wheelchair locks, as well as either a lap belt or shoulder safety belt. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 29, 2024, revealed that the resident was cognitively intact, had limited range of motion to her upper and lower extremities, used a wheelchair, received dialysis services, and had diagnoses that included renal failure. The resident's care plan, dated November 26, 2024, revealed that she required dialysis on Mondays, Wednesdays, and Fridays. A nursing note, dated December 24, 2024, at 9:20 a.m. revealed that Resident 1's wheelchair tipped over backwards while in the facility's van. On assessment by the Director of Nursing and the Registered Nurse Supervisor, Resident 1 was already returned to the upright position and being secured to the van. Resident 1 stated that her chest hurt and that her knees hit her in the chest when she tipped over backwards. She refused any further assessment and requested to go ahead to dialysis. At 11:31 a.m., dialysis sent the resident to the local hospital for further evaluation and treatment. Hospital records, dated December 24, 2024, revealed Resident 1 reported that she was on her way to dialysis via a wheelchair van and when they attempted to start moving, her wheelchair was not locked into place and she was ejected from her wheelchair. Her knees subsequently struck her chest, specifically her sternal (bone located in center of the chest) area. She admitted to a marked amount of sternal pain since then. A CT scan (diagnostic test) report revealed that the resident had an age indeterminate, possibly chronic, sternal fracture deformity. This was to be correlated clinically at the point of tenderness in this location. Hospital records revealed that the resident was made aware of the concerning CT scan findings for a sternal fracture and she was agreeable to transfer. Given the traumatic findings found on the scan as well as the need for emergent dialysis, she required a transfer. Resident 1 was transferred as a Level 2 trauma (a patient with a traumatic injury that is considered potentially life-threatening, meaning they have significant injuries but are currently stable with vital signs within normal ranges, requiring immediate specialized care at a Level 2 trauma center) to a hospital in Pittsburgh. A review of hospital records from Pittsburgh, dated December 24, 2024 through January 2, 2025, revealed that Resident 1 was admitted to ICU for acute respiratory insufficiency requiring significant respiratory support, treatment for a sternal fracture, and dialysis. Information submitted by the facility, dated December 24, 2024, revealed that Resident 1 was being transported to her dialysis appointment in the facility van and when the van was pulling out of the driveway, which had a slight upward grade, Resident 1's wheelchair tipped backwards causing the resident to hit her head. She reported that her chest hurt from her knees coming up and hitting her chest. Resident 1 stated that she was okay and was transported to dialysis. The facility received a call from dialysis that they were sending Resident 1 to the hospital for evaluation and treatment and that the resident sustained a sternal fracture. The facility's investigation dated December 24, 2024, revealed that the straps to hold Resident 1's wheelchair in place were not secured properly. A statement from Nurse Aide 2, dated December 24, 2024, revealed that when the transport van went to pull out of the parking lot she heard a loud noise, and when she looked back she saw that Resident 1's wheelchair tipped backwards. The resident stated that her chest hurt from her knees hitting her chest. A statement from Van Driver 3, dated December 24, 2024, revealed that when he was hooking up Resident 1's wheelchair to the back chair locks, he got distracted when someone asked about hooking up their seat belt, and he did not lock the front of Resident 1's wheelchair to the chair holders. An interview with the Director of Nursing on December 30, 2024, at 12:29 p.m. confirmed that Van Driver 3 did not lock Resident 1's wheelchair properly, which resulted in her falling backwards. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, job descriptions, staff education records, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect while being transported to dialysis for one of 12 residents reviewed (Resident 1), resulting in harm to Resident 1 due to a fall that resulted in a fracture. Findings include: The facility's policy regarding abuse and neglect, dated November 24, 2024, indicated that the resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect referred to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medications, therapies, and activities of daily living. The facility's transportation policy, dated November 24, 2024, revealed that all employees who operate a vehicle would receive, upon hire, training in bus/van policies, procedures, and operations. Additionally training was to be provided on a regular basis. Both staff and clients were to wear a seatbelt at all times when the vehicle was in operation and clients in wheelchairs were to be secured with the use of wheelchair locks, as well as either a lap belt or shoulder safety belt. The job description for the transportation driver, undated, revealed that the driver was to perform all assigned tasks in accordance with established policies and procedures, and as instructed by their supervisor, and was to ensure a safe environment. Education records for Van Driver 3, dated October 4, 2024, revealed that he received training on the transportation policy and procedures. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 29, 2024, revealed that the resident was cognitively intact, had limited range of motion to her upper and lower extremities, used a wheelchair, received dialysis services, and had diagnoses that included renal failure. The resident's care plan, dated November 26, 2024, revealed that she required dialysis on Mondays, Wednesdays, and Fridays. A nursing note, dated December 24, 2024, at 9:20 a.m. revealed that Resident 1's wheelchair tipped over backwards while in the facility's van. On assessment by the Director of Nursing and the Registered Nurse Supervisor, Resident 1 was already returned to the upright position and being secured to the van. Resident 1 stated that her chest hurt and that her knees hit her in the chest when she tipped over backwards. She refused any further assessment and requested to go ahead to dialysis. At 11:31 a.m., dialysis sent the resident to the local hospital for further evaluation and treatment. Hospital records, dated December 24, 2024, revealed that Resident 1 reported that she was on her way to dialysis via a wheelchair van and when they attempted to start moving, her wheelchair was not locked into place, and she was ejected from her wheelchair. Her knees subsequently struck her chest, specifically her sternal (bone located in center of the chest) area. She admitted to a marked amount of sternal pain since then. A CT scan (diagnostic test) report revealed that the resident had an age indeterminate, possibly chronic, sternal fracture deformity. This was to be correlated clinically at the point of tenderness in this location. Hospital records revealed that the resident was made aware of the concerning CT scan findings for a sternal fracture, and she was agreeable to transfer. Given the traumatic findings found on the scan as well as the need for emergent dialysis, she required a transfer. Resident 1 was transferred as a Level 2 trauma (a patient with a traumatic injury that is considered potentially life-threatening, meaning they have significant injuries but are currently stable with vital signs within normal ranges, requiring immediate specialized care at a Level 2 trauma center) to a hospital in Pittsburgh. A review of hospital records from Pittsburgh, dated December 24, 2024, through January 2, 2025, revealed that Resident 1 was admitted to ICU for acute respiratory insufficiency requiring significant respiratory support, treatment for a sternal fracture, and dialysis. Information submitted by the facility, dated December 24, 2024, revealed that Resident 1 was being transported to her dialysis appointment in the facility van and when the van was pulling out of the driveway, which had a slight upward grade, Resident 1's wheelchair tipped backwards causing the resident to hit her head. She reported that her chest hurt from her knees coming up and hitting her chest. Resident 1 stated that she was okay and was transported to dialysis. The facility received a call from dialysis that they were sending Resident 1 to the hospital for evaluation and treatment and that the resident sustained a sternal fracture. The facility's investigation, dated December 24, 2024, revealed that the straps to hold Resident 1's wheelchair in place in the van were not secured properly. A statement from Nurse Aide 2, dated December 24, 2024, revealed that when the transport van went to pull out of the parking lot she heard a loud noise, and when she looked back she saw that Resident 1's wheelchair tipped backwards. The resident stated that her chest hurt from her knees hitting her chest. A statement from Van Driver 3, dated December 24, 2024, revealed that when he was hooking up Resident 1's wheelchair to the back chair locks, he got distracted when someone asked about hooking up their seat belt, and he did not lock the front of Resident 1's wheelchair to the chair holders. An interview with the Director of Nursing on December 30, 2024, at 12:29 p.m. confirmed that Van Driver 3 did not lock Resident 1's wheelchair properly, which resulted in her falling backwards. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of facility policies, facility reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained as free of accident hazards as possible by failing to provide assistance and supervision during an outdoor activity for one of 48 residents reviewed (Resident 13), which resulted in a fracture; failed to provide ongoing supervision in the bathroom for one of 48 residents reviewed who was identified as a fall risk, which resulted in a fall with a fracture for the resident (Resident 74); failed to ensure that a safe environment was provided by failing to secure syringes and lancets for two of 48 residents reviewed (Residents 6, 76) who had wandering behaviors; failed to ensure that a safe environment was provided by not following the facility's policy/protocol for elopements for one of 48 residents reviewed (Resident 24); and failed to complete thorough investigations into incidents for two of 48 residents reviewed (Residents 38, 74). