Every finding on record at Lafayette Manor, Inc

Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for five of nine residents (Resident R10, R11, R39, R49, and R91).Findings include: The facility policy Controlled Substances last reviewed 2/19/26, indicated The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (medicines or substances that have a high potential for abuse) and other controlled substances. Review of Resident R10's MARs (medication administration records) for July, August, and September 2026, revealed an order for oxycodone 5 mg (a narcotic pain medication used to treat moderate to severe pain) to be given every eight hours as needed for pain. Review of Resident R10's Controlled Drug Record (7/15/26 - 9/7/26) indicated that four doses of oxycodone were signed out without corresponding documentation of administration to the resident on 7/21/26, 7/30/26, 8/21/26, and 9/7/26. Review of Resident R11's MAR for August and September 2026, revealed an order for oxycodone 10 mg to be given every four hours as needed for pain. Review of Resident R11's Controlled Drug Record (8/29/26 - 9/10/26) indicated that six doses of oxycodone were signed out without corresponding documentation of administration to the resident on 8/31/26 x2 doses, 9/1/26, 9/2/26, 9/7/26, and 9/9/26. Review of Resident R39's MAR for September 2026, revealed an order for oxycodone 5mg to be given every six hours as needed for pain. Review of Resident R39's Controlled Drug Record (8/27/26 - 9/8/26) indicated that one additional dose of oxycodone were signed out without corresponding documentation of administration to the resident on 9/3/26. Review of Resident R49's MAR for July 2026, revealed an order for Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) mg to be given every twelve hours as needed for pain. Review of Resident R49's Controlled Drug Record (7/27/26 - 7/30/26) indicated that that one additional dose of Tramadol was signed out without corresponding documentation of administration to the resident on 7/283/26. Review of Resident R91's MAR for July 2026, revealed an order for hydrocodone/ acetaminophen 5-325 (hydrocodone, an opiate narcotic pain medication and acetaminophen) to be given every six hours as needed for moderate pain. Review of Resident R91's Controlled Drug Record (9/8/26 - 9/9/26) indicated that one additional dose of hydrocodone/ acetaminophen was signed out without corresponding documentation of administration to the resident on 9/9/26. During an interview on 9/10/26, at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain controlled substances were accounted for accurately for five of nine residents. 28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to implement control programs that included a system surveillance to identify possible communicable diseases or infections for five of twelve months (April 2026, May 2026, June 2026, July 2026, August 2026).Findings include: Review of facility policy Infection Control Policies and Practices last reviewed 2/19/26, indicated the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection. The objectives of the infection control policies and practices are to: 1) Prevent, detect, investigate, and control infections in the facility. 2) Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. 3) Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based precautions. 4) Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard and Transmission-Based Precautions. 5) Maintain records of incidents and corrective actions related to infections: and 6) Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of the facility's Infection Control documentation for the previous five months (April 2026-August 2026) failed to reveal surveillance for tracking infections for residents in five of six months (April 2026-August 2026), the previous six months (October 2025-March 2025) were unavailable for review. During an interview on 9/10/26, at 11:50 a.m. Infection Preventionist (IP) Employee E1 and Director of Nursing confirmed that the facility failed to accurately track communicable diseases and infections. 28 Pa. Code:201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident Care policies.28 Pa. Code 211.12(d)(2)(5) Nursing Services.

Based on a review of facility policy and records and staff interviews, it was determined that the facility failed to ensure that facility nursing personnel maintain current CPR (cardiopulmonary resuscitation) certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for two of fifteen Licensed Practical Nurses (LPN) (Employees E3 and E4).Findings include: Review of the facility policy, CPR dated [DATE], indicated Staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. On [DATE], the Nursing Home Administrator (NHA) provided a list of fifteen currently employed licensed practical nurses and associated CPR certification cards. CPR certification cards were not available for review for LPN Employees E3 and E4.During an interview on [DATE], at approximately 2:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that facility nursing personnel maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards for two of fifteen Licensed Practical Nurses,28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for nine of sixteen residents (Resident R4, R13, R19, R23, R38, R41, R46, R56, and R69).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2025, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood.-Resident R4 had an MDS completed on 8/28/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R4 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R4 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R4 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R13 had an MDS completed on 8/19/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R13 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R13 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R13 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R19 had an MDS completed on 6/22/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R19 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R19 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R19 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R23 had an MDS completed on 6/16/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R23 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R23 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R23 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R38 had an MDS completed on 7/30/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R38 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R38 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R38 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R41 had an MDS completed on 6/10/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R41 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R41 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R41 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R46 had an MDS completed on 8/2/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R46 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R46 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R46 is rarely understood, and the Resident Mood Interview assessment was not completed. -Resident R56 had an MDS completed on 8/26/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R56 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R56 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R56 is rarely understood, and the Resident Mood Interview assessment was not completed.-Resident R69 had an MDS completed on 8/18/26. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R69 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R69 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R69 is rarely understood, and the Resident Mood Interview assessment was not completed. During an interview on 9/10/26, at approximately 12:00 p.m. the Resident Nurse Assessment Coordinator Employee E2 confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for nine of sixteen residents.28 Pa. Code: 211.5(f) Clinical records.