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 10, 2022, revealed that the resident was cognitively impaired, did not walk, used a wheelchair, required supervision with locomotion (how resident moves between locations in wheelchair), and had diagnoses that included intellectual disabilities and schizophrenia (a serious mental disorder in which people interpret reality abnormally). A Certified Registered Nurse Practitioner (CRNP) note for Resident 13, dated May 12, 2022, at 10:27 a.m. revealed that the resident was seen for pain to his left middle finger that had swelling and bruising. He said his finger got caught in his wheelchair yesterday. The plan was to x-ray his left middle finger. A nursing note, dated May 12, 2022, at 10:48 a.m. revealed that while was passing medications to Resident 13 the resident showed the nurse a bruise on his left third finger and indicated that he did it on his wheelchair. He complained of pain and was unable to bend his finger. Staff witnessed the resident outside at a picnic yesterday and he started rolling down an embankment and therapy staff stopped him. X-ray results, dated May 12, 2022, revealed that Resident 13 had a fracture of the left third distal phalanx (tip of the finger). The facility's investigation report, dated May 12, 2022, revealed that Resident 13 had a dark purple bruise measuring 5.0 x 4.0 centimeters (cm) on his left third finger. A witness statement from Occupational Therapist 11, dated May 12, 2022, revealed that on May 11, 2022, during a picnic, Resident 13 had been cued to wheel himself to the picnic. The resident made his way out the door and proceeded to lose control as he rolled down the hillside. The other therapist yelled and everyone was alerted to the situation. Occupational Therapist 11 ran to the resident; however, by the time she got to him the wheelchair brakes were on. She grabbed the back handles of his wheelchair to prevent him from advancing further down the hill. The resident had no indication of injury after the incident. A statement from Resident 13, dated May 13, 2022, revealed that during an interview with the Director of Nursing on May 12, 2022, he revealed that he injured his finger at the picnic while propelling in his wheelchair. Interview with the Rehabilitation Director on February 23, 2023, at 3:42 p.m. revealed that during an outside picnic an activity staff assisted Resident 13 from inside the building to outside. The activity staff did not assist the resident while outside and he was going down the hill. He should have been assisted due to not being safe to go down the hill by himself. He put the break of his wheelchair on and hurt his finger. Interview from Occupational Therapist 11 on February 24, 2023, at 3:00 p.m. revealed that during an outside picnic staff left Resident 13 at the top of the hill and he lost control of his wheelchair and started to go down the hill unassisted. She indicated that the parking lot has a downhill dip and then continues to an embankment, which he could have gone over. The resident had his hands in the wheels of the wheelchair and put his brakes on half way down. She indicated that the resident could propel himself in his wheelchair but was not safe to propel himself down the hill of the parking lot. The facility's policy regarding falls, dated November 28, 2022, indicated that residents who experienced an actual fall (after one fall) would have an investigation completed to determine the root cause of the fall and/or if the event was isolated in nature. Immediate preventative measures would be implemented, and the fall would be reviewed to ensure the interventions were appropriate and evaluate the need for further interventions. The resident's care plan was to be updated with the new fall interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 74, dated June 13, 2022, revealed that the resident was alert and oriented and required extensive assistance from staff for bed mobility and transfers. He required extensive assistance of one staff for personal hygiene and total dependence for bathing and showers. Resident 74's care plan, dated March 21, 2022, included that he was at risk for falls, he was to be assisted with transfers, his bed was to be in a low position, and his call bell was to be always within reach. A nursing note for Resident 74, dated March 25, 2022, at 03:20 a.m. revealed that the resident was lying on his back on the bathroom floor. The resident indicated that he was attempting to take himself to the bathroom. The resident was assisted to a standing position and back to bed. X-rays were ordered of his right hip, shoulder and knee. He had no injuries from the fall, his bed was in low position, and he was reminded to use the call bell for assistance. There was no documented evidence that this fall was thoroughly investigated or that the resident's fall prevention care plan was updated with new and/or revised fall prevention interventions following this fall. A nursing note for Resident 74, dated April 5, 2022, at 10:00 a.m. indicated that the resident was found on the floor of his room in front of his wheelchair. The resident stated that he slid out of his wheelchair after using the bathroom. The resident complained of right hip pain and an x-ray was ordered with negative results. The resident was reminded to ask for assistance when needed. There was no documented evidence that this fall was thoroughly investigated or that the resident's fall prevention care plan was updated with new and/or revised fall prevention interventions following this fall. A nursing note for Resident 74, dated April 10, 2022, at 17:23 p.m. indicated that the resident was attempting to self-transfer from his wheelchair to bed and slipped at the side of the bed landing on his knees facing the bed with his arms on the bed. The bed was not in its lowest position. The resident was assisted back to bed. The resident complained of knee pain and x-rays were ordered with negative results. There was no documented evidence that this fall was thoroughly investigated or that the resident's fall prevention care plan was updated with new and/or revised fall prevention interventions following this fall. A nursing note for Resident 74, dated May 7, 2022, at 14:20 p.m. indicated that the resident was found on the floor of his bathroom after attempting to self-transfer from his wheelchair to the toilet. The resident denied pain or injury, and he was assisted back to his wheelchair. There was no documented evidence that this fall was thoroughly investigated or that the resident's fall prevention care plan was updated with new and/or revised fall prevention interventions following this fall. A nursing note for Resident 74, dated June 15, 2022, at 10:47 a.m. indicated that the resident had reported that he had a fall in the shower on June 14, 2022, in the afternoon. He was self-transferring from a shower chair to his wheelchair after waiting for 45 minutes for assistance. The resident was placed back in bed with no registered nurse assessment completed. The resident complained of hip pain and was immediately assessed on June 15, 2022, at 10:47 a.m. and x-rays of right hip were obtained. Results indicated that resident had a right femoral neck fracture. He was sent to the emergency room and was admitted . He had surgery to repair the right femoral neck fracture. There was no documented evidence that this fall was thoroughly investigated or that the resident's fall prevention care plan was updated with new and/or revised fall prevention interventions following this fall. Interview with the Director of Nursing on February 23, 2023, at 2:45 p.m. confirmed that Resident 74's fall incidents were not thoroughly investigated and there were no new or revised interventions attempted after each of Resident 74's falls to try to prevent further falls and/or injury. The facility's policy regarding medication storage, dated November 28, 2022, indicated that medications and medical products would be stored safely. A quarterly MDS assessment for Resident 6, dated January 30, 2023, revealed that the resident was cognitively impaired, required staff assistance with care, and was able to self propel around the unit in his wheelchair. A quarterly MDS assessment for Resident 76, dated February 1, 2023, revealed that the resident was cognitively impaired and could ambulate independently. Observations in the second dining room on the second floor on February 21, 2023, at 12:50 p.m. revealed that there were four boxes of insulin syringes, nine boxes of lancets (contains small needle to prick the finger), oxygen tubing, nasal cannulas, and wound care supplies in the room. The door to the room was propped open and the supplies were sitting inside the room in boxes. They were not secured or locked up. At that time, Resident 6 was sitting outside the room near the window and Resident 76 was observed walking around in the hallway and wandering in and out of various rooms. Interview with Licensed Practical Nurse 4 on February 21, 2023, at 12:55 p.m. revealed that they have been using the room as a store room because the storage room is full and the supply person recently quit so the new person does not know where to put the stuff. She then left the room and did not pull the door shut or secure the supplies. At 1:02 p.m. the Director of Nursing and Nursing Home Administrator arrived on the unit. Interview with the Nursing Home Administrator and Director of Nursing on February 21, 2023, at 1:02 p.m. confirmed that medical supplies should not have been in the dining room and that they should have been secured. The facility's policy for resident elopement, dated November 28, 2022, revealed that cognitively impaired residents at risk for elopement would be appropriately monitored to reduce the potential for injury. Elopement was defined as a resident leaving the physical structure of the facility without the knowledge of facility staff. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility, will be placed on a unit with an electronic monitoring system or similarly secured unit. In the event that a resident was identified as missing, the following steps were to be taken: The charge nurse would initiate a search on the unit to determine if the resident was in another location. The charge nurse would notify the nursing supervisor or designee that they have been unable to locate a resident during a routine check. The nursing supervisor was to notify the other units. Each unit would conduct a search for the resident. The nursing supervisor was to assign staff members to search non-resident areas and the facility perimeter. If the resident was not located within ten minutes the Director of Nursing and Nursing Home Administrator would be notified of the possible elopement. A quarterly MDS assessment for Resident 24, dated November 2, 2022, indicated that the resident was cognitively impaired, required supervision from staff for ambulation, and had diagnoses that included anxiety and depression. A physician's order and nursing note, dated June 14, 2022, indicated that Resident 24's wanderguard (alarm system that alerts when too close to exit doors) was discontinued due to no attempts to elope. An elopement risk assessment, dated September 26, 2022 revealed Resident 24 was not an elopement risk. A nursing note, dated December 4, 2022, at 3:57 p.m. revealed that therapy staff informed the registered nurse that Resident 24 was witnessed walking outside of the building and past the therapy room at approximately 2:15 p.m. The breezeway door alarm was heard shortly beforehand but was then silenced. Therapy staff and the nurse aide went outside and redirected and escorted the resident back into the building with no incident. The resident was wearing socks and shoes, long pants, and a t-shirt, and the temperature outside was 38 degrees Fahrenheit. The facility's investigation report, dated December 4, 2022, revealed that an employee reported a resident being observed outside of the physical therapy room along the side of the building. The resident was walking along side the building on the pavement. A witness statement from Nurse Aide 12, dated December 4, 2022, revealed that at approximately 2:15 p.m. the therapist went to the nurse's station and said that a resident from upstairs was outside. When they went outside they found Resident 24 outside at the side of the building. A witness statement from Physical Therapy Assistant 13, dated December 24, 2022, reveled that while he was completing his documentation in the rehabilitation office, he noticed Resident 24 walking alone outside of the building. A witness statement from Nurse Aide 14, dated December 24, 2022, revealed that while in the nurse's station around 2:15 p.m. she heard the buzzing of the breezeway door and about one minute or so afterwards Physical Therapy 13 notified her that he just saw a resident from upstairs walking outside. A witness statement from Cook 15, dated December 4, 2022, revealed that she was in the cooler and when she heard the alarm sound, she went over and turned the alarm off and then stepped out as far as she could without letting the door close. After looking in both directions and not seeing anyone, she went back into the building and shut the door behind her. Interview with Cook 15 on February 24, 2023, at 1:23 p.m. revealed that she heard the door alarm sound, opened the door and looked up and down, and did not see anybody. She indicated that she did not do a thorough search for the resident and did not notify a supervisor that the alarm had sounded and that no resident was seen. She indicated that she did not recall receiving any training regarding resident elopements and that the alarm to the breezeway door was sounding. Interviews with the Nursing Home Administrator on February 22, 2023, at 3:33 p.m. and February 23, 2023, at 12:14 p.m. confirmed that Resident 24 did elope outside and the staff member who responded to the alarm and shut it off went outside to look but did not do a thorough search for the resident or notify the supervisor that the alarm to the outside door had sounded and that no resident had been found. He indicated that Resident 24 was confused, resided upstairs, and must have gotten on the elevator to come downstairs. He confirmed that he could find no completed elopement training for Cook 4. The facility's policy regarding accidents, incidents, investigating and recording, dated November 28, 2022, revealed that an investigation is implemented and witness statements obtained. An annual MDS assessment for Resident 38, dated November 5, 2022, revealed that the resident was usually understood, could usually understand, required assistance from staff for his daily care tasks, had a diagnosis of dementia and used a Wander/Elopement alarm daily. A care plan for the resident, dated December 28, 2018, revealed that the resident was an elopment risk. A quarterly elopement risk assessment for Resident 38, dated November 4, 2022, revealed that the resident was at risk for elopement. A progress note for Resident 38, dated November 6, 2022, at 8:39 a.m. revealed that the resident eloped from the building via the breezeway door. The resident stated that he was going home. The resident was redirected back into his room in the facility and 15-minute safety checks were initiated. A progress note for the resident on November 6, 2022, at 2:29 p.m. revealed that the registered nurse supervisor had notified the nurse that the resident was observed sitting outside in his wheelchair near the breezeway door at approximately 8:45 a.m. The nurse administered his morning medications around 8:10 a.m. At that time, the resident was sitting in his room in his wheelchair wearing sweatpants, a zip-up hoodie, boots, and a hat. The resident was compliant with the medication administration and was not agitated. He was last observed eating breakfast in his room. A facility investigation report for Resident 38, dated November 6, 2022, revealed that the resident eloped from the facility around 8:49 a.m. through the breezeway door that had been propped open by dietary staff. Resident 38 was wearing a grey sweatshirt, sweatpants, boots, and a hat. He was sitting in his wheelchair directly outside of the building. The resident was easily directed back into his room in the facility and was placed on 15-minute checks for elopement prevention. A witness statement completed by Licensed Practical Nurse 16, dated November 6, 2022, revealed that she was administering morning medications to Resident 38 around 8:10 a.m. The resident was sitting in a wheelchair in his room wearing sweat pants, a zip-up hoodie, boots, and a hat. The resident was compliant with medication administration, was not agitated, and was last observed eating breakfast in his room. Registered Nurse Supervisor 17 notified the nurse that the resident was observed outside the breezeway door around 8:45 a.m. A witness statement completed by Registered Nurse Supervisor 17, dated November 6, 2022, revealed that Resident 38 eloped from the building at 8:39 a.m. She was escorting Emergency Medical Services (EMS) through the hallway when the breezeway door alarmed. Cook 15 saw the resident going through the door and into the parking lot. She assisted with getting the resident back into the facility. He stated, I was going home. The resident was easily able to be redirected back into his room in the facility. She last saw the resident in his room at 7:00 a.m. eating breakfast. A corrective action form, dated November 8, 2022, was provided to Dietary Worker 18 for failure to follow instructions. The entryway door was propped open while Dietary Worker 18 removed garbage. She accidently left the door propped open. Corrective action included keeping the door securely closed at all times when deliveries are received and the door will remain closed upon completion. Interview with Cook 15 on February 24, 2023, at 1:05 p.m. revealed that she was in the freezer and heard the door alarm, so she came out to investigate. When she looked outside she saw Resident 38 outside. She went out to get the resident and convinced him to come back in by offering him some food. She indicated that the door was closed when she went to see why the alarm was sounding. She indicated that there are two alarms to that door. One door alarm, which she said was the one that was sounding, and another one that is louder and you need to use the keypad to deactivate it. She indicated that she had asked about providing a statement, but they told her that they would take care of it. Interview with Dietary Worker 18 on February 24, 2023, at 1:45 p.m. revealed that she was working alone that weekend and placed a rag in the door so that she could get back into the facility. She indicated that she did not complete a statement and that she received re-education from the registered nurse supervisor and then received a disciplinary action from the dietary manager. There was no documented evidence that witness statements were obtained from Cook 15 and Dietary Worker 18 when the incident occurred. Interview with the Director of Nursing on February 24, 2023, 2:05 p.m. confirmed that statements were not obtained from Cook 15 and Dietary Worker 18 and should have been. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.14(a) Responsibility of the licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, manufacturer's instructions and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of five residents reviewed (Resident 1), resulting in severe pain for the resident. Findings include: The facility's medication administration policy, dated (MONTH) 26, (YEAR), revealed that medications were to be administered as prescribed, in accordance with good nursing principles and practices, and only by persons legally authorized to do so, in order to ensure the safe, accurate and timely administration of medications. The manufacturer's instructions for [MEDICATION NAME] (an antibiotic used to treat bacterial infections), dated (MONTH) 1, (YEAR), indicated that when given by injection it was irritating to tissue and must be given by a secure intravenous route (IV - directly into a vein). Pain, tenderness, and necrosis (tissue death) occur with intramuscular injection (IM - injected directly into a muscle) of [MEDICATION NAME]. A certified registered nurse practitioner note (CRNP - an advanced practice nurse with the authority to prescribe medications and treatments) for Resident 1, dated (MONTH) 29, (YEAR), revealed that the resident had a history of [REDACTED]. diff. - an intestinal bacteria that causes loose stools) and was to receive 250 milligrams (mg) of [MEDICATION NAME] every six hours for ten days, and orders from the CRNP, dated (MONTH) 29, (YEAR), included an order for [REDACTED]. An e-mail from Clinical Pharmacist 4, dated (MONTH) 1, (YEAR), at 3:25 p.m. revealed that 1.0 gram (gm) vials of [MEDICATION NAME] were dispensed from the electronic medication cabinet (EMC) on (MONTH) 29 and 30, (YEAR), for Resident 1. Resident 1's initial order for [MEDICATION NAME] was sent without a strength, and the pharmacy technician called the facility to request the strength and was told 250 mg. The nurse asked if it was in the EMC and was told yes, but that it would have to be reconstituted (add fluid to the powdered medication) with 20 milliliters (ml) of sterile water with one 1.0 gm vial; 1,000 mg/20 ml's would equal 50 mg/ml (each milliliter would contain 50 mg of [MEDICATION NAME], so a 1.0 gm vial of reconstituted [MEDICATION NAME] would be a 1,000 mg dose). Resident 1's Medication Administration Record [REDACTED]. Nursing notes for Resident 1, dated (MONTH) 30, (YEAR), at 8:51 a.m. revealed that the