Based on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of five residents (Resident R1). This was identified as past non-compliance.Findings include: Review of the facility policy Elopement - Missing Resident dated 1/29/25, indicated the facility will provide a safe environment for all residents regardless of orientation status and to supervise those residents at risk for elopement. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2025, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/29/24, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), unsteadiness on feet, muscle weakness, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of Section C: Cognitive Patterns indicated Resident R1 had severe cognitive impairment. Review of a progress note dated 1/6/26, at 6:01 p.m. indicated that Resident R1 was admitted to the facility. Review of a progress note dated 1/6/26, at 9:30 p.m. indicated, [Nurse Aide Employee E1] noticed that resident was not in her room. After checking resident's room for resident, she notified [Registered Nurse Employee E2], that resident was missing. When this RN asked resident what she was trying to do when she left the building, resident said when was that?'. I asked her if she remembered leaving the building she said no. Resident is alert with confusion, does not always follow commands. This RN notified all nursing staff on 1st and 2nd floors that resident had eloped and to do a thorough search of the facility, including kitchen, dining room, lobby, common areas, basement, parking lots. [Attached personal care home] notified of missing resident at [facility]. 911 called after resident not located after 15 minutes, PA (Pennsylvania) State Police notified. [Director of Nursing] notified of elopement, she notified [Nursing Home Administrator]. Resident was found at [Attached personal care home] in basement by time clock by [Personal Care Assistant Employee E3] at [personal care home] and [facility] was notified that resident had been found. Resident returned facility. Review of facility submitted information submitted 1/7/26, indicated that on 1/6/26, at 9:30 p.m. during routine rounds, staff became aware that the resident was not in her room. An immediate search was initiated. The resident was located at 2150 (9:50 p.m.) on the ground floor of the facility in the activities room. The resident was sitting in a chair. No behaviors noted. Staff immediately assessed resident for injuries where none was noted. Resident denied pain. Resident was transferred via wheelchair back to her room. We are unable to determine exact exit path. However, obvious exit route would be out the front doors into [attached personal care home] and down elevator to lower level. Resident has no history of elopement/elopement attempts from home/previous facility/current facility. Review of an employee statement written by PCA Employee E3 dated 1/6/26, indicated, On 1-6-26 at 9:50 pm, I just started to walk in [Assisted Living Facility] to start work and I saw workers looking for someone who was missing. I went to clock in and found missing client sitting down by clock in the basement. I then took her upstairs and [facility] was notified that she was found. Review of an employee statement written by Nurse Aide Employee E1 dated 1/7/26, indicated, I went in to check on the resident I seen her about 20 minutes before l'd say around 9:10. I kept checking in on her because she kept getting up we all aides kept redirecting her back in her room. I went in her room around 9:30 to check on her and do her inventory sheet and she wasn't in her bed. I looked in the bathroom she wasn't in there I checked residents room she wasn't there I then yelled and said resident is missing I need help everyone then got up and started looking. I doubled checked gold hall then went to the basement checked the laundry room the fire exits where we keep supplies. I ran back upstairs to get my phone because its pitch dark outside. I checked the little rooms that was open went outside checked the back the rooms ran around the building went by the [other buildings on campus] was everywhere I could walk. I walked back up they said they found her in the basement. The RN had us do a head count. I did blue hall all 10 residents was accounted for and also my other 4 was accounted for after we found her. On 1/6/26, the facility initiated a plan of correction that included:-Immediate count of all facility residents.-Elopement assessment completed.-Application of a Wanderguard (security bracelet that alerts when an identified resident approaches a monitored door).-Update to Resident R1's baseline care plan.-Audit of all facility residents for elopement risk.-Update of elopement binders located at the front desk and the first and second floor nurses' stations.-Education for all licensed nursing staff on resident orientation to the facility, admission audit tool, and admission policy.-Education for all staff on the facility elopement policy and elopement prevention.-Ad hoc QAPI (Quality Assurance and Performance Improvement) meeting, with resolutions to purchase/install concave mirrors and complete audits.