Director of Nursing was notified that Resident 1 received subcutaneous injections of 10 ml of [MEDICATION NAME] in each arm. The nurse was concerned and stated that she questioned the order and was directed to administer the medication. The resident was unaware that the medication was not to be administered subcutaneously or intramuscularly. The resident stated that her arm hurt and the area to her upper arm was swollen with hard, fluid-filled lumps. The subcutaneous tissue on each of her lower arms had fluid filled lumps and areas that were red and swollen. The resident complained of pain and tenderness to both arms. A written statement from Registered Nurse 3, dated (MONTH) 30, (YEAR), revealed that the pharmacy instructed her to mix 20 ml's of sterile water with the [MEDICATION NAME], which would be 250 mg, and to give the medication subcutaneously. A nursing note for Resident 1, dated (MONTH) 1, (YEAR), at 9:59 p.m. revealed that both of Resident 1's arms were blotchy red and the resident complained of discomfort upon light touch. The resident stated that she could feel sensation and discomfort to both arms and was medicated for pain. Interview with Resident 1 on (MONTH) 14, (YEAR), at 3:26 p.m. revealed that the ([MEDICATION NAME]) injection sites were very painful and she rated the pain as a 9 out of 10 (on a scale of 0 to 10 where 10 is the worst pain), and she had big knots on her arms. She stated that her arms were very itchy and she still had itchiness and the lumps on her arms where the injections were given. She confirmed that she received four injections. Interview with Licensed Practical Nurse 1 on (MONTH) 14, (YEAR), at 2:55 p.m. revealed that Licensed Practical Nurse 2 asked her to help with some intramuscular (IM) injections that Licensed Practical Nurse 2 had already mixed up. Licensed Practical Nurse 1 drew up all of the medication into two needles and both nurses administered them IM in Resident 1's left and right upper arm. She stated that Resident 1 complained of pain and had some swelling. She confirmed that she did not look at the bottle and did not even know what she was giving. Interview with Licensed Practical Nurse 2 on (MONTH) 14, (YEAR), at 3:02 p.m. revealed that Registered Nurse 3 called her and said that there were new orders for Resident 1. She stated that the medication was [MEDICATION NAME] and it was to be reconstituted (fluids added), and that Registered Nurse 3 told her to get the [MEDICATION NAME] out of the automated dispensing unit. She questioned Registered Nurse 3 whether or not she was to use the 250 mg capsules of [MEDICATION NAME] and Registered Nurse 3 told her to use the vial of [MEDICATION NAME] and to give it as an injection per the pharmacy, and to use a syringe that would hold the volume of [MEDICATION NAME]. Licensed Practical Nurse 2 confirmed that she used the entire vial of [MEDICATION NAME], filled two syringes, and gave the injections intramuscularly in Resident 1's upper arm. She indicated that Resident 1 complained of having discomfort and itchiness. Interview with Pharmacist 5 on (MONTH) 14, (YEAR), at 4:09 p.m. confirmed that Resident 1's [MEDICATION NAME] order that was sent to the pharmacy did not include the dose. The technician instructed the nurse on how to reconstitute the [MEDICATION NAME], but never instructed her to give the medication by injection. He confirmed that the resident was overmedicated with [MEDICATION NAME] and that injecting the medication could cause necrosis (tissue death), pain and swelling. Interview with the Director of Nursing on (MONTH) 14, (YEAR), at 12:45 p.m. revealed that Resident 1's original order for [MEDICATION NAME] did not include the route. The pharmacy called the facility and questioned the dosage because it was not included in the order that was sent to the pharmacy. The pharmacy gave the mixing instructions for reconstituted [MEDICATION NAME] to be given orally. The computer order was changed and included an order for [REDACTED]. Interview with Registered Nurse 3 on (MONTH) 17, (YEAR), at 9:00 a.m. revealed that she called the pharmacy and was told how to reconstitute the [MEDICATION NAME] with 20 ml of sterile water and was told to give it by IM injection. She confirmed that she did not reconstitute the vial of [MEDICATION NAME], but relayed the information from the pharmacy to the licensed practical nurse. She revealed that she was not aware of the dose that was reconstituted, but indicated that the LPN's administered the entire dose of 20 ml. She confirmed that she did not call the physician or CRNP to clarify the original order. 42 CFR 483.45(f)(2) Residents Are Free of Significant Med Errors. Previously cited 4/30/18, 10/12/17, 8/10/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/30/18, 10/12/17, 8/10/17, 5/17/17, 4/5/17, 11/9/16, 9/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/30/18, 1/9/18, 10/12/17, 8/10/17, 5/17/17, 4/5/17, 11/9/16, 9/23/16.

Based on review of Pennsylvania's Nurse Practice Act, facility policies, manufacturer's instructions and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable certified registered nurse practitioner's order for one of five residents reviewed (Resident 1), resulting in severe pain for the resident. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's medication administration policy, dated (MONTH) 26, (YEAR), revealed that medications were to be administered as prescribed, in accordance with good nursing principles and practices, and only by persons legally authorized to do so, in order to ensure the safe, accurate and timely administration of medications. The manufacturer's instructions for [MEDICATION NAME] (an antibiotic used to treat bacterial infections), dated (MONTH) 1, (YEAR), indicated that when given by injection it was irritating to tissue and must be given by a secure intravenous route (IV - directly into a vein). Pain, tenderness, and necrosis (tissue death) occur with intramuscular injection (IM - injected directly into a muscle) of [MEDICATION NAME]. A certified registered nurse practitioner note (CRNP - an advanced practice nurse with the authority to prescribe medications and treatments) for Resident 1, dated (MONTH) 29, (YEAR), revealed that the resident had a history of [REDACTED]. diff. - an intestinal bacteria that causes loose stools) and was to receive 250 milligrams (mg) of [MEDICATION NAME] every six hours for ten days, and orders from the CRNP, dated (MONTH) 29, (YEAR), included an order for [REDACTED]. An e-mail from Clinical Pharmacist 4, dated (MONTH) 1, (YEAR), at 3:25 p.m. revealed that 1.0 gram (gm) vials of [MEDICATION NAME] were dispensed from the electronic medication cabinet (EMC) on (MONTH) 29 and 30, (YEAR), for Resident 1. Resident 1's initial order for [MEDICATION NAME] was sent without a strength, and the pharmacy technician called the facility to request the strength and was told 250 mg. The nurse asked if it was in the EMC and was told yes, but that it would have to be reconstituted (add fluid to the powdered medication) with 20 milliliters (ml) of sterile water with one 1.0 gm vial; 1,000 mg/20 ml's would equal 50 mg/ml (each milliliter would contain 50 mg of [MEDICATION NAME], so a 1.0 gm vial of reconstituted [MEDICATION NAME] would be a 1,000 mg dose). Resident 1's Medication Administration Record [REDACTED]. Nursing notes for Resident 1, dated (MONTH) 30, (YEAR), at 8:51 a.m. revealed that the Director of Nursing was notified that Resident 1 received subcutaneous injections of 10 ml of [MEDICATION NAME] in each arm. The nurse was concerned and stated that she questioned the order and was directed to administer the medication. The resident was unaware that the medication was not to be administered subcutaneously or intramuscularly. The resident stated that her arm hurt and the area to her upper arm was swollen with hard, fluid-filled lumps. The subcutaneous tissue on each of her lower arms had fluid filled lumps and areas that were red and swollen. The resident complained of pain and tenderness to both arms. A written statement from Registered Nurse 3, dated (MONTH) 30, (YEAR), revealed that the pharmacy instructed her to mix 20 ml's of sterile water with the [MEDICATION NAME], which would be 250 mg, and to give the medication subcutaneously. A nursing note for Resident 1, dated (MONTH) 1, (YEAR), at 9:59 p.m. revealed that both of Resident 1's arms were blotchy red and the resident complained of discomfort upon light touch. The resident stated that she could feel sensation and discomfort to both arms and was medicated for pain. Interview with Resident 1 on (MONTH) 14, (YEAR), at 3:26 p.m. revealed that the ([MEDICATION NAME]) injection sites were very painful and she rated the pain as a 9 out of 10 (on a scale of 0 to 10 where 10 is the worst pain), and she had big knots on her arms. She stated that her arms were very itchy and she still had itchiness and the lumps on her arms where the injections were given. She confirmed that she received four injections. Interview with Licensed Practical Nurse 1 on (MONTH) 14, (YEAR), at 2:55 p.m. revealed that Licensed Practical Nurse 2 asked her to help with some intramuscular (IM) injections that Licensed Practical Nurse 2 had already mixed up. Licensed Practical Nurse 1 drew up all of the medication into two needles and both nurses administered them IM in Resident 1's left and right upper arm. She stated that Resident 1 complained of pain and had some swelling. She confirmed that she did not look at the bottle and did not even know what she was giving. Interview with Licensed Practical Nurse 2 on (MONTH) 14, (YEAR), at 3:02 p.m. revealed that Registered Nurse 3 called her and said that there were new orders for Resident 1. She stated that the medication was [MEDICATION NAME] and it was to be reconstituted (fluids added), and that Registered Nurse 3 told her to get the [MEDICATION NAME] out of the automated dispensing unit. She questioned Registered Nurse 3 about whether or not she was to use the 250 mg capsules of [MEDICATION NAME] and Registered Nurse 3 told her to use the vial of [MEDICATION NAME] and to give it as an injection per the pharmacy, and to use a syringe that would hold the volume of [MEDICATION NAME]. Licensed Practical Nurse 2 confirmed that she used the entire vial of [MEDICATION NAME], filled two syringes, and gave the injections intramuscularly in Resident 1's upper arm. She indicated that Resident 1 complained of having discomfort and itchiness. Interview with Pharmacist 5 on (MONTH) 14, (YEAR), at 4:09 p.m. confirmed that Resident 1's [MEDICATION NAME] order that was sent to the pharmacy did not include the dose. The technician instructed the nurse on how to reconstitute the [MEDICATION NAME], but never instructed her to give the medication by injection. He confirmed that the resident was overmedicated with [MEDICATION NAME] and that injecting the medication could cause necrosis (tissue death), pain and swelling. Interview with the Director of Nursing on (MONTH) 14, (YEAR), at 12:45 p.m. revealed that Resident 1's original order for [MEDICATION NAME] did not include the route. The pharmacy called the facility and questioned the dosage because it was not included in the order that was sent to the pharmacy. The pharmacy gave the mixing instructions for reconstituted [MEDICATION NAME] to be given orally. The computer order was changed and included an order for [REDACTED]. Interview with Registered Nurse 3 on (MONTH) 17, (YEAR), at 9:00 a.m. revealed that she called the pharmacy and was told how to reconstitute the [MEDICATION NAME] with 20 ml of sterile water and was told to give it by IM injection. She confirmed that she did not reconstitute the vial of [MEDICATION NAME], but relayed the information from the pharmacy to the licensed practical nurse. She revealed that she was not aware of the dose that was reconstituted, but indicated that the LPN's administered the entire dose of 20 ml. She confirmed that she did not call the physician or CRNP to clarify the original order. 42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards. Previously cited 4/30/18, 10/12/17, 8/10/17, 5/17/17, 4/5/17, 9/23/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 4/30/18, 10/12/17, 8/10/17, 5/17/17, 4/5/17, 11/9/16, 9/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/30/18, 1/9/18, 10/12/17, 8/10/17, 5/17/17, 4/5/17, 11/9/16, 9/23/16.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the resident's environment was maintained in a safe manner for two of six residents reviewed (Resident R1, R2), which resulted in a fractured wrist for Resident R1. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated September 1, 2017, indicated that the resident was confused and had [DIAGNOSES REDACTED]. The resident's care plan, dated August 29, 2017, indicated that the resident had behaviors of wandering aimlessly and a care plan, dated September 12, 2017, indicated that the resident had the potential for physical and verbal behaviors related to his [DIAGNOSES REDACTED]. An annual comprehensive Minimum Data Set (MDS) assessment for Resident R2, dated August 3, 2017, indicated that the resident had [DIAGNOSES REDACTED]. The resident's care plan, dated June 8, 2017, indicated that the resident had the potential for physical and verbal aggression related to dementia, and an intervention was in place to modify the resident's environment by placing a stop sign (usually a mesh barrier with a stop sign in the middle that attaches to each side of the door frame with velcro) across the resident's door to prevent other wandering residents from entering his room. An incident report, dated October 8, 2017, at 6:05 p.m. revealed that Resident R1 entered Resident R2's room and the two residents were observed on the floor, at the foot of the bed kicking and screaming at each other and the residents were separated by the staff. The report indicated that the incident could have been avoided if Resident R1 would not have entered Resident R2's room. A nursing note for Resident R1, dated October 8, 2017, at 7:00 p.m. indicated that the resident was guarding his left wrist/hand, edema (swelling) was noted, and the area looked abnormal. The note indicated that the resident's attending physician was notified and gave an order to transfer the resident to the hospital emergency department for evaluation of the left wrist. An emergency department report for Resident R1, dated October 8, 2017, indicated that the resident's left wrist was visibly deformed and was placed into a splint. An orthopedic consultation report (report from a physician who specializes in treating bones and muscles), dated October 12, 2017, indicated that the resident had a left wrist fracture and was scheduled for an open reduction with internal fixation (surgical procedure to repair the fracture). Review of a written statement and a summary of written information from an interview with Nurse Aide 1, dated October 11, 2017, revealed that she was assigned to provide care for Resident R2 on October 8, 2017, and at 5:30 p.m. she helped Resident R2 with his evening care. Prior to going into the resident's room, the stop sign was intact over the doorway, and she took it down when she entered the room. She indicated that upon exiting the resident's room, she was unsure about the stop sign, so she left it down and did not reattach it to the doorway. Interviews with the second floor Program Specialist and Licensed Practical Nurse 2 on October 12, 2017, at 9:32 a.m. revealed that Resident R2 preferred to be by himself, did not like other residents entering his room, and that the stop sign was an effective intervention to keep other residents from entering his room. Interview with Nurse Aide 1 on October 12, 2017, at 2:45 p.m. revealed that she provided care for both Residents R1 and R2 on October 8, 2017, and she did not replace the stop sign on Resident R2's doorway when she exited his room because she was unsure of what the stop sign on the resident's doorway was for. She indicated that she did not ask anyone what the stop sign was for. Interview with the Nursing Home Administrator on October 12, 2017, at 9:05 a.m. and with the Interim Director of Nursing on October 12, 2017, at 1:30 p.m. confirmed that Resident R2's care-planned intervention to place a stop sign over his doorway was not followed. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 8/10/17, 9/23/16. 28. Pa. Code 211.11(d) Resident care plan. Previously cited 8/10/17, 5/17/17, 11/9/16, 9/23/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/10/17, 5/17/17, 4/5/17, 11/9/16, 9/23/16.

Based on review of policies, clinical records, and text messages, as well as staff interviews, it was determined that the facility failed to inform the resident's physician when there was a significant change in the resident's condition for one of 14 residents reviewed (Resident R1), resulting in the resident experiencing ongoing pain. Findings include: The facility's policy regarding physician notification, dated April 1, 2016, revealed that the licensed nurse would provide timely and complete communication to the physician when a resident experienced clinical changes, a change in condition, abnormal lab values, or a condition/situation that warranted medical attention or intervention. A licensed nurse was to perform appropriate clinical observations and data collection, and report to the physician as indicated. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated March 10, 2017, revealed that the resident had unclear speech, was not able to understand others, could sometimes be understood, had [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. A nursing note for Resident R1, dated February 24, 2017, at 7:39 p.m., and authored by Licensed Practical Nurse 4, revealed that staff administered 650 milligrams (mg) of Tylenol (an over-the-counter pain medication) for facial grimacing and moaning when his left leg was touched. A nursing note, dated February 24, 2017, at 8:51 p.m., and authored by Licensed Practical Nurse 4, revealed that during evening care, a nurse aide noted that the resident was being very combative and moaning in pain whenever his left hip/leg was touched. The licensed practical nurse documented that the registered nurse was notified. Review of a text message sent by Registered Nurse 9 to Certified Registered Nurse Practitioner 6 (CRNP - a Registered Nurse with advanced medical training) on February 24, 2017, at 7:49 p.m. revealed that the nurse notified the CRNP that Resident R1 seemed to be having pain in the left hip and groin area and that he only has Tylenol nothing we can do about that. A return text from CRNP 6 revealed that the resident always had [MEDICAL CONDITION] and always swings at staff, and she would look at him on Monday (February 27, 2017). A nursing note for Resident R1, dated February 25, 2017, at 5:44 a.m., and authored by Licensed Practical Nurse 2, revealed that the Registered Nurse Supervisor was notified that during care the resident was screaming out in pain when he was rolled onto his left leg, his left foot was extremely swollen with 3+ (a rating for swelling ranging from 1+ to 4+, with 4+ being the worst) [MEDICAL CONDITION] (fluid builds up in the extremities to such a degree that when the extremity is gently pushed with a finger it leaves an indentation), and was red and warm to touch. A nursing note for Resident R1, dated February 25, 2017, at 8:37 a.m., and authored by Licensed Practical Nurse 3, revealed that 650 milligrams of Tylenol was administered for signs and symptoms of pain to the left foot, and when she was assessing, the resident tried to punch and hit her. A nursing note for Resident R1, dated February 25, 2017, at 10:19 a.m., and authored by Licensed Practical Nurse 3, revealed that the resident continued to show [MEDICAL CONDITION] to both legs with mild redness near the little toe and the bottom of the foot. When assessing, the resident kept hitting and punching her, and also staff during care. He was medicated with Tylenol for signs and symptoms of pain. A nursing note, dated February 25, 2017, at 6:20 p.m., and authored by Registered Nurse 1, indicated that Resident R1 had 3+ to 4+ [MEDICAL CONDITION] to both legs, his vital signs were stable, his oxygen saturation level (percentage of oxygen in the blood) was 91 percent, he did not have a fever, and the licensed practical nurse was made aware to call the on-call physician if his vital signs were unstable. The note indicated that the CRNP was contacted and stated that she would see the resident on Monday (February 27, 2017). Interview with Registered Nurse 1 on April 4, 2017, at 3:50 p.m. revealed that on February 25, 2017, she was not notified by the nursing staff regarding Resident R1's pain; therefore, she did not assess him for pain at that time, and the CRNP was not notified about the resident's ongoing leg pain. She indicated that the CRNP was only notified about the resident's [MEDICAL CONDITION], and the CRNP indicated that [MEDICAL CONDITION] was not a new concern for Resident R1. A nursing note for Resident R1, dated February 25, 2017, at 7:44 p.m., and authored by Licensed Practical Nurse 4, revealed that 325 mg of Tylenol was administered for temperature, and the resident was guarding his leg and moaning in pain when touched. A nursing note for Resident R1, dated February 26, 2017, at 7:04 a.m., and authored by Licensed Practical Nurse 3, indicated that the resident was medicated for pain to the left leg and foot and was crying out in pain when he was touched or moved. A nursing note for Resident