-Audits of admissions to be completed by Director of Nursing or designee five times per week for four weeks, to be reviewed at next QAPI meeting. Review of Resident R1's clinical record completed on 1/28/26, revealed the elopement assessment and care plan had been updated to include information on his elopement, risk for further elopement, and interventions. During four interviews on 1/28/26, licensed nurses confirmed they received education on resident orientation to the facility, admission audit tool, and admission policy. During eight interviews on 1/28/26, staff confirmed they received education on elopement prevention and procedures if an elopement occurs. During an interview on 1/28/26, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent elopement for one of five residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications and/or biologicals in one of two medication rooms (Second Floor Medication Room). Findings include:Review of facility policy Medication Storage in the Facility dated 1/28/25, indicated that medications and biologicals will be removed from the active supply and destroyed in the facility.During an observation on 9/23/25, at 10:25 a.m. of the First Floor Medication Room the following was observed:(14) DualCap IV Pole Strips disinfecting caps for male connectors with an expiration date of 5/4/22(3) [NAME] Binax Now Covid-19 Antigen self-test 2-pack with an expiration date of 5/15/23(5) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 3/8/25(5) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 3/17/25(4) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 4/26/25(3) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 4/1/25(5) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 4/5/25(6) Volumat VL PR72-11 Primary Infusion Set with 0.2-micron filter with an expiration date of 5/4/25(13) Statlock PICC Plus Stabilization Device with an expiration date of 5/28/2025(2) [NAME] dressing change tray with an expiration date of 8/31/25During an interview on 9/23/25, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to properly store medications and/or biologicals in one of two medication rooms.28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination on one of two nursing units ( first floor nursing unit).Findings include:Review of the facility policy Infection Control dated 1/29/25, indicated that staff noted to have a confirmed or suspected viral respiratory infection will be restricted from work until 3 days have passed since symptoms. This guidance supersedes existing CDC and DOH guidance specific to health care personnel.Review of the facility policy Infection Control COVID-19 dated 1/29/25, indicated that the facility will minimize exposures to respiratory pathogens and adhere to CDC's core principles of infection control. The staff and residents will utilize universal source control and wear masks, especially with close contact.During the Entrance Conference held on 9/23/25. at approximately 9:30 a.m., the Nursing Home Administrator indicated that the facility had two staff test positive for Covid-19 on 9/21/25 and staff, visitors and residents of the first-floor nursing unit were to wear masks due to potential exposure. During an observation on 9/24/25, from 8:31 a.m., through 8:56 a.m., Nurse Aide (NA) Employee E9, NA Employee E10 and NA Employee E11 were observed with masks not fully covering their faces going in and out of resident rooms on the first-floor nursing unit.During an interview on 9/24/25, at 8:56 a.m., Assistant Director of Nursing and Infection Control Preventionist Employee E2 confirmed that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination on one of two nursing units (first-floor nursing unit).28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, resident group meeting, clinical record review, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Residents R).Findings include:Review of facility policy Call Bell/Call Light dated 1/29/25, indicated to ensure resident has a means to summon assistance. To respond to a resident's call for assistance in a timely manner.During the resident group meeting held on 9/25/25, at 1:00 p.m., the resident consensus stated that the facility staff do not respond to call bells timely, they often have to wait, or staff turn off the call bell and say they'll come back and it's often and hour or longer before they return.Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with a most recent re-admission dated of 7/5/25, with diagnoses which included diabetes, heart flutter and pneumonia.Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/5/25, indicated diagnoses remained current. Section G0110 (ADL) Assistance with activities of daily living indicated Resident R1 required assistance of two for bed mobility.During an observation on 9/25/25, at 8:31 a.m., Resident R1's call light above her door illuminated, the call light was not responded to until 8:52 a.m., 21 minutes later, when the Assistant Director of Nursing(ADON) responded and the resident stated that she'd been waiting to use the bedpan and now she needed cleaned up as she could not wait any longer.During an interview on 9/25/25, at 8:52 a.m., the ADON confirmed that the facility failed to accommodate Resident R1's call bell needs.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on observations, facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of two nursing units (first floor nursing unit).Findings included:Review of the facility policy Homelike Environment dated 1/29/25, indicated residents are provided with a safe, clean, comfortable and homelike environment.During an observation on 9/23/25 at 9:44 a.m., the left shower room had a broken wall and floor border tiles and the shower room on the right had uneven flooring and broken wall tiles.During an observation on 9/25/25, from 9:30 a.m., through 9:40 a.m., the following was observed:Hall of the 100-room numbers had flooring uneven and liftingResident R69's room had broken loose floor tiles under sink. Tiles behind bed were warped and the cable wire was hanging such that it could get pulled down and cause potential injury.Resident R6's room had missing floor trim near bathroom leaving broken wall.Resident R70's room had loose, missing floor tiles by heater and flooring to entrance of bathroom and under heater in bathroomResident R25's room had the bathroom panel under heater loose. During an interview on 9/25/25, at 10:00 a.m., the Nursing Home Administrator confirmed that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of two nursing units (first floor nursing unit). 28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 201.29(k) Resident rights.

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for two of three residents (Resident R71 and R73).Findings include: Review of facility policy Elopement reviewed 1/28/25, indicated the facility will provide a safe environment for all residents to the extent possible. The facility will assess residents and their plans of care to prevent accidents related to wandering behavior or elopement within eight hours of admission and on a quarterly basis. The facility defines elopement as When a resident leaves the premises or a safe area without authorization. Review of the clinical record indicated Resident R71 was admitted to the facility on [DATE], with diagnoses that included history of traumatic brain injury, hemiplegia (paralysis of one side of the body), and impulse disorder. Review of a Elopement Risk Determination assessment completed 3/20/25, indicated Resident R71 was not at risk for elopement due to being unable to leave the building without help from staff, and requires assistance with locomotion, and does not wander.Review of a facility reported incident dated 8/18/25, indicated Resident R71 was seen in the dining room sitting in front of his wheelchair. Facility investigation revealed it was unknown how Resident R71 got into the dining room. Staff responded immediately.Review of progress note dated 8/18/25, indicated food service manager observed resident sitting on buttocks in front of her wheelchair when she opened up the dining room door to take supplies to nursing unit. Resident stated she was going to the dining room. Review of a facility investigation note on 8/20/25, indicated Resident R71 did leave her room via wheelchair and excited the floor without being seen. Review of the clinical record indicated Resident R73 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (stroke - blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), hemiplegia (paralysis of one side of the body), and muscle weakness. Review of a Elopement Risk Determination assessment completed 8/24/25, indicated Resident R73 was not at risk for elopement due to being unable to leave the building without help from staff, and requires assistance with locomotion, and does not wander. Review of a facility reported incident dated 8/27/25, indicated Resident R73 was seen in the parking lot sitting in front of his wheelchair. Facility investigation revealed Resident R73 was assisted outside by a visitor who then informed staff that he was outside. Staff responded immediately and returned the resident to the facility. During an interview on 9/23/25, at 10:27 a.m. Resident R73 stated he was trying to go home when he left the facility. Resident's spouse was present during interview, and she thinks he followed her out of the facility after she left. She visits every day and leaves around 7:00 p.m.-7:30 p.m. During an interview on 9/24/25, at 12:45 p.m. Licensed Practical Nurse (LPN) Employee E3 stated if they noticed a resident missing, or in a place they should not be, they would get the resident to a safe place, assess the resident for injuries, assess their vital signs (blood pressure, heartrate, breathing and oxygen level), notify administration and the residents responsible party, and document in the progress notes. During an Interview on 9/24/25, at 12:49 a.m. LPN Employee E4 stated they would alert the supervisor, administration, and Assistant Director of Nursing (ADON), search for the missing resident shutting the doors behind me as they go. During an interview on 9/24/25, at 12:51 p.m. LPN Employee E5 stated they would call the supervisor, do a room-to-room search and head count of the residents, call the family and document in the progress notes. During an interview on 9/24/25, at 12:52 p.m. LPN Employee E6 stated they would notify the supervisor immediately, announce the facility elopement code, do an audit of residents, notify the doctor, and document in the clinical record. During an interview on 9/24/25, at 12:58 p.m. Nurse Aide (NA) Employee E7 stated they received elopement training when hired and again the previous week. They would do a head count of the residents. During an interview on 9/24/25, at 1:00 p.m. NA Employee E8 stated they would check the resident's room, notify the supervisor, and continue to search the other resident rooms and all other facility areas for the resident. During an interview on 9/23/25, at 11:00 a.m. Nursing Home Administrator (NHA) stated Resident R73 was a new admission to the facility and did not have previous wandering or elopement attempts. On return to the facility a wander guard was placed around Resident R73's left ankle. During an interview on 9/25/25, at 2:30 p.m. the NHA confirmed that the facility failed to provide adequate supervision to prevent elopement for two of three residents (Resident R71 and R73).