R1, dated February 26, 2017, at 9:47 a.m., and authored by Licensed Practical Nurse 3, indicated that the resident's left foot continued to be [MEDICAL CONDITION] (swollen) and the pedal pulses (a pulse felt in the foot) were faint due to the [MEDICAL CONDITION]. The resident appeared to have pain to the area when assessing, he was yelling out, and was medicated with Tylenol. A nursing note for Resident R1, dated February 26, 2017, at 11:33 a.m., and authored by Registered Nurse 1, indicated that as a nursing measure, ACE wraps were applied to both legs. A nursing note for Resident R1, dated February 26, 2017, at 1:26 p.m., and authored by Licensed Practical Nurse 3, revealed that the resident cried out when his left foot was touched or assessed. A nursing note for Resident R1, dated February 26, 2017, at 4:35 p.m., and authored by Licensed Practical Nurse 4, revealed that 650 mg of Tylenol was administered for signs and symptoms of pain. Following the initial notification of the CRNP on February 24, 2017, there was no documented evidence that Resident R1's physician was notified about the ongoing symptoms of pain that the resident experienced throughout February 25 through 27, 2017, until a nursing note, dated February 27, 2017, at 1:25 p.m., and authored by Registered Nurse 5, indicated that the resident yelled out when moved in bed, and new orders were received for X-rays of the left hip and leg, and a venous Doppler (an ultrasound) of the left leg. A nursing note for Resident R1, dated February 28, 2017, at 12:30 a.m., and authored by Registered Nurse 7, revealed that the X-ray results were received and showed an acute left subcapital femoral neck fracture (a broken hip) with modest displacement (the bone is not aligned). The resident's physician was contacted and gave an order to send the resident to the emergency room in the a.m. when the orthopedic surgeon (a doctor who specializes in the musculoskeletal system) was available. An interview with CRNP 6 on March 31, 2017, at 12:00 p.m. confirmed that she was notified via text message on February 24, 2017, at 8:00 p.m. that Resident R1 appeared to have pain in his leg, was combative, and had 3+ to 4+ [MEDICAL CONDITION]. She stated that from the information provided, she did not think that the resident had a significant change in condition and she would see him on Monday, February 27, 2017. She confirmed that after she was initially notified on February 24, 2017, she was not notified about the resident's ongoing symptoms of pain until Monday, February 27, 2017. An interview with the Assistant Director of Nursing on March 30, 2017, at 4:40 p.m. revealed that her staff were to contact the physician when a resident had a change in condition or continued to have ongoing pain. 42 CFR 483.10(g)(14) Notify of Changes (Injury/Decline/Room, Etc). Previously cited 11/9/16, 9/23/16. 28 Pa. Code 201.18(b)(1) Management. Previously cited 1/25/17, 9/23/16, 4/5/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 11/9/16, 9/23/16, 4/5/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/9/16, 9/23/16, 4/5/16, 3/15/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/9/16, 9/23/16, 4/5/16, 3/15/16, 1/6/16, 12/23/15.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with appropriate pain management for one of 14 residents reviewed (Resident R1) resulting in severe ongoing pain for the resident. The facility also failed to notify the physician about the ineffectiveness of a resident's pain relief medications for one of 14 residents reviewed (Resident CR3), failed to provide appropriate pain management for one of 14 residents reviewed (Resident CR6), failed to follow physician's orders [REDACTED]. Findings include: The facility's policy regarding pain, dated August 12, 2016, revealed that when assessing pain, staff were to have the resident identify the severity of the pain with a facility-approved pain scale (on a scale of 0 to 10, where 10 is the worst pain possible), which would provide consistency among assessments. If the pain continued, the facility was to contact the physician. The facility's policy regarding physician notification, dated April 1, 2016, revealed that the licensed nurse would provide timely and complete communication to the physician when a resident experienced clinical changes, a change in condition, abnormal lab values, or a condition/situation that warranted medical attention or intervention. A licensed nurse was to perform appropriate clinical observations and data collection, and report to the physician as indicated. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated March 10, 2017, revealed that the resident had unclear speech, was not able to understand others, could sometimes be understood, had [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A nursing note for Resident R1, dated February 24, 2017, at 7:39 p.m., and authored by Licensed Practical Nurse 4, revealed that staff administered 650 mg of Tylenol for facial grimacing and moaning when his left leg was touched. A nursing note, dated February 24, 2017, at 8:51 p.m. and authored by Licensed Practical Nurse 4, revealed that during evening care a nurse aide noted that the resident was being very combative and moaning in pain whenever his left hip/leg was touched. The licensed practical nurse documented that the registered nurse was notified. Review of a text message sent by Registered Nurse 9 to Certified Registered Nurse Practitioner 6 (CRNP - a Legistered Nurse with advanced medical training) on February 24, 2017, at 7:49 p.m. revealed that the nurse notified CRNP 6 that Resident R1 seemed to be having pain in the left hip and groin area and only has Tylenol nothing we can do about that. There was no documented evidence that any new orders were given related to the resident's pain. A return text from CRNP 6 revealed that the resident always had [MEDICAL CONDITION] and always swings at staff, and she would look at him on Monday (February 27, 2017). A nursing note for Resident R1, dated February 25, 2017, at 5:44 a.m., and authored by Licensed Practical Nurse 2, revealed that the Registered Nurse Supervisor was notified that during care the resident was screaming out in pain when he was rolled onto his left leg, his left foot was extremely swollen with 3+ (a rating for swelling ranging from 1+ to 4+, with 4+ being the worst) [MEDICAL CONDITION] (fluid builds up in the extremities to such a degree that when the extremity is gently pushed with a finger it leaves an indentation), and was red and warm to touch. There was no documented evidence that staff administered pain medication at this time. A nursing note for Resident R1, dated February 25, 2017, at 8:37 a.m., and authored by Licensed Practical Nurse 3, revealed that 650 milligrams of Tylenol was administered for signs and symptoms of pain to the left foot, and when she was assessing, the resident tried to punch and hit her. A nursing note for Resident R1, dated February 25, 2017, at 10:19 a.m., and authored by Licensed Practical Nurse 3, revealed that the resident continued to show [MEDICAL CONDITION] to both legs with mild redness near the little toe and the bottom of the foot. When assessing, the resident kept hitting and punching her, and also staff during care. He was medicated with Tylenol for signs and symptoms of pain. A nursing note, dated February 25, 2017, at 6:20 p.m., and authored by Registered Nurse 1, indicated that Resident R1 had 3+ to 4+ [MEDICAL CONDITION] to both legs, his vital signs were stable, his oxygen saturation level (percentage of oxygen in the blood) was 91 percent, he did not have a fever, and the Licensed Practical Nurse was made aware to call the on-call physician if his vital signs were unstable. The note indicated that the CRNP was contacted and stated that she would see the resident on Monday (February 27, 2017). Interview with Registered Nurse 1 on April 4, 2017, at 3:50 p.m. revealed that on February 25, 2017, she was not notified by the nursing staff regarding Resident R1's pain; therefore, she did not assess him for pain at that time, and the CRNP was not notified about the resident's ongoing leg pain. She indicated that the CRNP was only notified about the resident's [MEDICAL CONDITION], and the CRNP indicated that [MEDICAL CONDITION] was not a new concern for Resident R1. A nursing note for Resident R1, dated February 25, 2017, at 7:44 p.m., and authored by Licensed Practical Nurse 4, revealed that 325 mg of Tylenol was administered for temperature, and the resident was guarding his leg and moaning in pain when touched. A nursing note for Resident R1, dated February 26, 2017, at 7:04 a.m., and authored by Licensed Practical Nurse 3, indicated that the resident was medicated for pain to the left leg and foot and was crying out in pain when he was touched or moved. A nursing note for Resident R1, dated February 26, 2017, at 9:47 a.m., and authored by Licensed Practical Nurse 3, indicated that the resident's left foot continued to be [MEDICAL CONDITION] (swollen) and the pedal pulses (a pulse felt in the foot) were faint due to [MEDICAL CONDITION]. The resident appeared to have pain to the area when assessing, he was yelling out, and was medicated with Tylenol. A nursing note for Resident R1, dated February 26, 2017, at 11:33 a.m., and authored by Registered Nurse 1, indicated that as a nursing measure, ACE wraps were applied to both legs. A nursing note for Resident R1, dated February 26, 2017, at 1:26 p.m., and authored by Licensed Practical Nurse 3, revealed that the resident cried out when his left foot was touched or assessed. A nursing note for Resident R1, dated February 26, 2017, at 4:35 p.m., and authored by Licensed Practical Nurse 4, revealed that 650 mg of Tylenol was administered for signs and symptoms of pain. Following the initial notification of the CRNP on February 24, 2017, there was no documented evidence that Resident R1's physician was notified about the ongoing symptoms of pain that the resident experienced throughout February 25 through 27, 2017, until a nursing note, dated February 27, 2017, at 1:25 p.m., and authored by Registered Nurse 5, indicated that the resident yelled out when moved in bed, and new orders were received for X-rays of the left hip and leg, a venous Doppler (an ultrasound) of the left leg, and 5/325 milligrams (mg) of [MEDICATION NAME] (a narcotic pain medication) every six hours as needed for pain for seven days. A nursing note for Resident R1, dated February 27, 2017, at 7:38 p.m. indicated that movement was painful for the resident, that he was swinging at staff, and held onto his left leg; therefore, Tylenol was provided. A nursing note at 8:29 p.m. indicated that the effectiveness of his pain medication was unknown. A nursing note for Resident R1, dated February 27, 2017, at 9:41 p.m., and authored by Licensed Practical Nurse 8, revealed that the resident became aggressive during care when his body had to be moved. When the nurse lowered his head he grimaced, grabbed onto his left hip area, was trying to hit staff during care, and was unable to verbally communicate about his pain. The note indicated that the Registered Nurse was notified, and an x-ray was to be completed. There was no documented evidence that staff administered any medication for the resident's non-verbal symptoms of pain at this time. A nursing note for Resident R1, dated February 28, 2017, at 12:30 a.m., and authored by Registered Nurse 7, revealed that the X-ray results were received and showed an acute left subcapital femoral neck fracture (a broken hip) with modest displacement (the bone is not aligned). The resident's physician was contacted and gave an order to send the resident to the emergency room in the a.m. when the orthopedic surgeon (a doctor who specializes in the musculoskeletal system) was available. An interview with CRNP 6 on March 31, 2017, at 12:00 p.m. confirmed that she was notified via text message on February 24, 2017, at 8:00 p.m. that Resident R1 appeared to have pain in his leg, was combative, and had 3+ to 4+ [MEDICAL CONDITION]. She stated that from the information provided, she did not think that the resident had a significant change in condition and she would see him on Monday, February 27, 2017. She confirmed that after she was initially notified on February 24, 2017, she was not notified about the resident's ongoing symptoms of pain until Monday, February 27, 2017. An interview with the Assistant Director of Nursing on March 30, 2017, at 4:40 p.m. revealed that her staff were to contact the physician when a resident had a change in condition or continued to have ongoing pain. She indicated that the physician should have been contacted for Resident R1 on February 25, and 26, 2017, when the resident continued to cry and moan in pain with all movement and care. A physician's discharge summary for Resident CR6, dated February 23, 2017, revealed that the resident had a history of [REDACTED]. physician's orders [REDACTED]. An interview with the Director of Nursing on April 5, 2017, at 3:05 p.m. revealed that the facility used a pain scale of 0 to 10, where a pain rating of 1-3 was considered mild pain, a rating of 4-6 was considered moderate pain, and a rating of 7-10 was considered severe pain. Resident CR6's MAR for March 2017 revealed that on March 7, 2017, at 12:46 a.m. staff administered Tylenol for a pain rating of 9, which was ineffective for the resident's pain. There was no documented evidence of any follow-up interventions for pain management until staff administered 10 mg of [MEDICATION NAME] at 1:53 a.m. Resident CR6's MAR indicated [REDACTED]. However, at 5:18 a.m., staff adminsitered Tylenol for a pain rating of 8 because the [MEDICATION NAME] was not due to be given again until 7:54 a.m. However, the Tylenol was documented as ineffective, and there was no documented evidence of any follow-up interventions for pain management, and no documented evidence that the physician was notified that [MEDICATION NAME] every six hours was not effective for the resident's pain management. Resident CR6's MAR indicated [REDACTED]. There was no documented evidence of any follow-up interventions for pain management until staff administered [MEDICATION NAME] at 7:34 a.m. Resident CR6's MAR indicated [REDACTED]. There was no documented evidence of any follow-up intervention for the resident's pain management. Resident CR6's MAR indicated [REDACTED]. There was no documented evidence of any follow-up interventions for pain management, until staff administered [MEDICATION NAME] at 1:53 a.m. Resident CR6's MAR indicated [REDACTED]. However, on March 30, 2017, at 12:03 a.m. staff administered Tylenol for a pain rating of 7 because [MEDICATION NAME] was not due to be given again until 1:30 a.m. The Tylenol was documented as ineffective for the resident's pain, and there was no documented evidence of any follow-up interventions for pain management, and no documented evidence that the physician was notified that [MEDICATION NAME] every six hours was not effective for managing the resident's pain. Interviews with the Nursing Home Administrator and the Director of Nursing on March 31, 2017, at 3:20 p.m. and April 5, 2017, at 3:05 p.m., respectively, revealed that the facility did not have a facility-specific policy regarding pain management and pain scale ratings. The Director of Nursing indicated that if a resident's pain medication was not effective, the physician was to be notified. physician's orders [REDACTED]. An interview with the Assistant Director of Nursing on March 30, 2017, at 3:00 p.m. confirmed that Resident CR3's physician should have been notified that the resident did not have pain relief with the use of [MEDICATION NAME] on the above dates and times. physician's orders [REDACTED]. The resident's MAR for February 2017 revealed that staff administered [MEDICATION NAME] to the resident from February 5, 2017, at 2:00 p.m. through February 15, 2017, at 8:00 p.m. for a total of 32 dosages, instead of 30 doses as ordered by the physician. An interview with the Assistant Director of Nursing on March 30, 2017, at 4:00 p.m. confirmed that Resident CR3's MAR indicated [REDACTED] physician's orders [REDACTED]. A nursing note, dated March 15, 2017, revealed that staff were waiting to shower the resident and that the next shift was notified to provide her (foot) treatment. A nursing note, dated March 16, 2017, indicated that the resident was out of the facility at an appointment and that the next shift was to be notified to provide her (foot) treatment. However, there was no documented evidence that the resident's foot treatment was applied on March 15 and 16, 2017. An interview with the Director of Nursing on April 5, 2017, at 2:30 p.m. confirmed that there was no documented evidence that Resident CR6's wound treatment was applied as ordered on March 15 and 16, 2017. 42 CFR 483.24, 483.25(k)(1) Provide Care/services for Highest Well Being. Previously cited 11/9/16, 9/23/16. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/9/16, 9/23/16, 4/5/16, 3/15/16, 1/6/16, 12/23/15.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide adequate supervision for safe smoking for five of 23 residents reviewed (Residents R7, R14, R15, R16, R21), creating a situation in which resident safety was in Immediate Jeopardy, failed to ensure that smoking safety evaluations were completed according to the facility's policy for two of five residents reviewed (Resident R8, R15), and failed to ensure that residents who were identified as at risk for falls were safe to be outdoors unsupervised for two of 25 residents reviewed (Residents R14, R17). Findings include: The facility's smoking policy, dated August 16, 2016, indicated that residents and visitors were permitted to smoke in the designated resident/visitor smoking area, and smoking supplies were to be kept locked in the medication cart and provided to the resident upon request. Residents who smoked would be reviewed on admission, at least quarterly, and as necessary, depending on individual circumstances and changes in condition. All residents who smoked, who were capable of understanding the rules and regulations, would be asked to sign a, smoking agreement to demonstrate their understanding of the rules. Those residents who were unable to demonstrate understanding of the rules would be required to be supervised when smoking. A posting on the facility bulletin board indicated that the designated, supervised smoking times were 9:20 a.m., 1:20 p.m., 4:00 p.m., and 7:30 p.m. The facility's, Resident Smoking Agreement dated August 16, 2016, indicated that residents identified with unsafe smoking practices would not be permitted to smoke without supervision, and that the facility would provide assistance and supervision to accommodate reasonable smoking habits. The agreement indicated that failure to abide by the terms of the agreement would result in forfeiture of all or part of the smoking privileges. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R7, dated August 2, 2016, indicated that the resident had [DIAGNOSES REDACTED]. A smoking evaluation, dated July 14, 2016, and the resident's care plan, dated January 25, 2016, indicated that the resident was determined to be safe to smoke with direct supervision, due to a decline in medical status, and that the resident was non-compliant with the facility's smoking policy and frequently fell asleep while in his wheelchair. A nursing note for Resident R7, dated June 16, 2016, at 10:42 a.m. indicated that the resident continued to exit outside to the front of the building to smoke against the facility's policy and that the Nursing Home Administrator (NHA), the Director of Nursing (DON), and a registered nurse supervisor were all aware that the resident was non-compliant with the facility's smoking policy. The note also indicated that the resident had multiple items of clothing noted to have burn marks and holes in them. A nursing note, dated July 3, 2016, at 10:41 a.m. indicated that the resident went outside the front doors, where he set fire to an empty cigarette box because he had no cigarettes. A nursing note, dated July 18, 2016, at 10:59 a.m. indicated that a nurse aide reported that the resident had a burn area to his scrotum, that he refused to be supervised while smoking, and refused to smoke in the designated area at the designated times, refused a smoking apron, refused to relinquish smoking supplies to the staff, and that the NHA, the DON, and a registered nurse supervisor were aware. A nursing note, dated July 27, 2016, at 4:38 p.m. revealed that the staff reported that there was a burn hole in the resident's pillow, and the resident denied smoking in his room. Observations of Resident R7 on September 19, 2016, at 12:10 p.m. revealed that the resident had a pack of cigarettes in his shirt pocket, and observations at 1:00 p.m., 4:00 p.m., and 5:15 p.m. revealed that the resident was outside in the front of the building, in an area that was not a designated smoking area, and he was smoking, without supervision. A quarterly Minimum Data Set (MDS) assessment for Resident R14, dated September 8, 2016, indicated that the resident had moderate cognitive impairment and was independent or needed set-up help with activities of daily living. The resident's care plan for smoking, dated May 4, 2015, and a smoking evaluation, dated September 20, 2016, indicated that the resident was at risk for injury from smoking due to lack of safety awareness, range of motion limitations, and non-compliance with the facility's smoking policy, including