Based on review of facility policy, clinical record review, and staff interviews it was determined that the facility failed to obtain a physician order for and care of an urostomy (surgical procedure that creates an opening in the abdomen wall to allow urine to exit the body when the bladder is not functioning properly), and failed to provide resident-centered interventions for urostomy in the care plan for one of three residents reviewed (Resident R8). Findings include: Review of facility policy Suprapubic Catheter / Urological Device Care and Management dated 1/28/25, indicated a physician order for the urological device is obtained including the size of the catheter (a hollow flexible tube that is inserted through a narrow opening in the body cavity for removing fluid), the frequency of the catheter change, flushes, and routine care. Review of facility policy Comprehensive Person-Centered Care Planning dated 1/28/25, indicated a comprehensive person-centered care plan including necessary and appropriate care, attending physician orders, services and accommodations of resident needs and preferences in order for the resident to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment, quantifiable objectives for the highest level of functioning the resident may be expected to attain, and steps or approaches for each outcome objective within 21 days of admission. Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE], with diagnoses which included cancer, scoliosis (condition where the spine curves sideways, often in an S or C shape), and anxiety. Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 7/22/25, Section H - Bladder and Bowel Question H0100. Appliances indicated Resident R8 had an indwelling catheter and urostomy on admission. Review of the comprehensive care plan initiated 7/16/25, included the following interventions: Monitor and document intake and output as per facility policy. Monitor/record/report to MD (doctor) for s/sx (signs and symptoms) UTI (urinary tract infection). During an interview on 9/26/25, at 9:00 a.m. the Assistant Director of Nursing (ADON) Employee E2 confirmed the facility failed to obtain a physician's order for Resident R8's urostomy and failed to provide a person-centered care plan with interventions for the urostomy.

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS - periodic assessment of resident care needs) assessment for one of five hospice (a special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) residents reviewed (Residents R8).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual (reference used to complete an MDS) effective 10/1/2019, indicated that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. Review of facility policy Hospice Services reviewed 1/28/25, indicated the facility contracts with hospice provider(s) to afford the resident's an opportunity to elect hospice services when the resident is diagnosed with a terminal condition and meets the requirements of hospice service. A review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE], with diagnoses which included cancer, scoliosis (condition where the spine curves sideways, often in an S or C shape), and anxiety. Review of a physician order dated 8/18/25, indicated Resident R8 was admitted to hospice services on 8/15/25. Review of the MDS failed to indicate a significant change MDS was completed following admission to hospice services. During an interview on 9/26/25, at 8:44 a.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E1 confirmed the facility failed to complete a significant change MDS within 14 days of Resident R8's hospice admission.

Based on observations, review of facility policy, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (First and Second Floor Nursing Units). Based on observations, review of facility policy, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of two nursing units (First and Second Floor Nursing Units). Findings included: Review of the facility policy Homelike Environment dated 1/28/25, indicated in part The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. Review of Title 42 Code of Federal Regulations S483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. S483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During an observation on 8/12/25, from 9:40 a.m., through 11:20 a.m., of the first floor nursing unit identified: Observation of the linen carts identified torn towels and bed blankets and ripped washcloths being provided from laundry as washcloths. During an interview on 8/12/25, at 10:22 a.m., Licensed Practical Nurses E1 and E2 confirmed that the facility utilizes torn towels, blankets and ripped washcloths to clean residents for washcloths due to not having wipes and the only wash cloths being provided. During an interview on 8/12/25, at 11:20 a.m., Nurse Aide Employees E7 and E8 stated that they use the ripped washcloths and pieces of blankets and towels as washcloths and that is what facility provides. During an interview on 8/12/25, at 11:22 a.m., Maintenance Director Employee E3 stated that those were being provided as washcloths. Stated the facility has new washcloths and showed them to the surveyor still packaged. During an interview on 8/12/25, at 11:30 a.m., the Nursing Home Administrator confirmed the ripped washcloths and torn blankets and towels were what was being provided. The facility failed to provide a safe, comfortable and homelike environment for the residents of the first and second floor nursing units. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights.

Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for five of 25 residents reviewed (Resident R1, R2, R3, R4 and R5). Based on observations, review of clinical records, and staff interview it was determined that the facility failed to provide reasonable accommodation of needs for five of 25 residents reviewed (Resident R1, R2, R3, R4 and R5). Findings Include: During observations of resident rooms on the first and second floors on 8/12/25, from 9:40 a.m., through 11:45 a.m., incontinence diapers were being placed in rooms.During an interview on 8/12/25, at 10:22 a.m., Licensed Practical Nurse (LPN) Employees E1 and E2 confirmed that the facility only allows eight incontinence diapers per resident, and they were told they are not to get any more, if they run out, they have to wait for the Supervisor to get them. Staff stated, residents are to be changed every two hours, we need 12 then at least and what happens if the resident goes through more because of diarrhea? During an interview on 8/12/25, at 10:42 a.m., Nurse Aide (NA) Employee E4 stated that you only have eight incontinence diapers for each resident. During an interview on 8/12/25, at 11:10 NA Employees E5 and E8 stated that the facility only allows eight incontinence diapers per resident, and we used to be able to get more now you have to hunt down the Supervisor to get them or you get into trouble. During an interview on 8/12/25, at 11:20 a.m., NA Employees E7 and E9 stated that they the facility does not allow no more than eight incontinence diapers for each resident in 24 hours. There are no wipes and washcloths are used and at times the washcloths don't look clean and we're using a rag that may have been used on someone's behind now using it on a resident's face. During an interview on 8/12/25, at 11:35 a.m., Housekeeper/central/custodian Employee E11 stated that places the supplies of diapers in each resident room, if there are four, I put in four more, the extra-large users only get four at a time. During an interview on 8/12/25, at 11;40 a.m., LPN Employee E7 and NA Employee E9 stated Resident R6 has small diapers in her room but requires extra-large, when observed, there were four small diapers in her drawer. Review of Resident R5's clinical record indicated her weight as being 169 pounds, incontinence of bowel and bladder and recently having a healed pressure ulcer of her sacrum that started as shearing and had developed and worsened while in the facility. On 8/12/25, she had developed a urinary tract infection. Review of the facility pressure ulcer list indicated four residents (Residents R1, R2, R3 and R4) with Incontinence Associated Dermatitis and staged as partial thickness and all developing in the facility. During an interview on 8/12/25, at 11:45 a.m., the Nursing Home Administrator confirmed that the facility failed provide reasonable accommodation of needs for five of 25 residents reviewed (Resident R1, R2, R3, R4 and R5). 28 Pa. Code 201.29 (a) Resident Rights.28 Pa. Code 211.10 (d) Resident care policies.

Based on the review of facility policy, observations, clinical records, and staff interviews, it was determined that the facility failed to accurately document meal consumption for six of seven residents observed. (Residents R1, R2, R3, R4, R5, and R6). Findings include: Review of the facility policy, Charting and Documentation dated 1/2/24, indicated Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. During an observation on 6/29/25, at 12:40 p.m. Resident R1's meal was noted to be approximately 25% consumed. Review of Resident R1's Task List history indicated that on 6/29/25, at 11:42 a.m. NA Employee E1 documented Resident R1's meal consumption was 75%. During an observation on 6/29/25, at 12:47 p.m. Resident R2's meal was noted to be approximately 75% consumed. Review of Resident R2's Task List history indicated that on 6/29/25, at 11:41 a.m. NA Employee E1 documented Resident R2's meal consumption was 100%. During an observation on 6/29/25, at 12:48 p.m. Resident R3's meal was noted to be approximately 25% consumed. Review of Resident R3's Task List history indicated that on 6/29/25, at 11:42 a.m. NA Employee E1 documented Resident R3's meal consumption was 75%. During an observation on 6/29/25, at 12:50 p.m. Resident R4's meal was noted to be approximately 100% consumed. Review of Resident R4's Task List history indicated that on 6/29/25, at 12:29 p.m. NA Employee E2 documented Resident R4's meal consumption was 75%. During an observation on 6/29/25, at 12:51 p.m. Resident R5's meal was noted to be approximately 25% consumed. Review of Resident R5's Task List history indicated that on 6/29/25, at 12:27 p.m. NA Employee E2 documented Resident R5's meal consumption was 75%. During an observation on 6/29/25, at 12:52 p.m. Resident R6's meal was noted to be approximately 25% consumed. Review of Resident R6's Task List history indicated that on 6/29/25, at 12:27 p.m. NA Employee E1 documented Resident R6's meal consumption was 75%. During an interview on 6/29/25, at 12:53 p.m. when asked why she had charted Resident R1's meal consumption prior to the meal being consumed, NA Employee E1 stated, Maybe that's the one I charted too fast. During an interview on 6/29/25 at approximately 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to accurately document meal consumption for six of seven residents observed. 28 Pa. Code: 211.5(f)(g)(h) Clinical records.

Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to verify the washing temperature of the dish machine in the main kitchen, which created the potential for foodborne illness. Findings include: Review of the facility policy Automated Ware Washing Policy, dated 1/2/24, with a previous review date of 8/17/23, indicated that the dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. The food service manager will train staff to monitor dish machine temperatures throughout the process. Review of the facility policy Dish Machine Temperature Log, dated 1/4/24, with a previous review date of 8/17/23, indicated that dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Temperatures for wash is identified as >/= 160 degrees, with the final rinse temperature as >/= 180 degrees. During observation of the main kitchen on 9/4/24, at 9: 30 a.m., the following was identified: The dish machine valves did not function during the running of the wash and rinse cycles Confirmed with Dietary Manager Employee E5. During a second observation of the kitchen on 9/4/24, at 9:43 a.m., the dish machine was indicated as functioning properly. When observed it did not reach temperatures as indicated for proper sanitation. Pa. 28 Code: 211.6(c)(d)(f) Dietary services.

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change. Findings include: Review of the facility policy Dry/Clean Dressings dated 1/4/24, indicated to clean the bedside stand before and after dressing change. Tape a biohazard bag or plastic bag on the bedside stand or use the waste basket below clean field. Pull glove over old dressing and discard into plastic or biohazard bag. Cleanse the wound with ordered cleanser. Clean for the least contaminated area to the most contaminated area (usually from center outward). Review of the facility policy Infection Prevention and Control Program dated 1/4/24, indicated the infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified. Policies and procedures are utilized as the standards of the infection prevention and control program. Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. During an observation on 9/4/24, at 12:50 p.m. with Licensed Practical Nurse (LPN) Employee E1 and LPN Employee E2 the following occurred during a dressing change: -LPN Employees E1 and E2 washed their hands and donned gloves. -LPN Employee E1 placed a clean drape on the resident's bedside table. *Table was not cleansed prior to drape being placed; resident's belongings were not removed from the table. -LPN Employee E1 placed the supplies on the drape. -LPN Employee E2 pulled the drapes around resident bed for privacy; she did not wash her hands after completing this. -LPN Employee E2 removed the old dressings from four wounds located on resident's right lower leg. The areas are as follows: #1 middle right calf, #2 Right outer calf, #3 right shin, #4 top of right foot. At that time the drape was not placed under the wounds to protect the bedding. -LPN Employee E2 removed soiled gloves inside out and placed on foot of resident' s bed and did not wash hands. -LPN Employee E2 removed new gloves from her pocket and donned. LPN Employee E1 handed the supplies to LPN Employee E2 as they were needed. All four wounds cleansed with wound cleanser and gauze. During this process each wound was wiped multiple times with the same piece of gauze, the gauze was folded over and used to dry the wound with multiple swipes of the soiled gauze. -LPN Employee E2 picked up previous discarded gloves, removed current gloves inside out with all soiled items inside gloves and placed gloves back on the residents bed; did not wash hands. -LPN Employee E2 removed gloves from her pocket and donned. -LPN Employee E1 removed scissors from his pocket to cut the ordered treatment to size; the scissors were not cleaned prior this use. -LPN Employee E2 applied each dressing to the four wounds. -LPN Employee E2 picked up the previously discarded gloves, removed her current gloves inside out, and placed the ball of soiled gloves and soiled dressings into her pocket. This soiled trash was not placed in the trash/bin. -LPN Employee E1 gathered supplies and replaced bedside table next to the resident for use. The table was not cleansed after this use. -LPN Employee E1 returned the supplies to the storage room. The scissors were replaced in his pocket. The wound cleanser spray bottle was returned to the storage room, this was used during this procedure in the resident's room. The scissors were not cleansed after use. -LPN Employee E2 threw the ball of soiled gloves in the trash in the storage room. During an interview on 9/4/24, at 1:30 p.m. LPN Employee E1 confirmed the above observations and stated he was orienting/training LPN Employee E2 as a new employee at the facility. During an interview on 9/4/22, at 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to maintain infection control to prevent the potential for cross-contamination during a dressing change. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility documentation, review of cited deficiencies from the facility's abbreviated survey of 5/24/24, and staff interview, it was determined that the facility's Quality assurance and performance improvement (QAPI) program failed to correct previous cited deficiencies. This has the potential to effect all 83 residents of the facility. The findings include: The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending May 24, 2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 6,2024, identified a repeated deficiency related to misappropriation of property and implementation of the policies and procedures to prohibit abuse and misappropriation of resident property for three of three residents. The facility QAPI Committee is responsible for the review and approval of facility policies, procedures and guidelines on an annual basis. The following schedule should be followed to assure review and adoption of key policies, procedures and guidelines. Additional requirements may be specified in other company programs. The facility policy Quality Assurance Process Improvement Plan, last reviewed 1/2/24, indicated that the purpose is to develop the means and methods to go beyond the Quality Assessment and Assurance (QAA) regulation and implement processes in order to meet the regulatory provisions of Section 6102(c) and March 2010 Patient Protection and Affordable Act. The purpose is to pursue continuous identification and correction of quality deficiencies as well as sustain performance improvement through implementation of QAPI principles utilizing a systematic, comprehensive , data- driven, proactive approach to performance management and improvement. During an interview on 9/4/24, at 9:08 a.m., the Nursing Home Administrator confirmed the facility failed to maintain their plan of correction for the deficient practices. Federal and state deficiencies cited in this report demonstrated that the facility failed to maintain an effective Quality Assurance Committee to ensure that the concerns related to abuse and misappropriation needs of the residents were identified. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(3)(e)(1)(3)(4) Management. 28 Pa. Code 211.12(c) Nursing services.