keeping his smoking materials with him, and he required supervision for smoking. An admission MDS assessment for Resident R15, dated September 15, 2016, revealed that the resident was admitted to the facility on [DATE], that he was able to make himself understood and could understand others, and he required extensive assistance with his care. The resident's care plan for smoking, dated September 20, 2016, indicated that the resident was at risk for injury from smoking due to a lack of safety awareness. There was no documented evidence that an initial smoking safety evaluation was completed until September 20, 2016, 13 days after his admission, which revealed that the resident required a smoking apron and was deemed safe to smoke with supervision. A quarterly MDS assessment for Resident R21, dated August 2, 2016, revealed that the resident was admitted to the facility on [DATE], that she was able to make herself understood and could understand others, and she required extensive assistance with her care. The resident's care plan, dated June 6, 2016, indicated that the resident was at risk for injury from smoking due to lack of safety awareness and sensory deprivation (diminished senses). A smoking safety evaluation, dated June 6, 2016, indicated that the resident required a smoking apron and was deemed safe to smoke with supervision. A comprehensive MDS assessment for Resident R16, dated August 29, 2016, indicated that the resident was alert and oriented and required limited assistance for activities of daily living. The resident's care plan for smoking, dated May 4, 2015, and a smoking evaluation, dated September 20, 2016, indicated that the resident was safe to smoke with supervision and was non-compliant with the facility's smoking policy. A quarterly MDS assessment for Resident R8, dated August 9, 2016, indicated that the resident was admitted to the facility on [DATE], and was cognitively impaired. An initial smoking evaluation completed on September 3, 2014, and a quarterly smoking evaluation completed on December 4, 2014, indicated that the resident was safe to smoke with supervision. The resident's care plan, dated August 8, 2016, indicated that the resident was non-compliant with the facility's smoking policy. There was no documented evidence that quarterly smoking safety evaluations were completed according to the facility's policy until July 11, 2016. Observations on September 20, 2016, at 10:45 a.m., 12:00 p.m., and 3:35 p.m. revealed that Residents R8, R14, R15, R16 and R21 were outside smoking in the front of the facility, in an area that was not designated for smoking, and there were no staff present. An interview with the NHA on September 20, 2016, at 5:25 p.m. revealed that at different times when they tried to confiscate Resident R7's smoking materials, he became agitated. He confirmed that the front of the building was not a designated smoking area and that he was aware that there were residents who were non-compliant with the facility's smoking policy; however, the facility continued to allow those residents to smoke and did not revoke their privileges. He further indicated that supervision could not always be provided outside of the designated smoking times. On September 20, 2016, at 6:15 p.m. the Nursing Home Administrator was informed that the health and safety of residents who were not provided with the required supervision to smoke was in Immediate Jeopardy. The facility submitted and implemented a plan to ensure the residents' safety by monitoring all residents to ensure that the facility's smoking policy was followed, re-educated residents and staff on the facility's smoking policy, including the designated smoking area and smoking times, removed all smoking materials from resident rooms for proper storage at the nursing station, provided smoking aprons to all smokers, and indicated that there would be no non-compliance with the policy. The Immediate Jeopardy was removed on September 21, 2016, at 3:10 p.m. A fall risk assessment for Resident R17, dated July 8, 2016, indicated that the resident was at high risk for falls. A quarterly MDS assessment, dated August 4, 2016, indicated that the resident had [DIAGNOSES REDACTED]. An occupational therapy assessment, dated August 30, 2016, indicated that the resident needed increased assistance with her activities of daily living. Nursing notes, dated April 16, 2016, indicated that the resident was walking in the hallway, lost her balance, and fell forward, and on August 8, 2016, the resident was lowered to the ground kneeling on both knees. A nursing note on September 20, 2016, at 1:35 a.m. indicated that the resident was calling out and was on the floor next to her bed and stated her knees gave out when she was walking from the bathroom. Observations on September 20, 2016, at 3:40 p.m. revealed that the resident was outside without supervision and was attempting to push another resident, who was in a wheelchair, back into the building, and fell . There were no staff present and staff were alerted that the resident fell by survey staff. There was no documented evidence that an assessment was completed to determine if the resident was safe to be outdoors without supervision. Interviews with Registered Nurse 8, Licensed Practical Nurse 9, and Nurse Aide 10 on September 20, 2016, at 5:20 p.m. revealed that the resident refused to use her wheeled walker and refused to wear footwear. They also indicated that the resident went outside frequently without supervision, and there were no assessments completed to determine if she was safe to be outside without supervision. A quarterly MDS assessment for Resident R14, dated September 8, 2016, indicated that the resident had moderate cognitive impairment, muscle weakness, and was at risk for falls. A care plan for fall risk, dated October 6, 2015, indicated that the resident had poor safety awareness and had a fall outside on September 24, 2015, without injury. An intervention was added to the resident's care plan on March 11, 2016, to provide supervision with ambulation and on uneven surfaces. Observations on September 20, 2016, at 10:45 a.m., 12:00 p.m., and 3:35 p.m. revealed that Resident R14 was outside ambulating without supervision. An interview with the Director of Nursing on September 22, 2016, at 1:45 p.m. revealed that safety assessments were not routinely completed for residents who preferred to go outdoors frequently to determine if they were safe to be outside unsupervised. 42 CFR 482.25(h) Free of Accident Hazards/supervision/devices. Previously cited 8/15/15, 6/11/15, 7/3/14. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 1/6/16, 6/11/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/5/16, 3/15/16, 1/6/16, 12/23/15, 11/17/15, 9/30/15, 8/15/15, 8/9/15, 7/30/15, 7/22/15, 6/11/15, 11/14/14, 11/4/14, 9/5/14, 7/3/14.

Based on a review of vendor invoices and interviews with staff and vendors, it was determined that the facility failed to operate in compliance with state regulations and codes. Findings include: A review of the vendors' invoices revealed that the facility failed to comply with the requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g) requiring the facility owner to pay in a timely manner bills incurred in the operation of the facility that were not in dispute and that were for services without which the residents' health and safety were jeopardized. When requested to provide bills for the food vendor the facility only provided an invoice dated 5/3/12, for $2006.08. An interview on 5/9/12, at 12:15 p.m., with the food vendor revealed an outstanding balance of $50,173.00, of which $39,419.00 was past due, with the oldest unpaid invoice dated 2/12/12. The vendor indicated that on this date, the facility was "basically given a five-day notice" that services would be discontinued if a payment was not received. The vendor invoice, dated 4/5/12, for sewage service revealed an account balance of $5,789.26. An interview on 5/8/12, at 10:00 a.m., with the vendor revealed an overdue balance of $4,579.60 and that further action would be taken against the facility. The vendor invoice, dated 4/1/12, for water service revealed an account balance of $5,983.82. An interview on 5/8/12, at 10:20 a.m., with the vendor revealed an overdue balance of $3,426.38 and that if this amount was not paid by 7/1/12, the water service would be terminated. The vendor invoice, dated 4/10/12, for propane gas service revealed an account balance of $2,114.45. An interview with the vendor on 5/8/12, at 9:45 a.m., revealed a total amount due of $2,150.45 (of which $1,398.49 is overdue). The vendor invoice, dated 3/31/12, for laundry/linen services revealed a balance due of $12,222.63. An interview on 5/9/12, at 8:30 a.m., with the vendor revealed that there was an issue with the facility and they would be contacting the facility later that day, but they would not provide specific information. The vendor invoice, dated 5/3/12, for dairy products revealed a charge of $139.83 for products delivered 5/3/12. An interview on 5/9/12, at 9:00 a.m., with the vendor revealed that no information would be provided without a written request. The vendor invoice, dated 4/23/12, for laboratory supplies revealed charges of $122.19 for products shipped on 4/23/12. An interview on 5/8/12, at 2:45 p.m., with the vendor revealed that no information would be provided without a written request. The vendor invoice, dated 3/29/12, for miscellaneous medical supplies revealed charges of $196.30. An interview on 5/8/12, at 3:00 p.m., with the vendor revealed that no information would be provided without a written request. The vendor invoice, dated 4/4/12, for pest control service revealed a charge of $133.56 for services provided on 4/2/12. An interview with the vendor on 5/8/12, at 1:30 p.m., revealed a total overdue balance of $704.65. The company indicated that they had not yet determined if they would continue to provide service. The vendor invoice, dated 4/24/12, for medical waste services revealed new charges of $125.35 for services provided on 4/24/12. The invoice indicated that the total amount due was $399.47. Interview with the medical waste service company on 5/10/12, at 3:45 p.m., revealed that the facility owed for four months, approximately $3000.00. He indicated that he spoke to someone from the corporate office who indicated that he would get the bill caught up, but this had not happened as yet. The Director of Nursing, acting for the Administrator, was informed on 5/10/12, at 4:15 p.m., that the health and safety of the residents was in immediate jeopardy due to the facility not paying bills timely. The immediate jeopardy was lifted on 5/15/12, at 8:00 a.m. 28 Pa. Code 201.14 (g) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management.