Based on a review of resident chosen menus, observations, resident council minutes and meeting and resident and staff interview it was determined that the facility failed to follow resident food preferences for three of four residents (Resident R63, R92 and R700). Findings include: During an observation conducted for tray accuracy on 9/5/24, for the breakfast and lunch meals it was revealed that the facility failed to provide the residents with their food preferences as follows: Breakfast Meal: * Resident R63 requested scrambled eggs and cranberry juice, the facility failed to provide either item and the resident received pancakes. * Resident R92 requested oatmeal and received cold cereal. During an interview on 9/5/24, at 8:24 a.m., Resident R63 stated that they always put on what they want to give you. During an interview on 9/5/24, at 8:25 a.m., Resident R92's representative stated that she has seen when her mother has not had items on her trays for all meals. Lunch Meal * Resident R700 wanted a hotdog and cheese curls and received a chopped hot dog and no cheese curls. During an interview on 9/5/24, at 11:40 a.m., Resident R700 stated that she often has preferred items missing off of her tray. Review of the Resident Council Minutes dated 8/29/24, indicated that residents identified that menus are not matching food provided. Review of the Resident Council Meeting dated 9/4/24, at 10:42 am, indicated that 12 of the 16 residents who attended group identified that menus were not matching the food provided. During an interview on 9/5/24, at 12:00 p.m., the concern regarding the facility's dietary staff not providing or substituting food items preferred by residents and menu selection process was reviewed with the Nursing Home Administrator. Pa Code: 211.6(a) Dietary Services

Based on a review of facility policy, clinical records, and incident investigation documents, it was determined that the facility failed to ensure that residents are free from misappropriation of property for three of five residents (Resident R54, R92 and R94)/ This was identified as past non-compliance. Findings include: Review of the facility Abuse Prevention Policy and Procedure dated 1/2/24, indicated that the facility will assure that the resident is free from misappropriation of property, which the policy defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Review of facility provided documents indicated medications signed out by LPN Employee E6 form 8/15/24, at 7:00 p.m., shift through 8/17/24, 7:00 a.m., revealed the following: Resident R54 had 3 pills of Oxycodone 5mg (commonly referred to as Percocet, an opiod pain medication used to treat moderately severe pain) signed out, but not administered. Resident R92 had four pills of Hydrocodone/APAP 5/325mg (commonly known as Vicodin, a narcotic used for severe pain) signed out but not administered. Resident R94 had 3 pills of Oxycodone 5mg signed out, but not administered. Review of the facility provided documents indicated On 8/20/24, the Licensed Practical Nurse(LPN) Employee E7 began the investigation as she had questioned the residents. The Director of Nursing(DON) was notified of the controlled medication discrepancies involving three residents. The DON and supervisors conducted an audit of controlled substance documentation and identified ten discrepancies involving three residents from 8/15/24 through 8/17/24, with one LPN identified as not completing documentation on EMAR (electronic medication administration record) but signed off on controlled substance count sheet. Two alert and oriented residents were interviewed by nursing supervisor, two residents reported that they did not receive pain medications. The DON immediately removed the LPN in question from the schedule. The State police were notified and conducted an investigation. Residents were interviewed by police. The conclusion of the investigation revealed, LPN Employee E6 was suspended until investigation completed and then terminated from position. State board of licensure was notified. Adult Protective Services were notified. On 8/23/24, the facility initiated a plan of correction that included: -Staff education on controlled substance policy. -Suspension and subsequent termination of LPN Employee E6. -State board of licensure notified. -on-going monitoring During interviews completed on 9/4/24, four staff members confirmed that they were provided abuse,neglect and misappropriation trainings with the previous citation. During an interview on 9/4/24, at 9:08 a. m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure that residents are free from misappropriation of property for three of three residents who are ordered controlled medications. 28 Pa. Code 211.5(f)(g) Clinical records. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.